John Rickard, MD
John Rickard, MD

Mohamed Kanj, MD
Mohamed Kanj, MD


Monday, September 19, 2016 - 12 Noon

Description:

Arrhythmias (irregular or abnormal heart beats) are very common and are often a mere annoyance. However, they can also be responsible for life-threatening medical emergencies that may result in cardiac arrest and sudden death. John Rickard, MD and Mohamed Kanj, MD answer your questions about arrhythmias.

More Information

  • Find more information on atrial fibrillation and abnormal heartbeats.
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  • View previous chat transcripts.

Arrhythmia – General

Lewbu: Does having arrhythmia shorten my life?

Mohamed_Kanj,_MD: It depends what arrhythmia. Infrequent extra heart beats, no. But if you have atrial fibrillation or ventricular tachycardia then may be to some degree.

Jayhawk1: Have an irregular, (consistently irregular) heartbeat, generally skips every third or fourth beat. Will go for several days with it beating regularly, then suddenly I'll go a day or so with the irregular beat. When that occurs, it makes me extremely short of breath and difficult to function with normal physical activity. Will suddenly go back to a normal beat and everything is ok. Cannot figure out what causes the episodes of the irregular beats. Any advice what to do to keep it from occurring and is there a medication?

Mohamed_Kanj,_MD: Caffeine, alcohol, and sleep apnea can cause arrhythmias. There are many medications to suppress these arrhythmias though and one could consider an ablation to address this arrhythmia. The latter approach could offer a cure. I would recommend a consultation with an electrophysiologist.

Zin52: I have coronary microvascular disease, endothelial dysfunction, RBBB and CAS, s/p MI 2012. When my chest pain is at its worst I get arrhythmias. How concerning is this with my other issues involved?

Mohamed_Kanj,_MD: This will all depend on what kind of arrhythmia you are having. Having a ventricular arrhythmia is concerning!


Atrial Fibrillation (Afib or AF)

ccheartafib: Q1 - I have paroxysmal AF. My meds are 20 mg atenolol and 5 mg Eliquis®, 2x/day. I am a healthy 73-year-old male. (Good diet and exercise regularly). In the event I need to go in for surgery of some kind, or even a dental extraction where bleeding is likely, what is the suggested procedure? Stop the meds or not? What are the risks? Q2 – Over time, will my AF likely stay the same, change or possibly progress into something else? What might be the next stage of AF for me?

John_Rickard,_MD: Stopping Eliquis® for a few days before a dental procedure is typically advised so long as your stroke risk is not exorbitant. Typically your risk for a stroke over a few days is not high although this does depend on your other risk factors. No reason to stop atenolol. As far as what will happen to your atrial fibrillation (AF) everyone is a bit different. Typically AF becomes more frequent over time but not in everyone. Should your AF become a recurrent problem and be associated with symptoms, typically the first step is the use of an anti-arrhythmic medication.

bergem: Have AFib since 2001, took Amiodarone until 2011 when I developed CHF and had to stop. I take Coreg 12.5 mg ' , Clonidine 0.1 mg, Micardis 40 mg: Can you suggest any other treatment for my Paroxysmal AFib? Thank you

Mohamed_Kanj,_MD: If you have heart failure, then Tikosyn (dofetilide) or ablation is another reasonable strategy. We would be happy to evaluate you for treatment strategies.

xdwl: Hi, doctor, I am a 58-year-old female with HCM, and had myectomy in 2012. I experienced three short episodes of AF within three days post myectomy (peri-surgery stage). Each episode stopped in a few minutes after IV Amiodarone treatment. I was on oral Amiodarone for a few months to prevent AF recurrent& and then stopped it. Since then I have been doing well with sinus rhythm in the past four years. My father had AF. So my doctor told me I will have AF again sooner or later. I would like to get your advice if any prevention measures available for AF? I am on Metoprolol Succinate 71.25mg/day now. HR 48-55, sinus. NYHA II. My recent echo: mild-moderate (1+-2+) MR and (1+-2+) AR. LA ID 4.7 cm; LA Volume 38 ml/M2; LV ID (diastole) 5.4 cm; EF 65%. No LVOT obstruction. Thank you very much!

