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Atrial Fibrillation - The Most Common Irregular Heart Rhythm (Dr. Lindsay 2/22/10)

Monday, February 22, 2010
Dr. Bruce Lindsay

Bruce Lindsay, MD
Section Head,
Cardiac Electrophysiology and Pacing Cardiovascular Medicine

Description

Atrial fibrillation is an abnormal heart rhythm and is the most common irregular heart rhythm in the United States. In at least ten percent of the cases, no underlying heart disease is found and many people live for years with atrial fibrillation without problems. However, chronic atrial fibrillation can result in future problems. Cleveland Clinic is expert at a wide range of treatments to effectively cure atrial fibrillation. Join us in a free online chat with leading Cleveland Clinic cardiologist Bruce Lindsay, MD. Dr. Lindsay will be answering the most frequently asked questions about diagnosis and the latest treatment options for atrial fibrillation.

More Information

Cleveland_Clinic_Host: Welcome to our Online Health Chat with Bruce Lindsay, MD. Dr. Lindsay is an expert in the field of Atrial Fibrillation. We are thrilled to have him here today for this chat. So thank you for joining us Dr. Lindsay. Let’s begin with the questions.

Speaker_-_Dr__Bruce_Lindsay: Thank you for having me today.


Atrial Fibrillation Questions

RichardL: IS THERE ANY ESTABLISHED CONNECTION BETWEEN NAPROSYN (ANTI-INFLAMATORY) AND A-FIB?

Speaker_-_Dr__Bruce_Lindsay: I know of no connection between the two.

williamG: I have had problems with Atrial Fibrillation for years, used medications to try to control it, but seem not to work as well, I was wondering if electrocardioversion , or (cardioversion) would help me

Speaker_-_Dr__Bruce_Lindsay: Cardioversion is used to restore the rhythm in patients who have relapsed into atrial fibrillation. But it does not prevent the atrial fibrillation from recurring. If you have been in atrial fibrillation for several years, it may be difficult to keep you in a normal rhythm. Medications and ablation procedures can be helpful to achieve this goal.

RCB: Does the incidence of AF increase with the number of re-operations and is this a risk factor in multiple surgeries?

Speaker_-_Dr__Bruce_Lindsay: Atrial fibrillation can develop after open heart surgery, particularly in patients with heart failure or valvular disease. The risk probably does increase with multiple open heart operations.

stephenE: :I may have already asked this. Is one considered in A-fib if they had an incident that was resolved by cardioversion and then 15 months later had another episode caused by alcohol that resolved itself in 2 hours. Once you have had an incident are you always considered A-fib ? Thanks!

Speaker_-_Dr__Bruce_Lindsay: You have paroxysmal atrial fibrillation as opposed to long standing persistent atrial fibrillation. The difference is that your episodes have been relatively short

stimpysan: I was just diagnosed with AFIB a month ago. They said the upper chambers in my heart were on the larger side of normal. I'm 48 and have not worked in 6 years due to a failed neck surgery. Is there anything I can do to keep those chambers from getting bigger and making my condition worse. I have not drank or smoked since I left the hospital. Thank You

Speaker_-_Dr__Bruce_Lindsay: Enlargement of the left atrium can be related to high blood pressure, valvular problems, heart failure or long standing atrial fibrillation. Treatment of these conditions helps to prevent enlargement of the atria from progressing.

Buck: I was admitted to the hospital in 1985 and ended up being confined for 31 days. I was anemic and was ultimately diagnosed with a plural effusion. They were giving me 2 and 3 EKG's a day. I was too sick to realize that my heart was in arrhythmia(sic). Around 2006 I was admitted for 3 days with severe weakness in my muscles. I felt very weak all over my body. They diagnosed me as being in Atrial Fibrillation. It was recommended that I start taking cardizem. I haven't had any symptoms since. My question is why my internist would not have been able to tell me that I had atrial fib between 1985 and 2006?

Speaker_-_Dr__Bruce_Lindsay: I cannot really answer your question without evaluating your records.

Stevedon41: Can A-Fib ever be a one or two time event over two or three years and then never happen again ??

Speaker_-_Dr__Bruce_Lindsay: It is difficult to predict the course in a specific patient. The natural course of the problem is that over the course of 10 years or less it tends to become more frequent and last longer. There are always exceptions to any rule, so some patients may not have as much difficulty. I think this would be more likely if the events were associated with some particular stress or illness that had resolved.

Birdie: I had my Aortic Valve replaced at CC in OCT of 2007 with a cow valve. I was admitted to our local hospital on 2-2-10 for rapid atrial fibrillation with rapid ventricular response. My pulse was 190. They got me back in rhythm with IVheparin and them Cardizem with no evidence of pulmonary embolism. They put me on Zocor 10MG -Cardizem 180 MG - Sapirm 81 MG and Pepcid 20MG. My question is "Will I have to stay on this medicine the rest of my life and should I try and find out what caused my Atrial Fibrillation? Thanking you in advance!

Speaker_-_Dr__Bruce_Lindsay: I do not have enough information to answer your question. You are welcome to forward detailed records for a eCleveland Clinic consultation if you wish, or you could ask your doctor.

Ccr123: Would elimination of all alcohol reduce or minimize long standing AFIB.

