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January 21st, 2018
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I am a 56 year old Male. I was diagnosed with both A-fib and sick sinus syndrome. I am on my 2nd pacemaker first one implanted when I was 48 years old the first one malfunctioned so they change it out. Pacer tech from St jude tells me that my underlying heart beat some times beats when the pacer paces does causing me some double beats that drives me up the walls, I get some bad head aches from that. Do you have any suggestions I need help. Thank you.
2013-03-04 Answered By : Dr. Gregory Feld M.D., F.A.C.C. F.H.R.S.

Since I am not aware of your pacemaker programming, I cannot offer you much helpful advice. However, if the pacemaker paces and you have premature atrial beats in response, then reprogramming your pacemaker or adding an antiarrhythmic drug may in some cases help. The atrial fibrillation may be prevented by pacing in cases with sick sinus syndrome, but again in some cases addition of an antiarrhythmic drug may be necessary. I recommend that you speak with your EP doctor about adjusting the pacemaker or trying an antiarrhytmic drug to suppress the extra beats that are bothering you.

Hello Dr: Iím a 52 year old male with symptomatic, paroxysmal afib for 30 years, but generally infrequent episodes (1-2 per year or less). I had an ablation in 2011. EP indicated that in addition to the PVís he ablated the atrial roof and some other areas of electrical activity. Due to recurrence, I had a second ablation in 2012. After the second procedure, EP indicated there was some PV reconnection, and also typical atrial flutter. Both were ablated, I was told that no further arrhythmias were inducible, even after the administration of an agent (donít know name) that is supposed to identify areas of even minimal reconnection. I did well for about seven months, but recently had a recurrence of afib. I am obviously very frustrated. What would be your opinion as to a reasonable next step? Should I consider a second opinion at this point? What about a third procedure? Is reconnection after two ablations likely? Or, should I wait for improvements in the procedure or technology. Iím getting a bit concerned about the cumulative fluoroscopy exposure. Any advice would be most appreciated. Thank you!
2013-03-04 Answered By : Dr. Gregory Feld M.D., F.A.C.C. F.H.R.S.

After two ablation procedures at one center, it would be reasonable to obtain a second opinion. A third ablation is sometimes warranted, if the AF recurs and is triggered by premature atrial beats on monitor, or if atypical atrial flutter occurs. If a third ablation is recommended it might be appropriate to ask for a referral to a center that does complex ablations or repeat ablations. Reconnection of the PVs is possible even after a second procedure, although it sound like testing with adenosive was done during the second procedure to demonstrate dormant (or as you put it \"minimal\") reconnections. A third procedure does increase the risk from fluoroscopy exposure, so you might want to have it done at a center that used 3-D mapping and minimizes fluoroscopy exposure. After a single or even multiple procedures, it is sometimes necessary to stay on an antiarrhythic drug to prevent AF recurrence. So that would also be an option in your case.

Im the 23 y.o. fit male again. Does giving blood trigger the vagal nerve to put me into AFib? My BP was better then normal when I gave blood and went into AFib. What is that explanation? Does the Effexor assist in keeping my BP at bay. I dont want to be on these meds forever...there are long term side effects. The metropolol did not work on me so this is the combo I was given (tenormin and effexor). I failed to mention I have a low CHAD score so how could I get a stroke if there is no plaque in my arteries? Why did the ER rush for me to choose a cardioverting shock in stead of trying Cardizem or other med to get me back to NSR? I have to look into other areas of the AFib cause. Im too young, fit and with no family history for me to have hypertension. What other areas should be checked besides endo which was done. Thank you for your help.
2013-03-04 Answered By : Dr. Gregory Feld M.D., F.A.C.C. F.H.R.S.

Giving blood may trigger a vagal reaction, which can trigger AF regardless of a normal BP. High blood pressure is also a known risk factor for AF. With regards to the Effexor and Tenormin (Atenolol), I am not able to advise you on what medications are controlling your BP, since I do not know the cause of your BP, and what other medications you are on. Further evaluation and treatment of your BP should be done by your primary physician. Unfortunately, stroke can occur even with a low CHADS2 score in rare cases. The occurrence of stroke is minimized by a low CHADS2 score, but not eliminated. Other causes of your high BP should be evaluated by your primary physician, but I am unable to offer further advice regarding your condition.

