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Arrhythmias&Device Therapy (Drs Wilkoff&Saliba 08 16 13)

Monday, August 16, 2013 - Noon


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. Walid Saliba answer your questions about arrhythmias and device therapy.

More Information

Ventricular Tachycardia

fitness: Hi I have been diagnosed with ventricular tachycardia- had an ablation in May 2012 under total anesthetic- had to quit procedure due to complications with the anesthetic- did not work- I will not have another ablation done- two questions- will a pacemaker and or defibrillator work - also does the vt affect blood pressure- blood sugar and lightheadeness.

Bruce_Wilkoff,_MD: Unfortunately there isn’t enough detail here to be certain of the precise advantages and disadvantages of the next steps. Certainly there are times when a pacemaker and usually an implantable defibrillator with a pacemaker included are useful in patients with ventricular tachycardia. Ventricular tachycardia is one reason, among many, that can reduce a patient’s blood pressure and often will then cause lightheadedness. Blood sugar is not affected by ventricular tachycardia, but is another reason, if low, that people can feel lightheaded.

kcmministry: Hi, Ken here. I am 57 years old and have ventricular tachycardia. Two years ago I had a ICD put into my chest and place on Metoprolol. At that time 100 mgs a day now today after losing 55 lbs I am taking 25 mg a day. This year I've had my ICD shock me 3 times most recently last Saturday evening (8/10/13). Each time I've come close to passing out and then the ICD shocks me. My blood pressure is normal but my pulse is around 42-48. What can I do to get my pulse rate up and is the medication lowering my blood pressure when I'm near passing out? Thanks, Ken.

Bruce_Wilkoff,_MD: If you are feeling well with a heart rate of 42, there is no problem and no need to increase your heart rate unless the low heart rate seems to trigger your ventricular tachycardia (VT) episodes. It is possible that the Metoprolol is contributing to the slowing of your heart rate, but again without symptoms this is not an issue. The question is how to reduce the number of shocks you get and light-headed spells you get. Hopefully, your ICD has been set-up to use anti-tachycardia pacing (ATP). This is a painless way of stopping a VT. Often, some adjustments in the settings of the ATP are required to make this work. It is the VT that is lowering your blood pressure, not your medications.

chris9323: I have an ICD with remote monitoring implanted 2 months ago because of VT. Immediately after the implant, I had 3 valid shocks (150-180 bpm) within 24 hours and was re-admitted to hospital. The VTs were monomporhic sustained in nature and ATP did not help. Was given amiodarone (600mg daily for first week, 400mg for second and 200mg third week) and bisoprolol (10mg daily). For the past 5 weeks, I was on daily amiodarone of 100mg and 7.5mg of bisoprolol. I have not received any shock since (new ICD set to 176 bpm and remote monitoring was OK). My questions are:
a. As amiodarone has a half-life of 2 months, will VT recur with only 100mg of amiodarone now?
b. As amiodarone has significant side effect, how long should I be on it? Are there alternatives?
c. As VT is due to patches of scars in LV, should I consider EPS to rectify them? Any chance of VT recurring after ablation?
d. As scarring was due to LV Non-Compaction, should I consider LV reconstruction surgery? EF is 57% measured using echo.

(a) The goal of amiodarone therapy is to use the lowest dose that is effective. This is because side effects are often proportional to the dose. Depending on what your effective minimum dose requires, 100mg could be effective or not. Usually you will know in three months.
(b) You don’t have a lot of other choices and likely, you will be on amiodarone until either you have an intolerable side effect or it no longer works.
(c) & (d) Left ventricular non-compaction, is a challenging problem to treat and not easily treated with ablation or LV reconstructive surgery because it is diffuse process. There would be a significant chance of recurrence after either VT ablation or reconstructive surgery. Usually we take this situation one step at a time and only progress to more invasive strategies when absolutely required.

mumtaz923: History: 66 yrs male. Lifetime smoker. History of coronary disease, previous MI in 1992; in- stent restenosis in 1998 and 2005.

July , 2013: Admitted to emergency with chest tightness and radiation to arm and jaws. Fully awake and alert. Treated with Indocin, lidocaine, as well as covered with lidocaine to atrial fibrillation. EKG showed T-wave inversions in 2,3,and a VF. Elevated troponins associated with marked T-wave changes. Selective coronary aortography demonstrated no critical stenosis.

