Health Chats
Atrial Fibrillation - Surgical and Nonsurgical Advances
Monday Apr 13, 2009, 12:00PM - 01:00PM (EST)
Cleveland Clinic
Cardiac Electrophysiology and Pacing, Cleveland, OH
Cleveland Clinic cardiovascular specialists are at the forefront of development and utilization of the newest therapies for treating atrial fibrillation (AF), the most common of all irregular heart rhythms. At the Center for Atrial Fibrillation, one of the nation's busiest AF programs, our staff provides a full array of approaches to diagnose and treat atrial fibrillation, whether medical, catheter based, or surgical. Please join us to chat with Dr. Bruce Lindsay as he takes your questions about the causes and new treatment options for atrial fibrillation.<br><br> Dr. Bruce D. Lindsay is Section Head, Cardiac Electrophysiology and Pacing at the Cleveland Clinic Sydell and Arnold Miller Family Heart & Vascular Institute. He is board-certified in Internal Medicine, Cardiology, and Clinical Cardiac Electrophysiology.He served as President of the Heart Rhythm Society 2007-2008 and chaired the Heart Rhythm Society's Annual Scientific Program in Boston in 2006, which was attended by more than 13,000 international physicians, scientists, and allied health professionals. Dr. Lindsay recently completed a term on Board of Trustees for the American College of Cardiology, and formerly chaired the College's Board of Governors. He also serves on the ABIM test writing committee for Clinical Cardiac Electrophysiology
Does atrial fibrillation lead to any chest pain?
Bruce D. Lindsay, MD:
Patients often experience chest discomfort when they are in atrial fibrillation even if they do not have coronary artery disease.  This may be related to the rate and irregularity of atrial fibrillation - you should discuss your symptoms with your doctor to see whether he is concerned about underlying coronary artery disease.
I had a Cox Maze procedure done during by-pass surgery three years ago.  Approximately a year ago I had a minor stroke. The genesis of the stroke was attributed to paroxymal a-fib.  Is another ablation in order to avoid life long warfarin therapy? Thanks!
Bruce D. Lindsay, MD:
Strokes are uncommon with the Maze operation as it was originally designed but the risk may not be eliminated if you underwent a modified Maze operation. An ablation procedure could eliminate the atrial fibrillation if the surgical procedure did not successfully isolate the pulmonary veins but I would be extremely cautious about stopping your warfarin.  Further information would be needed to make that decision.
I was put on a beta blocker for slightly elevated blood pressure and racing heart. I recently was switched from Toprol XL to Lopressor. Do beta blockers make you tired? Also, are these two meds really comparable?
Bruce D. Lindsay, MD:
Toprol XL and Lopressor are different brand names for Metropolol.  Most beta blockers can cause some fatigue.  
I am 40, male. Operated for ASD in Oct 1978, was diagnosed A-Flutter in Jan 2005, cardioverted in Mar 2005. Off and on A-Flutter while taking Sotalol/Warf. EPS/RFA done in June 2008 in India. EP confident A-Flutter cleared after ablation. For no apparent reason (even w/o exertion) HR goes to 120, most times stretching/vagal will bring it down to 60-66. No chest pain/fatigue during palpitations. Can continue doing regular activity. Taking Seloken XL 37.5mg. EP says it is unspecified atrial tachy, not to worry. Will the HR of 120 cause heart muscle weakness? Do I need any tests?
Bruce D. Lindsay, MD:
Yours is a complicated question.  Sometimes patients develop atrial tachycardias after ablation procedures.  Treatment with medications or a second ablation procedure might help to control the problem.  It is unlikely to damage your heart as long as your heart rate decreases when you are not physically active.
I have been told that I am not a candidate for pulmonary vein ablation because my a-fib is permanent and my left atrium is enlarged (52 mm). An AV node ablation was recommended. My a-fib is mostly under control with cardizem and digoxyn and a pacemaker. Would there be any advantages or disadvantages to the AV node ablation?
Bruce D. Lindsay, MD:
An av node ablation would be indicated if your heart rate cannot be controlled by medications.  On the other hand, it would not be necessary if your heart rate is well controlled.
Is there any connection between GERD and PVC's?
Bruce D. Lindsay, MD:
The esophagus is immediately behind the heart.  Nerves from the esophagus transmit pain or discomfort to the brain and this may elicit reflexes that effect the heart.  Sometimes patients note that their arrhythmias are worse when they eat, especially when they drink cold fluids.  
Six weeks ago I had an AVJ ablation due to many years of A-Fib  and treatments. I have felt tremendously better but I still have A-Fib and I can feel it.  At this point I can live with what I have but fear that A-Fib will continue to get worse.  I am off all drugs except for Coumadin.  Are there any more treatment options for me if A-Fib becomes intolerable again?
Bruce D. Lindsay, MD:
Your residual symptoms may be related to lack of synchrony between the atria and ventricles.  Sometimes, ablation of atrial fibrillation restores that synchrony and alleviates symptoms.  I would need further information to decide whether you would be a candidate for an ablation procedure.  
In general, do medicines for a-fib also prevent ectopics?  Or only certain a-fib meds?  Which are the most effective at preventing ectopics?
Bruce D. Lindsay, MD:
Some medicines do not prevent ectopics or atrial fibrillation but they are helpful in controlling the heart rate when you go into atrial fibrillation.  Other medications help to prevent atrial fibrillation.  These include sotolol, propafenone, flecainide, dofetilide, and amiodarone.  Other drugs are under study and may be approved soon.
