Doctors & patients are saying about ''...

" is a great web site for patients, that is unequaled by anything else out there."

Dr. Douglas L. Packer, MD, FHRS, Mayo Clinic, Rochester, MN

"Jill and I put you and your work in our prayers every night. What you do to help people through this [A-Fib] process is really incredible."

Jill and Steve Douglas, East Troy, WI 

“I really appreciate all the information on your website as it allows me to be a better informed patient and to know what questions to ask my EP. 

Faye Spencer, Boise, ID, April 2017

“I think your site has helped a lot of patients.”

Dr. Hugh G. Calkins, MD  Johns Hopkins, Baltimore, MD 

Doctors & patients are saying about 'Beat Your A-Fib'...

"If I had [your book] 10 years ago, it would have saved me 8 years of hell.”

Roy Salmon, Patient, A-Fib Free, Adelaide, Australia

"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

"...masterful. You managed to combine an encyclopedic compilation of information with the simplicity of presentation that enhances the delivery of the information to the reader. This is not an easy thing to do, but you have been very, very successful at it."

Ira David Levin, heart patient, Rome, Italy

"Within the pages of Beat Your A-Fib, Dr. Steve Ryan, PhD, provides a comprehensive guide for persons seeking to find a cure for their Atrial Fibrillation."

Walter Kerwin, MD, Cedars-Sinai Medical Center, Los Angeles, CA


No Magic A-Fib Pill: Learn All Your Treatment Options

“To date, the magic pill that will permanently cure your A-Fib probably doesn’t exist.

‘Drugs don’t cure A-Fib. But merely keep it at bay.’ Dr. Dhiraj Gupta, Heart rhythm specialist, UK”

Don’t let your doctor leave you in A-Fib.

Educate yourself about Atrial Fibrillation. Learn about all treatments for Atrial Fibrillation. Review all your options on our page, Decisions About Treatment Options.

And always aim for a Cure!




Now A-Fib Free: A 23-Year Atrial Fibrillation Ordeal, Trial, Tribulations and Recovery

By Charn Deol, Richmond, British Columbia, Canada, May 2017
Personal A-Fib story by Charn Deol, BC, Canada at

Charn Deol, B.C., Canada

My medical issues with atrial fibrillation started when I was 43 in August of 1993 when I was aware of having a few skipped heartbeats. I had just returned to Canada having been working extensively for the last few years in Southeast Asia. About a week later, the irregular heart beating got worse in duration.

At the same time, a dull aching pain started in the left chest region the size of a 50-cent piece.

A-Fib Drugs Don’t Work, Chest Pain Condition Worse

Upon being sent to a heart specialist in September 1993, numerous drugs were prescribed to keep my heart in rhythm (digoxin, flecainide, sotalol). They did not work, some had serious side effects, and every few days I would go into atrial fibrillation.

The atrial fibrillation happened once or twice per week and lasted from a few hours to 24 hours. Then it would stop on its own, and the heart would go into normal sinus rhythm.

Second medical condition: At the same time, the very centered pain in the upper left chest area kept getting worse and added to the debilitation of daily life. These medical conditions started my long journey to find relief (cure) from two medical conditions that were not being controlled or cured by conventional medical treatments.

Alternative Healthcare Practitioners―India & China, Too

In my search for a cure(s), I met a family practitioner and other medical and alternative specialists who used treatment protocols that could be labeled ‘experimental’ or ‘out of the box’, as they say.

I was all mixed up as to what was going on in my body. This can be psychologically very distressing if you do not have a strong family/friend support network.

While discovering alternative medical treatments in 1994, I also went to India for Ayurvedic treatment [one of the world’s oldest holistic healing systems] and even to China for treatment. Most alternative (non-allopathic) medical practitioners look at the body as an interconnected processing unit and believed in my case that the pain in the left chest and the atrial fibrillation were connected. This was not the thinking of the allopathic doctors, so I was all mixed up as to what was going on in my body. This can be psychologically very distressing if you do not have a strong family/friend support network.

Having been to a multitude of healthcare practitioners, numerous chiropractors, massage therapists and other more esoteric healthcare practitioners (100s over the 23 years), there was no resolution to my medical condition.

Encainide Drug Therapy: Up and Out

The heart specialist that gave me sotalol [an antiarrhythmic drug] in 1995 gave me a dose that dropped the heartbeat to 30 beats per minute putting me into the emergency room, but the drug had no effect on my atrial fibrillation.

In 1996 seeing my third cardiologist, I was put on a drug called encainide [also an antiarrhythmic drug], to be used on an as needed basis [pill-in-the-pocket].  It worked and would stop my atrial fibrillation in approximately 20 minutes.

But it had no effect on the chest pain which was getting worse now with a pain spot in the left shoulder blade area also the size of a 50-cent piece having started out of nowhere.

Encainide is a class Ic antiarrhythmic agent. It is no longer used because of its frequent proarrhythmic side effects.

About 6 months after starting on the encainide, one of my friend’s son with a heart condition since childhood passed away. And I was told he had just been started on a new drug for him called “encainide” along with “sotalol”. The same cardiologist had been providing this drug free of charge to me, so I was pleased that it worked for me and cost me nothing.

The problem I found out was that it was illegal for the cardiologist to prescribe this drug because it had killed too many people. When he got caught, then encainide was no longer available. (Encainide is a class 1C antiarrhythmic drug no longer used because of its frequent proarrhythmic effects.)

Chelation for Very High Levels of Mercury

I had the highest level of mercury ever seen by the lab in any of their patients.

While all the above was going on, I was tested for heavy metals through urine analysis. It was discovered that I had the highest level of mercury ever seen by the lab in any of their patients (7400 nmol/dl). So I started protocols to take the mercury out of my body using chelation treatments with EDTA and then DMPS and DMSA (metal chelators).

At the same time, my other medical practitioners had me on oral and IV multivitamins and mineral protocols.

Mercury Cleared, Atrial Fibrillation Stops!

By 2000, the mercury was finally out of my system and my atrial fibrillation stopped! It is known mercury can concentrate in nerve tissue. While only a correlative relationship―mercury out of system―my atrial fibrillation did stop.

Chest Pain Condition Worse than Ever

From 2000 to 2010 I had NO atrial fibrillation. But the chest pain condition did not stop, and it got worse.