Mohamed_Kanj,_MD: You are likely at higher risk of AF. However, we wouldn't know if you will develop it. Strategies to decrease the incidence or the frequency of AF: control blood pressure, lose weight and exercise, treat sleep apnea if present, etc. Given your higher risk, serial monitoring with Holter monitoring may be a reasonable strategy.

Afibfree: Has Cleveland Clinic linked one of the possible causes of Afib to food allergies? I suffered for more than 25 years before having a cardiologist make the link. Today, I am Afib free, but occasionally get arrhythmias if I eat something with hidden gluten. Then I take a very lose dose of diltiazem which gets me back in rhythm.

John_Rickard,_MD: As far as I know there is no conclusive evidence linking food allergies with atrial fibrillation. That said, I am happy for your successful outcome.

kmworld: Do flights affect afib? I am anxious about long flights.

John_Rickard,_MD: I am not aware of any data linking air flights and AF.

crdlives: If a patient has recently been diagnosed with mild afib, should the patient be referred to a cardiologist for evaluation and continued monitoring, or is monitoring by the general practitioner sufficient?

Mohamed_Kanj,_MD: Patient should see a cardiologist, at least for an initial visit.

yogacat: I used to binge drink, and got afib. I haven't had a drink in 5 yrs. Afib seemed to decrease, now increasing because of too much stress. If I get my stress under control, change of decreasing again? I am 74 and had paroxysmal afib for 5 yrs.

John_Rickard,_MD: Alcohol use has been linked to the development of AF. Binge drinking can lead to a condition famously known as "holiday heart." Alcohol cessation can cut down on the episodes. The association of stress and AF is poorly characterized likely because stress is a very subjective thing. Age in and of itself is a risk factor for AF. While stress reduction is always a good thing that in and of itself is unlikely to be the magic bullet if you had PAF for five years already.

DrDKlos: Patient, a 48-year-old male in good health with normal BP 110/70, lives in Cincinnati, OH; single. April 2016 surgical repair of torn bicep tendon due to playing rugby. Afib identified at that time without any symptoms. Stopped consumption of beer (no other alcohol), stopped playing rugby even after PT for arm, continuing minimal-moderate workouts. Three cardioversions since have not put him in NSR. Medication now only Eliquis® as all others, e.g., beta-blocker, result in lowering BP and energy level and muscle fatigue. What options should he consider? Ablation? Mini-Maze? Other?

John_Rickard,_MD: In this patient, an AF ablation is probably what is needed. That said I usually like my AF patients to fail at least one anti-arrhythmic medication before PVI. If the patient has not been on an AAD, I would start that and retry DCCV. If that fails would refer for a pulmonary vein isolation.


Atrial fibrillation Medications

Golla1809: I have A-fib but since I am on medications, my attacks have stopped but I am constantly fatigued. How can this be changed?

Mohamed_Kanj,_MD: The medication could be causing the fatigue. I would consult your physician, the medication may need to be decreased or changed. If the change in dose or medication didn't help, then I suggest an ablation.

dtk: I am a 76-year-old woman. I have had afib for the last two years. I have been told that I am too old for any kind of surgical procedure. I have tried different rhythm and rate medications and found one that seems to be working well for the last eight months - Coreg. I am on the lowest dose (3.125 mg), twice a day. I get tired by the end of the day from the afib, but really no other problems. If this rate medication seems to be working for me, can I be on Coreg for as long as it seems effective? Or, is my heart muscle bring remodeled? Thanks for your assistance and any suggestions.

Mohamed_Kanj,_MD: Seventy-six is not too old for anything. The decision to treat a patient should be based on the benefits vs risk of treatment option. Please know that Coreg doesn’t treat atrial fibrillation, it is to control heart rate in patients with AF.

