Oussama Wazni, MD
Oussama Wazni, MD

Walid Saliba, MD
Walid Saliba, MD

Friday, September 8, 2017


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. Oussama Wazni, MD and Walid Saliba, MD answer your questions about atrial fibrillation and other arrhythmias.

More Information


Arrhythmias

davidX: How do these asymptomatic elderly know what heart rhythms they have? DavidX

Oussama Wazni, MD:  By using heart monitors and EKG's.

Supapera:  What is the relation between ejection fraction and ventricular arrhythmia? I have been prescribed amiodarone 100mg, once a day. Any comments for the dose. I also have Heart Failure issue with ejection fraction 0.23. If arrhythmia is reduced, will it increase ejection fraction. I also have condition called RBBB. Has it anything to do with ventricular arrhythmia? Is it possible to remove blockage from Right Bundle Branch? This can be a naive question but please comment in whatever detail possible?

Oussama Wazni, MD:  Patients with decreased ejection fraction have a higher propensity to develop ventricular tachycardia. If not done yet, you should be considered for ICD (defibrillator). The lowest effective dose of Amiodarone should be used, and if your current dose is effective, then you should remain on that dose. In most cases, the arrhythmia is due to the depressed left ventricular function. Occasionally, very frequent PVC's cause heart failure and if these are abolished, the heart function can improve. However, from your question, I do not know what your specific issue is.  RBBB is a common finding in patients with heart failure; and it is really not a blockage but rather a decreased conduction in the right bundle. It is an electrical issue and not a vascular issue - there is no blockage to be removed.

mf1536:  I have an enlarged aortic root with related aortic regurgitation. I also experience super ventricular tachycardia. Is it possible that the SVT is related to the aortic regurgitation?

Walid Saliba, MD: Less likely to be the case.

Antonio1:  I am an 85-year-old male with long-term hypertrophic cardiomyopathy. I have had an ICD implanted for 11 years, resulting from diagnosed ventricular tachycardia.  Recently, as a result of arrhythmia, I was diagnosed with congestive heart failure and had a cardio-version procedure which returned my heart to normal rhythm for a period of about three weeks. I took one diuretic per say plus 5mg Eliquis 2x per day, plus 75 mg Metoprolol 2x per day. My heart rate has been around 100 for the past several days and after an echo cardiogram my cardiologist has suggested eliminating the diuretic, reducing the Metoprolol to 50 mg, 2x per day, continuing the Eliquis and starting on Amiodarone 200MG, 2 tablets 2x per day for 7 days, 1 tablet, 2x per day for 14 days, and then 1 tablet daily.
Would be grateful for your opinion. Thank you.

Oussama Wazni, MD: The plan of care sounds appropriate.

davidX:  Ages 85-90: Is diurnal arrhythmia common and what is the pulse to pulse distribution, such as peak to peak RR periods in bpm. Is 1:00 Pm in the early afternoon often related to a peak pulse-to-pulse heart rate? Related to "controlled AF" heart rate in bpm boundaries, 60-100 bpm?  Special arrhythmia behaviors for this 85 o 90 year old group? SCD risk? Exceed "controlled AF" often, when? Is this group arrhythmia aware? Any other insight about this aging arrhythmia group? Any new references, studies? DavidX age 89. Thank you.

Oussama Wazni, MD: These are very specific questions with a lot of variability. We would recommend a direct conversation with a physician to address your concerns.


Atrial Flutter

wgaust:  I have a history of AFib/AFlutters of about 20 years. In 2005 I had two catheter ablations and have had seven cardio-versions with no success in maintaining normal sinus rhythm. I have been prescribed 13 different medications over this period. They worked for a time but eventually I was back to square one. The latest drug was Amiodarone. I was on it at the beginning for nine years at 200 mg/day. I was also put back on it about four years ago and then it did seemed to stop working. It was stopped about April 2017. Presently I am told that I am in A-Flutter 100% of the time. Lately, it has become a real problem with shortness of breath to point it is hard for me to function as I want to. Have there been any new procedures introduced that might help me? Thank you.

