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Arrhythmias and Device Therapy (Drs. Kanj and Wilkoff 8/15/11)

Monday, August 15, 2011 - Noon

Description

Arrhythmias are very common and are often a mere annoyance. However, they can also be responsible for life-threatening medical emergencies that result in cardiac arrest and sudden death. There are several treatment options for this condition, one of which is often with devices such as a pacemaker or defibrillator. Dr. Bruce Wilkoff and Dr. Mohamed Kanj answer questions about arrhythmias and device therapy.

More Information

Cleveland_Clinic_Host: Welcome to our "Arrhythmias and Device Therapy" online health chat with Bruce Wilkoff, MD and Mohamed Kanj, MD. They will be answering a variety of questions on the topic. We are very excited to have them here today! Thank you for joining us, let's begin with the questions.

Dr__Bruce_Wilkoff: Thanks for having us today.

Dr__Mohamed_Kanj: Thank you for having us.


Defibrillator

charles: I had a heart attack 4 months ago. My doctor wants me to have a defibrillator placed and I do not understand why. At the time of the heart attack I had two stents placed. When do you need a defibrillator after a heart attack?

Dr__Bruce_Wilkoff: First of all, there are two broad categories of problems you can have with your heart. One is with the blood supply to the heart and the other is with the electrical activation of the heart or heart rhythm.

The heart attack was caused by one of the arteries to your heart closing down and not allowing enough blood to get to your heart muscle. It caused damage to the heart muscle and the stents were used to open up the artery to allow better blood supply to your heart. The damage done by the heart attack upsets the electrical message for your heart to pump. If the message gets so disrupted that it causes a very fast rhythm, it can be life threatening causing a cardiac arrest. defibrillator is designed to rescue you from that very fast heart rhythm.

To summarize - the heart attack caused damage to your heart muscle but the defibrillator is there to protect you in case your heart rhythm develops a dangerous rhythm.


Cardiac Ablation

Susie: I had a Cardiac ablation 5 days ago. Went great took only an hour. But I have been feeling a little fatigued and short of breath and having some irregular beats not SVT; is this normal and how long can this last. I have an appointment with my cardiologist in a couple of weeks. Thanks.

Dr__Mohamed_Kanj: It is not uncommon to have extra beats after an ablation. This can sometimes be caused by the cells around the ablated area. However, It can be a problem by itself. These extra heart beats can be a trigger for the heart arrhythmia like the SVT. Time will tell - if the extra beats was caused by the ablation itself. It will take about three weeks or so and then we will see.

nancyh: Ablation of node at age 82?

Dr__Bruce_Wilkoff: The AV node is the connection between the atrium and ventricle and often when someone has atrial fibrillation the first priority is to control the heart rate to keep it from going to fast - the second priority is to prevent a stroke with anticoagulation. Ablation of the AV node is the most consistently effective way of controlling the heart rate but also requires a placement of a pacemaker to keep the heart from beating too slowly. Age 82 is certainly not too old to have an AV node ablation or a pacemaker.

nancyh: Is sick sinus node a good reason for ablation?

Dr__Bruce_Wilkoff: Sick sinus node is a broad topic which sometimes is assoc with slow heart rhythms and sometimes assoc with rapid heart rhythms. Sometimes this is called sick sinus syndrome or tachycardia/bradycardia syndrome.

  • For the bradycardia - pacemakers are the usual therapy.
  • For the tachycardia - medications and/or ablations are the usual therapies.

The prognosis for patients with sick sinus nodes is excellent so the goal is to reduce your symptoms without causing any complications.


Atrial Fibrillation

renate: I have had 5 A-Fib episodes in one year; first 2 were 3 weeks apart; then 7 mo., again 3 weeks, then 4 mo. Pulse raced between 120-160; took 6 hrs. to go into sinus rhythm. Was hospitalized for it once. Was given Cardizem, Heparin, cordarone drip; then was given sotalol for 2 weeks, which was discontinued since I could not tolerate. Currently I am not on any specific anti-arrhythmia drug. I take Plavix, 81 mg Aspirin, 25 mg Metoprolol, Crestor 10 mg. I have 2 bare metal stents in LAD, 1 medicated stent in first marginal. Stents in LAD had radiation therapy after 3 months due to blockage.That particular stent was diagnosed 50% blocked in late 2009. I do have moderate mitral valve prolapse. Question: Can the occasional A-Fib episodes damage my heart?? During the episodes I chew 1-2 whole Aspirin, take 1-2 Xanax and 1 Sotalol.

