"This book is incredibly complete and easy-to-understand for anybody. I certainly recommend it for patients who want to know more about atrial fibrillation than what they will learn from doctors...."

Pierre Jaïs, M.D. Professor of Cardiology, Haut-Lévêque Hospital, Bordeaux, France

"Dear Steve, I saw a patient this morning with your book [in hand] and highlights throughout. She loves it and finds it very useful to help her in dealing with atrial fibrillation."

Dr. Wilber Su Cavanaugh Heart Center, Phoenix, AZ

"Your book [Beat Your A-Fib] is the quintessential most important guide not only for the individual experiencing atrial fibrillation and his family, but also for primary physicians, and cardiologists."

Jane-Alexandra Krehbiel, nurse, blogger and author "Rational Preparedness: A Primer to Preparedness"


"Steve Ryan's summaries of the Boston A-Fib Symposium are terrific. Steve has the ability to synthesize and communicate accurately in clear and simple terms the essence of complex subjects. This is an exceptional skill and a great service to patients with atrial fibrillation."

Dr. Jeremy Ruskin of Mass. General Hospital and Harvard Medical School

"I love your [A-fib.com] website, Patti and Steve! An excellent resource for anybody seeking credible science on atrial fibrillation plus compelling real-life stories from others living with A-Fib. Congratulations…"

Carolyn Thomas, blogger and heart attack survivor; MyHeartSisters.org

"Steve, your website was so helpful. Thank you! After two ablations I am now A-fib free. You are a great help to a lot of people, keep up the good work."

Terry Traver, former A-Fib patient

"If you want to do some research on AF go to A-Fib.com by Steve Ryan, this site was a big help to me, and helped me be free of AF."

Roy Salmon Patient, A-Fib Free; pacemakerclub.com, Sept. 2013


Difficult Cases in Atrial Fibrillation Management

by Steve S. Ryan, PhD

One of the most hotly discussed cases at this years Symposium was that of a 14-year-old boy who developed A-Fib. This case was presented by Dr. Claudio Tondo from the Centro Cardiologico Monzino of Milan, Italy. (This is the youngest person the author has ever heard of who developed A-Fib.) The boy regularly exercised intensely (the type of exercise was’t specified). He developed frequent palpitations throughout the day not necessarily related to the times he was exercising. He felt very weak. ECGs and Holter monitoring revealed frequent, repetitive atrial ectopic beats and sustained episodes of A-Fib. They gave him atenolol to slow his heart rate, but it had seemingly no effect. His family didn’t have a history of A-Fib.

As in previous Symposiums, audience members had remotes where they could select 1-10 choices. Dr. Tondo gave the audience the following choices:

  1. Stop sport activity and increase beta-blocker dose.(No one selected this. Beta-blockers don’t normally stop A-Fib.)
  2. Add an AAD (antiarrhythmic drug) and see how it goes. (12% selected this. An AAD might restore him to sinus rhythm. But no one has much experience prescribing antiarrhythmic drugs to young children.)
  3. Discontinue beta-blocker therapy, impose no physical activity for at least three months and prescribe OAT (oral anticoagulant). (No one selected this. It’s very doubtful that someone this young and athletic would be at a real risk of an A-Fib stroke.)
  4. No beta-blocker, no sport and just add aspirin. (2% did select this. I have no idea why. Many studies have shown that aspirin has very limited effectiveness in preventing A-Fib stroke. Aspirin has been removed from the current guidelines.)
  5. Give him Class 1C AAD + ILR to monitor the frequency of arrhythmias.(11% selected this. It seems a better choice than #2 above. But one wonders how well an active 14-year-old boy would tolerate a monitor.)
  6. Counseling patient and parents about the nature of the arrhythmia(s), highlighting the clinical risk of sustained and frequent A-Fib episodes. Making them aware of the different therapeutic choices. (48% selected this.I personally think this is a horrible and cruel choice. You are basically leaving this 14-year-old in A-Fib with his heart jumping around in his chest. He has got to be terrified, not to mention the frustration of no longer being able to play the sport he obviously loves.)
  7. Mapping of atrial arrhythmias, define the sites or origin and ablate. (27% selected this choice including me. A 14-year-old can’t possibly have developed an extensive type of A-Fib. An ablation for him would be relatively simple. There is probably no need to ablate (isolate)) all four of his Pulmonary Vein openings. In fact, it would probably be a mistake to burn all four of his veins unnecessarily. Doctors take an oath to do no harm. [Back in 1998 when I had my Pulmonary Vein Ablation (Isolation) (PVI), only one of my veins was isolated. I’ve been A-Fib free for 14 years.] Once this young boy is cured and matures, he may never have A-Fib again.)

Dr. Tondo decided on option #6 to treat this young boy. He succeeded in convincing him to not play his sport for three months (this kid must have been really terrified of his A-Fib to agree to this.) But he was still highly symptomatic and had long periods of A-Fib. In addition, he had frequent nose bleeds from taking low molecular weight heparin (an anticoagulant).

Dr. Tondo then performed an ablation and only had to isolate one vein to stop the young boy’s A-Fib (it probably would have been considered overkill to ablate all four PVs on this young boy. Why perform any damage to his other veins when he may never have A-Fib again?) He was released on low molecular weight heparin. He had further complications but is now doing well.

Some doctors asserted that you don’t take a 14-year-old into the lab without a lot of soul searching. Others countered that patients like this often have a rapid-firing focus on a particular vein. When it is ablated, they do very well.


Last updated: Tuesday, December 2, 2014

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