Walid Saliba, MD: Most probably you have fairly advanced atrial fibrillation disease. While we do have new mapping technology to ablate the atrial flutter, it is likely that long term maintenance of normal rhythm will be difficult. Never the less, a review of your EKGs and rate control, might allow us to address your problems differently and more strategically to determine if a repeat ablation with this new mapping technology would be worthwhile.


Atrial Fibrillation

Munster2017:  I have afib and also other arrhythmias. How do I tell the difference by the symptoms I am having? One feels like my heart has stopped.

Walid Saliba, MD:  It depends what other arrhythmias you are having. Did you have a monitor to sort out this issue? Have you considered treatment of either atrial fibrillation or other arrhythmias if they are bothering you?

AppState:  I am 59 years old, male and have Afib on occasion, usually at night, usually brought on by alcohol and/or high fat and/or spicy dinner. I also have Bradycardia and a stent in the LAD. I have just started using a CPAP machine, for low grade sleep apnea, which appears to cause more AFIB attacks?  Night time low PR around mid-40's. My question is, usually after an Afib attack, for the next few weeks or longer, my heart rate is lower, I have angina, PVC's, tired and "icky" feeling. BP is fine. My cardiologist cannot explain this. What is you diagnosis, any treatment options? Should I get a pacemaker? Thanks.

Walid Saliba, MD: I don't think a pacemaker is the solution - the CPAP should make atrial fibrillation better. You might be having more atrial fib than you think and that may be causing your symptoms. Have you had long term monitoring? Is there any correlation between your symptoms and rhythm/rate.? These are things you might want to consider?

beat159:  Can a myocardial infarction cause afib, and subsequently, cardiomyopathy?

Oussama Wazni, MD: Yes to both.

Panacea:  Please describe at start of AFib the progression of treatment from chemicals and the correct level of chemicals, and then if that doesn't control the next step and how do you know when it is controlled. How much is subjective patient feeling about when controlled and how much is determined by machine or other monitoring?

Walid Saliba, MD: It is reasonable to try antiarrhythmic medications to treat symptomatic atrial fibrillation - if patient continues to have frequent recurrences that are symptomatic then an ablation would be recommended. We rely on symptoms to determine the aggressiveness of the therapy.

Munster2017:  Is there anything new treatment wise on the horizon for afib and arrhythmias? Why do I have more episodes one day than another?

Oussama Wazni, MD: The incidence and frequency of afib can be variable in the same person. In terms of new treatment, there is nothing at this time that will result in major changes in outcomes. However, there are always ongoing clinical trials that are evaluating new technologies and strategies for afib ablation, depending upon the specific clinical scenario.

beat159:  Hello - My 69-year-old husband was diagnosed in 2007 with atrial fibrillation, EF = 51%.He had a heart cath, which revealed a prior MI (described as a "silent heart attack") and CAD blockage considered "insignificant". He was prescribed warfarin, which he has taken throughout the years. In 2013 his EF dropped to 16%. He had the usual SOB, dyspnea, etc. and was diagnosed with cardiomyopathy. He had a heart cath, which revealed a LAD/RCA-Luminal irregularities; RamusIntermedius 60%> proximal 40 % followed by a 60%; 1st Obtuse Marginal 30. The doctor felt this blockage was not extensive enough to have caused the cardiomyopathy. An AICD was subsequently implanted. His EF has improved to 50%. Is it possible that the old MI caused the afib, which
caused the cardiomyopathy, ultimately resulting in low EF? Prior to the 2007 incident, he drank alcohol in normal amounts, but stopped drinking completely, and has continued his abstinence. He is a Vietnam veteran with exposure to Agent Orange.

Walid Saliba, MD:  It is difficult to say but atrial fibrillation can cause heart failure and reduced LVEF if left untreated. On the other hand, primary cardiomyopathy can also exacerbate or cause atrial fibrillation. These two conditions are tightly connected.

jimc:  Can weight loss reverse AFib?

Walid Saliba, MD: it can definitely improve your symptoms and potentially the burden of the arrhythmia but less likely eliminate it completely.

Zoey1:  Do certain foods trigger arrhythmias?

Oussama Wazni, MD: Maybe - in some people this is possible.

agaliceg:  It seems like I go into afib every night. I'm wondering if lying down is a positional trigger.  I also feel like once I go into afib at night, I have to urinate frequently, like every 45 minutes or so. Is this related to the afib?What can I do about these issues?