SteveK007: Diagnosed with AFib 2+ years ago. Pacemaker two years ago (somewhat slow heart rate + sick sinus syndrome). Have had periods of little arrhythmias and some periods of significant activity. Am currently on Amiodarone (last three months) and that has resulted in no AFib. But I understand that is not a long term solution due to potential serious side effects. My cardiologist strongly suggests that I think about an ablation. My family doctor says that I can live to a ripe old age with AFib. I am just not sure how to think about this. I am now 67 years old. All of my tests come back without any obvious issues (nuclear stress tests, etc.). My father also had a pacemaker put in at about my age, but I believe that was due to a slow heartbeat rather than an irregular heartbeat. He is now 91. Can you provide any further food for thought? Thank you.

Mohamed_Kanj,_MD: There are other drugs beside Amiodarone that can address AF. If there is a concern on the long-term safety, I would recommend a discussion with a cardiologist about other classes of medication.

lebon: What is the best way to treat intermittent Afib, SVT, PAC, PVC, tachycardia all in the& same person. Using verapamil, and beta blocker. Would an ablation be in order? No cardioversion was ever done. Thank you.

Mohamed_Kanj,_MD: Antiarrhythmic medications would be a good start. The choice of the medication will depend on whether you have a history of heart disease or not.

kmworld: Amiodarone has such dramatic side effects -- prescribed by my doc to stop afib when it happens. It works after several hours or a day or so, and makes me so tired that I can hardly move, takes forever to wear off. What else would you recommend for just stopping occasional afib when it happens?

Mohamed_Kanj,_MD: I agree with your concerns. There are many other antiarrhythmic medications that one can take beside amiodarone. You may need to discuss that with your cardiologist or we would be happy to evaluate you.

kmworld: Propafenone prescribed for twice daily use (150mg tablet) to avoid afib -- once I get on it, will that avoid afib altogether? Can I just take it for occasional afib?

Mohamed_Kanj,_MD: The drug is given usually as 2-4 tablets at the same time after the onset of atrial fibrillation (no more than 4 tablets in 24 hours). The other option is to take it three times a day to prevent future episodes of AF. Please consult with your cardiologist or we will be happy to evaluate you if needed.

gardendeer: I am 83, taking sectrol and paradox, and feel tired. I have had cardio versions but the last one didn't work so I am in Afib all the time. I don't feel a fast or slow heart beat but don't like being tired or nausea at times. Can you give me suggestions? I am 84, and the last cardio version failed. Is it possible to have an ablation?

John_Rickard,_MD: I assume you mean Pradaxa. Sectral is a beta blocker and as such won't help you maintain sinus rhythm. Rather it will simply slow down the atrial fibrillation when you go into it. Loading with an anti-arrhythmic medication with a retrial of cardioversion could be considered. If that were to fail pulmonary vein isolation (PVI) ablation could be considered. AF ablation in selected 80-year-olds can be reasonable.


Anticoagulation Medications

hsrosen440: I have had Afib for about 3-4 years and taking Warfarin. I test my INR at home...not a problem. However, diet and fluctuations in my INR are problems and of concern. The new breed of anticoagulants ...Pradaxa, Xarelto, and Eliquis®... are interesting alternatives but I am concerned that without monitoring how will I know if I am a candidate for a stroke or a bleed out? Then there's the question of antidote for Xarelto and Eliquis®. What is your recommendation? Thanks!

Mohamed_Kanj,_MD: I personally favor these medications over warfarin especially if there is fluctuation in the INRs. The incidence of intracerebral bleeding is lower with these medications. Pradaxa has an antidote, Xarelto is once a day, and Eliquis® has the lower bleeding risk!

KrystynaTeresa: 1) After a second successful ablation for Afib and being symptoms free for nine months, should I continue taking Xarelto? What is the protocol for that? Is it different for men than it is for women? 2) What is the average period being Afib free after a successful ablation?

Mohamed_Kanj,_MD: The need for anticoagulation DOESN'T depend on whether the ablation was successful or not. It depends on CHADSVASC score (heart failure, hypertension, age, diabetes, stroke, vascular disease,..etc). Patients may continue to do well for a long time after an ablation.

swain2: My cardiologist said I have mild arrhythmia with a 4% chance of stroke. He ordered savaysa which I started but hated for a couple reasons: I was leaking blood with every little scratch, and I am on Cymbalta, which makes the bleeding worse, I understand. So I have stopped taking it. Question: does this 4% risk of stroke compound or increase every year?

