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Arrhythmias - Dr Saliba

Arrhythmias - Atrial Fibrillation and More!

November 20, 2009

Dr. Walid Saliba
Staff Cardiologist
Cleveland Clinic Robert and Suzanne Tomsich Department of Cardiovascular Medicine


There are many different types of cardiac arrhythmias; atrial fibrillation is the most common, affecting about 1% of the population, mostly in people over 50 years of age. Many arrhythmias are benign and do not require any specific treatment. However there are some arrhythmias that need to be controlled with the use of medications, electric Cardioversion, implantable devices such as defibrillators or pacemakers and catheter ablation. Dr. Saliba, a Cleveland Clinic cardiologist who provides answers to your questions about the different types of arrhythmias and their available treatment options.

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Cleveland_Clinic_Host: Welcome to our Online Health Chat with cardiologist Walid Saliba, MD and sorry for the slight delay. We are thrilled to have him here today for this chat. Dr. Saliba, thank you for joining us. Let’s begin with the questions.

Atrial Fibrillation

formymom: With atrial fib, if you start having TIAs, can you assume it's caused by the heart condition? My mom has a TIA about every 3 days. Is it a matter of waiting for the new medication to take affect for these TIAs to stop?

Speaker_-_Dr__Saliba: Most probably atrial fibrillation is the cause if not the cause also an exacerbating factor of the TIAs every 3 days. She should be on blood thinning medication by mouth and while waiting for the medication to take effect she should be on blood thinning intravenously if in fact her episodes are in fact TIAs.

carl: I have been in a-fib for 14 months. I am on medication. It has recently been recommended that I get shocked to try and return to a normal heart beat. My heart is pumping at 40%. I am fatigued most of the time. Two years ago I had irregular heart beat but no other issues until I was given toprol to help the irregular beat. It nearly stopped my heart. I need a second opinion.

Speaker_-_Dr__Saliba: Since there has been no prior attempt to putting you into normal rhythm - you at least deserve one attempt for restoring normal sinus rhythm. The aggressiveness of the therapy thereafter will depend on several factors including how much better you feel while in normal rhythm and how much improvement in your heart function occurs while you are in normal heart rhythm. If you don't have any other significant medical problems, an aggressive approach in keeping you in normal rhythm is reasonable. We can help with that.

llew10: I am on Dig, lipitor, coumadin and diltiazem. I am in atrial fibrillation. I had cardioversion tried twice and both time reverted back to atrial fibrillation. I tried a beta blocker but was too tired. What are my other options? I am 65 year old woman.

Speaker_-_Dr__Saliba: You are still at the beginning of the road. Options include antiarrhythmic drug therapy in conjunction with a cardioversion; as well as the consideration for an afib ablation if you do not respond or can not tolerate antiarrhythmic therapy. The option of continuing the way you are is also reasonable if you do not have any symptoms at all. But I would suggest at least a trial of restoring normal rhythm.

quiltingmom: How serious is atrial fib when occurring 2-3 times weekly with heart rate 190-200?

Speaker_-_Dr__Saliba: The fact that the heart rate is significantly elevated will lead to symptoms of shortness of breath and fatigue. If left untreated may lead to weakening of the heart muscle. Therefore it is very important to control the heart rate in response to atrial fibrillation.

Atrial Fibrillation – Medical Management

mistero: Hello, can you comment on the long-term effectiveness of medicine, such as Rythmol SR for control of a-fib? In particular, if the med is working quite well now, in conjunction with two ablations, is there a reason to believe that three years from now it wont still be effective?

Speaker_-_Dr__Saliba: The success rate of Rhythmol to control afib is about 60 percent at 6 months prior to an ablation. We don't have much information about its effectiveness after the ablation mostly due to the variability in the ablation procedure. However, since the goal of any intervention be it medication or ablation is to decrease the burden of afib, I would suggest that you continue on such medical therapy unless you have side effects of the medications. One option would be to try at some point to discontinue the medication and if you have recurrence of atrial fibrillation you will have the choice to either restart the medication or go for another ablation.

mistero: Hello, I am seeing information regarding magnesium to reduce a-fib. The Blaylock report states such. Any comment??