Oussama Wazni, MD: Yes, your observations are accurate. The afib has to be treated to avoid these symptoms.

Tiger1954:  Is there a direct connection between sleep apnea and AFib? I have been diagnosed with both but because of facial pain from trigeminal neuralgia I'm unable to wear CPap most nights. How much does this contribute to my generally feeling weak and nauseous a good deal of the time?

Walid Saliba, MD: Yes. Your symptoms seem to be predominantly related to sleep apnea. There are some low profile CPAP machines that you may want to try.

tabialex:  Female, 75 years, I have AFib (confirmed 3-4 years ago) controlled by sotalol 40mg bid (& Eliquis 5mg bid) and have not had an episode for over a year. Recently I had an endoscopic ultrasound for pancreatic cysts and was in/out of afib during (took sotalol prior to) but discharged in NSR, no problem post exam. My TSH is low (0.58 mlU/L, range 0.40-4.50), the endocrinologist says so mildly hyperthyroid. Knowing how I reacted during the endoscopic procedure, I would like to know if operated on for a total thyroidectomy, would I most likely go into afib and how would that be treated during surgery? How do patients with afib tolerate surgery? The other thyroid options are medication (endocrinologist advised) or radioactive iodine treatment. My second question is about changing my anti-arrhythmic sotalol to another med because of its many drug interactions. I was on metoprolol but went into afib, possibly because of low dose. It seems to have less serious drug interactions. Thank you.

Walid Saliba, MD:  The hyperthyroid state might be making the atrial fib worse. There is no problem in undergoing surgery if there is a need for it and atrial fib can be controlled during the operation.   Sotalol seems to be giving you good control of the AFib. You are taking low dose of this medication. If you continue to have increasing episodes of atrial fib despite thyroid treatment then options include increasing the sotalol dose or changing the antiarrhythmic medication.

beat159:  Would a cardiomyopathy, caused by AFib, be considered ischemic?

Oussama Wazni, MD: No, it would not. Ischemic cardiomyopathy is due to previous myocardial infarctions (heart attacks). Cardiomyopathy caused by afib is usually tachycardia (fast heart rate) mediated. In some patients, even rate controlled afib may cause cardiomyopathy.

mariearc2015: I am 85 years old, I have arrhythmias that come several times a month, lasting about 2 to 4 hrs. sometimes only about 20 mins. My heart rate goes to 155 to 167. I take 240mg of Diltiazem and 2.5 mg of Eliquis. The arrhythmias leave me tired and weak. What other options do i have, is there another medication that could be better for me? I look forward to you for some advice. Thank you for helping.

Walid Saliba, MD: We have to know what is the nature of the arrhythmia that you are having. It appears that you have afib because you are on Eliquis. If this is the case, this can be treated with specific antiarrhythmic drugs and/or ablation. You have a fair amount of recurrence of these episodes and I would suggest you consider these options for symptomatic relief. We would be more than happy to see you here.

dbmolski:  Is it common for afib to morph into ventricular tachycardia?

Oussama Wazni, MD: Atrial fibrillation can induce ventricular tachycardia in certain conditions such as in patients with heart failure or cardiomyopathy. It does not morph into it - they are separate entities.

Shane:  Due to AFib, an echocardiogram revealed that my ejector fraction has decreased from 60% three years ago to 15% when I was tested approximately one month ago. Does this heart failure prevent an ablation operation or some other operation to correct AFib? I am currently taking Ramipril to strengthen my heart. Thank you.

Oussama Wazni, MD: Given the reduction in ejection fraction and assuming that there is no other reason for this drop other than AFib, then the AFib should be treated and sinus rhythm should be maintained. This can be accomplished by using antiarrhythmic drugs like dofetilide or amiodarone, or an ablation. It seems that you may need a high level of care by experienced cardiologists to reverse the heart failure.

jeffrey:  Why is it more difficult to convert to normal rhythm for someone who has been in constant afib for a long time? Is it impossible?

Walid Saliba, MD: Because atrial fibrillation causes changes in your heart both on the structural and electrical level that tends to perpetuate the arrhythmia. It is not impossible to convert but it is hard to maintain long term normal rhythm if you have been in constant AFib for a long time.