Speaker_-_Dr__Bruce_Lindsay: Probably not. The metabolites of alcohol can trigger atrial fibrillation, especially when too much is consumed. Chronic alcohol abuse can damage the heart, in which case the paroxysmal atrial fibrillation might subside with abstinence. It is unlikely that abstinence from modest alcohol intake would have any effect on long standing atrial fibrillation.

Stimpysan: I had a herniated disc at C6-C7 and had it fused in 06. After a recent mRI it has reherniated causing arm chest and neck pain and muscle twinges. I had my first afib a month ago. Could this have caused it

Speaker_-_Dr__Bruce_Lindsay: It is probably unrelated, but we do know that nerves that connect with the heart play a role in triggering atrial fibrillation. It is possible that pain or stress could trigger atrial fibrillation, but it is more likely that other factors are involved.

Coac38: I am 60 years old and have had 3 AFib occurrences over the last 5 years requiring medication to get back to a normal heart rate. I am currently taking Viagra and have noticed a more rapid heartbeat than normal after sex. Should I be concerned

Speaker_-_Dr__Bruce_Lindsay: Not necessarily. You should discuss it with your doctor. One option would be to use an event monitor to determine whether your heart rhythm is abnormal when you have these symptoms.

Stimpysan: why is it that every time I lay down, especially on my left side my AFIB starts.

Speaker_-_Dr__Bruce_Lindsay: I have wondered about this too. Many patients have experienced the onset of atrial fibrillation in certain positions. One explanation is that the heart is suspended in the chest and it shifts when you lie on your side or bend over. This may stretch some of the muscle fibers extending into the pulmonary veins and cause them to discharge electrical potentials that trigger atrial fibrillation.


Symptoms of Atrial Flutter and Fibrillation

basil: Having been diagnosed with Atrial Flutter, how does "shortness of breath" in cardiac symptoms that also occur in High Altitude Sickness, differ or are they related?

Speaker_-_Dr__Bruce_Lindsay: Patients who experience atrial flutter often have shortness of breath which may be similar to the symptoms people experience at high altitude but the problem is very different.

BJW: I am scheduled for Cardioversion next week. I am in Afib 100% of the time according to my pacemaker which was implanted at the same time when ablation was attempted. Immediately after this procedure, pericardial effusion almost ended my life. The Afib has increased to constant pain and my heart doctor is trying Cardioversion. I am on Warfarin and aspirin. Can I expect any relief with this treatment?

Speaker_-_Dr__Bruce_Lindsay: I am uncertain whether your chest pain is related to your atrial fibrillation as opposed to other problems. Cardioversion may alleviate your pain if the cause is atrial fibrillation but it will not make any difference if the pain is caused by other problems. Your pain could be related to a chronic form of pericarditis or it is possible that one of the pacemaker leads is contributing to the problem. A careful review of your records would be required.


Paroxysmal Atrial Fibrillation

Jaklyn2212: Would keeping track/logging the frequency & duration of Paroxysmal AF episodes be a good idea in helping one decide when medications are no longer effective & have an ablation performed?

Speaker_-_Dr__Bruce_Lindsay: Yes. You need not be obsessed with it, but your physician can give you better advice if you can provide information about how often you have atrial fibrillation and how long it generally lasts.

stan: I was Do’s w/ Paroxysmal AF in 1/07. Echo showed only mild mitral valve regurgitation, otherwise structurally sound heart. Ax’s daily aspirin (325mg) & 25mg Atenolol. Increased AF frequency one year ago resulted in adding 150mg Rythmol 3x/day. Episode frequency now ~ 1x every 4-6 weeks, lasting 30 min to 3 hrs., each self-converting to NSR w/out need to make ER trip for conversion as in the past. 1. How many episodes (& their duration) is considered too many before more aggressive measures need to be considered (e.g. ablation)? 2. Can chronic, intermittent AF episodes lead to early heart failure or cardiomyopathy? 3. What, if any, are the long-term side-effect of taking Rythmol? Thank you very much.

Speaker_-_Dr__Bruce_Lindsay: The natural history of paroxysmal atrial fibrillation is that it tends to progress in frequency and duration over time. The aggressiveness of treatment depends on the severity of symptoms. In your case, it would be worthwhile to consider a different medication or an ablation procedure. Long standing atrial fibrillation is well tolerated by some patients but can lead to heart failure in others. There are no long term side effects related to taking rhythmol.

stevedon41: Can an ablation procedure actually cure Paroxysmal A-fib ??

Speaker_-_Dr__Bruce_Lindsay Yes. The cure rate appears to be about 70-80% for a single ablation procedure in patients who do not have other heart disease. It is somewhat lower in patients who do. Some patients require a second ablation to achieve a good result. Ultimately, cure rates as high as 85-90% can be achieved in patients with paroxysmal atrial fibrillation who go through two or three ablation procedures. Most of these statistics are base on one year follow-up. We are currently looking at our data to determine the risk of late recurrence. It appears that the risk of late recurrence is about 7% when follow-up is extended several years. My experience is that in most of the patients the pulmonary veins have recovered partially and that another ablation is worth considering if medications do not alleviate symptoms.