Dr__Mohamed_Kanj: Usually atrial fibrillation does not hurt your heart. However - It may - if your heart rate is fast during these episodes and thus we would recommend better heart rate control during these episodes - less than 100 beats per minute. The more atrial fib you have, the more you will have in the future. In fact afib begets atrial fibrillation.

The xanax may calm you down and thus decrease your heart rate during your episodes although it should not have an impact on the atrial fibrillation. I would recommend you see an electrophysiologist to review your medications and treatment during these episodes.

Natalie: I am a 58 year old female who over the last 10 years has had 3 ablations for afib and 2 surgeries to place a stent in the left upper pulmonary vein (now fully occluded even with the stent). My current problems with afib are quite difficult when I have a respiratory illness; otherwise they remain intermittent and manageable. Is it time to consider a 4th ablation, device therapy, or are there other approaches? What considerations would lead a patient to choose device therapy over the others?

Dr__Mohamed_Kanj: It depends - if the recurrence is due to something besides afib such as atrial flutter or atrial tachycardia then one can consider a 4th ablation procedure. However - you have had 3 atrial fib ablations - one has to ask - what will we achieve with the 4th ablation?

To start with - I would suggest monitoring your heart to look to see what type of arrhythmia you currently have to determine the best treatment options for you. One thing that may find is what did we find during the 3rd ablation. If we found out that there is a significant recovery around the pulmonary veins then we may consider a fourth ablation - otherwise I would look for different treatment options. Like - starting on an anti arrhythmic medication. Take in consideration that an anti arrhythmic medication may work that did not work prior to the ablation. 

We would be happy to see you.

ray112846: What is the difference between A-fib and A-flutter and is one more dangerous than the other?

Dr__Mohamed_Kanj: They are both electrical problems in the top chambers of the heart which is the atrium. Atrial fib carries a slightly increased risk of stroke compared to atrial flutter. Sometimes patients can have both of these arrhythmias at the same time. Ablation for atrial flutter carries a much higher success rate.

Toledo: I had a 24 hour heart monitor which showed no AFib but did show some "extra" beats during that period. An earlier EKG showed definite AFib. I have no outward symptoms but assume I have AFib. Can AFib occur only occasionally and how serious should I take it?

Dr__Mohamed_Kanj: Yes - afib is often intermittent. Afib can be a manifestation of a structural heart disease thus I would recommend an evaluation by a cardiologist to check for any structural heart disease that may be the cause.

Toledo: Can I test myself at home for Afib and/or atrial flutter on for ventricular flutter?

Dr__Mohamed_Kanj: Taking your pulse is a good idea because you can feel for any irregularities - however diagnosing the actual monitor would require a specialized monitoring device and to be read by a qualified physician.

Toledo: Follow up - I have been tested and am in very good general health. I have no signs of blockage or restrictions in the heart arteries. I have no thyroid or kidney issues and I do not have diabetes. I swim daily and experience no symptoms. Occasionally, I sense that I may have an irregular heart beat but it never restricts my activities. in fact, now that AFib has been detected, my sense is that I probably had this for some time. It is not detected because any time I have an EKG, the heart is normal with a pulse of 60-70 and blood pressure of 115 over 75. AFib was detected in a random way as a nurse was listening to my heart for another purpose. I have an appointment with a cardiologist and my doctor has put me on Warfarin just in case, but I am uncertain how serious this condition is. What is your opinion?

Dr__Mohamed_Kanj: it is not unusual for patients to be asymptomatic during episodes of afib. The treatment of atrial fib should consist of:

  1. rate control during the episodes of atrial fib. 
  2. rhythm control if patients continue to have symptoms despite rate control management
  3. anticoagulation therapy to prevent stroke formation - this can be done by either aspirin; warfarin; or a newer medication called dabigatran. The choice of anticoagulation therapy should depend on the patient health: the presence of diabetes, hypertension, heart failure, history of stroke, and age.

nancyh: Heart failure -does it occur with chronic afib?