Atrial Fibrillation Medications

clcl1932/34:  I have an implanted ICD. I have been on Tikosyn to control rhythm for five years. It has worked pretty well. I had a cryoablation four years ago. My ICD has indicated very little AFib activity since the ablation. I would like to discontinue the Tikosyn. The electrophysiologist that did the ablation says no. My current EP says ok and my primary care doctor rolled his eyes. I have been erroneously shocked twice before the ablation and it is frightening. The tech. said they were a ventricular and should never have happened. I am afraid that stopping the Tikosyn will open me up to very rapid heartbeats and a discharge of the ICD. My wife says "if it ain't broke don't fix it". What do you say?

Walid Saliba, MD:  It is very possible that if you stop the Tikosyn you may have recurrence of AFib. While you can stop it on a trial basis, I would personally suggest you continue this medication as it is providing adequate control.

brilim59:  I have AFib and no matter what they try to slow it down, it seems to get worse.

Walid Saliba, MD: You can be evaluated for medications or ablation.

PeterF:  Hello doctors and thank you for conducting this important forum. I have been in persistent afib for about five years, deciding to try rate control after discussions with my EP when I was first diagnosed. I'm male, 67 years young, overweight, and feeling well and have few symptoms. No diabetes, valve or heart disease. I am worried that I missed the opportunity to try more aggressive therapy for the AFib and would like your view on my situation. Should I stay the course, or is it not too late for further evaluation and alternative therapy? Is there anything new that I should consider? TYVM.

Walid Saliba, MD: You can always to restore normal rhythm with possibly back up antiarrhythmic medication to see if you actually would feel better while in normal rhythm. This can help you determine the aggressiveness of therapy for your atrial fibrillation going forward. Alternatively, staying on the course you are on is not necessarily the wrong approach.

Rubybeatrice:  Beta blockers are contraindicated for asthma and COPD but Sotalol, a "sort of” beta blocker is very effective and useful for AFib. What is the best treatment for AFib with comorbid COPD and asthma?

Walid Saliba, MD: There are other antiarrhythmic medications such as Tikosyn which is a strong sotalol without the beta blocker.

bedy35:  What medication is most effective for holding sinus rhythm after being shocked to restore it?
If the first ablation therapy doesn't work, would it be prudent to repeat the procedure once or twice again?

Oussama Wazni, MD: The most effective medications to maintain sinus rhythm after cardioversion are either Amiodarone or Dofetilide (Tikosyn). If the first ablation had been unsuccessful, a second ablation may be considered. If a third ablation is required, would suggest a different operator.

BamaKat:  I was diagnosed with afib in 2011 and was in normal sinus rhythm until September 2016. A cardioversion restored rhythm but once again this year I have had cardioversions in April, May, and June. I have been on Multaq, Flecainide, metoprolol and currently on diltiazem for rate control only. The medication causes extreme fatigue. Are there other medications for rate control to try or is it possible to have a cardiac ablation even though I am morbidly obese? I would like to restore my rhythm, as I am 53 and being in AFib constantly has caused a decline in my quality of life the past six months. My cardiologist does not feel I am a candidate for a cardioversion at my current weight and I would like to know the guidelines for the procedure. Thank you.

Walid Saliba, MD:  We can do cardioversion irrespective of weight - this would require general anesthesia in some cases. An ablation is recommended but may be prohibited in view of your weight.  Have you considered bariatric surgery? What is your weight?

Daniel1199:  I have afib and am currently taking Tikosyn to keep it in check. This drug works for me but I was wondering if there are any long term adverse effects of this treatment. My qtc number is 442. Thank you for your assistance.

Walid Saliba, MD:  No known long term side effects. The ongoing potential side effect of Tikosyn is minimized by checking your EKG on a regular basis as well as K, Mg, renal function, which I am sure you are doing, and avoiding other medications that prolong the QT interval.

mikel:  Male, age 79, with AF that seems to occur on occasion every few weeks. Taking 5mg of Eliquis, two questions: 1) Is it ok to take a Beta Blocker, or other meds that slow the heart, for additional support only when I am aware of an AF attack. Taking it full time makes me too sluggish. I realize I might not always know when an attack occurs, but so far the doctors have said it is ok to be off of it. Interestingly, at this moment, my blood pressure is normal but my heart rate is 135.  2) Being on Eliquis is like walking a tightrope. If I am on a trip overseas and lose my medication, or cannot take it for some other reason, I understand that this increases the likelihood of blood clot formation, not necessarily from not taking the medication but from a "rebound phenomena”. What is this rebound phenomena all about and what can one do about it. Is it a real issue?

