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Atrial Fibrilation and Treatment Options

  i'm a 42 year old male that has been in chronic a-fib for the past 2.5 years.  Cardioversion (external) has been attempted twice with no success (not even a temporary normal sinus rhythm).  Amiodarone did no good. currently, i am also on multiple meds to try and control my rate. (240 mg Verapamil, 100 mg Metoprolol 3x day, Lanoxin .25 mg, 2.5 Coumadin, Lasix and Potassium as needed.) Limiting my lifestyle, can't walk a round of golf etc.  
  Starting to explore other options and had first meeting with electrophisiologist.  radio ablation seems like an option but am not thrilled with dependence on pacemaker.  electrophysiologist indicated that an emergency/baseline rate of anywhere from 25-40 beats per minute is usually present after a procedure that provides a lifeline if pacemaker fails.  This is reasurring (although i know i would pass out with that slow a heart rate but at least i wouldn't die without a chance of getting to a hospital etc.).
  Questions are:  Is ablation the only way to go?  Have heard of the Maze procedure pioneered by Dr. Cox of Georgetown but it is so invasive it is really scary.  Have heard also of some work with catheters/ablation that try to mimic Maze procedure.  Do not know if these were successful or not, any thoughts?  Since external cardioversion had no success at all would trying internal cardioversion be an option?  Finally, what is life like with a demand pacemaker?  Can one exercise vigorously full court basketball, swimming, scuba diving?
  thanks for the forum,
  tom
1 Responses
238668 tn?1232735930
MEDICAL PROFESSIONAL

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Dear Tom,

Questions are: Is ablation the only way to go? Have heard of the Maze procedure pioneered by Dr. Cox of Georgetown but it is so invasive it is really scary. Have heard also of some work with catheters/ablation that try to mimic Maze procedure. Do not know if these were successful or not, any thoughts?

thanks for the forum,
Thank you for your question.  Atrial fibrillation is a difficult condition to control and you have my commendation for continuing on.  The treatment you are referring to is called the "Maze procedure".  What this procedure does is create multiple blockages in the atrium (the site of atrial fibrillation) and creates a "maze" that channels the rhythm down a normal pathway.  This can be done either surgically (by opening the chest, cutting up the atrium and then sewing it back together) or with a catheter through the groin and putting multiple linear burns in the atrium.  There are benefits and disadvantages to both methods.  
The surgical method has a higher success rate but involves opening up the chest.  It is not usually done for lone atrial fibrillation.  It was developed by Dr. J Cox at the University of Washington in St. Louis and I would recommend him if you are interested in this approach.  The catheter procedure is less invasive but has a lower success rate.  It is not done at many centers and is a long procedure lasting up to 8 hours.   Only certain types of atrial fibrillation respond to these procedures and the success rate is higher with some types than others.  
Q: Since external cardioversion had no success at all would trying internal cardioversion be an option?
A: There are some trials with internal defibrillators but this dosen't sound like it would be a good option for your.
Q: Finally, what is life like with a demand pacemaker? Can one exercise vigorously full court basketball, swimming, scuba diving?
A: Most people tolerate it very well and are able to do everything they were able to do prior to the procedure.
Below is some additional information on the Maze procedure and afib.  Good luck.
Q: Does anyone know of a specialist in the Houston or Dallas Texas area?
A: I don't know of anyone who does the procedure in these areas.  Dr. Chris Wyndam at Presbyterian Hospital of Dallas is a specialist in the area of atrial fibrillation and may be able to direct you to someone locally.  There is a doctor in Tulsa, OK that does the catheter procedure.  I am not sure of his name (Dr. Black?) but he works out of St. Francis or Hillcrest Hospitals.  Another doctor that has done some of the catheter procedures is Dr. Morady at the University of Michigan.
Q:  If I have this proceedure what are the possible complications?
Q:  What is the recovery time before I can go back to work?
A: Both of these questions would have to be addressed by the doctor performing the procedure.  Obviously the catheter based procedure has a shorter recovery time than the surgical procedure.
I have listed some review articles below about these procedures.  Your local medical library can help you obtain copies.