From 2000 to 2010 I had no atrial fibrillation. But the chest pain condition did not stop, and it got worse extending into my gut region. All medical protocols tried could not alleviate this pain, nor was any etiology discovered as to what was the underlying cause of the pain condition.

Thanks to my resiliency, I was still able to go hiking, skiing, travel and work part-time on my own schedule. But it took great perseverance.

After 10 Years A-Fib Returns―and Heavy Levels of Lead (This Time)!

In 2010, while starting a hike, the atrial fibrillation began again. The A-Fib would last 6-8 hours and occur an average of 2 times per week.

I was immediately tested for heavy metals again, and this time I had high levels of lead, not mercury. Even with thorough investigations of potential sources for this lead contamination in my body, no source was discovered. We worked (and continue to work) on getting these lead levels down (I had no high lead levels back in the 1990’s when tested―only mercury).

Amiodarone Bad Side Effects

I again began doing alternative treatments to deal with the atrial fibrillation and the pain condition, nothing worked. I went to China again for treatments, IV EDTA infusions again, etc., but the pain persisted at high levels and the atrial fibrillation kept getting worse.

A new cardiologist put me on a new drug called amiodarone. This drug lead to paranoia. This is another cardiologist I dropped.

In 2012, I saw a new cardiologist who put me on flecainide again. And when it did not work, he provided me with a new drug called amiodarone. This drug lead to paranoia and left me with an epididymitis in my right testicle which I suffer from to this day. (Epididymitis is inflammation of the tube at the back of the testicle that stores and carries sperm.) He had no compassion for my dilemma. This is another cardiologist I dropped.

Ablation in Vancouver, B.C. Fails―A-Fib Worse and More Chest Pain

By late 2014, the atrial fibrillation was occurring on average every second day and lasting 24-38 hours.  My next cardiologist sent me to the Atrial Fibrillation clinic in Vancouver where I was evaluated by an electrophysiologist. The A-Fib was very debilitating, so I was ready for surgery.

VIDEO: Catheter Ablation For A-Fib: What it is, How it’s Done and What Results Can Be Expected

WATCH A VIDEO: Catheter Ablation For A-Fib: What it is, How it’s Done and What Results Can Be Expected (4:15)

I asked for the most experienced electrophysiologist at the clinic to do the surgery. I waited an extra 3 months for the surgery because this highly qualified electrophysiologist was in so much demand.

Finally, in November 2015 I had the ablation therapy (it took approximately 2.5 hours). I came out of the surgery worse than ever. The atrial fibrillation did not stop, and the pain was worse than ever in my left chest, left shoulder-blade and gut regions.

AV Node Ablation & Pacemaker?―No! No! No!

The electrophysiologist wanted to wait for the 6 month recuperation period after the ablation therapy to see if I would go into regular sinus rhythm. By September 2016 (9 months later), I was worse than ever. In November, I saw my electrophysiologist under the impression that he would do another ablation treatment, since I was told and with my own research had confirmed that ablation treatments may be required for up to four times for the treatment to work.

This “top” electrophysiologist recommended I have a pacemaker put in and the AV node be ablated instead, so that the pacemaker could take over the regular beating of the heart. I asked the electrophysiologist why not do further ablation treatments as per the standard practice. He said if that is what I wanted, he would do another ablation. This was quite disconcerting―I am relying on his extensive knowledge to help me in a field where I am no expert. We agreed to set up a surgical date for a second ablation on December 12, 2016.

My gut said to ‘no longer trust’ this supposed best electrophysiologist at the hospital.

Upon leaving the office and arriving home, I informed my wife of the unpleasant appointment I had with the electrophysiologist, especially his lackadaisical attitude towards my serious heart condition. As a patient, the relationship is somewhat like that of a child with a parent. The patient is naïve, scared, distraught and looking for a path of reassurance from the medical profession. This was not the case in this situation.

This is when “gut instincts” come into play. My gut said to ‘no longer trust’ this supposed best electrophysiologist at the hospital and search for an alternative path. (And I canceled my December 12, 2016 scheduled ablation.)

Counseling with Steve Ryan

Having been a reader of Steve Ryan’s website, I reached out to him and agreed for him to become my advocate and provide me with advice on how to deal with my current concerns over either going along with having a pacemaker placed in my chest along with ablation of the AV node OR to try a second ablation. Steve recommended a second ablation and the Bordeaux Clinic―it was too early to place a pacemaker/ablate the AV node at this stage.

Following this detailed discussion with Steve, I spoke with my wife and got a hold of the Bordeaux Clinic in France on December 2, 2016. With some back and forth email communication, ablation therapy was arranged for December 12, 2016. Somehow with luck and quick action, my wife and I were on an airplane to France and arrived in Bordeaux on December 10.

Second Ablation in Bordeaux and Use of CardioInsight Vest

The surgery on December 12 was done by Prof. Mélèze Hocini. Instead of taking the standard time of 2.5 to 3 hours for the surgery, it took well over 6 hours until approximately 4 pm. Dr Hocini was on her feet and exhausted.

My surgery was much more complicated than envisioned, and there were many areas that had to be ablated not only for the atrial fibrillation but also for atrial flutter.

I was informed the next day that my surgery was much more complicated than envisioned, and there were many areas that had to be ablated not only for the atrial fibrillation but also for atrial flutter. It appeared the “top” specialist I had used in Vancouver had not done his job properly. (Remember that I had been worse for the year after my first ablation).

Dr. Hocini was able to see the numerous sites leading to the atrial fibrillation/flutter in my heart due to an advanced computer assisted mapping vest (CardioInsight) which helps the electrophysiologist see in more detail cells in the heart that are acting erratically.  This system is just starting to be used in the U.S. by a few doctors. (See Bordeaux ECGI CardioInsight)

Successful Ablation—No A-Fib, But Chest Pain Condition Continues

I felt great the day after the surgery, no atrial fibrillation or flutter. Pain syndrome still there. I remained in the hospital for 4 more days and all went well, and then stayed in France for 7 more days sightseeing. No problems. I was to continue on Xarelto to keep the blood thin [for risk of stroke].

At Home A-Fib Returns with Persistent A-Flutter

Upon arriving back in Canada, the atrial fibrillation and flutter returned. Dr Hocini recommended cardioversion which I did twice but I still ended up in persistent atrial flutter with a heartbeat in the 130 range but no longer irregular.