Dr__Mohamed_Kanj: Heart failure can be a manifestation of atrial fib with poorly controlled heart rates. Atrial fibrillation occurs more commonly in patients with heart failure as a result of the heart failure as well.

cohnanita: I have a double chamber pacemaker for 3 years. I know that the pacemaker don’t helped with the atrial fibrillation, but from that time my A-fib became almost permanent. I DON’T want to do an AV node ablation. How you can explain that, and what are my chances in the future? I am 65 years old and have a prosthetic mitral valve.

Dr__Mohamed_Kanj: Atrial fibrillation in your case is most likely due to mitral valve disease and the cardiac surgery that you had. There are other therapeutic options to control your afib besides av node ablation including medications and afib ablation. We would be more than happy to evaluate.

FMR1952: I have had bouts of afib (about one per year, each lasting 12-18 hours). I experience premature beats and brief atrial runs much more frequently. It is not unusual (mostly when lying down) for the premature beats to happen with great regularity... perhaps every 10-12 beats. That can go on for extended periods. I have had a lot of testing done and am told I have a very healthy heart. Is there a connection between the afib and the premature beats? If I were to have a procedure done (ablation, mini maze, etc) would it address both issues? One other note... I have a low tolerance for meds (I've been on Toprol and Rythmol for afib in the past).

Dr__Mohamed_Kanj: Premature beats could act as a trigger for atrial fibrillation. Catheter ablation, unlike mini maze, could potentially address both the atrial fibrillation and premature beats. We would happy to evaluate you.


Pacemaker

katharine: My dad went to the doctor - he has been feeling sluggish. He had an echo. My dad said the doctor said his atrium is enlarged on both sides. His heart is functioning good. but he needs a pacemaker. Why would that be? Can medications be used instead?

Dr__Bruce_Wilkoff: Feeling sluggish is a very vague symptom. It is important to understand whether these feelings are all the time or intermittent. Having an enlarged atrium is really not an important finding in regard to needing a pacemaker. Pacemakers are used to treat people with slow heart rhythms. Unless your father's heart rate is slow and associated with the symptoms of sluggishness - then the pacemaker is not going to help. Often it is useful to monitor the heart rhythm using an event recorder or holter monitor to try to correlate the symptoms with the heart rhythm. There is not enough information yet for your father to get a pacemaker at this time.

GeorgePA: How long does the swelling last after a pacemaker insertion. Is there a time when I should be concerned?

Dr__Bruce_Wilkoff: The placement of the pacemaker is a surgery. It is a small surgery but it is common for there to be a small amount of swelling and or bleeding into the pocket where the pacemaker is placed. As long as the swelling does not continue to increase it will resolve over time. If there is a fair amount of swelling early after the surgery, it may take a long time, even months for it to resolve completely.

You should be concerned if there is drainage from the incision; if the incision opens up; if you have a fever or chills; or if you see a red rash surrounding the swelling. It is important to talk to your doctor if you have any concerns - it is not important that you know the right answer - it is just important that you talk to your doctor and he or she will help you out.

Marianne174: My husband had a pacemaker inserted two weeks ago and he wants to go back to all his activities which include golf and swimming in the mornings. When is it advised to go back to these things?

Dr__Bruce_Wilkoff: After the placement of the pacemaker, the incision has to heal before any significant activities can occur. Although many physicians have restricted activities altogether or for prolonged periods of time after pacemaker placement, there is no data that suggests restricting activities after the first 2 weeks prevents the leads or pacemaker from developing a problem.

I encourage my patients from day 1 to reach over their head and pat the tops of their heads to prevent under-use of the arm and the possibility of developing shoulder pain. I would think that after 2 weeks your husband should be able to resume full activities.

shawna: I have a pacemaker and the lead is not functioning. My doctor does not want to remove the lead - I read on the website that you do lead extraction. when do you remove a lead or leave it in? how do you make the pacemaker work if you leave it in?

Dr__Bruce_Wilkoff: There are many factors that go into the decision to remove or replace or to just add additional leads to a pacemaker system. The vein that the lead goes through is usually large enough to accept more than one or two leads and can often accept as many as 4 or 5 leads. However, the more leads and the longer that they are in the vein, the more scar tissue and the greater risk for future infection exists.