John_Rickard,_MD: Age is a determinant for CVA risk. Year to year the risk goes up but not significantly and certainly not compounded. Once you reach 75, the risk is a good bit higher. A 4% CVA risk is not insignificant. Many patients on blood thinners experience minor bleeds as you describe. Would make sure you really can't tolerate it, as a stroke could be devastating.

sbusko: I am a 79-year-old female with advanced osteoarthritis and a degenerative back condition. Was taking Celebrex and receiving Facet spinal injections. Last year, after an accident and in the ER, I was diagnosed with Afib. I am now taking a blood thinner, Rivaroxaban 20 mg and Diltiazem 180 mg. I was told to stop Celebrex and not take any anti-inflammatory meds. Am taking Tylenol arthritis but does not provide much joint pain relief. Rheumatologist does not agree with not taking anti-inflammatory. Any alternatives and who is correct?

Mohamed_Kanj,_MD: I don’t believe that you SHOULDN'T take anti-inflammatory. I think it is reasonable to believe that you may be at increased risk of bleeding if you take Anti-inflammatory agent and you should make a decision based on the benefits/risks. It is not an absolute contraindication and if you want to take, it may be a reasonable option to change xarelto to Eliquis® which may have a better safety profile and take anti-inflammatory on as needed basis??? Please discuss with your physicians before.

Lmg93: I am probably going to need major dental work in the near future. I am on Xarelto blood thinner. My Afib has been well controlled with medication. Should I be concerned about going off the blood thinner for this procedure? How far in advance do I need to be off Xarelto before the procedure? Thanks

Mohamed_Kanj,_MD: Management of anticoagulation depends on the procedure you're having and whether you have had a prior stroke or if you have significant valvular heart disease. For example, if you are getting dental cleaning, there is no need to stop Xarelto, but if you are having major jaw surgery or extraction where there is a high risk of major bleeding, then it may be a good idea to stop it 2-3 days before the procedure. It is important to discuss your medications with your dentist.

mediator1: I have had Afib for 14 years. It is well controlled with Flecainide. My instances of Afib are quite noticeable to me and fairly rare now. I monitor with a LifeSource blood pressure monitor which verifies irregular heartbeats. A year ago, I stopped taking Coumadin and now take a baby aspirin daily. When I do experience Afib, it lasts between 8 and 12 hours (never more). Is it true that it takes 14 to 48 hours for a blood clot to form? If true, why would I have to stay on Coumadin? Thank you.

Mohamed_Kanj,_MD: Short episodes as short as a few minutes increase the risk of stroke. The decision to be on blood thinner should NOT be driven by how long the episodes are; it should be driven by your risk: presence of hypertension, heart failure, age, gender, prior history of stroke, presence of coronary artery disease, etc.

kmworld: Will taking Propafenone daily completely eliminate afib episodes! if not, what else can I take if/when I get Afib?

Mohamed_Kanj,_MD: You can take it on a regular schedule,: this will prevent AF. Taking it as needed will treat the episode of AF. So if you are having frequent episodes of AF, then take it on a regular scheduled dose. If you were having rare but long episodes of AF then one could take it as needed.

Benbo: 70-year-old male with Afib taking Diltiazem 180, toprol 100 and Eliquis® as blood thinner. I am hypertensive and take Benicar 40-25 which keeps it at 125 over 75 or lower. I will suffer an episode every 12 to 24 months, other than that in sinus rhythm. I would like to begin centrum silver or some other multi-vitamin but have heard that it could trigger Afib. Any truth to that? Am I a candidate for ablation with so few episodes of Afib? I know my condition seems quite trivial compared to issues of others but wanted to ask.