I have a genetic clotting disorder - prothrombin gene variant (factor 2) and afib that is controlled by medication. I am on coumadin due to the clotting disorder - would an ablation be contraindicated for me due to the clotting disorder? I am a 55 year old female and in otherwise good health - no heart disease. Thank you.
2013-03-04 Answered By : Dr. Gregory Feld M.D., F.A.C.C. F.H.R.S.

Over the past decade warfarin has been increasingly used before and after ablation for AFib, and now even during ablation for Afib in many laboratories, while some laboratories prefer to use a bridge of lovenox before and after ablation, in order to reduce the risk of bleeding complications during ablation from warfarin. A genetic clotting disorder may increase the risk of bleeding complications during AFib ablation, but it is not an absolute contraindication to ablation. The decision to undergo ablation should be based on the severity of symptoms that you have during Afib, and whether or not the Afib is adequately controlled by the antiarrhythmic drug you are on. If your symptoms are significant, and the arrhythmia is not well controlled by antiarrhythmic drugs, then ablation would still be an option for someone with your history.

Hello Doctor I\'m 51 yr old male. I have been diagnosed with \"Acquired PV Stenosis from PVI Ablation\'s (3). I\'m looking for information on where to go for treatment ( an experienced and successful Center) for PV stenosis treatment. I\'ve been told I have stenosis of all four veins; LSPV 80%, LIPV 50% and the other two I was not given a number. I am experiencing some shortness of breath upon exertion, I can\'t seem to tolerate more than 700mg of sodium and/or hardly any exertion or I go into A-fib with elevated H. Rate ranging from 90\'s to 115 for 6 to 12 hours until I go back into Sinus Rhythm after taking my 60 mgs of Sotalol 3 times a day. One, do you think my symptoms as I described warrant treatment, and two, where would you go if you were in need of this kind of treatment (in the U.S.)? Thank you.
2013-03-04 Answered By : Dr. Gregory Feld M.D., F.A.C.C. F.H.R.S.

It would be important to distinguish whether your symptoms of shortness of breath occur with exertion, at times when you are not in atrial fibrillation. If the shortness of breath occurs with exertion, when you are not in atrial fibrillation, it may suggest that the PV stenosis is responsible for your symptoms. A right heart catheterization, with selective PA pressure measurements, and possibly a transseptal LA catheterization with PV angiograms and trans-stenosis pressure measurements may be required to determine if the 80% stenosis warrants angioplasty or stenting. A stenosis over 80% is likely to cause symptoms, and can be treated by PV balloon angioplasty, but may require stenting if the stenosis recurs after angioplasty. A stenosis of 50% or less is not likely to cause symptoms, and would typically not require treatment. In contrast, if your symptoms are primarily related to the atrial fibrillation, then more aggressive treatment with a higher dose of sotalol (up to 160 mg twice a day) or an alternative antiarrhythmic drug may be required to prevent its recurrence. We have performed a number of PV angioplasty and stent procedures at our center (University of California San Diego, Sulpizio Family Cardiovascular Center), for patients that have been referred to us, with good results and relief of symptoms. A center that performs a large number of AF ablations, will likely have a program to treat PV stenosis as well.

