Treatment Options

59 white male.  Treated with beta blockers almost continuously since being diagnosed at age 30 with HCM (IHSS).  HCM more or less asymptomatic.  A-Flutter diagnosed approximately 12 years ago after a year or so off beta blocker.  Cardioverted, restarted beta blocker, NSR returned for about 5 years.  A-flutter returned.  Catheter ablation to right atrium.  NSR for about 2 years.  A-fib diagnosed 3 years ago.  Tikosyn started and NSR maintained until two weeks ago.  (All a-flutter and a-fib events described are constant.  Also had occasional proximal a-flutter and/or a-fib throughout these years, but converted without treatment except as noted.)  All non-self-converting a-flutter/a-fib events occurred during international or otherwise stressful travel.  Currently on Coumadin and EP says may be time for minimally invasive scope procedure by surgeon rather than previously suggested left atrium PVI.  Last echo shows larger left ventricle (excess of 5.0?). Getting ready for follow up appointment with EP for discussion of full range of options.  Questions:

1. Is cardioversion appropriate before more invasive procedure?  
2. If cardioversion successful but A-fib recurs, what guidelines are applicable to determining when more invasive procedure is appropriate.
3. Is min-maze indicated as next step, or would catheter PVI be more appropriate?
4. EP is Dr. Harvey at Oklahoma Cardiovascular Associates at Oklahoma Heart Hosptial.  Mini-maze would probably be done by Dr. Bodenhammer of OCA.  What is reputation of this team?
5. Would you recommend second opinion and/or treatment from Dr. Warren Jackman at University of Oklahoma?
6. Would you recommend second opinion and/or treatment from Cleveland Clinic?

[Michael J. McWilliams, M.D.]

1. Is cardioversion appropriate before more invasive procedure?  

absolutely, as long as you have been therapeutic with your INRs.

2. If cardioversion successful but A-fib recurs, what guidelines are applicable to determining when more invasive procedure is appropriate.

The guidelines state the a procedure based treatment to atrial fibrillation is appropriate in symptomatic patients that have failed at least on anti arrhythmic medication -- tikosyn counts for that.

3. Is min-maze indicated as next step, or would catheter PVI be more appropriate?

There is not a  right answer to this question and my answer has to be taken in context that I perform the percutaneous procedure and believe in it.  "I think" that the role for minimally invasive surgical maze is when there are other surgical procedures indicated like a valve replacement or if you have a significant obstruction because of your IHSS (hypertrophic cardiomyopathy).  If your septum is obstructive and surgery is indicated for that, I would recommend Dr. Smedira at the Cleveland Clinic to do a myectomy and atrial fib procedure.  If you do not need other surgical procedures, I think a percutaneous procedures is a good choice.  I can't say it is better but it is less invasive.

4. EP is Dr. Harvey at Oklahoma Cardiovascular Associates at Oklahoma Heart Hosptial.  Mini-maze would probably be done by Dr. Bodenhammer of OCA.  What is reputation of this team?

I am not familiar with that team and cannot comment on their experience.

5. Would you recommend second opinion and/or treatment from Dr. Warren Jackman at University of Oklahoma?

Dr. Jackman is very well respected in the EP community.  I am not saying the other doctors are not, but Dr. Jackman is an international figure and known for atrial fibrillation.

6. Would you recommend second opinion and/or treatment from Cleveland Clinic?

I think a second opinion is reasonable.  they can explain the pro/con's of both approaches so you can decide which is best for you.  The Cleveland Clinic is always ready and willing to give second opinions and procedures when appropriate.  Dr. Jackman is very good also. I guess it depends on how far you want to travel, both places are very good.

I hope this helps.  Good luck with your decision and thanks for posting.

[SoonerJim]

Thank you for your help and for being specfically responsive to my questions.

I have a great deal of confidence in my docs, but having Dr. Jackman with his reputation in the same town, and knowing of the great reputation of CC, the idea of a second opinion is very appealing.  The difficulty is in deciding how to  proceed without overkill.

My last echo (August) was good, and I do not think there is any obstruction that would imply a surgical necessity.  It was suggested that the increase in my left ventricle from, I think, 4.3 to 5.0+ over a one year period (coupled with my history and HCM, I assume) is an indicator that the percutaneous procedure might not be as effective.  I take it you would not necessarily agree with this conclusion?

[Michael J. McWilliams, M.D.]

I would agree that the larger the atrium, the more likely you will have recurrent atrial arrhythmias.  I do not think there is data to suggests a surgical mini maze is better than a percutaneous PVI based on atrial size.  You success rates will not be as high as someone with a normal left atrial size, but you still have a decent chance for success.