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February 19th, 2018
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I have had permanent afib for 7 years that has been rate controlled by carvedilol. Recently I was put on amiadarone and cardioverted and am in NSR for 3 weeks. I am trying to get an ablation and wonder if I need to get off amiodarone before the procedure. Can the Dr map the trigger spots while I am in NSR? Are the pulmonary veins checked for triggers or just routinely ablated? Also does a LAA occlusion reduce the EF ?
2017-12-12 Answered By : Dr.Rakesh Gopinathannair

Thank you for this question. There is a lot of debate on how best to ablate long-standing afib but achieving durable pulmonary vein isolation still remains the cornerstone. I do not think you need to stop amiodarone prior to ablation. Although approaches vary, pulmonary veins are routinely isolated in all approaches. Beyond that, there are diverging practices. My approach would be to do pulmonary vein isolation, then do a 3D voltage map to assess amount of scarring in the atrium to see if there are potential areas that would need ablation, which can be a linear ablation (ablating a small area in a linear fashion) or focal ablation (ablating a particular spot). Following that, I will use escalating doses of a medication called isoproterenol (similar to adrenaline) to induce afib and look for potential triggers and ablate the triggers. Once completed, I will likely continue, along with blood thinners, amiodarone at a small dose (100-200 mg/day) for about 6-9 months to maintain normal sinus rhythm and allow favorable electrical remodeling of upper chambers of the heart. I believe it is important for your heart to get used to normal rhythm after being out of rhythm for 7 years. Also very important in the post-ablation period would be aggressive lifestyle and risk factor modification including weight loss (lose at least 10% of your body weight), testing for and treating sleep apnea if you have that issue and maintaining strict control of blood pressure and, if you have it, diabetes. I do not think LAA occlusion has any clinically significant negative impact on ejection fraction. Wish you the best!

Hi!Can be access via jugular veins and subclavia veins also successful if we compare to stereotaxis robot intervention.I have obtrs,v.cava inferior no access to femoral veins.Maris
2017-12-12 Answered By : Dr.Rakesh Gopinathannair

Thank you for your question. The success of approach through jugular or subclavian veins depends on what arrhythmia is being treated and which chamber it is coming from. I could only find one report of a stereotaxis guided ablation from the left subclavian and that was for treating an extra electrical pathway (accessory pathway) in the right side of the heart. I am also aware of a report that used stereotaxis for ablation of afib (pulmonary vein isolation) approaching through the femoral artery in groin through aorta and then into the left atrium that way. Best wishes!

I have had chronic a-fib for 7 years and am reasonably rate controlled. I have a 30 % EF. I have been trying to get an ablation , to minimize my drug intake and to improve my EF. Are these reasonable expectations? My a-fib was preceded by a lymes infection that seems to be successfully treated and my overall health has always been good.
2017-12-12 Answered By : Dr.Rakesh Gopinathannair

Thank you for this question. If there are no other causes for your low EF (such as heart artery blockages/prior heart attacks etc), it is likely that the long-standing afib is the likely reason behind your low EF. This is also called arrhythmia-induced cardiomyopathy. In this scenario, restoring and maintaining normal sinus rhythm, although easier said than done, can likely result in partial or complete recovery of your EF (it may take anywhere between 2-4 months to see an improvement, if any, in the EF). In my opinion, catheter ablation, along with a prolonged course (9-12 months) of an anti-rhythm medication such as amiodarone or dofetilide would be your best option. Given this scenario, I would highly recommend restoration and maintenance of normal sinus rhythm to give your heart a chance to see if the EF can recover. The goal of ablation here is not to get rid of anti-rhythm drugs but to improve/normalize heart function. Long-term success will depend of how enlarged the atria/upper chambers are as well as other factors but I would say that with 1-2 ablation procedures and 9-12 months of an anti-rhythm drug such as amiodarone or dofetilide, you have a good chance to get back and stay in sinus rhythm and potentially improve your heart function. Good luck!

I have had 5 ablations and after the 5th one (atrial appendage area) I have been Afib free for 10 years. I do suffer from Pacs, but I can mostly manage them by my diet and controlling stomach acid. I am a 65 yr. old woman, and have recently been diagnosed with osteoporosis by a Dexa scan. I have no symptions, no height loss, stay fit, and have normal weight and good health. My question is my concern for the medicines prescribed for osteoporosis. Will they increase my risk fo a reincurrance of Afib by the medicine alone, or by stomach upset which could lead me into a pattern of irregular beats, rhythms and potential Afib. Thank you for your help.
2017-12-12 Answered By : Dr.Rakesh Gopinathannair

Studies have shown association between acid reflux and PACs/atrial fibrillation, although the exact mechanisms are unclear. It may have to do with causing alterations in the nervous system that controls the heart rate and blood pressure. I think in your case, the stomach upset/acid reflux, is perhaps the likely culprit than the osteoporosis medications alone. The focus, in my opinion, should be in successfully combating the acid reflux/stomach upset symptoms. All the best!