Another cardioversion with sotalol converted my heart beat to sinus rhythm. I have now remained in rhythm since February 17, 2017.

Beta Blockers were tried to lower the heartbeat for a few weeks which did not work. Dr. Hocini recommended another cardioversion with sotalol prescribed for after the cardioversion. This was done on February 17, 2017. The heartbeat converted to sinus rhythm (65 heartbeat and was regular).

Normal Sinus Rhythm―4+ Months So Far

I have now remained in rhythm since February 17, 2017 with a quick flutter occurring once in a while. Since I am sensitive to prescription medications, I was placed on a low dose of 40 mg sotalol 2 times per day.

Minerals, Vitamin IVs for Inflammation of the Heart

With my other medical practitioners, I also had mineral and vitamin IVs during this time to help alleviate the inflammation in my heart from the surgery. I also took (and continue to take) vitamins and supplements as recommended by the other medical professionals treating me to keep the inflammation in the heart down.

Dr. Hocini had stated that since my ablation surgery was so complicated, I might have to go back to Bordeaux for another ablation. I have to get through the recommended 6 month recuperation time frame to see if the surgery has been successful. The last 3 months have me heading in the right direction of recovery.

Lessons Learned: After 23 Years with A-Fib

From this experience I’ve learned to obtain as much knowledge as possible of your condition. Trust your gut feelings if you feel uncomfortable with your surgeon. Increase your intake of nutritious foods and supplements prior to and after the surgery. Steve Ryan’s website provided me with the knowledge to make educated decisions.

If you have the funds and/or a complicated atrial fibrillation situation, please find the best surgeon you can and then still question him/her. Get a second [or third] opinion if your gut tells you to.

Doctors are just human beings with positive and negative traits like the rest of us. My first surgeon did not do his job properly in my first ablation and was flippant in his attitude in recommending a second surgical treatment.

With luck, trusting my gut instinct, educating myself, and a great family support system, I was able to find the best clinic in the world to treat me for this very debilitating medical condition.

I welcome your email if I can be of help to you.

Charn Deol, May 2017

P.S. FYI: My chest pain problem persists and goes undiagnosed, but that’s a story for another website!

Editor’s Comments:
Three month ‘blanking’ period: Charn’s A-Fib returned after his successful second ablation. This is quite common in more difficult cases. Your heart is ‘learning’ to beat normally again. That’s why doctors wait for at least three months before declaring your ablation a success. In Charn’s case, during the first two months, a couple rounds of cardioversions were followed by a third with sotalol prescribed after the cardioversion. This worked to get his heart back into and stay in normal sinus rhythm (NSR).
Be a proactive patient: Charn’s story is truly inspiring and an example of being proactive and not giving up. Do research yourself, get advice, and check out alternatives! We’ve been conditioned to trust doctors. Sometimes we just have to say “NO! That doesn’t make sense to me”. It’s okay to fire your doctor!
I told Charn an AV Node ablation is a treatment of last resort; it destroys the AV Node, the heart’s natural pacemaker. There’s no going back and you are forever pacemaker dependent.
Instead, I advised Charn to seek a second ablation and supplied him a list of Master EPs who routinely treat difficult, complex cases. Kudos to him for deciding to go to the Bordeaux group, considered the best in the world. [For more about Bordeaux, see my article, ‘2016 Cost of Ablation by Bordeaux Group (It’s Less Than You Might Think)’].
Chelation therapy: Chelation is FDA approved for lead removal and is the preferred medical treatment for metal poisoning. But few doctors perform chelation therapy or provide heavy metal testing. To find a doctor for these therapies, go to: (They also do IV therapy for vitamin C and other vitamins and minerals which seems to have helped Charn.)
Amiodarone drug therapy: Amiodarone is considered the most effective of the antiarrhythmic drugs, but it’s also the most toxic and is notorious for bad side effects, including death. It’s generally prescribed only for short periods of time such as for a few months after a catheter ablation and under very close supervision. (For more about Amiodarone, see my article, ‘Amiodarone: Most Effective and Most Toxic‘.

Read our 12-page free report.

Charn’s second ablation Operating Report: Charn’s ablation was more difficult than most. He had been in A-Fib off and on for 23 years. In addition to having to work around a previous failed ablation, Dr. Hocini had to track down and ablate many non-PV triggers. Using the CardioInsight system, Dr. Hocini found A-Fib sources in the septum and in the anterior Left Atrium (LA) region, and his left and right inferior PVs had to be re-isolated.
But Dr. Hocini didn’t stop there. Using pacing again, Dr. Hocini found peri-mitral flutter in Charn’s left atrium which terminated by completing an anterior mitral line and required high energy because of the thickness of his heart tissue. Dr. Hocini had to work on Charn for six hours to the point of exhaustion.
Charn’s chest pain continues: Charn’s debilitating chest pain seemed to start when he first developed A-Fib. I’m disappointed that being A-Fib-free didn’t get rid of the pain he still experiences. I’ve never heard of pain like this coming from A-Fib. Charn has seen many doctors and tried alternative strategies to no avail.
If anyone has any ideas, strategies, or insights to help Charn’s pain, please email me.


When Tracking Your Heart: Is a Wrist-Worn Heart Rate Monitor Just as Good as a Chest Strap Monitor?

Wrist-worn heart rate fitness trackers like Fitbit and Apple Watch have become trendy wrist accessories, but are they accurate enough for Atrial Fibrillation patients? How do fitness trackers compare to chest strap heart rate monitors (HRMs)?

What’s Behind the Discrepancies? Different Technologies

Chest-band HRM transmitted to wristwatch

Chest strap style heart rate monitors are consumer products designed for athletes and runners, but used by A-Fib patients, too. They measure the electrical activity of the heart. They’re usually a belt-like elastic band that wraps snugly around your chest with a small electrode pad against your skin and a snap-on transmitter.

The pad needs moisture (water or sweat) to pick up any electrical signal. That information is sent to a microprocessor in the transmitter that records and analyzes heart rate and sends it to a wrist watch display or smartphone app.

Optical HRM with LEDs on inside

Wrist fitness trackers typically sit on your wrist and don’t measure what the heart does. Most glean heart-rate data through “photoplethysmography” (PPG) with small LEDs on their undersides that shine green light onto the skin on your wrist.

The different wavelengths of light interact differently with the blood flowing through your wrist, the data is captured and processed to produce understandable pulse readings on the band itself (or transmitted to another device or app).