Diagnosis: Had Non ST- elevation myocardial infraction followed by sustained ventricular tachycardia, converted to atrial fibrillation.

1. What is the connection between MI and ventricular tachycardia / atrial fibrillation?
2.Why does this ONE time event make me a candidate for EP study?
3. What are the possible medical approaches for treatment ?
4. What are the probable outcomes for a treatment ?

(1) MI causes damage to the heart muscle and it is in this scar that abnormal heart rhythms are produced. In the ventricle, ventricular tachycardia (VT) and in the atrium, atrial fibrillation. By far, VT is the more important and dangerous heart rhythm. If somebody is not immediately present to do CPR and call for the emergency squad who will defibrillate the patient in less than 10 minutes, the patient will die.
(2) It is not the MI, but how much damage to the heart muscle was caused by the MI that makes you a candidate for an ICD much more than an EP study.
(3) Although medications are useful for atrial fibrillation (anti-coagulation and rhythm control medications) they are not effective in keeping people alive with VT. An ICD is the only tool that has helped us to prolong the life of patients at risk with VT. Other techniques such as VT ablation and other medications are used instead to reduce the frequency of the shocks that are sometimes needed to preserve the patient's life through the ICD.
(4) The prognosis of patients with VT is good from the standpoint of the arrhythmias, but the patient also needs to prevent further damage to the heart muscle due to a heart attack or heart failure.

Pacemakers and Internal Defibrillators (ICD)

AngelaM: Hi. My dad had a pacemaker - ICD placed last month and they were unable to put the third lead in. Will it still work? Should I go somewhere else to see if this can be placed? Can it still be placed in another procedure?

Bruce_Wilkoff,_MD: What you are talking about is the difference between an implantable defibrillator and an implantable defibrillator with cardiac resynchronization therapy also called biventricular pacing. Implantable defibrillators provide protection against sudden cardiac death due to ventricular tachycardia or fibrillation with pacing therapies (unfelt by the patient) or shock therapies (patient feels a big thump). This is life saving and extremely important, proven to help patients to live long. The Implantable defibrillator also includes a pacemaker to protect against slow heart rhythms. Although this is important for some patients it is usually just for backup for most patients who already have a good heart rate most of the time. The third lead provides for an impulse from a third location, this time in the left ventricle and coordinates with impulse in the right ventricle to coordinate the contraction of the heart to make it more effective.

Not everyone with an implantable defibrillator has a good reason for a third lead and some people have more or less symptoms or issues that make it a better or less good idea to have a third lead. The first issue would be to determine how important the third lead is in this situation, then the second would be to figure out why the attempt did not succeed. It is possible that someone else would be more successful depending on the situation. Lastly, if it is important and if another attempt through the veins to the heart seems unlikely to succeed then the third lead can be surgically placed on the outside of the heart and a similar and often better result can be achieved. We often see patients at Cleveland Clinic in this situation and are able to work through the evaluation and decide the next step.

SueKay: My husband has a defibrillator with a bad lead based on manufacturer notification. When we found this out, his doctor said it is very risky to remove the leads and did not want to extract it. Now, his doctor wants to remove the lead - I am not 100 percent sure what the change would be that would make this decision, but I am nervous about the original discussion about the riskiness. Can you talk about this procedure, the risks involved and if he should have his local doctor do this or if we should look at other places. I like his doctor but nervous about this.

Bruce_Wilkoff,_MD: There are two issues here. The first is what is the problem with the lead that you have - and the second is about lead extraction. Unfortunately anything manufactured will eventually wear out. Some leads have been less reliable than others, but even the least reliable lead still functions for very long periods of time in the vast majority of patients. So depending on the particular lead, whether the lead is still working well or not, the patient’s overall condition and age and a number of other issues the decision is made to either keep using this lead, wait until the next battery change to make a decision, just add another lead or to extract and replace the lead.

