Flecainide as well as other antiarrhythmic drugs that are “loaded” in a patient prior to cardioversion do improve the chances of staying in sinus rhythm, and if sinus rhythm can be maintained for a long duration, then weaning off the antiarrhythmic drug may be reasonable with the understanding the AF may recur. General anesthetics as well the surgical procedure itself can incite a generalized inflammatory state and alter the normal balance of neurohormones in the body that can induce AF.

Your doctor is correct from the perspective of the current literature, but that’s not the complete story nor the end of the discussion – rather it is the beginning of a very long discussion and life choices that may be difficult. First the patient and family have to be willing to accept that a medical problem that is causing no symptoms or deterioration in health does not necessarily need treatment (as your doctor said). Further in medical literature we often look at whether a medical problem will shorten lifespan to help determine if the problem should be treated – in this case a study know as the AFFIRM trial demonstrated that AF is not better than sinus rhythm from a mortality perspective. HOWEVER, this is a very skewed and limited view of the problem. For most people death is not the concern, but rather their quality of life. Lifestyle and quality of life may deteriorate over time, not to mention physical health, and by then many more medical problems may manifest that potentially could have been prevented by attempting to restore and maintain sinus rhythm. Also, the longer AF is allowed to exist/persist the worse the chances of ever restoring regular rhythm, the familiar adage “AF begets AF”, and this is particularly relevant to later life, when AF will require long-term and likely lifelong blood thinners and possibly other treatments for the secondary problems that can develop. Alternatively treating AF too aggressively can be wrought with its own problems. There are many other dimensions but these are the big issues. You are always entitled to a second opinion but you must also be willing to accept the opinion of the physician rendering the second opinion, keeping in mind that individual physicians all have differing opinions on how AF should be managed – internists differ from cardiologists, who differ somewhat from electrophysiologists.

Dr. Natale is an accomplished electrophysiologist and one of our former fellows from Aurora Sinai/St. Lukes Medical Centers, Milwaukee, WI. The location of the ablation is likely immaterial and I’m sure his outcomes are the same at both sites.

<p>There are many triggers for AF including alcohol, caffeine, adrenaline, and changes in hormonal state that occur during sleep.</p>

The development of AF is a long road with many different directions and final destinations – some people don’t feel it and others feel every single beat. The ability to control AF differs from patient to patient because everybody’s AF is different, depending on their specific medical condition(s), lifestyle, and general habits. Believe it or not, some people who are “too healthy”, that is competitive athletes or people with athletic physical conditioning have a different neurohormonal makeup than the general public – they often have lower resting heart rates related to elevated “vagal” tone from being in peak physical shape. Vagal tone is increased also at night, and we do see that in some people elevated vagal tone provokes AF. Sometimes a degree of “deconditioning” is required to reduce vagal tone. This does not relegate one to a sedentary life, but it may be different than the physical activity level and lifestyle you describe. Amiodarone is the strongest of antiarrhythmics available but if that is not effective in maintaining sinus rhythm after cardioversion, there are less potent antiarrhythmics that your particular physical make-up may still respond to better, such as Dronedarone (Multaq) – there may be some evidence that Multaq works better in people with vagally-mediated AF. If medications are unsuccessful, then an ablation is likely the next best step to prevent or at least reduce your AF burden.

Cardioversion is very safe and there is generally no limit to the number of cardioversions that can be performed, though patient’s and their doctors may decide that in specific situations cardioversion may be less effective or even unsafe (e.g. presence of left atrial clot), and therefore not worth attempting.

Yes. Atrial fibrillation is simply a chaotic and erratic electromechanical state of the atria and actually has nothing to do with the ventricular response. The heart rate in AF reflects the ventricles’ ability to respond to the atrial rate in atrial fibrillation.

There are many triggers for AF including alcohol, caffeine, adrenaline, and changes in hormonal state that occur during sleep.

Sotalol is usually effective in suppressing AF or reducing episodes, and the electrophysiological effects of Sotalol on heart cells – prolongation of effective refractory period – is opposite to the changes that are seen in patients who develop AF. However, conceivably the heart-rate slowing effect of Sotalol may permit more time for APCs/premature beats to develop between heart beats and these APCs are often triggers for AF. Also this may be compounded by increased “vagal” tone which occurs during sleep that also promotes AF occurrences. Hence pacing people at a heart rate just faster than their own rate has been shown in some studies to reduce AF occurrences. The development of AF is a long road with many different directions and final destinations – some people don’t feel it and others feel every single beat. The ability to control AF differs from patient to patient because everybody’s AF is different, depending on their specific medical condition(s), lifestyle, and general habits. Believe it or not, some people who are “too healthy”, that is competitive athletes or people with athletic physical conditioning have a different neurohormonal makeup than the general public – they often have lower resting heart rates related to elevated “vagal” tone from being in peak physical shape. Vagal tone is increased also at night, and we do see that in some people elevated vagal tone provokes AF. Sometimes a degree of “deconditioning” is required to reduce vagal tone. This does not relegate one to a sedentary life, but it may be different than the physical activity level and lifestyle you describe. Amiodarone is the strongest of antiarrhythmics available but if that is not effective in maintaining sinus rhythm after cardioversion, there are less potent antiarrhythmics that your particular physical make-up may still respond to better, such as Dronedarone (Multaq) – there may be some evidence that Multaq works better in people with vagally-mediated AF. If medications are unsuccessful, then an ablation is likely the next best step to prevent or at least reduce your AF burden.

First it should be understood that not all people with AF progress require ablation. In fact ablation is just another treatment option - people who are symptomatic from AF and intolerant to or failing medical therapy are candidates for ablation, but ablation is not mandatory. There are other options including pacemaker implantation with AV junction ablation that can be done in most countries. Medical tourism exists and our particular institution participates. You can find more information at: http://www.onlinemedicaltourism.com/Aurora-St-Lukes-Medical-Center.html