HRMs Research Study

A 2016 single-center study was designed to find out whether wrist-worn heart rate monitors readings are accurate. Four brands of fitness trackers were compared against the Polar H7 chest strap heart monitor (HRM) and, as a baseline, with a standard electrocardiogram (ECG).

On a personal note, I used a Polar-brand chest-band monitor when I had A-Fib, and that’s what I recommend to other A-Fib patients.

Researchers at the Cleveland Clinic enrolled 50 healthy adults, mean age, 37 years. In addition to ECG leads and the Polar chest-band heart rate monitor, patients were randomly assigned to wear two different wrist-worn heart rate monitors (out of the four).

Participants completed a treadmill protocol, in which heart rate was assessed at rest and at different paces: between two and six miles per hour. Heart rate was assessed again after the treadmill exercise during recovery at 30 seconds, 60 seconds and 90 seconds.

In total, 1,773 heart rate values ranging from 49 bpm to 200 bpm were recorded during the study. Accuracy was not affected by age, BMI or sex. The four wrist-worn heart rate monitors assessed were the Apple Watch (Apple), Fitbit Charge HR (Fitbit), Mio Alpha (Mio Global) and Basis Peak (Basis).1

HRMs Study Results

Chest Strap Monitors: The chest strap monitor was the most accurate, with readings closely matching readings from the electrocardiogram (ECG).

The chest strap monitor was the most accurate, closely matching the ECG; The wrist-bands were best when the heart was at rest.
In general, the chest straps were more accurate because the sensor is placed closer to the heart (than a wristband), allowing it to capture a stronger heart-beat signal.

Wrist-Worn Monitors: Accuracy of wrist-worn monitors was best at rest and became less accurate with more vigorous exercise, which presumably is when you’d most want to know your heart rate.

None of the wrist-worn monitors achieved the accuracy of a chest strap-based monitor. According to the electrocardiograph, some wrist-worn devices over- or underestimated heart rate by 50 bpm or more.

What Patients Need to Know

Blue-tooth chest-band with smartphone app at

Blue-tooth chest-band with smartphone app

Wrist-band optical heart-rate monitors may be more convenient or comfortable and have advanced over the years. But in this small study, researchers found that chest-strap monitors were always more accurate than their wrist counterparts and more reliable and consistent.

When monitoring your heart beat rate is important to you (while exercising or doing heavy work), you’ll want to stick with an electrode-containing monitor (chest band-style, shirts or sports bras with built-in electrode pads, etc.).

To help you choose a HRM, see Steve’s Top Picks: DIY Heart Rate Monitors for A-Fib Patients at Amazon.

Bottom line 
Leave the wrist-worn trackers for the casual fitness enthusiasts

References for this Article
Footnote Citations    (↵ returns to text)

  1. Safety Recall of Basic Peak Watch, Sept. 16, 2016:

The Effect of Diet & Nutrition on Your A-Fib: My Top 5 Articles

Many patients wonder if eating or avoiding the right foods might lessen or improve their A-Fib symptoms. While we don’t know of any diet to “cure” your A-Fib, you might consider the “DASH” eating plan recommended by U.S. National Heart, Lung and Blood Institute which reduces the risk of developing cardiovascular disease.

The following articles may answer some of your A-Fib-related questions involving diet and nutrition:

1. Caffeine: “Is drinking coffee (tea, colas, other products with caffeine) going to make my A-Fib worse or trigger an A-Fib attack?”

2. Diet: Is a whole food or organic diet helpful for patients with Atrial Fibrillation? Is there any research recommending one or the other?”

3. Personal A-Fib story: “No Way Am I Having an Ablation! But Diet and Meds Disappoint—A-Fib Free After Ablation” by Saul Lisauskas

4. Nutrition: Why are doctors so opposed to nutrition as a way of helping A-Fib. I tried to talk with my doctor about magnesium and other nutritional supplements. ‘There’s no proof that they work,’ was his response.”

5. Holistic Approach:  “I want nutritional counseling and a more integrated approach to my A-Fib treatment plan. How do I find a doctor with a more “holistic” approach?”

Be a Sleuth: Keep an Episode Diary

Keep a diary of your A-Fib episodes

To determine if certain foods or beverages may be triggering the number and duration of your A-Fib attacks, start by keeping a log or diary. When an episode occurs, note the day & time, duration and what you were doing, eating or drinking.

As you collect data, scrutinize your log entries for patterns and specific triggers. This may lead you to lessen or eliminate certain foods or beverages or even activities that appear to trigger your A-Fib. You may want to share your log with your doctor.

Updated Steve’s List: US Doctors Installing the Watchman Device

If you are at high risk for stroke but can’t or don’t want to take anticoagulants, your doctor may suggest closing off the Left Atrial Appendage using an occluder such as the FDA approved Boston Scientific WATCHMAN™.

Steve’s List of Specialists Installing the Watchman: My original list of doctors installing the Watchman was limited to those EPs participating in the clinical trials. In 2015 the FDA approved the Watchman for use in the U.S. Since then my list of doctors installing the Watchman has expanded. (Internationally, the Watchman has been available since 2009.)

Watchman device -

Watchman occlusion device by Boston Scientific

How to Find a Specialist: Today, you can visit the Boston Scientific website to find medical centers installing the Watchman device; just enter a state or postal code.

Use Steve’s List instead: When looking to install a Watchman device, I recommend you seek an electrophysiologist (EP) who is certified in “Clinical Cardiac Electrocardiography”. Use my list which is organized by state and city. Go to, Steve’s List of Specialists Installing the Watchman Device.

To learn more about the Watchman, see: The Watchman Device: My Top 5 Articles.

New FAQ About A-Fib Drug Therapy: Any Guarantee Against Stroke?

The following FAQ is very timely as a close friend of mine just suffered a major stroke, even though she was on Coumadin and her INR was in the correct range. I can’t tell you how discouraging this is, not just for her but for me, too. I worked with her to get the best treatment possible and by one of the best EPs in our area. But she still had a stroke.

Q: “I’ve heard of people with A-Fib on anticoagulants who still had a stroke. What can I do to make sure I never have a stroke?”

A: There is currently no way to absolutely guarantee you will never experience a stroke. “Even when A-Fib patients are effectively anti-coagulated, 14% are still found with clots,” stated Dr. John Camm of St. George’s Medical School, London, England, at the 2008 Boston AF Symposium.