Mohamed_Kanj,_MD: I favor no ablation. The data on vitamins and AF is very weak.

pest02basil: I was diagnosed w/afib about 10 months ago. My cardiologist put me on Eliquis® + .12mg metoprolol/one a day. I do not have high BP, just the occasional high pulse that may or may not contribute to my Afib. I never feel my Afib and I am only in Afib 1-2 days/week, and because of this my cardio doctor does not feel an aversion or ablation is necessary. Do you agree? Also, any suggestions/advice you have to offer would be most appreciated. Thank you.

Mohamed_Kanj,_MD: Symptoms of AF include : palpitation and fatigue. Around 40% of patient will have fatigue but no palpitation. If there are no symptoms then it is reasonable to rate control and anticoagulate. However, if you are symptomatic even with fatigue, then I recommend treatment.


Atrial fibrillation after heart surgery

mridder: I had aortic valve replacement surgery at Cleveland Clinic in November of 2012. Following surgery, I had several days of Afib but I converted back to regular rhythm with meds only prior to leaving for home. During my first 6-12 months of recovery, I had some issues with isolated PVC's and palpitations but they appear to have resolved and I am not bothered by the flutters and skipped beats that I used to feel. Can I be confident that my routine follow-up exams and echo ECG's will detect any issues with my heart rhythm? Should I watch for any particular symptoms that would indicate a serious problem with my heart rhythm in the years ahead? Thank you.

Mohamed_Kanj,_MD: Yes. Around 80-90% of post-op AF don’t come back. However, having valve surgery will always increase your risk of development of future arrhythmias. Your physician can work with you to detect any future recurrence of arrhythmia.

martiscamman: I had aortic valve surgery at CC in 2009. Very recently I have developed Afib --my cardiologist says it is probably due to the valve surgery. Is this true? Why? I have very negative reactions to Afib medication (especially Multaq) and I have stopped taking it. How risky is it if I just do nothing? Should I consider a pacemaker?

John_Rickard,_MD: Your AF may or may not be related to your aortic valve disease. Difficult to tell. Depends on your other comorbidities. If your aortic valve was diseased due to rheumatic disease, in that case, it is probably due to the valvular heart disease. We typically think mitral valve disease is responsible for AF, aortic valve, less so. We prescribe AF medications in patients with recurrent symptomatic AF. If you are not symptomatic with AF you may not need anti-arrhythmic medications. If you have symptoms, there are multiple other meds you could try besides multaq. Catheter ablation for AF would also be an option.


Skipped Heartbeats

PcTech: One type of irregular heartbeat that I experience is three normal beats and then no beat (skipped beat) and this continues for quite some time, three beats, skipped beat, etc. Also one other time I was just sitting down reading a newspaper and I felt my heart rate increase to 145 beats/min. This lasted for about 10 minutes and then it slowed to normal. I am 79 years old, better than average health and quite active on a daily basis. Thank you for any information.

Mohamed_Kanj,_MD: Often the feeling of "skipped heart beat” is in fact due to an extra heart beat. These arrhythmias are often benign but if frequent can be addressed. A heart monitor will establish the frequency of these arrhythmias. As for the rapid rhythm you need a prolonged monitor to see what the rapid rhythm was. Recommend a follow-up appointment with a cardiologist.


Premature ventricular contractions (PVCs)

robcleve: At what number of PVCs should ablation be considered an important treatment.

John_Rickard,_MD: I usually like to see at least 10-12,000 premature ventricular contractions (PVCs) in a 24 hour period. You really need to be having them in the lab for them to be mapped and successfully ablated.

TKR: Good afternoon. I am a young grandma, age 68. I have been told I have PVC's, and to diagnose possible TIA and/or heart issues, I underwent transthoracic echocardiogram and MRI, MRA brain and neck and EEG. Current meds are low dose of propranolol, lisinopril with HCTZ, nexium, Premarin vag cream, 81 gr aspirin. My question is whether you feel I need treatment for these conditions:
1. Estimated ejection fraction 60 to 65%.
2. Mild to moderate concentric left ventricular hypertrophy.
3. Mild aortic regurgitation.
4. Trace of mitral regurgitation.
5. Evidence of mild pulmonary hypertension.
6. Trivial pericardial effusion noted, but since has been corrected.
7. Neurological: Narrowed carotid arteries, probably hereditary. Hx of chronic complex migraine with aura. Moderate to severe micro vascular ischemic change involving pons. Thank you.