I have been doing transvenous lead extraction at Cleveland Clinic since 1988 and we have extracted over 5000 leads since 1996 in over 3000 patients. Using the appropriate tools, with the appropriately trained physicians, nurses, anesthesia and surgeons this can be done effectively and usually safely. However all procedures have potential complications. In this case there is about a 2% risk of internal bleeding which would require opening of the chest to sew up the hole in the vein or heart to rescue the patient from death. About 1% of the time this could be fatal. Understanding the reasons for lead extraction and the other options are important and each decision is individualized with the patient and their family. The other issue is that the implantable defibrillator is protection for the patient’s life that needs to be dependable. So the first priority is to provide the best protection possible. We like to think that we can provide protection and that there is no risk, but that is never really the choice. We sit down and work this out with the patient and their family.

indie1962: It looks like I may need to switch from a one-lead to a two-lead AICD. What complications should I be aware of before switching? Is it appropriate to do this before the battery is low? Right now it says I have about 3 years left. Also, I found out after the implementation that the lead I have now is one of the Riata's on a watch list. How do avoid this happening again?

Bruce_Wilkoff,_MD: Most patients, do quite well with only a single lead defibrillator and only, patients that have symptoms from a low heart rate and require pacing require the addition of an atrial lead with any urgency. Most patients should wait for surgery if at all possible, until there is a need for a battery change or a lead change. Your Riata lead may actually last as long or longer than leads not on a watch list. Usually, if a lead like the Riata is currently functioning well then I would wait until the battery needs to be replaced before I would change any of the leads. The Riata lead was not on a watch list when it was implanted and neither will your next lead be on a watch list, but sometimes, leads are later found not to be as reliable. Most of these leads will continue to work well even though they have a slightly higher risk of failure. Unfortunately we do not know the future before it occurs.

collers8: I have Hypertrophic Cardiomyopathy (HCM) and had an ICD inserted to protect against Ventricular Tachycardia. Due to the beta blockers that I take to control my HCM, and a genetic disposition, my resting heart rate is in the low 40's. For the first three years my pacemaker was set at 40 BPM, but my electrophysiologist recently reset it to 60 BPM. Generally I feel much better, energy wise, at 60 BPM. Unfortunately I seem to have more chest pain at the higher setting, but the energy trade off is worth it. My question is why is it thought to be better to keep patients at their natural heart rate rather than being paced? Is it detrimental to the progression of my disease to be paced higher than my natural rate? Thank you for your time and consideration to this concern.

Bruce_Wilkoff,_MD: Patients with HCM are different than most patients who require ICD therapy. Patients with HCM have excellent to over active heart function while most patients who require an ICD have poor heart function - this is measured by an ejection fraction (EF). Normal EF is 55% or higher and poor EF is usually under 35%. Pacing, can reduce the ejection fraction. It doesn’t happen in everybody and most patients, preserve the ejection fraction. In a patient with HCM, reducing the EF is considered a good thing while a person with a poor EF it is bad. At one point, it was popular to specifically place pacemakers to force pacing in HCM patients. This was only partially effective and is now only a good side effect of ICD therapy in patients when they get a defibrillator.

Shimmer: My 90 year-old mother in law's cardiologist recommended a pacemaker for heart arrhythmia. She reports no symptoms, but the doctor feels that medical treatment is reaching the end of its effectiveness to treat her blood pressure and Afib. She doesn't want the pacemaker. Can you offer any insights that would be useful for all of us to consider?

Bruce_Wilkoff,_MD: In somebody who is 90 years old the symptoms of the patient are primary driver of what decisions should be made. There are only two goals in medicine: 1) to make person live longer and 2) help them feel better. If a person is already without symptoms, unless the therapy is designed to help the patient live longer, it is usually ill-advised. At 90 years you need to ask what the goal of the pacemaker would be.

PVC44: Hello, I had a pacemaker inserted 4 years ago at age 42 due to syncope caused by sudden drops in heart rate and blood pressure. In the past few years I had 2 ablations for pvcs and non-sustained v-tach which were not completely successful. My questions are; Is there a pacemaker that responds to the sudden drops in blood pressure? Also, Is there a pacemaker that is safe to use for MRI scans? I've had too many ct scans over the years plus the ablations. Thanks.

Bruce_Wilkoff,_MD: There are many reasons that people can have fainting spells (syncope), but they all involve low blood pressure to the brain. Some of these episodes are related to the heart rate going too slow, some, from the heart rate going to fast, and some, due to poor regulation of blood pressure. Pacemakers treat heart rhythms that are too slow and implantable defibrillators protect against slow and some fast heart rhythms, but poor regulation of the blood pressure when not associated with slow or fast heart rhythm, is not treated with a pacemaker or ICD. This kind of syncope is usually called vasovagal syncope, but even this type, is also associated with slow heart rhythms. Pacemakers help with this situation, but just to the degree to the low blood pressure is related to the slow heart rate.

