Future Steps

[BABlocker]

I am a 51 year old woman with 3 year history of diagnosed lone af, with to 2 failed PVIs, a failed cardioversion, 4 failed antiarrythmics (Flec, Sotolol, Tikosyn, Rythmol)  and finally AV Nodal Ablation with implantation of Biventricular Pacemaker in August of 2005. I was taken off of Warfarin in June of 2006 because of low risk factor and was on Baby aspirin since that time.
Last Thursday, during my PM interrogation it was discovered that finally after 2.5 years, I am in persistent AF.
Options presented to me are: cardioversion and new antiarrythmic, live with the af or pursue 3rd ablation.
My questions:
1) What are the repercussions of keeping me in afib permanently given that I have hopeful decades more to live?
2) Is there anything that could be done to the pacemaker to make the AF more comfortable (Medtronic INSYNC III 8042) and tolerable for me? (I am having optimization of the pacemaker done on 2/1/2008, at my request, both at rest and then when exercising in a 2nd procedure)?
3) My current EP's practice only uses the Pappone method of isolating the PVs (that has been done on me 2 times, with no success) and that is what he would redo, he told me, if I wanted to attempt a third procedure. My cardiologist is encouraging me to leave that practice and travel to Brigham and Women's Hospital to consult with Dr. Stevenson for possible third ablation. Have you comments on this program? What would you do for me if you were my EP?

Thank you in advance for your time and thoughtful response.

[Michael J. McWilliams, M.D.]

That sounds like a reasonable plan.  I hope it is successful.

[BABlocker]

What I did not have room to post is that I am very symptomatic and have felt the arrythmias despite the AV Node ablation.

Currently, during exertion, I become quite winded and fatigued easily, needing to complete my workout sessions in multiple sessions. My symptoms include chest pressure, shortness of breath and dizziness, during exertion.  My heart rate is well controlled with the pacemaker settings.

So, I am guessing that given this, you would think that it be a worthwhile pursuit to see Dr. Stevenson to consult re: another ablation attempt?

By the way, I am spending this next month trying to live with the afib to see if my body will adjust and allow for more activity over time. Then I see my present EP and cardiologists for some decision making time. My biggest need is to be able to be active and do the things that I enjoy to a much greater ability than I have currently, without feeling unwell. Sounds reasonable to want that; who wouldn't?

Thanks again for your time.

[Michael J. McWilliams, M.D.]

1) What are the repercussions of keeping me in afib permanently given that I have hopeful decades more to live?

The studies show that if you do not have symptoms, you will do just as well with a rate control as a rhythm control management.  If  your symptoms are controlled, I would stop taking anti arrhythmic medications and move on.  Having atrial fibrillation, like many other conditions, has been shown to increase your long term risk of cardiovascular events, but that does not mean you do not have decades more to go.  My 92-93 year old grandmother has had atrial fibrillation for over 20 years is still living alone taking care of herself.  Don't let it debilitate you.

2) Is there anything that could be done to the pacemaker to make the AF more comfortable (Medtronic INSYNC III 8042) and tolerable for me? (I am having optimization of the pacemaker done on 2/1/2008, at my request, both at rest and then when exercising in a 2nd procedure)?

Not always.  The purpose of your pacemaker is to keep your heart rate controlled.  It does not help with the atrial fibrillation.


3) My current EP's practice only uses the Pappone method of isolating the PVs (that has been done on me 2 times, with no success) and that is what he would redo, he told me, if I wanted to attempt a third procedure. My cardiologist is encouraging me to leave that practice and travel to Brigham and Women's Hospital to consult with Dr. Stevenson for possible third ablation. Have you comments on this program? What would you do for me if you were my EP?

Dr. Stevenson is very well known.  I would agree that if you are thinking of a third procedure, it sounds like a good idea to see someone like Dr. Stevenson.  I do not think that anti arrhythmic meds will be any more successful now if you have already failed four different meds.

I hope this helps.