Treatment options, please

[DG]

My mother is a 69 year old type II diabetic with a history of "rheumatic fever" in her teens.  She never had a heart symptom (but did have a heart murmur) until she took Pondimin for four months, when she went into atrial fibrillation.  (This was just before all the information about phen-fen came out.)  Until that time she was active though not athletic, traveling, gardening, etc.  Since then, she has been in the hospital numerous times for a-fib and has been cardioverted several times (the last time requiring four shocks, increasing each time.) (Also, 24 hours after her last cardioversion, she went into congestive heart failure in a normal sinus rhythm.)

She just had her first heart cath and had some kind of vagal episode in the recovery room in which her heart rate dropped to 37 (reversed with atropine.)  The doctors told us that her pressures were okay, but that she had a unique layout of her coronary arteries, probably congenital.("I've done 1500 of these, but I've never seen anything like this.")They didn't find significant blockages. She also has some heart enlargement and problems with the mitral valve.  Her cardiologists recommended against valve replacement, saying "We could do the valve replacement and she could go into a-fib the next week, and stay there."  So they are managing her with a cardiac rehab program, lanoxin, cardizem, coumadin, laxix, pravachol, K-dur, pacerone, altace, along with resulin and assorted hormones, laxatives, and vitamins.

My folks are in a very rural area.  They have good insurance, but little money, energy, or inclination to travel to a major medical center for care.  The situation is deteriorating.  My mother is losing mental acuity and just had her first episode of burning pain radiating down the left arm and up her neck--this was several days after altace was added to her regimen.  (The on-call physician she reported this to reassured her that it must be nothing, as no blockages were evident on the cath.)  What I need to know is whether or not there are other treatment options that we should explore.  Can consults be done without the patient actually having to travel to your clinic?  I appreciate any advice you can give me.

[STEVE S.]

To the Dr., speaking of atrial fibrillation, I underwent surgery to replace the aortic valve in January, due to CHF symptoms and the ejection fraction between 25% and 35% (depending on who was doing the measuring).  On a chest x-ray, the heart was enlarged.  The AS apparently was the result of a congenital birth defect.  Anyhow, the next day after the surgery, I went into atrial fibrillation, and as such, they used their defib machine, followed by drugs, to correct this condition.  Currently, I am taking Procainamide, Digoxin, and furosemide, in addition to Coumadin.  For the past 4 weeks, my weight has been stable at about 190 pounds (even when I drink 2+ quarts of water per day) I have the following questions:

1)  Is atrial fibrillation a common occurrence after heart surgery?  What causes this response to happen?  Does this condition correct itself over time?

2)  In your experience, do folks in a similar position as myself wind up taking procainamide for a long time?  I understand that the procainamide prescription is as a result of the A-fib.

3)  I notice that my heart will occasionally skip a beat.  Is this also a normal part of the surgery, or is it a side effect of  the drug regimen I am taking?

4)  I go to the Q-club at least 4 times a week and am on the treadmill for 32 minutes at 3.6 mph.  I typically cover about 1.9 miles.  I also do a mild amount of weightlifting using the weight  lifting machines (no free weights).

Am I doing my heart any harm, or preventing it from recovering, with my exercise regimen?

5)  Finally, is it likely for the heart to return to normal size?  One physician told me that because I am young (30 years old) and am working to become more healthy, that this is possible.

[CCF CARDIO MD - DLB]

It sounds like the major problems are episodes of atrial fibrillation and mitral valve disease. If the mitral valve is severely diseased, surgery sounds like it would be a reasonable option. It may not cure the atrial fibrillation, but is unlikely to make it any worse. I think that her situation warrants a visit to a major medical center for consideration of valve replacement, though the symptoms you list are not typically due to mitral valve disease.