There are specific pacemakers, but not ICDs that are designed to be able to withstand MRI scans. If one of these pacemakers and leads are implanted, then all non-MRI safe pacemakers or leads need to be removed.

mumtaz923: I had sent some questions previously with my history, diagnosis and some questions. The follow up questions are:
1. How do you determine whether a patient needs to be only medication; Ablation ; a pace maker or a defibrillator?
2. Do you typically decide what to do during the EP study, while the patient is in the surgical room?
3. What are the pros and cons of each of the treatments under 1.

(1) MI causes damage to the heart muscle and it is in this scar that abnormal heart rhythms are produced. In the ventricle, ventricular tachycardia (VT) and in the atrium, atrial fibrillation. By far, VT is the more important and dangerous heart rhythm. If somebody is not immediately present to do CPR and call for the emergency squad who will defibrillate the patient in less than 10 minutes, the patient will die.
(2) It is not the MI, but how much damage to the heart muscle was caused by the MI that makes you a candidate for an ICD much more than an EP study.
(3) Although medications are useful for atrial fibrillation (anti-coagulation and rhythm control medications) they are not effective in keeping people alive with VT. An ICD is the only tool that has helped us to prolong the life of patients at risk with VT. Other techniques such as VT ablation and other medications are used instead to reduce the frequency of the shocks that are sometimes needed to preserve the patient's life through the ICD.
(4) The prognosis of patients with VT is good from the standpoint of the arrhythmias, but the patient also needs to prevent further damage to the heart muscle due to a heart attack or heart failure.

Atrial Fibrillation Ablation

cowbaby50: I had a second ablation four weeks ago. I went back into A-fib a week ago and have been in it ever since. Does this mean that the ablation didn't work? Would more ablations be helpful or are there other treatment/management options available?

Walid_Saliba,_MD: It is too soon to make a final decision. It is still possible that the ablation worked - you will need to re-evaluated at 3 months following the procedure and figure out how much atrial fibrillation you are having. You obviously will need to be put back into normal rhythm sometimes over the next 4 weeks to see if atrial fib will re-occur subsequently.

RobertR: I have AFIB, have had two ablations, with limited success. Last was effective in establishing a regular beat for about two years, then failed. My heart is currently fibrillating much of the time. My cardiologist tells me that there has been some slight loss of pumping function. I would like to get my heart back in rhythm permanently. Can you help? What is likelihood of success? Can you make it permanent?

Walid_Saliba,_MD: If this is your first re-occurrence in 2 years I would suggest a cardioversion and see how long it will last. Unfortunately - permanent success is not available - what we can do is maximize the chance of staying in normal rhythm with either medications, ablation or both.

RobertR: How dangerous is an ablation to get my heart back in rhythm-from AFIB condition?

Walid_Saliba,_MD: The risk from an ablation for afib is around 3% and includes perforation requiring surgery; stroke; pulmonary vein stenosis; and bleeding. At Cleveland Clinic we are very well equipped and have adequate back up to deal with these problems should they happen.

CHT: Questions and answers are below:

Walid_Saliba,_MD: To answer your questions:

  • What determines when I need the Ablation? Symptoms.
  • What is the success rate for Ablation? 50-85% depending on your clinical background.
  • If I wait to have Ablation what are the risk? The longer you are in afib the harder it is to maintain normal rhythm.
  • After the Ablation will I be free of AFib? There is no cure to afib - the goal is for you to have much less afib to a level that is satisfactory to you.
  • What are the side effects of Ablation? Risks are noted previously
  • What is the Maze procedure? Maze procedure is a surgical procedure performed by surgeons that is similar to the ablation procedure that we do from the inside using catheters.

Bristolpainter: Thank-you for taking my question. I am a very active 58yr old female who plays a lot of competitive sports. I have decided with my Dr. that an ablation is now worth trying for my paroxysmal AF of 2 years. I have no heart disease or other chronic condition. Is there a clear benefit of RF techniques over cryo-ablation, or vice versa, in terms of efficacy long term, safety (does 1 use more or less radiation etc.), or risk factors. After either procedure, how long should I wait before playing hard racquetball again? Thank-you!