Read more of my answer: how anticoagulants can significantly lower your overall stroke risk by as much as 70%, how closing off your Left Atrial Appendage (LAA) can stop 90%–95% of A-Fib clots which usually originate in the LAA, and whether you should consider combining the Watchman with anti-coagulation… Continue reading… .

FAQ: With A-Fib, Can I Make Sure I Never Have a Stroke?

Drug Therapies for Atrial Fibrillation, A-Fib, Afib

FAQs A-Fib Drug Therapy: Guarantee Against Stroke?

“I’ve heard of people with A-Fib on anticoagulants who still had a stroke. What can I do to make sure I never have a stroke?”

This question is very timely as a close friend of mine just suffered a major stroke, even though she was on Coumadin and her INR was in the correct range. I can’t tell you how discouraging this is, not just for her but for me, too. I worked with her to get the best treatment possible and by one of the best EPs in our area. But she still had a stroke.

There’s No Absolute Guarantee

There is currently no way to absolutely guarantee you will never experience a stroke. “Even when A-Fib patients are effectively anticoagulated, 14% are still found with clots,” stated Dr. John Camm of St. George’s Medical School, London, England, at the 2008 Boston AF Symposium.

Anticoagulants Reduces A-Fib Stroke Risk

Anticoagulants can significantly lower your overall stroke risk. When warfarin was first approved (in 1954 with brand names: Coumadin and Jantoven), it was considered a ‘wonder drug’. It reduced the risk of an A-Fib stroke by as much as 70%―a huge reduction. For the first time, doctors (and patients) had something that would work to significantly lower the risk of an A-Fib stroke.

Caution: Anticoagulants are High Risk Drugs

Be aware that anticoagulants in general are considered high risk medications. They work by causing or increasing bleeding. They aren’t like taking vitamins.

As Thomas J. Moore of the Institute for Safe Medical Practices points out, “Anticoagulant treatment for people with A-Fib ranks as one of the highest risk treatments in older Americans…more than 15% of older patients treated with blood thinners for 1 year have bleeding.”

Nevertheless, for most people, even though anticoagulants are considered high risk meds, they are a welcome trade-off to having an A-Fib stroke.

An Medication Alternative: The Watchman Occlusion Device

The Left Atrial appendage (LAA) is where 90%–95% of A-Fib clots originate. Closing off the LAA is an alternative strategy for people who can’t or don’t want to take anticoagulants. The Watchman Device (Boston Scientific), an occlusion device, is an ingenious method of closing off the LAA. (Other occlusion devices include the Lariat II and AtriClip surgical device.)

Inserting the Watchman is a very low risk procedure which takes as little as 20 minutes. Usually afterwards, the patient doesn’t need to be on an anticoagulant.

Combine the Watchman with an Anticoagulant?

One may wonder: Could combining a Watchman Device with an anticoagulant (to prevent strokes from other parts of your heart) come close to guaranteeing you will never have a stroke?

This treatment strategy is very speculative. I don’t know of any clinical studies on this subject.

However, if you have a Watchman Device installed, you could discuss with your doctor continuing on an anticoagulant as added protection.

Reference for this Article

Return to FAQ Drug Therapies
Last updated: Tuesday, May 16, 2017


FAQ: After Ablation—What’s my Chance of Staying A-Fib Free?

There is a tendency for ablated heart tissue to heal itself, regrow the ablated tissue, reconnect, and start producing A-Fib signals again. But if this happens, it usually occurs within the first three to six months of the initial PVA(I).

An reader sent me this question about recurrence of his A-Fib after a successful ablation:

Illustration of catheter ablation

Illustration of catheter ablation of pulmonary vein

“Since my PVI, I have been A-Fib free with no symptoms for 32 months. What do you think my chances of staying A-Fib free are?”

Regrowth/Reconnection of Ablated Heart Tissue

I think your chances of staying A-Fib free are pretty good.

If your Pulmonary Veins (PV) are well isolated and stay that way, you can’t get A-Fib there again. When the PVs are isolated and disconnected and haven’t reconnected, it seems to be permanent. But it’s too early in the history of PVA(I)s to say this definitively. …read the rest of my answer.

In Persistent A-Fib? Time Matters: Ablate Sooner for Better Outcomes

Note: This research study is important if you have Persistent A-Fib or your Paroxysmal A-Fib has progressed to Persistent A-Fib.

The Cost of Waiting to Ablate

In patients with persistent atrial fibrillation undergoing ablation, the time interval between the first diagnosis of persistent A-Fib and the catheter ablation procedure had a strong association with the ablation outcomes.

Cleveland Clinic researchers found that shorter diagnosis-to-ablation time spans were associated with better outcomes. Longer diagnosis-to-ablation times was associated with a greater degree of atrial remodeling.

When A-Fib becomes persistent A-Fib, the ‘first diagnosis-to-ablation time span’ had a stronger impact on outcomes than the time spent in paroxysmal A-Fib.

According to electrophysiologist Dr. Oussama Wazni, “once the diagnosis of atrial fibrillation is made, it’s important not to spend too much time trying to keep a patient in normal rhythm with medical [drug] therapy” before referring for radio-frequency ablation.” Dr. Wazni is Co-Director of the Center for Atrial Fibrillation at the Cleveland Clinic.

His comments are based on the published analysis of two-year outcomes among 1,241 consecutive patients undergoing first-time ablation of persistent atrial fibrillation over an eight-year period at Cleveland Clinic. All patients had successful isolation of all 4 PVs (pulmonary veins), and the superior vena cava was isolated in 69.6%. In addition, Left Atrium ablations (including complex fractionated electrograms) were performed in 65.6% of patients.

First Diagnosis-to-Ablation Time Span: The Shorter the Better

Importantly, the first diagnosis-to-ablation time interval (of persistent A-Fib) had a stronger impact on outcomes than the time spent with a paroxysmal A-Fib diagnosis or the duration of continuous A-Fib before the ablation procedure.

These findings suggest that A-Fib is a disease with a continuous spectrum…
The findings suggest that A-Fib is a disease with a continuous spectrum, with patients at the extreme end of that spectrum having higher arrhythmia recurrence rates after catheter ablation, whereas patients with shorter diagnosis-to-ablation times having lower recurrence rates.

The analysis was published in the Jan. 2016 issue of Circulation: Arrhythmia and Electrophysiology. (Read online or download as a PDF.)