Im a fit athletic 23 year old male...all natural (no sterioids). I eat well and am the ideal weight. I only go into A-fib occasionally when I choke/vomit, donate blood, or get inebriated (the later happens rarely. It was in early college days when this was discovered). It was discovered I had high blood pressure in High School in which I was in denial about. (Why? no family history, Im young and healthy). I saw several doctors at NYU, St. Francis in Roslyn and No. Shore University hosp.) I had a 2 week heart monitor in which the report found nothing except a few normal palpitations and irregular heartbeats. Some Drs say it is not worth the risk and some say to go for getting ablated. I really cant be bothered getting cardio-verted in the ER 1 or 2Xs a year. Im am presently on 50mg of tenormin and 75mg of effexor. My BP has been at bay ever since I started these about a year ago. I really dont want to be on forever meds so early in my life. My Dr. prescribed these both because he felt I was stressed and under pressure being on a college ball team trying to make it in the majors. Im done now. Can I get weaned off? Will the afib come more often if Im off these meds? One of my past Drs. was reluctant to prescribe a pill in the pocket just in case... he says its too dangerous for me. why?? He gave it to me once but it took 12 hours before it kicked in for me. I also went for a vigorous run for a few miles and came out of a-fib. Can I have a heart attack from it? I have also seen endocrinologists to rule out other conditions like pheocromocytoma and cushings disease. All bloods,EKG and Echo normal and checked yearly. What is your opinion? Please help. Thank you Dr.
2013-03-04 Answered By : Dr. Gregory Feld M.D., F.A.C.C. F.H.R.S.

There may not be an appropriate answer for your many questions, but I will try to answer them as best I can. Your Afib sounds vagal in nature, in that the triggers are typically vagal. High blood pressure is also a common cause of Afib. At the present time, if your episodes are infrequent, a pill-in-the-pocket approach may be quite reasonable. If your doctor observes you for a few hours after your first episode of AF treated with a pill-in-the-pocket approach, and there are no adverse effects, then this approach may be safe and effective for you. If the frequency of your episodes of Afib is unacceptable to you, then a daily dose of an antiarrhythmic drug may be appropriate, or an ablation may be a reasonable next step. Afib is unlikely to cause a heart attack, but Afib can cause a stroke if you have significant risk factors such as hypertension, or the episodes last over 48 hours before conversion. Primary hypertension (i.e. no endocrine cause) is unusual for someone your age, but weaning off your medications could be dangerous if your blood pressure rises, so it should be watched closely if you try to wean off your medication. This may be possible however in some cases. Currently, renal artery denervation has been shown to be an effective treatment for hypertension in some cases, and many advanced medical centers are performing this procedure, as well as Afib ablation. A combined treatment may be appropriate in a case such as yours.

I have been having 7-10 episodes of paroxysmal Afib per month and I treat them with \"pill in the pocket \" taking 450 mg of Propafenone. These episodes go away after 2-3 hours. Is there any problem in doing that ? Do I cause any damage to me heart by letting these episodes take place and then treat them ? Do I take a risk by what I am doing to develop a permanent Afib ? My Heart is otherwise completely normal. I do appreciate your reply. Thank you
2013-03-04 Answered By : Dr. Gregory Feld M.D., F.A.C.C. F.H.R.S.

Treatment with a pill-in-pocket approach is often an acceptable approach for control of symptomatic atrial fibrillation. The decision to begin daily suppressive treatment with an antiarrhythmic drug (e.g. propafenone twice a day or three times a day) is dependent on the frequency of episodes and the patientís decision as to what is too frequent to continue using the pill-in-the-pocket approach. In my experience, 7-10 episodes of AF per month would generally be considered too frequent for the pill-in-the-pocket approach, and require daily suppressive therapy, and if this fails to control the AF, then ablation would be considered. The risk of too frequent episodes of AF is that this may lead to electrical remodeling and ultimately damage to the atrium and development of persistent AF. With your frequency of episodes it may be reasonable to consider daily antiarrhythmic drug therapy or ablation. You also have to consider your risk factors for stroke (i.e. CHADS2 score, Congestive heart failure, Hypertension, Age over 75 years, Diabetes, Stroke), which are independent of the frequency of paroxysmal AF or persistent AF, but nonetheless may require treatment with anticoagulants if high enough.

I was diagnosed with paroxsymal afib in early September. I am a 52 year old woman with no other heart or medical issues. My only symptom of Afib is palpitations. I have only had two short (less than 1 hour) episodes of Afib since my diagnosis. I find them extremely unsettling. My EP prescribed very low dose metoprolol and said since my episodes were so short and infrequent I could go without any drugs. He also told me that episodes of that duration are not long enough to cause a stroke. Do you agree with that? I want an ablation but he feels my symptoms and severity don\'t justify one at this time. What are your thought? Thanks-Sue
2013-03-04 Answered By : Dr. Gregory Feld M.D., F.A.C.C. F.H.R.S.

