Cardioversion

I have been diagnosed with atrial fibrillation which has become more persistent over the last few years. I am 63 years old, reasonably athletic and in good health. Catheter work and stress tests have shown that the heart is in good shape, i.e. 'the motor is good but the ignition has problems'.

The first cardioversion was successful but sinus rythm lasted only 24 hrs. Subsequent treatment with Tambocor had no effect; Betapace was effective initially but after a few days I went back to afib. Increasing the dose did not help.

For my second scheduled cardioversion I was given procainamide in the IV about two hours before the conversion. By the time the conversion was to take place I was back in sinus rythm. Thus the cardioversion was cancelled.

With the apparent effectivenes of procainamide I tried to go on Procanbid, a time release form of procainamide. The first pill lodged in my throat and had to be removed in the emergency room by the GI doctor while under sedation. It turned out my esophageal opening is only 6 mm - the Procanbid pill requires about 10 mm. So, contrary to the instructions for the Procanbid, but with my doc's approval, I ground up the Procanbid. The initial prescribed 'load' or ramp-up dose was to be two 3000 mg doses about 8 hours appart, followed 1000 mg every 8 hours.

My stomach revolted violently to the ramp-up and I spent the night calling Ralph every 2 hours. A week later I tried the 1000 mg every 8 hours schedule again, without ramp-up. This time things went down ok, with regular heartbeat of about 60-65 setting in about 6 hours after the first dose (in fibrillation the beat is about 80). Unfortunately the Procanbid gives me partial insomnia, with rapidly moving images perceived as soon as I close my eyes. Sporatic sweats, fluid retention and reduced initial night vision (i.e. just after you turn off the lights) were other side effects. So I came off Procanbid for now.

This brings me to my questions:

1.)If initial cardioversion is successful for a limited period of time (as in my case), will subsequent cardioversions have a better chance and what can be done to improve the chances of more permanent success?
2.) What is the electro-physiological theory behind cardioversion and why can atrial fibrillation return shortly after a successful conversion to sinus rythm.
3.) Any other comments on the above case history?

Thanks for your time - this forum is very useful and instructive for us patients.

[Cleveland Clinic, MD]

1.)If initial cardioversion is successful for a limited period of time (as in my case), will subsequent cardioversions have a better chance and what can be done to improve the chances of more permanent success?
A: Afib is a chronic condition and the goal of therapy is to maintain sinus rhythm as long as possible.  However, relapses requiring repeated cardioversions are par for the course.  There are many different medications that can be used and procanamide, although an effective drug, is well known to cause side-effects and most people can't tolerate it long term.  So you will need to work with your doctor on finding a drug that helps maintain sinus rhythm but is still well tolerated by you.

     2.) What is the electro-physiological theory behind cardioversion and why can atrial fibrillation return shortly after a successful conversion to sinus rythm.
A: There is a "resetting" of the electrical currents in the atrium following cardioversion.  The reinitiation of afib is a subject of research and there is some evidence to suggest that the afib begins on the left side of the heart in the pulmonary veins.

     3.) Any other comments on the above case history?
A: Hang in there.  Afib is a common condition and with your doctors help you can find a good treatment for you.