John_Rickard,_MD: In terms of PVC treatment, we prescribe therapy in two situations. First, if patients have symptoms related to the PVC's and second if the PVC’s are so frequent they are leading to a decline in heart function. In your case, there is no decline in heart functions so we're good there. If based on Holter monitoring you have frequent PVC's and these have been shown to correlate with symptoms, treatment with either anti arrhythmic medications or ablation could be entertained.


Paroxysmal Supraventricular Tachycardia (PSVT)

WR: Would you please address recommendations for PSVT prevention and treatment options. Is PSVT a precursor for atrial fibrillation? Thank You!

Mohamed_Kanj,_MD: Certain PSVTs are: Wolff-Parkinson-White (WPW) for example or fast atrial tachycardias could act as a precursor for AF. If it is sustained SVT, the recommendation is ablation especially if it was symptomatic. Other options include medical therapy.


Short PR syndrome

RobynGM: I have been diagnosed with short PR syndrome. Is this something to have treated, and if so, how?

Mohamed_Kanj,_MD: If it short PR without pre-excitation or without WPW then things should be good as long as you don’t have arrhythmias or palpitation.


Cardioversion

Moey: Is cardioversion an option at age 84? And if so, are there any side effects? Thank you.

Mohamed_Kanj,_MD: Absolutely, the safety record of cardioversion is phenomenal. The risks are very low.


Atrial Fibrillation Ablation (Pulmonary Vein Isolation Ablation, PVI)

Missoula: Hello, I have paroxysmal Afib, and am considering ablation. Does Cleveland Clinic use RF, or Cryoablation? Also, what are the success rates of both? Thank you, Jim

Mohamed_Kanj,_MD: We use both types of ablation for atrial fibrillation and that depends on the patient and the physician. The success rate will depend on you more than us. For example: age, obesity, size of he left atrium, presence of heart or valvular disease, length of time you have been in AF. One thing for sure is that at Cleveland Clinic you will get the best ablation possible! Our outcomes are excellent and validated and are reported on our website!

jitterbug: Can you have an Afib ablation if you already have a pacemaker?

John_Rickard,_MD: Yes a pacemaker is not a contraindication for pulmonary vein isolation.

sbdavisrn: I have had Afib for about 20 years - on Coumadin without problems. Rate control - on Digoxin, Tenormin, Imdur, Avapro. Had Maze procedure 10 years ago during mv repair - NSR lasted 24-30 hours. I've been told that at this point, cardioversion probably wouldn't work. How about the new convergent procedure or cryoablation? Am I a good candidate? Is it worth the risk? I have lots of med side effects, mostly orthostatic hypotension and intolerance. I am a 73-year-old female. Also have a touch of pulmonary hypertension, heart failure, and regular old hypertension. Other than that I'm fine. Getting old is not for cowards.

Mohamed_Kanj,_MD: The chances of addressing your atrial fibrillation (AF) after many years of AF is low now after 20 years. And it is unlikely that an ablation is going to work after 20 years of AF and even if it works, I doubt that restoring sinus rhythm may be beneficial now because I think the atrium will remain stunned even if we restore sinus rhythm.

Jim E: I have had a seemingly successful cryoablation in mid-April and have not had a recurrence of any arrhythmia for five months. Am I cured? I am taking Metoprolol to control my heart rate and Coumadin. Do I have to watch out for anything unusual? I am 66 and have been playing competitive tennis for years and play golf. My heart rate doesn't get above 115-120, even when playing tennis.

Mohamed_Kanj,_MD: No, a cure is hard to achieve. We have been doing AF ablation for 18 years or so and the long-term data is lacking. You are always at some risk of recurrence. But enjoy it while you are in sinus rhythm and I hope you stay in sinus rhythm. As for you slow heart rate during exercise, this is most likely from metoprolol and if symptomatic then feel free to discuss this with your cardiologist to see if a lower dose is reasonable.