Walid_Saliba,_MD: Because you have paroxysmal afib either approach is reasonable and depends on the expertise of the operator. We have had much more experience with RF ablation and have longer track records and follow up. You can play racquetball after 10 days of the procedure.

rbere: Dear doctors, I’m Rien from the Netherlands , man age 60. Ten years ago I was diagnosed with an overactive thyroid gland. I was treated for that. At the same time I was diagnosed with chronic atrial fibrillation. I had cardioversion (2 times) which did not work. The last 8 years I’m on a daily dose of digoxin/verapamil/irbertisan/ nebivolol/marcoumar/euthyrox/metformin. Due to side-effects such as psoriasis a.o. my cardiologist suggested an ablation. He put me on the waiting list (up to 6 months. over here). He told me: success rate 30% first time, 70% second time. The last 6 months I was on a sabbatical. I was overworked and the doctor gave me an antidepressants. Cipramil. To my surprise it also slowed down my afib. Now my question is: Will I have the ablation (it will be in October) or just go on with my medication? 30% success, I have many doubts. Rien.

Walid_Saliba,_MD: The main reason to have afib ablation is to decrease or alleviate symptoms. If you are doing well in afib and your heart rate is well controlled, then it is reasonable not to consider the ablation. However, there is a chance that you might feel better in normal rhythm - that is up for you to decide.

jstrap: I am 70 yo male. Mitral valve repair 1998 (Dr. Cosgrove) without Maze or ablation. Paroxysmal afib/flutter since 2010. Present meds: coumadin, multaq 400 bid, toprol 50 bid. Pacemaker needed two months after RF ablation attempt for at. flutter May 2011 when developed pulse of 30. Pacemaker printout shows afib/flutter of 150-260bpm 30% of time but no Sx, pulse 65-75, refused amiodarone. Despite no symptoms cardiologist suggests ablation possibly FIRM ablation since the heart will become less efficient over time.

Walid_Saliba,_MD: If there are no symptoms, an ablation is not required but it is possible that you may feel better if you were in normal rhythm all of the time. I am not sure that there is a problem with the heart becoming less efficient but it is possible that you may progress into having atrial fib all the time at which point you may develop symptoms. FIRM ablation is a new modality that is yet to be proven better than conventional ablation techniques.

bethany: I had a mitral valve replaced on October 30, 2012 at Cleveland Clinic. Sometime in November 2012, my Afib started. In February 2013, I had a cardioversion and my heart rate became normal. However, after one (1) month I went back to Afib again. I went to a arrhythmia specialist and was advised, I will be put on amiodarone and then try another cardioversion. If successful I will still continue the amiodarone and not known for how long. I decided not to take the amiodarone and just live with my afib. Are there other options or am I better off living with the afib. I have been taking Warfarin since my Afib in November 2012.

Walid_Saliba,_MD: There are options including other medications than amiodarone as well as the option of ablation of atrial fibrillation. It all depends on how much frustrated and symptomatic you are with this rhythm. We have vast experience in ablating atrial fib in patients following mitral valve surgery, as this requires a specific skill set and mapping techniques.

OnyxB: If you have a catheter ablation do you still have to take blood thinners?

Walid_Saliba,_MD: If your risk of stroke is high enough to be on blood thinners on the procedure, then chances are that you will have to continue on such therapy. I have been diagnosed with AF but also have significant and rather lengthy episodes of V tach confirmed via Holter Monitor. I also have a long history of hypertension which is more controlled at the moment. I am taking Benicar HCT 40/12.5mg tab q day and Sotalol 120 mg tabs q12hrs and enteric coated 81mg ASA q day. I am unable to take Coumadin since I have diverticular disease and had a slow intestinal bleed while taking coumadin, became severely anemic (HGB of 7.4), went into CHF and acute AF with heart rate >180 and was hospitalized in February for several days. In the process I had a cardiac cath with no blockages identified. I still experience some heart beat irregularities on a daily basis and am strongly considering ablation. Otherwise, I am in good health. What do you suggest?

Walid_Saliba,_MD: An ablation would be a good option but you will need to be on anticoagulation of a period of at least 2 - 3 months. Eventually, you might be a candidate also for a left atrial appendage occlusion device. Alternatively, if you have significant symptoms with atrial fibrillation you might also consider the option of a surgical maze with left atrial appendage excision, which would preclude taking anticoagulation if successful.

aliceinOwego: How does one know when it may be time for a surgical intervention for A-Fib? I think I am currently well-controlled using Cardizem twice daily (15 mg) since I am not aware of any symptoms. Cardiologist keeps pushing me to have an ablation saying that I am so young (67 years old).