Unique Identifier
98066875
Authors
Sundt TM 3rd.  Camillo CJ.  Cox JL.
Institution
Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA.
Title
The maze procedure for cure of atrial fibrillation. [Review] [25 refs]
Source
Cardiology Clinics.  15(4):739-48, 1997 Nov.
Local Messages
Abstract
Atrial fibrillation is the most common dysrhythmia encountered in clinical practice. A significant number of patients fail medical therapy because of inability to convert or control the rhythm pharmacologically, intolerance of the requisite medication, or persistent symptoms despite apparently satisfactory rate control. Based on experimental studies establishing the electrophysiologic basis of atrial fibrillation, a surgical procedure has been developed that is highly effective in restoring sinus rhythm without further requirement for medications. The evolution of this procedure, its current indications, and results are outlined. [References: 25]
Unique Identifier
98014535
Authors
Stevenson WG.  Ellison KE.  Lefroy DC.  Friedman PL.
Institution
Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts 02115, USA.
Title
Ablation therapy for cardiac arrhythmias. [Review] [124 refs]
Source
American Journal of Cardiology.  80(8A):56G-66G, 1997 Oct 23.
Abstract
Ablation has become an important and, in some cases, the first-line therapy for a number of tachyarrhythmias. The feasibility of treating arrhythmias with ablation was initially demonstrated with surgical ablation techniques. Recently, catheter ablation techniques have replaced the surgical approach in nearly all cases. Catheter ablation is highly effective for the Wolff-Parkinson-White syndrome, atrioventricular nodal reentry, and atrial ectopic tachycardia. It is effective for atrial flutter, although approximately one quarter of patients treated with catheter ablation continue to require therapy for concomitant atrial fibrillation. The surgical maze procedure has proved to be feasible for preventing atrial fibrillation. The risks and long-term efficacy of catheter ablation maze procedures for atrial fibrillation need to be defined. The efficacy of ablation for ventricular tachycardia varies with the type of tachycardia. Catheter ablation is very effective for the rare idiopathic ventricular tachycardias that occur in structurally normal hearts and for bundle-branch reentry ventricular tachycardia, which occurs most frequently in patients with dilated cardiomyopathy. When performed at an experienced center, surgical ablation is an excellent option for selected patients with ventricular tachycardia due to prior myocardial infarction who have a discrete aneurysm but otherwise well-preserved ventricular function. Catheter ablation shows promise for this arrhythmia, but it can be offered only to those patients who have relatively slow tachycardias that allow catheter mapping. Substantial advances in mapping and ablation technology will continue to occur, allowing nonpharmacologic control of cardiac arrhythmias to be achieved in an ever greater number of patients. [References: 124]

Here is some additional information on afib.
Atrial fibrillation
Definition:
A disorder of heart rate and rhythm in which the upper heart chambers (atria) are stimulated to contract in a very rapid and/or disorganized manner; this usually also affects contraction of the ventricles.
Causes, incidence, and risk factors:
Arrhythmias are caused by a disruption of the normal functioning of the electrical conduction system of the heart. Normally, the atria and ventricles contract in a coordinated manner. In atrial fibrillation and flutter, the atria are stimulated to contract very quickly. This results in ineffective and uncoordinated contraction of the atria.
The impulses may be transmitted to the ventricles in an irregular fashion, or only some of the impulses may be transmitted. This causes the ventricles to beat more rapidly than normal, resulting in a rapid or irregular pulse. The ventricles may fail to pump enough blood to meet the needs of the body.
Causes of atrial fibrillation and flutter include dysfunction of the sinus node (the "natural pacemaker" of the heart) and a number of heart and lung disorders including coronary artery disease, rheumatic heart disease, mitral valve disorders, pericarditis, and others. Hyperthyroidism, hypertension, and other diseases can cause arrhythmias, as can recent heavy alcohol use (binge drinking). Some cases have no identifiable cause. Atrial flutter is most often associated with a heart attack (myocardial infarction) or surgery on the heart.
Atrial fibrillation or flutter affects about 5 out of 1000 people. It can affect either sex. Atrial fibrillation is very common in the elderly, but it can occur in persons of any age.
Prevention:
Follow the health care provider's recommendations for the treatment of underlying disorders. Avoid binge drinking.
Symptoms:
     sensation of feeling heart beat (palpitations)
     pulse may feel rapid, racing, pounding, fluttering,
     pulse may feel regular or irregular
     dizziness, lightheadedness
     fainting
     confusion
     fatigue
     shortness of breath
     breathing difficulty, lying down
     sensation of tightness in the chest
Note: Symptoms may begin and/or stop suddenly.
Signs and tests:
Listening with a stethoscope (auscultation) of the heart shows a rapid or irregular rhythm. The pulse may feel rapid or irregular. The normal heart rate is 60 to 100, but in atrial fibrillation/flutter
the heart rate may be 100 to 175. Blood pressure may be normal or low.
An ECG shows atrial fibrillation or atrial flutter. Continuous ambulatory cardiac monitoring--Holter monitor (24 hour test)-- may be necessary because the condition is often sporadic (sudden beginning and ending of episodes of the arrhythmia).
Tests to determine the cause may include:
     an echocardiogram
     a coronary angiography (rarely)
     an exercise treadmill ECG