Walid Saliba, MD:  1) It is ok to take beta blocker on as needed basis. If your heart rhythm is 135, most likely you are in atrial fibrillation which means that you may have more atrial fib episodes than you are aware.
2) There is a small rebound phenomenon if you are in atrial fib. It is best to keep enough medications with you at all times.

Zoey1:  I have been on amiodarone 200-400 mg per day for almost four years. I have cardiac sarcoidosis and CHF. I'm 43 years old. In "bergem's" question, he said he discontinued amiodarone due to side effects (including start of CHF). Does amiodarone worsen CHF?

Oussama Wazni, MD: No. Amiodarone does not worsen CHF. However, you should be periodically checked for liver, lung, thyroid and eye/corneal abnormalities.

CIF:  A 77-year-old white female has pericarditis and pleurisy. She has had no previous history of heart disease or hypertension. Her cardiac cath was negative. On her 5th hospital day she had atrial fib from about 7 AM until 2 PM. Her medication was Eliquis 5 mg bid, Amiodarone 200 mg bid and metoprolol 25 mg bid. On her 12th day of hospitalization she had an episode of atrial fib in the afternoon that lasted less than five minutes. Prior to her hospitalization she was being treated for Lupus. Patient has been also taking methotrexate 15 mg. weekly for mucous membrane pemphigoid. How long should she be on cardiac medication?

Walid Saliba, MD:  Atrial fibrillation is not unusual occurrence in the setting of pericarditis. It is very possible that once the pericarditis flare subsides, the episode of atrial fibrillation would decrease. These pericarditis flares have variable duration and treatment with amiodarone would need to be managed accordingly. Typically, we stop amiodarone 6-8 weeks following resolution of the pericarditis.

iansgma:  I have had about 20 episodes of AFib since turning 40, 15 years ago. My son is 28, and has now had two episodes of AFib, was cardioverted successfully both times. He is on amiodarone. They tried to do a catheter ablation, but could not complete the procedure because they said his "heart was sensitive, and he kept going into AFib", so they stopped the procedure. It has been a year now, with no other recurrences. Do you suggest just waiting for another occurrence, or try another ablation? He feels like he is waiting for a shoe to drop.....

Walid Saliba, MD:  He is too young for amiodarone and should not take it for long period of time because if it’s potential multiple side effects. If he has recurrent atrial fibrillation off atrial fibrillation therapy then a redo ablation needs to be considered at an experienced center. We would be happy to evaluate him.


Atrial Fibrillation and Blood Thinners

SMDTS:  I am on Tikosyn, metoprolol and low dose aspirin. Pacemaker readings indicate a fib 20% of the time. Years ago I had two unsuccessful ablations. Can it be repeated? My cardiologist wants me to begin Eliquis. I will soon be 70 and have avoided prescription blood thinners due to problems with nose bleeds that require ER treatment when I'm on them. I understand there are now antidotes to the newer blood thinners. I've also read that you should be 135 pounds to take Eliquis. I'm 115. Is it safe to take at that weight or are there other alternatives?

Walid Saliba, MD: I think you should be on blood thinners. Alternatively, especially if you have problems with bleeding, we can offer the left atrial appendage occlusion procedure (WATCHMAN) that provides similar stroke prevention without the need to be on blood thinning meds. As for your atrial fib, reevaluation for possible re-ablation, depending on what was done during your prior procedure can be considered.

Krystyna:  Is blood thinner mandatory if I had a successful second ablation for AFib two years ago and no symptoms, except for some PAC or PVCs?

Oussama Wazni, MD: The need for anticoagulation depends on the CHADS-VASC Score and not on whether an ablation was deemed successful or not. If your CHADS-VASC score is 2 or higher, then it is advisable to continue taking anticoagulation. If you are not willing to take oral anticoagulation on a definite basis, then you may consider an implanted loop recorder for continuous monitoring and take anticoagulation only when atrial fibrillation is detected.