Walid_Saliba,_MD: It depends on how much afib you are having and how much afib is causing you to have symptoms. Furthermore, you have not tried any anti-arrhythmic medication and that may be the first step before considering an ablation.

Kathi: Hi, I am 60 years. I have been in 24/7 Afib for 1 1/2 years. I see my cardio doctor. I also see an Electrophysiologist . I take these meds to help me. Amiodarone, 200 mg, 1x daily.. Asprin, 325 mg, 1x bedtime.. Clonodine 0.2 mg 2x daily, a.m. & pm; Cymbalta, 60 mg, 1x bedtime.. Gemfibrozil, 600 mg, 2x b4 meals.. Glimepiride, 2mg, 1x @breakfast.. Losartan 50 mg, 3x am, lunch & @ bedtime.. Metformin 1000 mg 2x lunch & dinner.. warfarin 5 mg Wed, Sat, Sun, Mon, 2.5 mg on Tues & Fri.. Flecainide 12.5 1x. My INR as of 8-14 is 3.3. My BP 161/98. Cardio Version & TEE 5-17-13 Cardio Ablation & TEE 6-17-13. Currently back in 24/7 AFIB reason: too many electrical pathways very near my esophagus. Scheduled for another Cardio Version & TEE in 2 weeks. DR. advises me if this doesn't work, I will need a Mini Maze Surgical Procedure. Would you be able to do this Maze?

Walid_Saliba,_MD: I would suggest another opinion for a possible redo ablation before going for a maze procedure. At Cleveland Clinic, we have had extensive experience with ablation for long term persistent afib as well as redo ablations done elsewhere.

Kathi: Hi I just read Dr. Saliba's answer to my question. The reason my Dr. is suggesting a maze is because when he did my ablation, he Could Not ablate the pathways that were Very Close to my Esophagus so not to damage the esophagus. So with that said, why would he do another ablation and have the same situation? How would you, Dr Saliba achieve a successful ablation so as not to damage my esophagus? Thank you.

Walid_Saliba,_MD: We do monitor closely the temperature in the esophagus and can go around ablating specific areas that are close to the esophagus.

Bonniepilon: I am newly diagnosed with lone afib. I have had 4 episodes in 12 months. I self convert within 4 hours after taking cardiazem. Am I a candidate for ablation? I do also take 325mt ASA per day.

Walid_Saliba,_MD: Yes you are a candidate for an ablation. But, only if these 4 episodes in one year bother you.

Atrial Flutter

beatright: I'm a 68 female who just had a successful ablation that corrected my Afib and a roof flutter, but found I also had an atrial flutter. During the ablation attempt to correct this atrial flutter it would stop and restart within 10 to 15 minutes. The doctor identified the area which may require a 2nd ablation (the first ablation attempt had gone to the point where additional ablating could have caused a problem) if the next EKG indicates the flutter is still there. It's been 2 months since the ablation and we hope the scarring (healing) may stop the flutter. If a 2nd ablation is necessary, but doesn't work, the doctor said I may have an external signal problem on the outside surface of my heart which requires special expertise and operating facilities. It sounds like a much more difficult procedure? Could you please shed some additional information on this external procedure for me. Thanks.

Walid_Saliba,_MD: Most of the flutter can be stopped with ablation from the inside. During your initial ablation, there might have been significant swelling that can get in the way of performing the ablation. I would definitely suggest another ablation from the inside as an external procedure has limited access to areas of the atrium. The alternative would be a surgical approach with not necessarily a better outcome. Call us - we would be happy to see you.

Gary Waters: I had a pericardium stripping over the Christmas holidays by Dr. Johnston and everything went great. I have been given a 30 day supply of amiodarone. 4 weeks after the final dose, I developed a flutter and was placed on diltiazem and coumadin. I had a cardioversion. Month later, I wore a 24 hr. monitor which showed the flutter had returned. I am scheduled for consultation the end of this month for an ablation. If an ablation is performed, what are the chances that it will correct the flutter? If it does not, is the next step a pace-maker or difference medicine? I am very active, if the pace-maker is the answer, what type of life style can I expect?