christopher: have Paroxysmal A-Fib with excellent control on Rhythmol. I live in Charleston, SC and have been told by a Medical University of South Carolina electrophysiologist that I am a candidate for PVAI, a procedure that has a "high rate of cure." After talking with the EP and my cardiologist (the cardiologist is against any procedure), I am confused as to 1) should I have a procedure, 2) what is the prognosis for one with A-Fib treated and untreated, 3) is there an optimal time for a "fix", 3) what type of procedure would be best for me, 4) who on your staff has performed the most procedures and has the highest success rate. I have heard good things about the EP's here in Charleston, but I would like a second opinion before embarking on an invasive procedure involving my heart. Thanks

Speaker_-_Dr__Bruce_Lindsay: You probably are a good candidate for an ablation procedure but there is no need to undergo the procedure if you are doing well on medications. Results of ablation procedure are best in patients with paroxysmal atrial fibrillation before they progress to persistent atrial fibrillation.

As indicated in a prior response, we do a large volume of ablation procedures for atrial fibrillation and have many electrophysiologists in our section who are extremely experienced and have comparable results.


Atrial Flutter

alice: What is the difference between atrial flutter and atrial fibrillation? Are procedures to cure the same? What is the success rate of a cardiac ablation for atrial flutter? What are the risks

Speaker_-_Dr__Bruce_Lindsay: Atrial flutter is a more organized rhythm during which an electrical wavefront spins in a circle. Each time the wavefront follows the same pathway, the circuit is eliminated by ablating tissue across the pathway so that electrical impulses can no longer conduct through it.

Speaker_-_Dr__Bruce_Lindsay: The success rates for ablation for atrial flutter depends on where the circuit is - the success rate is 90% or more for patients with right atrial flutter. It may be lower for left atrial flutters depending on the experience of the center where the procedure is performed. The risks depend on where the flutter circuit is so you would have to discuss this with your electrophysiologist.

JoanK: I was operated on at Cleveland Clinic. I would like to know the Basic mechanisms responsible for cardiac arrhythmias such as abnormal automaticity or triggering of arrhythmias re-entry. There are two types of basic mechanisms. I have atrial fibrillation/atrial flutter. I didn't realize there were two types of atrial fibrillation and atrial flutter - until I read the book I bought. The second question I have is I bought a book at the book store - can you talk about atrial fibrillation atrial flutter and the possibility of getting congestive heart failure. Based on this book - there are different types of afib - what type of medication do you recommend with chronic afib. Sounds like the different medications work with different types of afib.

Speaker_-_Dr__Bruce_Lindsay: It is a complex subject. In many patients atrial fib is triggered by premature beats arising from the pulmonary veins. The tissue in the pulmonary veins has abnormal automaticity. The concept underlying catheter ablation of atrial fibrillation is that these areas of abnormal automaticity are eliminated or isolated so they cannot conduct out into the atrium.

Some patients also have atrial flutter which is a re-entrant rhythm. The types of arrhythmias that patients have can influence what types of medications we chose to treat them. Most patients with atrial fibrillation do not develop heart failure as a consequence of their arrhythmia but it can occur. This would influence the kind of medicines we would prescribe and might affect recommendations for an ablation procedure.

Villager: I have had my aortic valve replaced 2 1/2 years ago. At that time, the surgeon did a "modified maze" procedure. I now have atrial flutter. and want to have an ablation. A doctor has recommended that I have the upper right chamber done first. If that does not work, then I will need to have the left side done. Does this seem reasonable?

Speaker_-_Dr__Bruce_Lindsay: It depends on the pattern seen on the electrocardiogram when you are in atrial flutter. If it is characteristic of right atrial flutter a right sided ablation is very likely to eliminate it. If the pattern is not characteristic of right atrial flutter, my concern is that it could be a left atrial flutter, which would not be eliminated by a right atrial procedure

JoanK: Explain chronic a-fib/flutter and the possibility of developing congestive heart failure. Please explain bvasic mechanisms responsible for cardiac arrhythmias...abnormal automaticity and triggering of arrhythmias re=entry. Please explain choice of medications for 1. alterations in impulse formation leading to enhanced or abnormal automaticity or triggered activity 2. alterations in impulse conduction resulting in re-entry phenomena

Speaker_-_Dr__Bruce_Lindsay: Atrial flutter is a wave front of electrical activity that travels in a circle and follows the same pathway each time the circuit spins. It can be eliminated by ablating across the pathway because the ablated tissue not longer conducts electrical impulses. In contrast, atrial fibrillation is caused by electrical wave fronts that spiral around the atria and do not follow the same pathway. It appears to have more random motion.

Atrial fibrillation is often triggered by muscle fibrils that extend like sleeves into the pulmonary veins. They have unstable electrical properties that cause them to discharge at a high frequency and trigger atrial fibrillation. This abnormal automaticity may be related to stretching of the muscle fibrils with change of position, neurological input, or other factors that are beyond the scope of this discussion. Drugs used to treat atrial fibrillation alter the electrical properties of the cell membrane. The Heart Rhythm Society developed a consensus document that you can read which discusses these in great detail. It can be found on their website. It was written by some of the leading experts in the field. http://www.hrsonline.org/


Atrial Fibrillation and Medications

raymondS: My Afib is under control with medications:Lanoxin and Atenolol but Coumadin is a real problem. Please tell me about the new medication that replaces Coumadin and how it thins the blood without all side effects and PT's required by Coumadin. Thank you

Speaker_-_Dr__Bruce_Lindsay: There is a new class of medications called thrombin inhibitors which act in a different way to prevent clots from forming. It appears that one dose is suitable for all patients and no blood testing is required to adjust the dose. The studies suggest that these medicines are as effective as coumadin and may have a slightly lower risk of bleeding complications. None of these have been approved for use in the United States but I expect that one or more will be approved over the next year or two.