Speaker_-_Dr__Saliba: We know that very low magnesium level can facilitate the occurrence of atrial fibrillation. However supplemental magnesium intake in a person with normal magnesium levels does not necessarily prevent afib.

j105sailor: A second question related to my earlier one. Since the ablation procedure, I have seen the onset of frequent PVCs (1 in every 4 to 5 heart beats). I notice when I eat a meal rich in garlic that the PVCs diminish or subside. Is there a medical explanation of this experience? Given the success of the garlic, is there any substance other than garlic that can be used to reduce the PVCs. My family has begun to refer to me by a number of unflattering names starting with garlic. Thank you.

Speaker_-_Dr__Saliba: I don't have any clear explanation but you might be up to a new medication that we will tell you if it works - keep up with the garlic! Why not?

Atrial Fibrillation – Medical Management: Coumadin

michele_45: What is the goal INR for someone on coumadin with atrial fibrillation?

Speaker_-_Dr__Saliba: The INR should be:

  • 2 - 3 in the absence of mitral valve disease (stenosis or replacement).
  • 2.5 - 3.5 if these are present.

Arizona50: When would it be safe to discontinue warfarin therapy?

Speaker_-_Dr__Saliba: It all depends as to how many risk factors for stroke you have as well as the possibility of occurrence of silent atrial fibrillation. This should be discussed with your doctor thoroughly before discontinuation of such therapy.

sajasaj: 81 year old male in controlled rate of atrial fibrillation for years. typically a few heart beats at a regular pace followed by a delayed beat. Basically asymptomatic. 60 bpm typical. Is it necessary to go on blood thinner? I've avoided them in past.

Speaker_-_Dr__Saliba: In view of your age, there is an associated risk of stroke in the setting of atrial fibrillation and in the absence of any bleeding tendencies it is strongly recommended to go on a blood thinner to reduce the risk of stroke.

sajasaj: 81 year old male with previous question about necessity of blood thinner for afib. In addition, I have severe MVR and TVR but basically asymptomatic. Am active physically, hiking 45 minutes each day, do weights and stretching regularly. In view of this additional info, any further comments?

Speaker_-_Dr__Saliba: You still need to be on blood thinner if you are in atrial fibrillation.

Atrial Fibrillation Treatment: Ablation

Arugunta: I am aged 37 and had a recent ablation procedure done for Atrial flutter (2 weeks ago). During the ablation procedure AVNODE was touched by mistake and I had a 3rd degree block for 11 seconds during procedure. Immediately after surgery AV node returned back to normal for 10 hrs and then went into a complete block. I had junctional rhythm at 62 BPM with no symptoms and complete heart block post surgery. To be on the safer side pacemaker had been implanted for me. I am a bit mentally stressed as what complications I may have down the line by having a pacemaker other than being careful with electro magnetic devices. Are there any chances of my AV node recovery? Is there anything you can help in improving my current medical condition?

Speaker_-_Dr__Saliba: It is less likely that you will have significant AF node conduction recovery. If you don't have any symptoms at this particular time, it would be best to follow a conservative route and follow you to check for any recurrence of atrial fibrillation or flutter.

I would say also - there is also recent data to suggest that patients with complete heart block who require pacing might be better off down the road with biventricular pacing rather than right ventricular pacing alone.

formymom: If you've been diagnosed w/atrial fib, how is it determined if you need a pacemaker or fibrillator.

Speaker_-_Dr__Saliba: The indication for a pacemaker is slow heart beat that is associated with symptoms. Sometimes medications that we give to treat atrial fib can worsen slowing of the heartbeat and the pacemaker would need to be placed in this situation.

On the other hand the indication for defibrillator is really not for atrial fibrillation - it is related to a specific weakness in the pumping chamber of the heart muscle. Should this be the case, a consultation with an electrophysiologist should be obtained to evaluate the need for such therapy.