Reference for this Article

2017 AF Symposium: Live Case of Ablation with FIRM Mapping System

Dr David Wilber Loyola University

D. Wilber, MD

In a live case, Dr. David Wilber from Loyola Un. Medical Center in Chicago, IL showed how he uses the Topera FIRM rotor mapping system to identify rotors in conjunction with a PVI. ‘FIRM’ stands for Focal Impulse and Rotor Modulation.

Patient background: The patient was a 54-year-old male in persistent A-Fib for 7 months, obese with a BMI of 31, hypertension, diabetes, and obstructive sleep apnea. He was symptomatic, with fatigue and decreased exercise tolerance. An MRI showed his Left Atrium was 15.5% fibrotic. (If using Dr. Nassir Marrouche’s Utah I–IV Classification System to rate the patient’s amount of fibrosis, this patient would be “Utah Stage 2”, i.e., a reasonable candidate for a catheter ablation.)

Voltage & FIRM Mapping: Rotors Ablated First

FIRM mapping display of left atrial rotor during atrial fibrillation.

FIRM mapping display of left atrial rotor during atrial fibrillation.

In live video streaming from Chicago, Dr. Wilber described how he first does voltage mapping while the patient is in normal sinus rhythm. He started in the right atrium, then moved to the left; he used the FIRM system to map where rotors were coming from. (In patients with persistent A-Fib, he typically finds as many as 4-8 rotors.) He mapped and ablated until there were no more rotors.

Only after using the FIRM system did he do a Pulmonary Vein ablation (PVI).

He explained that the concept of terminating A-Fib during a PVI ablation doesn’t work with the FIRM system. Instead, he looks to ablate rotational areas (which are usually 2.2 cm across). He does this by using a Contact Force sensing catheter usually at 35 watts for 30 sec.

During this ablation, he found one rotor at the base of the Left Atrial Appendage (LAA). (In the followup panel discussion, Dr. Andrea Natale commented that he and his colleagues now look first for A-Fib signals in the LAA.)

FIRM Rotors Hard to See

VIDEO examples: Dr. Wilber showed a video using FIRM in which [even to my untrained eye] it was easy to see a rotor. But he showed other videos where the overlapping, swirling waves made it difficult to see where exactly a rotor was coming from.

Editor’s Comments:
This patient was at great risk of recurrence after a catheter ablation, because of his various illnesses (comorbidities). By restoring him to normal sinus rhythm, he would be able to exercise and develop life-changing habits to reduce his obesity, diabetes, and hypertension.
ECGI CardioInsight system: Focal and re-entrant driver maps

ECGI CardioInsight system: Focal and re-entrant driver maps

Abbott Topera FIRM vs Medtronic ECGI CardioInsight:  In comparison to the ECGI CardioInsight system where the rotors and focal sources are very obvious (even to untrained observers), the FIRM system display of rotors are often confusing and hard to identify. Dr. Wilber acknowledged that it takes study and experience with the FIRM system to use it effectively.
To me, the Abbott Topera FIRM system seems hard to use. In head-to-head competition with the Medtronic ECGI CardioInsight system, I predict the FIRM system will probably not survive.
The Medtronic ECGI CardioInsight system has been in limited use in Europe and in 2017 has begun a limited rollout in the U.S.

For more on the Medtronic ECGI CardioInsight, see my article: ECGI Mapping Now Available in U.S.

For more about Dr. Nassir Marrouche’s Utah I–IV Classification System, see my article: Fibrosis Risk and the U. of Utah/CARMA website.

Reference for this Article

NOAC or Warfarin for Valvular A-Fib?

Patients with ‘Valvular Atrial Fibrillation’ are often restricted from most A-Fib clinical studies and research. In particular, for NOAC trials, people with Valvular A-Fib have generally been excluded because they may have a higher rate of forming clots (e.g.: left atrial clots). 

“Valvular Atrial Fibrillation” refers to those A-Fib patients with artificial heart valves or mitral stenosis.

Like most A-Fib patients, Valvular A-Fib patients with bioprosthetic or mechanical valves have to be on an anticoagulant which up to now was restricted to warfarin. So, are the new NOACs an option?

Bioprosthetic valves are non-synthetic (usually porcine) devices used to replace a defective heart valve. Compared to mechanical valves, bioprosthetic valves are less likely to cause clots, but are more prone to structural degeneration (35% fail within 15 years).

Warfarin vs Edoxaban (NOAC)

A 2017 study showed that the Novel Oral Anticoagulant (NOAC) edoxaban (brand name: Savaysa) was safer than warfarin in preventing an A-Fib stroke in people with bioprosthetic heart valves.

Edoxaban 30 and 60 mg (Savaysa)

Edoxaban works by inhibiting factor Xa in the coagulation process. The lower dose (30 mg) was associated with a reduced rate of major bleeding, but not the higher dose (60 mg).

Compared to warfarin, edoxaban was associated with lower annual stroke rates, systemic embolic events, major bleeds, and deaths annually.

“Our analysis suggests that edoxaban appears to be a reasonable alternative to warfarin in patients with Afib and remote bioprosthetic valve implantation,” according to Dr. Robert P. Giugliano of Brigham and Women’s Hospital in Boston, MA.

Edoxaban Works With Bioprosthetic Valves But Not Mechanical Ones

For the first time, research indicates that a NOAC (edoxaban) can be used for Valvular A-Fib to prevent an A-Fib stroke―but only in the case of bioprosthetic (porcine) valves.

The NOAC, Edoxaban (Savaysa), was safer than warfarin for A-Fib patients with bioprosthetic valves.

With regards to mechanical valves, the authors cited a study in which dabigatran (Pradaxa) fared poorly in mechanical valves.

What About Other Factor Xa NOACs?

What about the other ‘factor Xa inhibitors’ such as Xarelto and Eliquis? Can they be used like edoxaban? Currently there is little clinical data on this subject. But since all three are factor Xa inhibitors, most likely they will be proven to be effective in A-Fib patients with bioprosthetic valves.

What Patients Need to Know

Do you have Valvular A-Fib and a bioprosthetic valve? Are you on warfarin? If being on warfarin is difficult for you, you now have a choice of anticoagulant. Ask your doctor about switching to the NOAC, edoxaban.