Recent studies have shown that a duration of AF of even 5 minutes, in patients with pacemakers that recorded such episodes, may increase the risk of a stroke. However, the risk of stroke is more precisely predicted by oneís CHADS2 or CHA2DS2VASC scores. There is some discrepancy between the two scores, the latter being a bit more conservative. Since you are under age 65 your CHADS2 score is 0 and your CHA2DS2VASC score is 1 (female gender). In either case, the guidelines do not recommend anticoagulation with warfarin, but possibly only aspirin. With regards to your treatment to prevent Afib, I would also recommend metoprolol first and then if your Afib recurs and is symptomatic, I would consider adding a class 1c drug such as flecainide or propafenone to help suppress the Afib (since you have no history of coronary artery disease). If antiarrhythmic therapy fails to control your Afib, then an ablation may be appropriate.

Hello. I have had a-fib espisodes a few times a year for several years but in past six months has become weekly. Have been on Rythmol and now Tikosyn, but still having very symptomatic episodes weekly for about 4 hrs duration almost always at night. Considering abalation now. I also take small dose- first 25 now 12.5 of metoprolol. Have asked my doctor about what I have read about beta blockers not being advised for vagal a-fib, (he agrees that is what it prob. is) but he does not see it as a problem. WOndering if I have been taking wrong medications? should I try flecainide before ablation. Thank you
2013-03-04 Answered By : Dr. Gregory Feld M.D., F.A.C.C. F.H.R.S.

Whether the episodes of AF tend to be vagal in nature or not, we still often use a beta blocker to control ventricular response, if rapid, during AF. An alternative drug for rate control is a calcium blocker such as diltiazem, which will not aggravate bradycardia like a beta blocker. Having failed one or two drugs, at optimal doses, makes you a candidate for ablation of paroxysmal AF at this time. You could certainly try flecainide, but it may not provide better results than propafenone. In clear cut cases of vagally mediated AF, we have also tried disopyramide (Norpace), in some cases successfully, since it has vagolytic properties.

I have a family hx of HCM resulting in sudden cardiac dath. I had an episode 4 years ago (age 38) in which I experienced a pulseless arrest, have since had an ICD/pacemaker placed, have had a couple of EP studies, multiple episodes of a fib (rate 160-200), an unsuccessful pulmonary vein isolation (was warned it may be unsuccessful due to my enlarged left atria...6cm on last echo), and have been on multiple anti-arrhythmics (Sotolol, Amiodarone, Dronedarone, and now Tikosyn). The a-fib is my biggest problem. Although the current combination of Tikosyn with Atenolol are controlling it fairly well, I still have short episodes of rapid a fib (lasting 5-30 seconds) that are very intolerable. I become dizzy, lightheaded, and develop chest pain. This is obviously very anxiety provoking as I feel so poorly, and have experienced multiple shocks from my ICD due to rapid a fib rates and occassional deterioration of afib into v tach. What would you recommend next? Should I consider a pulmonary vein isolation again?
2013-03-04 Answered By : Dr. Gregory Feld M.D., F.A.C.C. F.H.R.S.

It sounds as though you have tried most available antiarrhythmic drugs without effect. An important thing to remember is that these drugs should be used in a maximally tolerated dose, before considering them to be ineffective. A simple PV isolation procedure may be insufficient in patients with HCM and left atrial enlargement. A more extensive substrate- based ablation, including linear ablation, and in some cases ablation of CFAE or dominant frequency areas, may increase the success rate for AF, and would frequently be recommended in a case such as yours. In some cases, a minimally invasive surgical ablation of AF (mini-MAZE) with or without additional endocardial catheter ablation, might improve the results overall. Lastly, an AV node ablation may eliminate your rapid ventricular response to AF, especially since you have an ICD/pacemaker already implanted. Unfortunately, AV node ablation may increase the rate of progression of paroxysmal to persistent AF, and the lack of atrial kick during AF may also create physiologic problems in someone with HCM.

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