HCM/ablation/afib

Im a 34 yr old male, with non-obstructive HCM, with AICD. I developed afib about 3 years ago. I had a radial ablation last year with little success. I was on 120mg cardizem, 25mg atenolol, and 500mcgx2 Tykosin. My atria are pretty scarred. I had a throcoscopic ablation 3 months ago, and the Dr said he was able to isolate the trigger points. He said what he saw in the lab was promising. Since the procedure I have been very symptomatic. I don't know what they are but my Dr said he thought it might be aflutter, and he cut my cardizem, in order to raise my synus rate, and diminsish the effects of these palpatations? I am still having these palpatations and afraid they are going to break into full out arrythmia. Here are my questions. Please address each one the best you can.

1. I did not have these symptoms before my thorocoscopic ablation. I did not have aflutter before this. What could these palpatations potentially be? My Dr is still unclear about this. Could he give me a holter or interogate my AICD to know for sure?
2. If it is aflutter like he suspects, why would I have that now, when I had only afib before?
3. No matter what it is, is reducing meds to raise my synus rate going to help? What about just giving my healing more time? What about trying something different than Tykosin?
4. I was told my whole life that cardizem or verapamil was needed to improve my heart function, because of my musclebound LV. Now he's taking me off cardizem. He told me that atenolol is what does that. Now Im confused. Which do I need for heart function, and which can I eliminate to elevate my synus rate?
5. Dr is taking me off cardizem AND  thinking of lowering my Tykosin too. When I was 15 I was having syncope and VT. I don't want to be fainting and getting shocked because I have almost no protection. Is there a balance between calcium channel blockers, beta blockers, and anti-arrythmics that can protect me from VT, but elevate my synus enough to fend off aflutter?

[Michael J. McWilliams, M.D.]

1. A holter will work if you have symptoms while wearing the monitor.  The ICD would work if you have an atrial lead and the arrhythmia events are faster than the mode switch rate on your device.  If neither of these options are true, your best best is a 30 day event monitor.

2. Atrial flutter complicates 25% of Afib ablation.  The new scar from the afib ablation creates a circuit for atrial flutter.  Atrial flutter is often more symptomatic than the atrial fib because it is an organized rhythm and often leads to faster ventricular rates.

3. If you had an atrial lead, I would increase the atrial lead pacing rate.  I doubt decreasing the cardizem will decrease the fluttering.  Medical options for af with HCM are tikosyn, sotalol, and amiodarone.  Amiodarone has the hightest success rate and also has the highest side effect rate.  You can give it more time to heal, but you are looking for a solution now.

4. That can be complicated.  I would discuss this question with your cardiologist.  A beta blocker is often first line treatment but may not be enough to control your heart rate with atrial fib/flutter.  It sounds like you are either too fast or two slow.  They may need to add an atrial lead to your device to allow them to effectively rate control your afib/flutter.

5. This becomes a delicate balancing acting that only the doctor that knows you best can do, even then it is often complicated.  An atrial lead to your ICD will allow them to increase your heart rate medications without compromising your sinus rate.