Birdie: Generally if you have had an atrial fibrillation are you put on medicine to control the problem for the rest of your life? I am taking Cardizem 180MG and Zocor 10MG. I had Aortic Valve replaced at CC. And are there tests to determine what caused Atrial Fibrillation? Thanks Birdie

Speaker_-_Dr__Bruce_Lindsay: Most patients with atrial fibrillation require life long treatment. Sometimes it occurs transiently after surgery and is not a long term problem, or it may be related to hyperthyroidism and subside when the thyroid is treated. In most cases it will not go away unless the patient undergoes an ablation or Maze operation.

Stimpysan: Is there any connection between Tramadol and AFIB. That’s when mine started.

Speaker_-_Dr__Bruce_Lindsay: I am not aware of an established connection between Tramadol and atrial fibrillation.

greej: I take Toprol XL for an irregular heart beat. I have for 15 years. It works quite well. What are the pros and cons of Shock treatment with Systrolol or ablation or what newer treatments are available? I get afib maybe 1 per month lasting between 10 to 30 minutes but when I take an additional toprol they go away after about an hour

Speaker_-_Dr__Bruce_Lindsay: I am not familiar with the term systrolol - perhaps you were referring to sotolol. The difference between drugs like sotolol and metoprolol - is that metoprolol does not prevent atrial fibrillation but it helps blunt the heart rate when atrial fibrillation occurs.

In contrast medicines like sotolol can prevent atrial fib. It sounds as though you have enough symptoms to warrant a change of medications - you might be a candidate for an ablation procedure if medical therapy is ineffective or not well tolerated.

BJW: Can medications control Afib, if a pacemaker has been implanted? I have not had any success with Lanoxin or Toprol

Speaker_-_Dr__Bruce_Lindsay: Neither Lanoxin nor Toprol prevents atrial fibrillation. They only control the rate when you have atrial fibrillation. A pacemaker will not prevent it either. Certain medications such as sotalol, propafenone, flecainide, dofetilide, dronedarone, or amiodarone can be used to prevent atrial fibrillation. Each has its share of problems. Catheter ablation is used to eliminate atrial fibrillation in patients who are appropriate candidates when medications are ineffective or not well tolerated. Some patients make an educated decision to go directly to an ablation procedure, but I generally recommend medications first.

joannH: Center for Atrial Fibrillation. My husband was recently diagnosed with Atrial Fibrillation. His doctor has prescribed him several medications, but I was hoping he could take natural supplements instead. I prefer homeopathy because of all of the possible side effects with medication. Will natural supplements work? I have been trying to call the clinic but I cannot get through. Thanks

Speaker_-_Dr__Bruce_Lindsay: There is no good evidence that natural substances will be beneficial. Most of the studies in support of these substances have not been conducted in a rigorous scientific method or published in a reputable scientific journal. They are excluded from the same rigorous standards that the FDA applies to prescription drugs. In my opinion the main beneficiary is the manufacturer.

david_L: For Dr. Lindsay, web chat on 2/22 I have been in persistent atrial fib since November. I started taking 80mg of nadolol. I recent holter showed avg HR of 100, 170 with exercise. I was advised to increase nadolol to 120mg with a potential to 160 should my avg HR not come down. Your thoughts? Thank you

Speaker_-_Dr__Bruce_Lindsay: That sounds there are two issues. An increase in dose is appropriate as long as you are not prone to slow heart rates. The dose you describe seems quite large so you should check with your physician.

Hoagie0013: What are the newest meds. to help with the a-fib

Speaker_-_Dr__Bruce_Lindsay: Dofetilide was approved several years ago. Dronedarone was approved over the past year. My impression is that the effectiveness of dronedarone is modest and gastrointestinal adverse effects have been a problem for some patients.

dennis: I have A-FIB, for which I am taking COUMADIN, and other meds. I will be having BARIATRIC SURGERY in the very near future, and I would like to know how long before surgery do I need to stop taking the coumadin?

Speaker_-_Dr__Bruce_Lindsay: Coumadin is generally discontinued for 5 days prior to surgery. Your surgeon should give you specific directions.

RCB: Does warfarin really "thin" the blood?

Speaker_-_Dr__Bruce_Lindsay: No. I am not certain how this widely used term came into usage. The blood appears the same and has the same viscosity. Warfarin blocks the synthesis of certain proteins that are involved in forming blood clots, but it does not “thin” the blood.

Denalidon: Does constant use of warfarin/coumadin contribute to calcification of the arteries in any major way? Thank you for your answer. Don

Speaker_-_Dr__Bruce_Lindsay: There is some experimental evidence that warfarin may contribute to calcification of vessels and the tissue supporting valves. Further study is needed to determine whether this is clinically significant. In the mean time, warfarin is indicated for patients with atrial fibrillation who have other risk factors for stroke. In those patients, the risk of stroke far outweighs the potential risk of taking warfarin. We must be careful not lose the forest through the trees.