I decided I will have an ablation in September and I wanted to ask you for a comment on one technical problem. I am deciding between Johns Hopkins and the Northern Virginia Hospital. It is not the location what is important but it is a slight difference in the interpretation of two electrophysiologists what in my case will be ablated. Both doctors will do the cryoablation. I have paroxysmal atrial fibrillation vagally mediated. The vagal character of my Afib was in the past acknowledged but basically received no attention. At Johns Hopkins the cryoablation would also include the ablation of the ganglia in the fat pads that are connected with parasympathetic system. In the Northern Virginia hospital the electrophysiologist maintains that the cryoablation will be pursued just by ablation of the four pulmonary veins in the left atrium and he will not ablate anything outside of the pulmonary veins; specifically the ganglia in fat pads that are above or outside of the four pulmonary veins. His reason is the following: parasympathetic system that is represented by ganglia in the fat pads that could trigger the pulmonary veins and these veins would trigger the atrial fibrillation. Considering that the pulmonary veins will be ablated those ganglia have nothing to trigger and therefore it is not necessary to ablate them. The ganglia would anyway regrow again. How would you target ganglia while doing cryoablation? I have been searching for any answers and reading even the article of Dr. Jackman about the fat pads and I have difficulties to decide what is right. I would appreciate if you could just give me some indication where to seek an answer or what is logical in this case.
2016-12-06 Answered By : Dr. Pugazhendhi Vijayaraman, MD, FACC, FHRS

If you are a healthy young individual with normal left atrium, and paroxysmal atrial fibrillation, Cryoablation is a reasonable first step. The work by Dr. Jackman had been fascinating but studies have not provided convincing evidence that ablation of fat pads with ganglionic plexi increase success rates compared to pulmonary veins alone. We have seen significant vagal modification during cryoablation of right sided pulmonary veins without specifically targeting the ganglionic plexi. Whether it is cryoablation or radiofrequency ablation, isolation of the pulmonary veins is the first step that all electrophysiologists agree upon in the treatment of paroxysmal AF.

I have had what amounts to three ablations for my A.Fib and none of them worked. I just suffered through all kinds of tests and had to take heavy doses of Multaq and blood thinners. The worse part was having to swallow a camera. One of the Nurse Practitioners was honest enough to tell me that none of those ablutions and treatments worked. I stopped all medications and blood thinners. I am one of those people who knows when I am getting an attack of A.Fib. It lasts for 6 to very rarely 21 hours, mostly 12 to 18. I get the attacks every 7 to 21 days but mostly 9 to 12. The Verapamil has no effect but to cause my heart to pause. I now have a pacemaker which prevents me from passing out. I refused to take Metoprolol because it causes me to feel like a zombie. Unless you come up with a tried method to really stop those A. Fib attacks I do not want to waste my time reading up on this subject. Thanks. Sincerely, Liliane Stern
2016-12-06 Answered By : Dr. Pugazhendhi Vijayaraman, MD, FACC, FHRS

Atrial fibrillation is a complex disease and requires individualized approach. It is unfortunate that despite 3 ablations you still get frequent AF episodes. It is possible to get better control of your AF with different antiarrhythmic therapy as there are several other medications available to treat your AF. The most important aspect of AF care is to ensure that your stroke risk is reduced with appropriate blood thinners based on your risk profile. If you do not tolerate metoprolol or verapamil, Av node ablation to prevent rapid heart rates may be an option to consider.

Hello, I had an ablation done in Bordeaux 14 months ago. I went from multiple daily episodes of Afib to nothing except some occasional pacs (though these can get bad during times of stress). Is there anything I can to to help prolong this \\\"cure\\\", maintain success and prevent reoccurrence? By this I mean is there anything in the literature but also is there anything in your professional opinion. (Supplements, diet, exercise, etc) interestingly for me, intense physical activity seems to make the ectopics worse afterwards.
2016-12-06 Answered By : Dr. Pugazhendhi Vijayaraman, MD, FACC, FHRS

This is a very good response considering your daily episodes of AF. There is clear evidence that regular aerobic exercises 20-30 minutes a day x 5 day a week, even modest weight loss, adequate control of BP and diabetes greatly improve the long term outcome of preventing AF. In case of PACs avoiding stimulants such as caffeine and alcohol should help. Small dose of betablockers may also reduce your PACs. High levels of adrenaline after intense exercise may precipitate premature beats. Exercising at 70% of predicted maximal heart rate would be reasonable alternative.