72male: What's the success rate of FIRM ablation today? Why is this individualized ablation procedure not replacing the one size fits all PVI approach? Not enough trained physicians? Rotors too hard to find and treat?

Mohamed_Kanj,_MD: The role of FIRM ablation remains questionable. Data from different centers are unfortunately showing contradicting results. I personally use it as an adjunctive therapy but NOT the primary therapy and I don’t think it should be used as primary therapy.

giorgio0668: Dear Doctors, I'm 48 years old. After two heart surgery (both for plastic to MV without replacement), in Dec 2008 and Oct 2013 (edge to edge Alfieri), I had some FA and flutter episodes every 3/4 months. I've taken all kind of medicine to avoid arrhythmias such as Cordarone, Sotalol, Flecainide, until May 28, 2015 when after the last episode I decide to keep my AF/Flutter like chronic, taking now 80 mg x 3 of Isoptin. Naturally, I’m in Coumadin therapy. After one year and a half in this condition, I'm really feeling better than when I was with paroxysmal AF or flutter. I decide to lose the battle against the AF because I think that my heart, after two surgeries, cannot support another treatment such as Ablation that cannot guarantee a good result. One important primary Doctor told me that if my paroxysmal AF becomes chronic, it'll be my salvation! What do you think about my situation? My LA is 50 mm (dilatation) and I’ve 60/65% of FE. Good blood pressure (115-70), 75 beating .How long I’ll reside in chronic AF?

Mohamed_Kanj,_MD: Success rate of AF ablation is not great but not grim either. If you are symptomatic from AF and it is interfering with your lifestyle, then maybe a discussion with your cardiologist /EP is reasonable.

Ohiohills: Is it true that Afib ablation is only a temporary fix. Eventually will the electrical impulses find a way around the scar tissue and afib will return? Is it worth the risk when you threw a blood clot during a flutter ablation? Fifty-four-year-old male. My current daily meds are 1 - 200mg Amiodarone, 2 - 5mg Eliquis® , 2 – 50mg Metoprolol, 1 – 40mg furosemide, 1 – 81mg low dose aspirin.

John_Rickard,_MD: In many patients undergoing atrial fibrillation (AF) ablation, AF does recur. This can be due to recovery of the scar allowing impulses to exit the pulmonary veins or the formation of new triggers outside pulmonary veins. Whether it is worth the risk depends on how symptomatic you are and how big and dilated your left atrium is. If you have minimal symptoms not worth the risk. If you have symptoms with a gigantic left atrium also not worth the risk. If your atrium is normal or mildly dilated and you are highly symptomatic it may be a good option. Certainly, a tee beforehand with compliance with Eliquis® would be required. Staying on Amiodarone long term also carries significant risks.

Ohiohills: In your opinions, Is Afib ablation currently the best treatment available for afib in a 54-year-old male that is currently taking 200mg of Amiodarone to stay in normal sinus rhythm? What is the success rate and percent of complications encountered? I've heard Afib ablation is not a cure, it's only a temporary fix. Is this true? If so what is the average time it takes for Afib to reoccur in patients who have had Afib ablation? Is it worth the risk? If I've already had the flutter ablation and threw a blood clot to my lung during the procedure, even though I was on Eliquis® for several weeks prior to the procedure, is there a greater risk that I could throw a blood clot to my brain during the much longer and more complicated Afib ablation? Isn't there a way to put a filter in place that would catch a blood clot during an ablation before it left the heart? Are there alternative procedures to treat Afib other than medicine and ablation? If so what are they and what are their success rate?

Mohamed_Kanj,_MD: Taking Amiodarone at a young age is a concern. There are other medications that one can take that I believe are safer. Please discuss with your cardiologist. We don't use filters during ablation. However, we do ablation with minimal interruption of anticoagulation. With this approach the risk of stroke has been 0.1-0.2%. There is a surgical alternative, but I won't recommend it unless there is other problems that need for surgery.