Tadpole: Referencing the earlier question about thrombin inhibitors as replacements for coumadin, do you know whether this applies to patients with mechanical valves as well as patients with a-fib?

Speaker_-_Dr__Bruce_Lindsay: To the best of my knowledge these studies have not been performed, so we do not know the answer.


Ablation Treatment for Atrial Fibrillation

anitaC: I had undergone several years ago a mitral valve replacement surgery+maze procedure because my severe mitral regurgitans (rheumatic valve) . Maybe not the ideal patient ;I have had good ventricular contraction but a dilated left atrium (54) meds for rate control don't help me even high doses. My heart rate remain 115-120. There is anything to do in my situation? Anita.

Speaker_-_Dr__Bruce_Lindsay: I would need to review your medications to see if there are any alternatives to what you are taking or what you have taken in the past. Ablation of atrial fibrillation is an option but the success rate is lower in patient who have artificial heart valves. I would need to review your records to provide a more specific recommendation.

Sajasaj: You mentioned above that the longer one is in afib, the more difficult it is to correct. If the afib is long term but at a controlled rate of 60 bpm and asymptomatic, does that make it any more likely to be fixed?

Speaker_-_Dr__Bruce_Lindsay: No. The reason is that your pulse measures how fast the ventricles are beating; however, medications that slow conduction through the AV node to the ventricles do not change atrial activation. Even when the ventricular rate is controlled, the atria are still fibrillating as fast as ever.

robertB: Would you give me a list of statistics on the number of PVAs done for AF and the success rate for each EP cardiologists?

Speaker_-_Dr__Bruce_Lindsay: We did approximately 700 ablation procedures for atrial fibrillation in 2009 and have done over 5000 accumulatively. The success rate depends on whether the atrial fibrillation is paroxysmal as opposed to long standing persistent atrial fibrillation and it is related to coexisting heart disease.

The success rate for paroxysmal atrial fibrillation is in the range of 70 - 80 percent for a single ablation procedure and can be as high as 90 percent for patients who undergo 2 or more procedures. We have posted this information on our website in our outcomes book.

denalidon: Thanks in advance for taking my question! I suffer from paroxysmal AFib and am considering having an ablation to avoid having more as I get older (I'm 65 and in otherwise good health). Can you give an assessment on the relative success rates and complication statistics of catheter ablations versus the success rates and complications of the Wolf MiniMaze operation. I am getting a PFO closure device placed in my atrial septum in the near future. An EP in a reputable hospital here said it would not be a bad idea to do a preventative CA as it is very difficult to do one after the PFO is closed. The best alternative procedure that I can find would be to do the PFO and if I then have increased frequencies of AFib events afterwards, I could use the Minimaze as a way to correct. Any thoughts as to which the best approach might be?

Speaker_-_Dr__Bruce_Lindsay: It will be difficult to perform catheter ablation of atrial fibrillation once the PFO closure has been performed. PFOs are common which raises the question whether your PFO needs to be closed. Most do not require closure. As with catheter ablation, the results of the mini maze depend on the experience of the center where it is performed. It is also important to determine how carefully they track their outcomes.

denalidon: Thank you for your initial answer to my Q about a preventative CA before a possible PFO closure. Pulmonologists from one of the nation's leading center in Denver have surmised (after extensive testing), that I should probably have the PFO closed as they feel it is causing hypoxemia. If that is the case, do you think a pre-emptive CA to avoid future AF problems is a reasonable choice, or do you think possible surgical options would be a better plan after closure?

Speaker_-_Dr__Bruce_Lindsay: It sounds like you have received expert advice. If medications are not controlling the atrial fibrillation, I would consider ablation prior to the PFO closure. Once the PFO is closed it would be much more difficult to cross the septum. It has been done, but experience is limited, the risks are greater, and it might affect the maneuverability of the catheter. If the catheter ablation did not work, a Maze or “mini” Maze would be an option in the future

RandyA: How many ablations are too many? Are there cases where ablations need to be done from the outside of the heart Can an ablation cause damage to the heart where it will never beat properly again? When is a pacemaker necessary verses an ablation I take Multaq, I am still in a-fib...what is your opinion of this med? Can A-fib or flutter damage the heart? If so, what period? Can heart meds damage other organs like liver or kidneys? Will a pacemaker work properly without surgery to anode?

Speaker_-_Dr__Bruce_Lindsay: In response to all your questions, approx 20 - 30 percent of patients require more than one ablation procedure to achieve a good long term result. It is uncommon to perform more than 2 ablations - but sometimes a third is required - it would be rare to undergo 4 ablation procedures though there are some patients in whom that has been necessary.

I have performed ablations in patients who have undergone several other procedures at other institutions other than the Cleveland Clinic, in some cases, they have extensive scarring of the left atrium that could be related to underlying heart disease or prior ablation procedures. It is likely that this does affect left atrial functioning.