Atrial Fibrillation and Ablation

Geno:  I have had AFib for approximately 10 years. I have had three ablations without success. I currently am in AFib about 95 percent of the time according to my three month pacemaker checks. I feel fine most of the time and have appointments with my two cardiologists, (one for five stents and the other for my past ablations.). My appointments are every six months rotating between the two doctors.
Finally, my question. Should I be happy with my current condition or should I be seeking further treatment to reduce the AFib? Another ablation? Thank You. PS: The pacemaker was due to "blocks" experienced a few years ago. Slow heartbeat.

Walid Saliba, MD: It is hard to justify a fourth ablation if you are not having any symptoms. If you are satisfied with your current status, (functional capacity, exercise) then you probably should continue your current plan of care.

Sheard.J:  I found out that I am not a candidate for ablation since my AFib/arrhythmia has been untreated for over 15 years and the success rate is minimal at best. I am an endurance athlete and find it difficult to train hard without gasping for air. Any suggestions? Thanks

Walid Saliba, MD: IF you have on and off atrial fibrillation, an ablation is still a consideration. If you have persistent atrial fibrillation, then the likelihood of maintaining long term normal rhythm after an ablation is relatively low but not necessarily impossible. It is a hard decision whether to proceed with an ablation in your situation but it is not a medical question, but more how frustrated you are with your symptoms.

donjr1951:  I had a PVI July 10 (my second, the first was in 2009) but have remained in highly symptomatic paroxysmal AFib since. Cardioversion doesn't seem to make sense because when I am in NSR - which is very infrequent - I go right back into AFib. I monitor my AFib closely using AliveCor Kardia. A mini-maze seems the best next step. How long after a PVI is it safe to perform a surgical procedure?

Walid Saliba, MD: I would wait at least six months but I would consider another ablation with a different approach before proceeding with a surgical approach

Oussama Wazni, MD: Before you proceed with a surgical procedure, you may want to consider being evaluated at a center where they specialize in re-do ablations.

Rubybeatrice:  I would like to know the success rate for ablation treatment for A-fib. What percentage of procedures have a good outcome, what are the possible adverse outcomes and what percentage of outcomes are poor. How common is this treatment currently? When is this treatment a good choice?

Walid Saliba, MD: we would refer you to our outcomes and complications - https://my.clevelandclinic.org/departments/heart/about/outcomes-stats/outcomes-by-specialty/cardiac-rhythm-disorders . Usually the outcome is related to associated medical problems and how long you have had your atrial fibrillation - chronic atrial fib.

iansgma:  I am a 55-year-old woman, have had multiple episodes of AFib over the last 15 years - have been successfully cardioverted about 20 times. I have had two catheter ablations, which did not decrease my episodes of AFib. I go into AFib out of nowhere...admit to the hospital, cardiovert and am sent home - and 6-12 months later it happens again. Is there any new treatment for me out there?

Oussama Wazni, MD: You should consider being evaluated in a center that performs a high number of ablations or that specialize in re-do ablations.

Kriepke17:  I have had a fib since 2007 having been treated at Cleveland Clinic in November 2007. Since then I have had seven cardio versions. They have corrected issue for a period ranging 1 - 2 years. It has been suggested I undergo surgery called an ablation.
I have spoken to three different people who have indicated they had to undergo repeat ablations. I also have spoken to individuals who have had long term success. I am 70 years old and plan to be around for a while. QUESTION- Are there different types of ablations or procedures. I'm concerned about local expertise. I have to meet with Dr. on 9-13-17 and have no clue what questions to ask. Thank You

Oussama Wazni, MD: Have you returned to Cleveland Clinic to discuss this with your cardiologist? I would suggest perhaps a discussion with him before going forward.


Atrial Fibrillation and Surgery

FitSeniorGal:  I was diagnosed with AFib three months ago at the same time my Mitral Valve regurgitation became “severe.” I’m hoping to come to Cleveland Clinic for surgery in October. I’m a fit, lean 80-year-old woman. Do you think my AFib can be treated and possibly ‘cured’ during my Mitral Valve repair surgery? Will my risk of a stroke caused by a blood clot still be higher than normal following surgery?