Treatment:
Treatment varies depending on the cause of the atrial fibrillation or flutter. Medication may include digitalis or other medications that slow the heart beat or that slow conduction of the impulse
to the ventricles.
Electrical cardioversion may be required to convert the arrhythmia to normal (sinus) rhythm.
There is not a consensus on the best long term management  of atrial fibrillation but many doctors feel it is important to try everything, including cardioversion (shock) to try to get the heart back into regular rhythm.  The risks of staying in afib are stroke (if not on anticoagulation) and decreased heart heart function (tachycardia induced cardiomyopathy).  Not all afib can be maintained in regular rhythm and those patients must live with the afib and take chronic anticoagulation (blood thinners).

Expectations (prognosis):
The disorder is usually controllable with treatment. Atrial fibrillation may become a chronic condition. Atrial flutter is usually a short-term problem.
Complications:
     incomplete emptying of the atria which can reduce the amount of blood the heart can pump
     emboli to the brain (stroke) or elsewhere--rare

Calling your health care provider:
Call your health care provider if symptoms indicate atrial
fibrillation or flutter may be present.
Q: Are there other safe drugs I could take at home to avoid cardioversion?
A: There are many different drugs that are used in the attempt to keep the heart in sinus rhythm (SR) but as with any medication they all have various side-effects.  You doctor can work with you on finding the best drug for your case.
Q:  What are the side effects to Toprol.
A: Toprol XL is a long acting version of metoprolol.  This drug is a beta-blocker.  Potential side-effects of beta-blockers include fatigue, problems with diabetic control, and impotence.
Q:  It seems that the better physical shape I stay in the less I have a problem with A.F. Could exercise have an impact?
A: There is no known effect of exercise on atrial fibrillation (AF).
Q: Is a pacemaker an alternative?
A: In some people who are unable to be controlled with drugs the electrical connection between the atria (upper heart chambers) and ventricles (lower heart chambers) is electrically severed and a pacemaker is placed to control the ventricles.  The atria remain in fibrillation but the side effect of the rapid heart rate is eliminated.  Chronic anticoagulation is required, as there is a risk of blood clots forming in the atria.
Q:  I have an uncle that was diagnosed with IHSS. Are IHSS and Mitral valve prolapse related problems?
A: No.

The links below are good sources of information about atrial fibrillation.
http://www.med-edu.com/patient/arrhythmia/atrial-fib.html
http://www.americanheart.org/Heart_and_Stroke_A_Z_Guide/afib.html
http://www.merck.com/!!vDXoe16kTvDXpz08Of/pubs/mmanual_home/chapt16.htm

I hope you find this information useful.  Information provided in the heart forum is for general purposes only.  Only your physician can provide specific diagnoses and therapies.  Please feel free to write back with additional questions.
If you would like to make an appointment at the Cleveland Clinic Heart Center, please call 1-800-CCF-CARE or inquire online by using the Heart Center website at www.ccf.org/heartcenter.  The Heart Center website contains a directory of the cardiology staff that can be used to select the physician best suited to address your cardiac problem.




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