Georgina: HI am a generally healthy 54 yr old female who jogs 3-5 miles per week and exercises with weights. Since last June, I have had episodes of atrial fibrillation lasting between 10 minutes and 12 hours. This only occurs at rest, never in response to exercise. I have been prescribed several different meds, most of which have failed to help (Cardizem, then Toprol, then Flecainide(some relief), then Dronedarone(which produced more frequent episodes). I am now back on Flecainide which at least is tolerable. My question is whether radio frequency ablation is appropriate for my particular condition (Vagally Mediated A-Fib ?) and if so what are the risks and success rate ? I am getting very discouraged and truly need some guidance.

Speaker_-_Dr__Bruce_Lindsay: It seems that you are an appropriate candidate for ablation of atrial fibrillation. The success rate is about 70-80% for a single procedure in patients with paroxysmal atrial fibrillation who do not have other heart disease. Approximately 20% of patients like you require more than one ablation procedure to achieve a good result. The risk of a serious complication is in the range of 1-3%. Risks include stroke 0.5%, perforation 1-2%, pulmonary vein stenosis <1%, and esophageal injury 0.2%.

davidL: On 2/1, the Today show had a clip on an ablation procedure done at Case where the Doctor is in a remote room using magnets. Does the Clinic use this procedure for atrial fib? The physician stated the success rate was 85-90%. Would that hold true in treating atrial fib? The question was asked but not answered concerning safety. What is the morality rate with this procedure?

Speaker_-_Dr__Bruce_Lindsay: I was instrumental in developing the stereotaxis magnetic navigation system and did all the initial work on humans. It is an evolving technology that has some advantages but there is still room for improvement. To date, there is no convincing evidence that it improves the success rate of the procedure though it can reduce x-ray exposure when used by an experienced physician. We have had stereotaxis at the Cleveland Clinic for several years and are still evaluating the technology.

I cannot comment on the success rate claimed during this program - I am uncertain what was being ablated or whether they are tracking long term outcomes. The mortality associated with ablation of atrial fibrillation is in the range of 0.1 % or 1:1000. It probably is not much different for stereotaxis.

A3Sneezer: Earlier this month Good Morning America had an episode about a new magnetic navigation procedure being used at the CC for ablation procedures. I am scheduled for a PVI next week with Dr. Saliba. Should I expect this for my procedure?

Speaker_-_Dr__Bruce_Lindsay: I did the initial investigations with the magnetic navigation system when it was first developed and we continue to evaluate it. It is an evolving technology, but I am not convinced that it improves outcomes or shortens procedures at this point. The TV documentary was done at another institution. I am not certain what they were ablating and cannot comment on any of their statements or outcomes.


Success Rate

jimS: If in atrial fib for several years but at a controlled rate (60 bpm) and somewhat asymptomatic, is it likely that an ablation procedure could correct it? And if not likely, is it likely that the maze procedure could correct it? Thank you.

Speaker_-_Dr__Bruce_Lindsay: The success rate for both the Maze operation and catheter ablation decreases after several years of atrial fibrillation. The specific success rate would depend on how long you have been in afib and coexisting heart problems such as heart failure or heart valve problems.

PaulC: 1. Is there a relationship to the length of time one has atrial fibrillation and the success rate of an ablation procedure? Is an ablation more effective if performed sooner rather than later? 2. I have been on flecainide for 7 months for paroxysmal atrial fibrillation. Although medication and lifestyle changes have somewhat reduced the frequency of a-fibs, I continue to have at least 2 episodes each week, lasting 2 hours each. Would you recommend an ablation procedure now or wait? Could I expect atrial fibrillations to alleviate through the measures I am already taking, or does it appear a procedure will be necessary for any further improvement? 3. Does paroxysmal atrial fibrillation cause damage to one’s heart over time? I am 59 years old, currently have no signs of heart disease, have experienced a-fibs for 9 months, and have been on flecainide. I still experience a-fib episodes several times a week lasting 2 hours each. 4. What are the new techniques on the horizon for “curing” atrial fibrillation? Can you anticipate the timeline for their availability for patient use?

Speaker_-_Dr__Bruce_Lindsay: From your description it sounds as though you are an appropriate candidate for an ablation procedure. Other medications might provide an alternative but the success rate for an ablation generally is higher in someone like you.

BonnieW: Where can I find the mortality and morbidity rates attributed to atrial fibrillation ablations at Cleveland Clinic? Also, how many ablations are done in a year at the clinic?

Speaker_-_Dr__Bruce_Lindsay: We have performed over 5,000 ablations for atrial fibrillation cumulatively and did 692 in 2009. I am working on the annual outcomes report for 2009. There were no deaths or strokes. The incidence of pulmonary vein stenosis was 0.1%. The overall incidence of complications is about 2.4%. This is consistent with the outcomes book that is available on the Website.

BJWF: I have been in AFib 100% of the time since 2000. Does this lower my success rate of treating it with Ablation? I have a pacemaker.

Speaker_-_Dr__Bruce_Lindsay: Yes. It is very unlikely that you would benefit from a catheter ablation procedure or Maze operation if you have been in atrial fibrillation for 10 years.