Arizona50: I have had 2 PV ablations, the last one at the CC 18 months ago. My local doctor is suggesting we try to go without antiarrhythmic drugs. So far so good at 2 weeks. Statistically can I expect this to last? I have been working with proximal afib for >10 years now. Age 57.

Speaker_-_Dr__Saliba: Statistically this is good news. And - a conservative follow up without medications is suggested. However - our data and data from others have suggested that there is a late recurrence of about 8 percent at 4 to 5 years following the ablation. You will just have to be attuned to recurrence of symptoms but hopefully things will be ok.

j105sailor: I underwent a successful PVI procedure @ CC approximately six months ago. Since that time, I have had no afib incidents. However, my resting heart rate has increased approximately 15 bpm and I have seen the onset of frequent PVCs. Can you help me understand the cause for these changes and what actions can be taken to correct them? Thank you.

Speaker_-_Dr__Saliba: It is not unusual to have an increase in resting Heart Rate after afib ablation. This is most probably related to a transient injury in the nerve that controls the rate of the sinus node. Usually it might take between 1 year and 18 mos after the ablation for things to go back to baseline. Similarly we have seen some PVC emergence following the ablation that is also probably related to interfering with the innervation of the heart during the ablation. If symptomatic these PVCs can be ablated as well.

j105sailor: Prior to my ablation procedure I had a consistent ejection fraction in the 48% - 50%. Since the procedure, it has dropped to the mid 30s. What would account for this reduction and what would you recommend to help return to the previous level? Thank you.

Speaker_-_Dr__Saliba: It is very unlikely that the afib ablation has contributed to the decrease in your ejection fraction. Sometimes there is significant variability in the reading of ejection fraction - especially when person is in atrial fib. However, further workup needs to be done to rule out other causes of the decreased EF in your situation such as coronary disease or other cardiomyopathies.

mistero: How many ablations can normally be considered to be the Maximum; does PV stenosis become more common with increased no. of ablations?

Speaker_-_Dr__Saliba: We have performed as many as 5 ablations on the same patient. The average is around 2 for patients with persistent atrial fibrillation.

The occurrence of PV stenosis relates to the technique used and the ablation location rather than the number of ablations.

sajasaj: Is ablation likely to succeed in correcting controlled rate of afib for one who has been in it for many years?

Speaker_-_Dr__Saliba: The longer the duration of afib the less the success rate of the ablation. This can vary from 50 - 60 percent.

F94jL63: Would an ablation procedure that successfully resolved A-Fib preclude other rhythm anomalies? How common are post-PVAI ectopic symptoms?

Speaker_-_Dr__Saliba: Atrial fibrillation ablation gets rid of atrial fib alone. It is possible that after the ablation you will still have some forms of atrial flutter or premature beats coming from the atrium or the ventricle as well as ventricular arrhythmia if you are prone to them otherwise.

vktion: I am a 58 yr old male who had triple bypass surgery Jan of 2000. My question is the scarring that ablation does and what that that means with future heart attacks?

Speaker_-_Dr__Saliba: The scarring that results from atrial fibrillation ablation is in the left atrium and does not carry any bearing that we know of on future heart attacks. Heart attacks usually cause scar in a different chamber - the left ventricle and this leads to a decrease in the function of the heart as a pump. It is less likely that scarring in the left atrium is big enough to cause decrease in any significant pumping ability from that chamber. These are two different things.

DRJ110145: Had a pulmonary vein ablation in June, and believe it was successful and am not on any medication. From time to time I get chest sensations that lead to anxiety. Is it common that post ablation patients experience anxiety and malaise? It is very discomforting.

Speaker_-_Dr__Saliba: It would be important to rule out the possibility of transient arrhythmia with a monitor that would explain some of the symptoms you are having. If negative then further evaluation for other medical conditions needs to be performed.

F94jL63: Re: Post-ablation flutter / premature beats: Do these subside over time or are medications / further ablations recommended?