Walid Saliba, MD: The surgeons can do a MAZE procedure along with left atrial appendage clamping at the same time of the mitral valve surgery.


Biventricular Pacemakers

bergem:  I am 90, have AFib since 2001, takingWarfarin 2 mg q d. Tikosyn did not help after 3 mos. of trial. Then took Amiodarone for 10 years but had to D/C due to side effects (including start of CHF). Then tried Sotalol but I had to stop due to Syncope.
Have been on beta blockers for 40 years, last five years on Coreg 12.5, but getting more frequent AFib episodes. Had two cardioversions, one 4 years ago and one 2 weeks ago.  I had a Dual Chamber pacemaker (due to bradycardia?) in 2016 which was upgraded to Biventricular PM inJanuary 2017, had six different adjustments for the last eight months but I still have dyspnea at rest. My recent cardiac cath three months ago did not reveal any occlusions. My EF is 50-60; Ht.5'7;Wt. 147; Use treadmill most days 34 minutes, 1.5 miles. My PFT test reveal no pulmonary issue (never been a smoker). I use a CPAP successfully without apnea episodes. My persistent dyspnea even at rest is my main issue, do you have any suggestions? Thank you

Walid Saliba, MD: There are many reasons why one has dyspnea. How much atrial fib do you have on your pacemaker check? How is your biventricular pacemaker programming adjusted - do you have any underlying thyroid disease or anemia? These are potential questions that may need to be answered.We have a bi v pacemaker expert clinic for patients who still have symptoms despite bi ventricular pacing - that may be a possible consideration for you

Supapera:  I already have ICD in my chest. Question is whether Dual Ventricular DeFib will help improving EF. And there by heart function?

Oussama Wazni, MD: If you have left bundle branch block, a Biv-ICD may result in improvement in heart failure symptoms and also may improve the heart function. In the absence of left bundle branch block, the outcomes have not been as positive.


Premature Beats: PACs, PVCs and Ventricular Tachycardia

SJP:  What impact do PAC and PVC arrhythmias have on blood flow through the heart? Chamber pooling? Is there a reason that
these arrhythmias be more pronounced when resting? For me, most pronounced when lying down. Thank you.

Walid Saliba, MD: Little effect, from the hemodynamic standpoint, typically these premature beats tend to subside with exercise and more prominent at rest.

oliver2:  Can PVCs make one short of breath?

Oussama Wazni, MD: Yes, they can.

weistart:  I had open heart surgery at Cleveland Clinic in 1975. Since then I have had PVC's. The PVC's were12000 per eight hours before mevacor came out. I have been on this drug since it came out. Do you recommend I stay on the drug? It sure helps. Thanks

Walid Saliba, MD: Have you considered changing this medication to one of the new medications?

dbmolski:  I had an ablation in 2008, for AFib. My symptoms continued, though much reduced. Earlier this year, after wearing a monitor for 30 days, I was diagnosed with ventricular tachycardia, and no longer AFib. I began taking cardizem while continuing flecainide. The atenolol was discontinued. I am 72 years old with no heart disease and no diabetes. My dysrhythmia, mostly PVC's is continuing, but much less frequently. I notice it especially when I lie down, and it even wakes me up during the night occasionally. My question is regarding whether another ablation should be considered. Thank you.

Oussama Wazni, MD: Yes, if the flecainide is ineffective, then a PVC ablation can be considered.

dbmolski:  What is Cleveland Clinic's success rate for Ablation in 70 year-olds to treat Ventricular Tachycardia that is characterized by multiple PVC's?

Walid Saliba, MD: It depends on the frequency and morphology of these PVCs. Overall, PVC ablation is successful in more than 95% of the time. VT ablation success rate is close to 70% at one year.

oliver2:  I have been having numerous PVCs every day. What is the best treatment to reduce or eliminate them? Also, can PVCs contribute to light headedness? My blood pressure is low normal. Thanks.

Oussama Wazni, MD: If you are having difficulty with PVC's, then the best treatment is an ablation targeting those PVC's. Yes, frequent PVC's can contribute to lightheadedness.

Reviewed: 09/17

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