Walid_Saliba,_MD: An ablation has a high chance of getting rid of the flutter. A pacemaker is less likely to be of benefit in these situations unless you have a very slow heart rate when in normal rhythm.

Supraventricular Tachycardia

SantaBarbara: I have SVT and have had a couple ablations both to no avail. I continue to have symptoms with fast heart rate. Is it worth it to try again? Is it possible to be eventually cured?

Walid_Saliba,_MD: It is worth trying again. The success depends on the mechanism and the nature of your SVT. If you can send us some tracing of your arrhythmia and the report of your last ablation we would be happy to give you a better estimate. Please contact us for help.

Heart Block

nusystem1: Please explain 2:1 heart block.

Bruce_Wilkoff,_MD: The heart has upper chambers called atria and lower chambers called ventricles. There is an electrical connection between the atrium and ventricle. Normally, the atrium will direct the heart to beat, but that message has to travel over the electrical connection to the ventricles for the heart to pump the blood to the rest of the body. When somebody has heart block, there is some interruption of that connection. 2:1 atrial ventricular (AV) block is a type of second degree AV block and says that there are two atrial beats for every one ventricular beat. So every other beat blocks the electrical connection to the ventricle.

nusystem1: What treatment is generally used when a 2:1 heartblock is evident? How does that heartblock relate to mobitz 1 or mobitz 2. Is a pacemaker necessary? Thank you.

Bruce_Wilkoff,_MD: Pacemakers are necessary when there are slow heart rhythms and symptoms from the slow heart rhythm if the patient only has 2:1 heart block when sleeping, or resting, they are likely not having any symptoms. When the patient stands up, more likely, their heart will start to beat 1:1 (atrium to ventricle). When this happens most likely the patient has Mobitz I 2:1 AV block and this is benign. When the heart rate does not improve with activity, then it very well may involve some scarring of the heart and may indicate the need for pacemaker therapy.

Multiple arrhythmias

LaFina: I am a surgical patient of mitral valve, tricuspid valve and baffle by Dr. Sabik, Dec. of 2011. I have a long complicated history of congenital heart disease and very early corrections in 1957/62 by Denton A. Cooley at Texas Children's of Tetrology of Fallot. I have a scar in my r. ventricle and surgery on my rvot. I had a cardiac arrest in 2010 which pre-dated all the subsequent surgeries.

My question is: I am still suffering with both v-fib and a-fib arrthythmias. It is uncomfortable. I have had 2 defibrillator engagements over the last 6 months, which I know is not often. When I walk I cannot go far with out having to stop. Recently I feel badly at meal time. Pharmacy: Dig 1/2 .125 qd,lasix20qd,lisinopril 2.5qd,synthroid75mcg qd,xarelto15mgqd,carvedilol 3.125 2xdaily,multaq400 2xdaily. My doctor here is reluctant to change meds because of my EF. Any ideas on how to decrease the arrthythmias is welcome. Thank you!

Walid_Saliba,_MD: I think it would be best for us to see you, evaluate your rhythm that is triggering the ICD firing and make appropriate recommendations. In some situations we are able to do ablation for your ventricular arrhythmia and for your atrial fibrillation but these are usually not straight forward.

General Arrhythmia

AlmostBlackOut: Over 20 years, periodically, heart races (flutter) to over 200+ bpm (tracked by halter monitor yrs ago) light headedness then bright light feeling like I am going to faint, but don’t. Takes breath away. Randomly occurs, not induced by activities or diet. Happens at home walking through house, sitting, driving car, once every few months. Cardiologist (while pregnant 17yrs ago) told me to cough when I feel it coming on. The cough helps put it back into the rhythm. I haven’t gone further medically for fear of surgery. I don’t know if I am doing the right thing by that or not. What if I do actually completely black out? what will happen next? what is the best thing for me? I practice a holistic lifestyle without medicines, eat healthy and walk for exercise. I am 49.

Walid_Saliba,_MD: It all depends on the nature of the abnormal rhythm you have. If you can send us tracings of your holter monitor - we can provide you a better answer for your question.

hilo323: What causes arrhythmias in Sarcoidosis?

Walid_Saliba,_MD: Residual scars left over from the inflammation of sarcoidosis create circuits for the arrhythmia.

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.

Reviewed: 08/13

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