Speaker_-_Dr__Saliba: If it is within the first 2 to 3 months following an ablation, it is recommended to wait as this might subside. However, if it has been longer than 3 months, then the treatment depends on the associated symptoms and can include either suppressive antiarrhythmic medications or repeat ablation.

Ablation: Technique

vktion: More and more hospitals are doing ablations. Most of them now using robotics. In your opinion which is more effective, robotics or manually?

Speaker_-_Dr__Saliba: In our hands manual ablation is still more effective - we do have both robotic systems in our institution and we use them quite extensively but not necessarily leading to a more effective outcome.

jenny: Do you use the stereotaxix system to do pulmonary vein ablation? If no - what types of ablation do you do?

Speaker_-_Dr__Saliba: We do have the stereotaxis system available and use it for ablation. However, the majority of our ablation is done manually.

mistero: How common is it to combine an ablation procedure with a "mini-maze" procedure? Does the CC do this?

Speaker_-_Dr__Saliba: This is not a common procedure. As usually the success rate from either procedure done alone is adequate. The Cleveland Clinic does not use this approach.

CLSTAR: How dangerous is it to go thru the upper chambers of the heart to do an ablation on both sides?

Speaker_-_Dr__Saliba: The risk of having a major problem from catheter navigation from going into those chambers is less than 1 percent.

sajasaj: What size incision required for doing manual ablation?

Speaker_-_Dr__Saliba: No incision. 4 catheters are inserted through your groin via needle sticks.

Atrial Fibrillation and Valve Disease

Anita: Two questions about arrhythmia problems 1 - new treatment for atrial fib. 2 - how to manage with atrial fib if you have a prosthetic valve?

Speaker_-_Dr__Saliba: There are several treatments for atrial fibrillation. This includes suppressive medical therapy with medications; ablation; surgical ablation The treatment depends on the burden of atrial fib you are having, the associated symptoms, and how much you want to get rid of it.

Most importantly - for question #2 - if you have a prosthetic valve hopefully you are on anticoagulation to decrease your risk of stroke. Even if you have a prosthetic valve, cardiac ablation can be considered if you have already failed anti-arrhythmic drug therapy.

sajasaj: If I undergo robotic procedure to correct mvr and tvr would it be advisable to try to correct the afib at the same time or rather do it manually? Thank you.

Speaker_-_Dr__Saliba: Same time - if the surgeon can do it.

carolyn: I have atrial fibrillation and now need mitral valve surgery. Can the maze procedure cure my atrial fibrillation? Will I still need coumadin if they can repair the valve?

Speaker_-_Dr__Saliba: Yes the maze procedure can cure your atrial fibrillation and it is recommended to do it in conjunction with your mitral valve surgery. The need to be on coumadin is determined by the success of the afib treatment as well as other risk factors including the presence of hypertension, diabetes, and heart function.

PFO and Atrial Fibrillation

denalidon: I am a 65 year old male who has had several bouts (4) of paroxysmal A Fib over the last 5 years. I have converted each time via medication (Rythmol) or naturally. I as also have a PFO and it probably is causing my O2 levels to be slightly low (84-86%) when at rest at 8,200' elevation (my home). I know that I shunt right to left fairly substantially when I do a Valsalva, but not much when at rest. My question is do most people with paroxysmal A Fib at my age have increasing episodes when getting older? Does the implanting of a PFO closure device greatly increase the odds of getting chronic A Fib? Should I get an ablation now such that I can then have the PFO closed? How many ablations has the Cleveland Clinic performed when Amplatzer PFO closure devices are in place, and have they been successful? Thanks in advance for some perspective on this issue!