In 2006 I had heart bypass with the installation of a metal valve coupled with a pacemaker. After 8 years of regular yearly pacemaker checks, in late 2014 i had a treadmill test which resulted in my heart only functioning one side. The cardiologist recommended an ICD implant which took place in early 2015. I was informed the surgery would take place under GA, the surgery commenced under LA, the pain was excruciating . After regular 6 monthly device checks it was noticed that the implant was protruding outwards, which caused a continual bruising pain and uncomfortable whilst sleeping. I am informed by the hospital that the protrusion can cause infection if not treated. The consequence of this is a second round of surgery to insert the ICD in deeper pocket this to rectify the substandard surgery of the first instants.
2016-12-06 Answered By : Dr. Pugazhendhi Vijayaraman, MD, FACC, FHRS

It appears that you received an appropriate upgrade of your pacemaker to an ICD due to weakening of your heart muscle function. Rarely if there is undue pressure on the skin from the device, it may cause breakdown of skin and infection. If there is impending risk for skin breakdown it is reasonable to revise the pocket before it happens. It may relieve the pain and discomfort from the pressure.

For the past 10 years, I have had paroxysmal afib episodes usually lasting 4-8 hours each time before spontaneously reverting to sinus rhythm. During episodes, am mildly symptomatic with lightheadedness, SOB, and weakness. Have gone as long as 1 year between noticeable episodes. Seem to have AF episodes associated with viral illness like URI. Do not use alcohol and caffeine. Took only aspirin for many years. Am now 66 years old female so have gone on warfarin. Have pill-in-pocket diltiazem and flecanide available but have never used as have always spontaneously reverted to SR within 8 hours. Have seen electrophysiologist to discuss ablation pros and cons and am uncertain about undergoing the risks of the procedure when episodes are infrequent and symptoms mild. What are your thoughts on that? Also, is there a \\\"window of opportunity\\\" that may be lost if I do not have the ablation procedure while I am relatively young and in overall good health?
2016-12-06 Answered By : Dr. Pugazhendhi Vijayaraman, MD, FACC, FHRS

You seem to have stable paroxysmal AF. Given the fact that your episode lasts upto 8 hours it is reasonable to use flecainide and diltiazem within 20-30 minutes of onset to try to shorten the duration of these episodes to 1-3 hours. If you only have 1-2 episodes per year, ablation is a choice and not a must. If the episodes become more frequent then catheter ablation is a very reasonable choice at that time.

I was diagnosed with paroxysmal afib in 2009. I have also had a lifelong history of pvc\\\'s. My doc has me on 50mg flecainide twice a day with 25 mg metoprolol split into half morning half evening. In the last year, my pvc\\\'s have become worse and worse. Usually they occur after dinner in the early or late evening. Lately I have been having them at night, when I try to sleep. I also possibly have sleap apnea, and have a PAC machine that I rarely use ( it\\\'s just too uncomfortable to wear that mask ). My doctor has always dismissed my pvc\\\'s, yet they scare me more than the afib. I have only had a few short episodes in all the years I have been taking the meds. The fact that the pvc\\\'s sometimes, preclude a bout of afib. Should I be concerned? When I have them, it\\\'s usually every third or second beat. They make me feel lightheaded and nervous. I had short bouts of afib on Thanksgiving, Christmas and this past Easter. Seems they always happen on holidays. I have wondered if it has to do with the stress, or with overindulgence. I do not drink. Doc has told me if this happens again, I am to use the \\\"pill in the pocket\\\" procedure. He told me to take six 50mg pills at once. This scares the heck out of me, as another doctor had suggested that my pvc\\\'s are being caused by the flecainide. My Doc says this is the normal procedure. Is that true? I am terrified to take this high a dose of flecainide!
2016-12-06 Answered By : Dr. Pugazhendhi Vijayaraman, MD, FACC, FHRS

PVCs and AF are different arrhythmias but both may respond to flecainide and metoprolol. It is possible that a higher dose of flecainide and metoprolol may suppress your PVCs and AF better. When we use pill in the pocket approach, the total dose of flecainide including your maintenace dose in 24 hrs should not exceed 300 mg. It is less likely that flecainide is causing your PVCs. If your daily PVC burden is high, then further discussion with your doctor about alternative options including catheter ablation may be considered.

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