Reference for this Article

2017 AF Symposium: Movin’ it—Protecting the Esophagus During Ablation

2017 AF Symposium

Movin’ it: Protecting the Esophagus During Ablation

Live case presenters: Drs. Rodney Horton, Amin Al-Ahmad and David Burkhardt from the Texas Cardiac Arrhythmia Institute at St. David’s Medical Center in Austin, TX. Moderator: Dr. Andrea Natale.

Patient background: A 79-year-old female needed a ‘re-do’ second ablation. She had persistent A-Fib and hypertension. Her first ablation was August 15, 2016 where they couldn’t terminate her Flutter. Because the temperature probe in her esophagus showed a rise in temperature when they tried to ablate certain areas, “we were not as aggressive as we would have liked.”

The Danger: Esophageal Fistula

During an ablation, doctors take great precautions to not heat or injure the esophagus which lies behind the posterior wall of the left atrium. Injuring the esophagus can, in very rare cases, cause an atrial esophageal fistula which can be fatal.

Fear of causing esophageal injury can cause the EP to modify the ablation lesion set delivery, thereby reducing ablation success by:

1. Reducing the wattage or amount of energy delivered to the left atrium wall which causes less complete scarring; and/or

2. Relocating the ablation lesion to a less desirable area

For this patient: During her first ablation: the doctors noticed a rise in temperature of the probe inserted in her esophagus, so her doctors stopped ablating in that area. Consequently, the A-Fib signal source(s) in that area were not isolated effectively. Result: her A-Flutter was not terminated.

Solution: Esophageal Displacement Tool

The esophagus is not a rigid, inflexible pipe but rather like a hose made out of flexible muscle fibers. It can naturally migrate side-to-side 2-3 cm on its own.

For this live streaming ablation, a new esophagus displacement tool was used: the EsoSure Esophageal Retractor. The tool allows doctors to re-position a section of the esophagus away from the nearby heart tissue and avoid the heat generated during ablation.

The inventor of the device, Steven W. Miller, RN and EP nurse, demonstrated his device to me at the AF Symposium Exhibit Hall.

EsoSure Esophageal Retractor: Shape adjusts to body temperature at

EsoSure Esophageal Retractor: Shape adjusts to body temperature

At room temperature, the stylet is fairly straight which allows it to be easily inserted into a commonly used gastric tube which is routinely placed down the esophagus by the anesthesia staff. But as the stylet warms to body temperature, it takes on a greater curve. He inserted the stylet into warmed water. You could see how the stylet changed shape and developed a greater curve.

Depending on how the stylet is positioned, it can displace the esophagus up to 2-3 cm to the left or right depending on each person’s anatomy.

Using the EsoSure Retractor, the EP can easily and safely move the esophagus away from any area being ablated. It is FDA approved and has been used by different practitioners more than 700 times without damaging the esophagus.

Live Case Using the EsoSure Retractor

In this re-do ablation, the 79-year-old female patient was in A-Fib when the ablation started. They cardioverted her, but she went right back into A-Fib.

Entrainment (pacing) mapping was used to identify non-PV triggers. Since they had to ablate in the posterior of the left atrium next to the esophagus, they simply moved the EsoSure Retractor up and down to displace the esophagus. It seemed very easy to do.

The EPs mentioned that, with the use of this displacement device, they could now ablate at a higher wattage without fear of harming the esophagus. They also ablated the Left Atrial Appendage area to restore her to sinus rhythm.

What Patients Need to Know

Displacing the esophagus is a major medical advance: The EsoSure Esophageal Retractor is a major medical advance that will significantly improve not only the safety but the effectiveness of catheter ablations. Compared to any other gear in the ablation lab, the EsoSure Retractor is inexpensive ($365-$395 depending on quantity ordered). Any EP lab can and should use it, (or something similar).

Esophagus injury: All too often the esophagus lies behind the right pulmonary vein openings. Doctors have to limit both the placement and the power of their lesions out of fear of damaging the esophagus.

But being able to move the esophagus solves this problem. Ablations will be more effective, and the danger of producing an Atrial Esophageal Fistula (while rare) will be greatly reduced, if not eliminated. It will also reduce ablation procedure time.

Ask your EP: If you are scheduling an ablation, ask your doctors about their plan to prevent esophageal injury.

Return to 2017 AF Symposium Reports
If you find any errors on this page, email us. Last updated: Saturday, March 11, 2017

Reference for this Article

2017 AF Symposium LIVE VIDEO: Can Adding Fibrosis Improve Ablation Success?

Updated March 9: We added two new slides comparing the patient’s initial and subsequent DE-MRI images.

Report 13 from 2107 AF Symposium: In a live ablation from from Mass. General Hospital in Boston, Drs. Heist and Van Houzen demonstrated a pioneering strategy to treat Atrial Fibrillation patients with patchy fibrotic areas of tissue. This tissue perpetuates A-Fib.

First, a DE-MRI scan defines and measures the heart’s areas of fibrosis. Next, the doctors ablated (or filled in) these patchy areas with more fibrosis (i.e., ablation scarring) turning the patchy areas into dense fibrotic areas. Transforming patchy fibrotic tissue to dense fibrotic tissue stops A-Fib signals from perpetuating in that tissue.

It may seem counter-intuitive―create more fibrosis to make patients A-Fib free. Read more about this innovative strategy.

2017 AF Symposium Live Video: Adding Fibrosis to Improve Ablation Success?

2017 AF Symposium

Live Case: Can Adding Fibrosis Improve Ablation Success?

Updated March 13: We added two new slides.

Streaming video of an ablation by Drs. Kevin Heist and Nathan Van Houzen from Massachusetts General Hospital (MGH) in Boston, MA (moderator, Dr. Moussa Mansour).

Patient background: The case of a 62-year-old male with symptomatic persistent A-Fib, despite a previous ablation 8/9/2016. Propafenone, amiodarone, and an electrical cardioversion weren’t effective. The patient had been taken off amiodarone a week before this ablation. They cardioverted him into sinus rhythm to better measure areas of low voltage (areas of fibrosis). Low voltage areas were defined as less than 0.5 V.

Mapping Views: Lesions and Remaining Fibrosis From First Ablation

THE TOP SLIDE: The RF point-by-point ablation lesions from the patient’s first ablation done months before the live case.

RED dots represent a greater force or more time making the lesion; PINK dots represent a lower efficiency lesion due to proximity to the esophagus.