Arrhythmia after Treatment

dennisW: I had 2 ablations for atrial fibrillation performed at the Cleveland Clinic within the last 4 years. For the last 3-1/2 years, it has been well maintained. Over the last 6 months, I have had 5 episodes of what was thought to be SVTat 180+. I become very symptomatic. On one of those occasions, I was given Adenosine for it. Upon converting from SVT it, slowed and was determined I was having underlying atrial fib at 130+. I was cardioverted the next day to NSR at 80-90. The other 4 episodes, the "supposed SVT" converted on it's own back to basically NSR with a few ectopics. What is today’s best course of treatment and recommendations of treatment to keep this from occurring

Speaker_-_Dr__Bruce_Lindsay: This is a complex problem. In order to provide a specific answer we would need to evaluate your previous recordings and medical records and medicine you have received. It may be feasible to treat your problem with other medications and in rare occasions a third ablation procedure may be needed.

tom: I had an Aortic Valve Reoperation/Mitral Valve Repair/Cyro Maze Procedure done at Cleveland Clinic on 1/30/09. A pacemaker check done in Sept. 09 indicated that I went back into permanent A-fib in August 09. Although the a-fib is primarily asymptomatic, I hear that it is fairly normal to require a second ablation procedure and that it is advisable to have the second procedure done before the a-fib causes permanent damage to the heart. Can you comment on what my options are?

Speaker_-_Dr__Bruce_Lindsay: You raise an interesting question. There is evidence that the longer patients are in atrial fibrillation the more difficult it is to eliminate it. The reason is that changes occur at a cellular level and they progress over time. We would need to review your records to decide whether you would be likely to benefit from treatment with cardioversion and medications vs. a catheter procedure.

kitty: In 2007 I had to have a duel pacemaker put in due to a fib. I still have a lot of afib still. My doctor did a ablation on both nodes and has me on amiodarone also. When I went back for my check up 6 month later the doctor said I had 6800 episodes in the six month period. He did not give me a answer as what I should do next. In December of 2008 I had a bleeding in my brain because of the afib. I have also had a few tia 's also. Luck for me they where able to stop the bleeding before any damage was done. I still feel the afib alot and I am concerned as to what to do. Just let the afib continue or what. Please can you give advise as what to do next

Speaker_-_Dr__Bruce_Lindsay: You have a complicated problem - you might benefit from a second ablation procedure or perhaps you should be considered for a maze operation which could potentially alleviate your need for coumadin. You require further review of your records to make a specific recommendation.

hoagie0013: I was diagnosed with a-fib 5yrs. ago. I finally got the nerve up to have ablation done may 2009. I now find that the a-fib is more controlled now but I seem to get different heart rates . it seems to run in cycles some days the rate is 100bpm an that can last for a few days. then the next few days it will lower to 60bpm. my question I guess is, can hormones cause the varying heart rates I am having on certain days.

Speaker_-_Dr__Bruce_Lindsay: Changes in hormones can effect heart rhythms though we are not certain why this occurs or how to treat it differently. You may require an adjustment in your medications or perhaps you would benefit from a second ablation procedure.


Exercise

stephenE: I had an A-fib incident with no symptoms in Sept 08 ( came to the Clinic and had cardioversion). I was an exercise runner ( 2miles a day) and I felt like I hit a wall after a lap around a track. If I wasn't running I would have never known. I was fine till 12-7-09 when I had quite a bit of wine while visiting my daughter in Florida. I had an incident that night ( went to ER ) but went back into normal rhythm after approx. 2 hours. I do have a long history of Hypertension but I am on medication ( atenolol, norvasc, lisinopril ) I am 68 years old but am now I am spooked when it comes to running, I only walk fast, getting my HR up to 100-104 - it returns to my normal 40-50 range after a few minutes. Do you think running is a possibility as I miss it ? Would any tests be required first ?

Speaker_-_Dr__Bruce_Lindsay: It might be feasible for you to resume running but I recommend that you talk to your cardiologist about undergoing a stress test to make sure you do not have significant coronary disease or other heart problems. The episode of atrial fibrillation that you experienced after consuming the wine is common in patients who drink more than their accustomed amount and it is related to the metabolites of alcohol.

Peter54: I am 54 years old and have occasional Arrhythmia, I am on Amiodarone, and I tried the new drug, can't remember the name and it made me very sluggish. I workout, spin class, 3-4 times a week, pretty intensely. What are my limitations in working out and can I effectively improve my heart to the point of reshaping by working out.?

Speaker_-_Dr__Bruce_Lindsay: Although I endorse exercise it is unlikely it will prevent atrial fibrillation in the future. In fact, endurance athletes have a higher incidence of atrial fibrillation.


Atrial Arrhythmia and Underlying Heart Disease: Hypertrophic Cardiomyopathy (HCM); Sarcoid

Tom_Kate: My 52 yr old Husband has been diagnosed with HCM, along with Atrial Fibrillation w/rapid ventricular response. In the past 4 wks he has been preparing for either a cardioversion or radio active ablation. (on multiple blood thinners; now within the 2-3 range) The question is some EKG's show flutter, most show fibrillation. It appears to be difficult to have our Dr's decide which procedure is best for my husband to proceed with. They seem to choose different procedures based on the findings of the most recent/current EKG. What is the best procedure that will have the more definitive successful outcome for him? Also, is it common for HCM patients to have Atrial Fibrillation/Flutter? We do not know anyone else with HCM...if treated properly, is it something that one can have a productive & long life with? Thank you in advance for your time and input

Speaker_-_Dr__Bruce_Lindsay: Atrial fibrillation and atrial flutter are common in patients with HCM. Sometimes it is associated with mitral regurgitation - the treatment of these problems depend on whether the HCM is obstructive or non-obstructive and whether Mitral Regurgitation is present.