Jim E: I have had Afib since January of this year. I had cryoablation for Afib in April and have been feeling fine with no recurrence of Afib at all. Two weeks ago I had an episode where I could not breathe deeply without pain in my chest. I went to the ER and they performed tests and determined that I had no Afib or heart issue or lung clots; and a tread mill stress test showed no issue either...they dismissed it as a muscular/skeletal issue and sent me home with no additional recurrence of the pain. Should I be concerned about anything else?

John_Rickard,_MD: Pleuritic chest pain as you describe can be due to pericarditis which we do see after atrial fibrillation ablations. Pericarditis presents the day after and commonly dissipates in 3-5 days. The time course for your development of symptoms this far out from your ablation doesn't fit this. I suspect it is a musculoskeletal issue. If you continue to have this symptom, however, would contact your cardiologist.

HarrysHeart: Hello and thank you. I am a male age 60, 6' 1", 200 lbs., non-smoker, moderate wine consumption, Mediterranean diet, near Aspen Colorado with paroxysmal Afib, diagnosed by Cleveland Clinic two years ago. I have three stents due to only arrhythmia symptoms, no typical ischemic symptoms, and subsequent catheterization procedures in '08 & '10, performed in Ohio, but not Cleveland Clinic. Due to family history (father died age 72) catheterization was advised. Mother died at age 92. I am very active, biking, skiing, hiking, etc. No symptoms other than P-Afib. I have a history of PAC's & PVC's. Lipid profile is well-controlled with 40mg Rosuvastatin. 37.5mg Metoprolol and 325mg aspirin to control Afib. Episodes of Afib are very infrequent, but the last few have lasted up to 30 seconds. The most intense have occurred during intense exertion, e.g. mountain biking and skiing. Q: At what point is ablation indicated for a patient like me?

Mohamed_Kanj,_MD: 30 seconds is too short for me to recommend an ablation. I recommend it when it becomes more frequent and symptomatic, when it interferes with your life style.

albertogarcia1: Happy Monday. My name is Alberto Garcia and I am acting on behalf of my wife Rosa, Here are the facts and then the question:
1)Rosa is 78 years old and she had quadruple bypass at Centennial Heart Center on 12/2015. She had some complications and she is doing now with that regard. The surgeon removed the appendage on the right atria.
2) She has a continuous heart flutter.
3) Dr. Peter Borek, formerly from Cleveland Clinic is her electrophysiologist. He tried to do an ablation on the right atria through her groin, but because of blockage in the veins he could not get the catheter to the atria.
4) We are meeting with him on 9/27 to discuss options.
5) She cannot tolerate Coumadin or Xarelto® as blood thinners. She has eliminated blood clots for the last six years using 15,000 units of Fragmin daily.
7) Is ablation through neck the only option?
We are very pleased with DR Borek. I just want to evaluate options and risks

John_Rickard,_MD: This is a difficult situation. If the inferior vena cava is occluded AF ablation will in all likelihood not be possible. If it is stenosed but not entirely blocked it could be ballooned open I suspect. PVI from the neck or from a hepatic vein is really not an option. Dr. Borek is an exceptional physician and a good friend!


Hybrid Ablation

bouthie: Hi, Curtis here, I have had three Catheter Ablations. The last one was 8/28/2014. Before having the 3rd one, the Doctor asked me if I would consider having what he called a "Hybrid" Ablation. I was told that my Electrophysiologist works in conjunction with a Heart Surgeon, that being the case, would you please discuss the procedure and the pros and cons of this "Hybrid Ablation"? Regards Curtis

Mohamed_Kanj,_MD: There hasn’t been large studies to establish the benefits/risks of this approach. However, if ablation failed and the center where you had it carries a good reputation, it may be reasonable to sit with a surgeon to discuss options.


Valve Disease

ANTHONYBJONES: I’m really trying to find out if there's anything besides surgery that I can do for Mitral Valve Regurgitation. They said one leaflet is better, so is it possible the other one will get better too?

Mohamed_Kanj,_MD: I would consult with a valve specialist. There are percutaneous approaches to this problem but I encourage to seek a specialist opinion on this. We, at Cleveland Clinic, have great physicians that would be more than happy to help you. I am an electrophysiologist.

Reviewed: 09/16

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.