Speaker_-_Dr__Saliba: We will address each of your questions:

  • Do most people with paroxysmal A Fib at my age have increasing episodes when getting older? It is expected that episodes of afib will increase with age - especially that you have evidence of PFO with intermittent shunting. This is the natural history of afib.
  • Does the implanting of a PFO closure device greatly increase the odds of getting chronic A Fib? Not necessarily.
  • Should I get an ablation now such that I can then have the PFO closed? It is much easier to perform an ablation before closing the PFO. However, we have performed several ablations - more than 10 - in patients who have had the PFO closure device without much problems - but this should be done beyond 6 months of the closure to make sure the device is stable.
  • Nevertheless - the recommendation would be to perform the ablation prior to the closure.

denalidon: Thanks for your previous answers, very helpful. A follow up Q: if one has had 4 paroxysmal A Fib episodes and have converted naturally or via Rythmol, would it be advisable to have an ablation to rid oneself of the discomfort and possible complications of aging and the need to soon have a PFO closure? Is it very risky? Would insurance generally pay if a medication seemed to be controlling the A Fib (at 65 years old)? Wouldn't there be a high risk that eventually the Rythmol effectiveness would wear off? Thanks again in advance!

Speaker_-_Dr__Saliba: First, if the episodes of atrial fibrillation are not frequent and you are controlled by rhythmol, then there is no reason to jump on to an ablation right away. However, if closure of the PFO is recommended early - it would not be a bad idea to consider the ablation before the procedure as eventually the risk of developing more frequent afib is a reality. Some insurance do pay - some insurance need more justification - check with your own insurance company.

The risk of an ablation averages 2 percent and includes stroke, cardiac perforation, PV stenosis, worsening arrhythmia among others.

Abnormal or Irregular Heart Rhythm

Dan: My mother has been having a severe irregular heart rate for the last year, but has gotten worse in the last 3 months. She was just hospitalized for 4 days and every test they could think of was done. She does not have any blockages problems with any other organs but her heart does not seem to pump out the blood from the right quadrant properly. They have prescribed 180mg of Diltiazem-ER, 12.5mg of Carvedilol bid, and 20mg of lasix. Her blood pressure continues to be all over the place and her heart rate my be as low as 67 then shoot up to 115 and stay high. Our family lives close to your clinic and we have heard excellent things about it and were wondering if our mother might benefit from seeing a doctor there.

Speaker_-_Dr__Saliba: We will need more information about her heart rhythm to be able to make informed decisions about what is the best to treat your mother with. A visit to the Clinic might be very appropriate.

Abnormal or Irregular Heart Rhythm: Ventricular Arrhythmias

Tallulah: I have an ICD and am on toprol for control of a PVC arrhythmia that escalated to Ventricular Tachycardia a year ago. My questions are 1) should I evaluate my treatment as a success because I have not gone into VTach again? Or, are there other areas of my health (medical stats) I should be evaluating? 2) When is it a good idea to get a second opinion?

Speaker_-_Dr__Saliba: The answer to this question depends on the cause or etiology of the VT that you have. The fact that you still have the ICD is indicative that you are still at risk for developing VT. Should this be a recurrent problem or should you be symptomatic from the PVC frequency an ablation can be done. We are available to help you answer the question of second opinion at your convenience. We offer second opinions online or by appointment.

jj5: I have had tachycardias for about 10 years. Had my first ablation in 1998. My second ablation two years ago. My tachycardia is increasing again. Why does that occur? Can arrhythmias come back like that throughout life? How successful is a third ablation? Are there more risks?

Speaker_-_Dr__Saliba: It all depends on what is the mechanism of your tachycardia and the nature of your arrhythmia. We do not know if it is the same arrhythmia that is coming back and therefore prior ablations were not successful or if this is a new kind of arrhythmia you are developing.

I would suggest that we review your records regarding the nature of your rhythm as this will allow us to make a more educated recommendation. Chances are that we may be able to cure your tachycardia with a repeat ablation.

Cleveland_Clinic_Host: I'm sorry to say that our time with Dr. Saliba is now over. Thank you again Dr. Saliba for taking the time to answer our questions about arrhythmias.

j105sailor: Dr Saliba, thank you very much for hosting the informative session.

Speaker_-_Dr__Saliba: Thank you for having me.

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

Reviewed: 08/11

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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