I have asthma so I can't take beta blockers.  I was diagnosed with PVCs last year after wearing a 24 hour Holter.  They were not bad then, so we decided no meds.  Then last month those PVCs got much worse. So bad that I was having them non stop all day long, with short burst of rapid beats in between and chest pains in the middle of my upper chest that lasted about 5 minutes after the last PVC.  The only relief I got was to lay down when they occured.  My doctor tried another EKG but of course nothing happened, so I have carte blanche with the EKG only my problems don't seem to occur until after 5pm or on weekends.  Is there some other form of meds that I can take to get rid of these annoying things without messing with my asthma meds?  Since my PVC, PACs have been getting worse, should I get another Holter reading? I am a 55 year old female.
Bruce D. Lindsay, MD:
An event monitor is a device that would allow you to record your heart rhythm at your convenience from at home and would help to determine what is causing your symptoms.  If you cannot take medications or they are ineffective, then you might be a candidate for ablation of your premature beats.  
I am a lifelong runner and cyclist who at age 54 was found to have a bifurcation lesion in the LAD that was treated with CABG. I have 6 years later continued my exercise regimen but have bouts of A-fib brought on by near maximal exertion while biking. They self convert normally after 24 hours. My doc gave me some amiodarone 100 mg/day but I have cut it back to about 200 mg/week with no episodes in the 4 months I have been on it. Do you think this is a good long term plan as I have read that the bad side effects of this drug seem to be related to the total lifetime dosage? P.S. Cardiac CT scan shows my mammary graft to be occluded and I am apparently living off of my collateral circulation.
Bruce D. Lindsay, MD:
You are on a very low dose of amiodarone and are unlikely to experience any bad side effects on such a small dose.  I do recommend that you undergo a stress test if you have not already done so - the purpose is to confirm that it is safe for you to continue exercising.
Hi Dr Lindsy, I am an internist. After a node ablation, if a 70 year old man is in sinus rhythm for one year, can I take him off Coumadin and put him on aspirin?
Bruce D. Lindsay, MD:
The decision to stop coumadin depends primarily on the risk of stroke.  These risk factors include underlying heart disease, age, diabetes, hypertension and prior stroke.  It would be reasonable to use aspirin if the stroke risk is low to begin with but I would not stop it otherwise if the patient has significant risk factors.  One reason is that the patient may still have unrecognized atrial fibrillation.
I have now been in continuous Bigeminy for 3 months. 54 yowm with long term CAD treated with stents in the past. Normal wt, N/S extremely athletic despite my CAD. Hx of isolated PVCs forever. Had been on Atenolol 50mg for 14 years when this started. Catheter last month, stents patent no other narrowing. Tried verapramil. Did not work. Back on Aten 25mg . All lytes, TSH, T4, CBC, BMP normal etc. EKG unifocal bigeminy, RBBB pattern, maybe septal which means LVOT. No hypertrophy. My choice for attempted ablation or Tambocor. I am leaning toward ablation first since the rhythm is so constant, I assume this would be the best time for ablation to work if you don't have to induce it. Then, if not long term Ic class med which increases the mortality post MI 14 years ago. I have been told 70% success. 1-2 % TE risk. If I was in your office, what would you recommend? What makes the LVOT harder then the RVOT except the risk of TE vs PE?? Thanks.
Bruce D. Lindsay, MD:
You are a reasonable candidate for ablation and the risk for ablating premature beats that arise in the LVOT is relatively low in experienced hands.  The main risks are related to potential injury to the coronary arteries which are near the LVOT.  
Hi. I'm 17 and having palpitations difficulty breathing coughing which are giving me problems with sleep. Should i be worried?
Bruce D. Lindsay, MD:
Your symptoms are probably not dangerous but I definitely recommend that you see your doctor to evaluate this problem.  
If you have atrial fibrillation is it more likely that you will develop ventricular fibrillation? Is there anything you can do to help prevent it?
Bruce D. Lindsay, MD:
There is no direct link between atrial fibrillation and ventricular fibrillation.  The risk of ventricular fibrillation depends on whether the patient has severe underlying heart disease.  
What is the risk of stroke during an ablation for a healthy 57 year old male with no heart disease or any health problems?  I have normal BP. I have a-fib but always self convert.  It is fairly well controlled with flecanice but I have some breakthroughs.  What is the risk of death? I am one of those tall skinny runners who seem to get a-fib more often.
Bruce D. Lindsay, MD:
The risk of dying during ablation for atrial fibrillation is approximately 0.1 - 0.2 percent.  The risk of stroke is approximately 0.5 percent.  
I have had 3 episodes of a-fib over a year's time in 2007 and ending in March of '08.  Twice when I experienced it was when I stepped off of my recumbent bicycle after 45 minutes of strenuous exercise achieving a heart rate of 130 to 140.  I was on BP medication that slowed my heart rate.  The other time, I ate a lot of chocolate candy at Halloween and I believe the caffeine brought on the irregular heartbeats.  Since that time, I have not gone over 107 to 110 heart rate on the recumbent bike, limited my caffeine intake, lost weight (6'1" and 214lbs), no alcohol intake. I have not had another episode.  My cardiologist thinks a-fib will come back and the exercise and caffeine did not cause it. What research has been done on lifestyle changes to address a-fib?
Bruce D. Lindsay, MD:
Lifestyle certainly can affect the risk of atrial fibrillation. While I agree that you are prone to atrial fibrillation and you may encounter this problem in the future, it is encouraging that you are doing so well now.  I recommend that you continue to do what you are presently doing.  If the atrial fibrillation recurs you may require treatment in the future.