The success rate for catheter ablation of atrial fibrillation and flutter is lower in patients with HCM but many patients are good candidates. In some cases we would recommend surgery and the Maze operation particularly if the patient has obstruction HCM or mitral regurgitation.

AnnaLee: What are A-Fib symptoms with sarcoid? What testing is done to confirm? How is it treated? What is the long-term outcome? How do I make an appointment with your facility for an overall evaluation of sarcoid?

Speaker_-_Dr__Bruce_Lindsay: The symptoms of atrial fibrillation associated with sarcoidosis are no different than atrial fib associated with other heart problems. However, sarcoidosis can cause a variety of symptoms which may make it difficult to determine whether the cause is the sarcoidosis or the atrial fibrillation.


Newest Treatments and Research for Atrial Fibrillation

charlie: Please discuss the latest in AFib treatments to eliminate the condition. Thanks

Speaker_-_Dr__Bruce_Lindsay: A huge amount of effort is being applied to the evaluation and treatment of atrial fibrillation. While there are some new medications none of them offer substantial advantages over the ones we have been using in recent years. Recent studies have shown that ablation of atrial fibrillation is more effective than medications in patients with paroxysmal atrial fibrillation. Many different technologies are being evaluated to improve the procedure.


Device Therapy

Londa: This is a question for Dr. Bruce Lindsay's web chat re: Atrial Fibrillation on 2/22/2010. Irregular heart rhythms run in my family. My question is about my 75 yr. old mother who suffers from congestive heart failure & tachyarrhythmia (1. dilated cardiomypathy 2. non-ischemic cardiomypathy 3. Left bundle branch block) Her ejection fraction 25%. She recently received a biventricular ICD where 3-leads were supposed to be connected. Due to some equipment issues (no patient limitations) there were only 2 leads hooked up. The placement of the coronary sinus lead was attempted but not completed because they didn't have the specialized equipment to place it, so only a dual-chamber defibrillator was done. The generator, however is a Bi-V ICD as they said they could add the 3rd wire at a later date. My question: How important is it that missing 3rd lead wire to her quality of life and or to her longevity? What % of congest. heart patients usually get a 3-lead device vs. a 2-lead device? I'm just trying to educate myself on if we should pursue getting the 3rd-wire put in at a later date. thanks for your comments

Speaker_-_Dr__Bruce_Lindsay: Approx. 2/3 of appropriately selected patients benefit from the third lead. If your mother meets the criteria for biventricular pacing, it would be worthwhile to have her evaluated at a more experienced center that may be able to implant the lead.


General Questions

Candy: Tell me about an irregular heart beat, Can people have an irregular heart beat and not have to take medicine if their heart beats some where between 76 and 90.

Speaker_-_Dr__Bruce_Lindsay: There are many different causes for an irregular heart beat ranging from premature ventricular or atrial beats to atrial fibrillation. Some problems are minor and do not require treatment whereas others are associated with more severe symptoms and do require treatment. Specific recommendations would depend on what you have.

Callie: I have an irregular heart beat. So far it has not reached a-Fib. I'm taking Diltiazem 240mg ER Cap ,one twice a day. The drug seems to be helping during the day, but everynight the irregular hearts beats start up and it's very nerve racking. I try to bear down to try and get my heart beat back in sink, but it doesn't seem to help everytime.

Speaker_-_Dr__Bruce_Lindsay: It is difficult to comment without knowing what irregularity you have experienced. This is generally document by using a holter or event monitor. Specific recommendations would depend on the results.

DRAJU: My Dad 70 yrs old, who has diabetes is diagnosed with irregular heart beat at hospital in chennai, south India. He is advised to take medication and for regular check up. Can this be treated without any intervening surgical procedure?. Is there any particular symptom that we need to be concerned about

Speaker_-_Dr__Bruce_Lindsay: There are many causes for an irregular heart beat. I cannot answer your question without knowing exactly what irregularity he has or whether he has coexisting heart disease.

Cleveland_Clinic_Host: I'm sorry to say that our time with Bruce Lindsay, MD is now over. Thank you again Dr. Lindsay for taking the time to answer our questions about Atrial Fibrillation.

Speaker_-_Dr__Bruce_Lindsay: I am sorry that I do have to see patients now. However, there have been many good questions. Thank you for having me today

Cleveland_Clinic_Host: A few of you have asked about Cleveland Clinic HVI outcomes. Please review our 2008 outcomes for the latest on success rates of our procedures and treatments at my.clevelandclinic.org/heart/disorders/vascular/default.aspx

Technology for webchats paid in part by an educational grant from AT&T Ohio and the AT&T Foundation (formerly SBC).

Reviewed: 02/10


This information is provided by Cleveland Clinic as a convenience service only and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition. Please remember that this information, in the absence of a visit with a health care professional, must be considered as an educational service only and is not designed to replace a physician's independent judgment about the appropriateness or risks of a procedure for a given patient. The views and opinions expressed by an individual in this forum are not necessarily the views of the Cleveland Clinic institution or other Cleveland Clinic physicians.


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