Depending on the age of the patient, the indications for the pacemaker, the age of the leads, the construction of the leads and particularly the skill and experience of the physician in removing the leads, this decision is made after discussing all the risks and benefits of taking one approach or another. At the Cleveland Clinic, we have been taking leads out with lead extraction for almost 25 years. The team which includes the doctors, nurses, anesthesiologists and many others has given us a major complication rate of less than 0.5% (one in 200). If you have a lead extraction, you should know this kind of data from your physician before making your decision.

fran: Dr. Wilkoff, how effective is Cardiac Resynchronization Therapy (CRT) in significantly improving symptoms of heart failure?

Dr__Bruce_Wilkoff: Assuming that the patient has particular findings on their electrocardiogram called QRS duration of more than 120 ms; and significant limitation of their activities during exertion, such as shortness of breath preventing the patient from walking up a flight of stairs; and particularly if the patient has a LBBB on their electrocardiogram, the chances are very good - at least 66% but depending could be higher as much as 80%. The response also depends upon the care with which the leads are placed and the programming of the device and especially the use of appropriate medications.


Ventricular Tachycardia

KaylaK: If you have an ablation to treat ventricular tachycardia - is it permanent? I had an ablation a couple years ago and lately I have been feeling the same symptoms with irregular beats and wonder if it can come back?

Dr__Mohamed_Kanj: I would recommend wearing a monitor to check for any arrhythmias. The fact that you are having the same symptoms does not necessarily mean that you are having recurrence of your ventricular tachycardia.


Symptoms

FibroJoe: I complained for over a year about an exaggerated "pulsing" sensation in my middle chest/throat area and even hands when resting like watching TV or reading. I do not notice it during exercise. It is particularly bothersome when in bed as it pounds in my ears. I've been forced to take Ambien to sleep. I've been wearing a pulse monitor (aerobics exercise type) and pulse was low (under 40). GP said the low pulse meant that metoprolol prescribe by cardiologist was working and not to worry. 10 weeks ago, a cardiac surgeon implanted a pacemaker as pulse had further dropped. I still have the "pulsing" problem. What should I do to resolve this?

Dr__Bruce_Wilkoff: The first rule in figuring out the best therapy to determine the cause of the symptoms. Therefore it is important to know what your heart rhythm was when you were feeling the pulsing without the pacemaker and now that you have the pacemaker. Once we know the heart rhythm, we can decide whether the heart rhythm had anything to do with this sensation or not. Then - we can re-address the issue.

Nubianspirit: I developed palpitations 12 years ago after the birth of my last child. They are annoying but my I have had stress test, holter monitors and am on a beta blocker. My heart rate was always in the 60's and the beta puts me in the 50's. Can palpitations damage the heart muscle? I'm afraid to work out.

Dr__Mohamed_Kanj: Palpitations can be a manifestation of multiple heart rhythm disturbances. Most of these are benign. I would not be afraid to work out since you have had a stress test which did not demonstrate any sustained rhythm disturbances.

drs21976: How common is ectopy after heart valve surgery and is it dangerous. I had my aortic valve replaced by Dr. Svensson on May 11th this year.

Dr__Mohamed_Kanj: Most likely your ectopy is not related to the heart surgery. Everybody has ectopy. It is not dangerous - usually benign arrhythmias. If you faint or feel like you are going to faint - you would need a monitor to investigate this further.


Anticoagulation

nancyh: Anti-coagulation in elderly-warfarin or new drugs?

Dr__Mohamed_Kanj: It depends. The newer drugs have shown better safety profile in a recent trial that was published a year ago. However, there was higher tendency of bleeding in the elderly population. I would use these newer drugs in patients who have been having trouble achieving therapeutic anticoagulation levels with warfarin. This drug cannot be used in patients with prosthetic valve disease; pregnancy and advanced renal disease. I would also be cautious in using these drugs in patients who have had prior history of stomach ulcers.


Other Questions

Poccione: Can psoriasis affect the heart and cause palpitations? Is there a treatment for that?

Dr__Mohamed_Kanj: I don't know of any correlation.

ChyvonneB: What do you recommend for arrhythmias due to medications (i.e. thyroid medications)...

Dr__Mohamed_Kanj: If you are over medicated - then you can cut the thyroid medication dose - if you are not over-medicated beta blockers is a class of medications that can help you.

Reviewed: 08/11


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