Some of these PINK dot area had reconnected and had to be re-ablated during the live case.

(“PA” is  the left atrium viewed from the back.)

THE BOTTOM SLIDE: The MRI done shortly before the live case. The BLUE areas are normal atrial tissue. The RED areas are fibrotic/scarred areas. Some of the red areas in this PA view were not ablated during the first procedure and represent spontaneous fibrosis.

Live: Ablating Areas of Fibrosis

In this live procedure from Boston, MA, Drs. Heist and Van Houzen did a normal PVI and found evidence that some areas from the patient’s previous ablation had reconnected.

The innovative aspect of this ablation is they also ablated areas of fibrosis. ‘Spontaneous fibrosis’ tends to be patchy in a way that perpetuates A-Fib.

Ablating or filling in these patchy areas with more fibrosis (i.e., ablation scarring) turns the patchy areas into dense fibrotic areas which can’t conduct or perpetuate A-Fib.

They first performed a Delayed Enhancement MRI (DE-MRI) scan of this patient’s heart in order to define and measure the areas of fibrosis.

The EPs then ablated (filled in) areas of this fibrosis, turning these patchy fibrotic regions into denser fibrotic areas. These dense fibrotic areas no longer conducted or perpetuated A-Fib.

Two months after the ablation the patient is doing well in sinus rhythm. Whereas after his first ablation, he experienced early recurrence.

What Patients Need to Know

Who Benefits from this Strategy? Adding or filling in patchy fibrotic areas with more fibrosis through ablation is a very innovative ablation strategy.

It is being applied to patients with persistent or persistent long-standing A-Fib who usually have more fibrosis, but is also being applied to paroxysmal patients who have had a durable (successful) PVI but are still in A-Fib (they often have some fibrotic areas).

The term ‘spontaneous fibrosis’ refers to fibrosis (scarring) which occurs naturally, that is, without a doctor’s procedural intervention.

Impractical for Diffused Fibrosis: This strategy doesn’t work if someone has a generalized distribution of fibrous tissue throughout their atrium. It would require ablation of the whole atrium creating too much fibrosis and causing other heart function problems.

Isn’t Creating More Fibrosis Dangerous for Patients? It certainly does seem counterintuitive―create more fibrosis to make patients A-Fib free. But we are looking at patients who already have patches of fibrosis. (If we could turn these fibrotic areas back into smooth heart muscle, then this strategy wouldn’t be necessary.)

This strategy can make people with difficult A-Fib cases A-Fib free, and make a huge difference for patients who have failed ablations.

While this strategy is exciting, we are only at the very beginning stages of this research.


Nassir Marrouche MD

N. Marrouche MD

Dr. Nassir Marrouche: The concept of ablating areas of fibrosis was conceived by Dr. Nassir Marrouche of the University of Utah (CARMA). Dr. Marrouche has started DECAAF II, a clinical study on fibrosis to compare ablation of fibrosis areas to standard PVI ablation.

Known for the completed DECAAF study, Dr. Mansour is now collaborating with Dr. Marrouche on the DECAAF II study, and Massachusetts General Hospital (the originating site of this live streaming video) is one of the participating sites. For more, see my 2017 AF Symposium article A-Fib Increases Fibrosis.

Dr. Kevin Heist: I would like to thank Dr. Kevin Heist, Mass. General Hospital, for patiently explaining to me the concept, rationale and strategy of ablating areas of fibrosis. (I really needed his help!)

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If you find any errors on this page, email us. Last updated: Monday, March 13, 2017

Reference for this Article

2017 AF Symposium: LIVE Video Ablation With Non-Contact Catheter Mapping

The Acutus Medical Non-Contact basket catheter with multiple electrodes

The Acutus Medical Non-Contact basket catheter with multiple electrodes

Report 12 from 2107 AF Symposium: In a live case from Prague, the Czech Republic, the EPs used the non-contact basket catheter to generate a 3D anatomy of the patient’s left atrium.

They produced propagation maps which looked like rotor action seen in other mapping systems, but sharper and with high resolution.

During the ablation, they used Acutus Medical’s basket catheter to re-map the left atrium. This showed that there were gaps in the ablation of one of the right vein openings which they corrected. …Read my full report…

Atrial Fibrillation and Atrial Flutter: Cause and Effect?

About Atrial Fibrillation and Atrial Flutter…are they linked? Does one precede the other? Can one procedure fix both? Can a typical catheter ablation fix both Atrial Fibrillation and Atrial Flutter at the same time? Can Maze surgery or Mini-maze surgery fix both?

Surgery vs. Ablation

In general, Atrial Flutter originates in the right atrium and Atrial Fibrillation in the left atrium.

Maze/Mini-maze surgical approaches typically don’t access the right atrium, and therefore can’t fix A-Flutter.

Maze/Mini-maze surgical approaches typically don’t access the right atrium, and therefore can’t fix A-Flutter. If you have both A-Fib and A-Flutter, a Maze procedure needs to be followed by a catheter ablation to fix the Atrial Flutter.

A catheter ablation procedure for A-Flutter is relatively easy and it’s highly successful (95%). It usually involves making a single line in the right atrium which blocks the A-Flutter (Caviotricuspid Isthmus line).

A Catheter Ablation Two-Fer? 

If you are having a catheter ablation, many doctors make this Caviotricuspid Isthmus ablation line while doing an A-Fib ablation (in the left atrium)—even if you don’t have A-Flutter at the time.

Catheter inserted into the heart and through septum wall into Left Atria

Catheter inserted into the heart and through septum wall into Left Atria

Catheters enter the heart through the right atrium. At the beginning of a catheter ablation for atrial fibrillation, doctors enter the heart through the right atrium. While there they may elect to make the right atrium ablation line at this point which takes 10-20 minutes.

They then go through the wall separating the right and left atria (transseptal wall) to do the ablation for A-Fib in the left atrium. (Some doctors chose to place the right atrium ablation line at the end of an ablation when they withdraw from the left atrium into the right atrium.)

Some say one should “do no harm” and not make this right atrium ablation line if there is no A-Flutter. Saying it can always be done later in another catheter ablation at little risk to the patient.

Research: Are A-Fib and A-Flutter Linked?

While you can have A-Flutter without A-Fib, more often than not, they are linked. When you have A-Flutter, A-Fib often lurks in the background or develops later.

Patients did much better if they had an ablation for both A-Fib and a A-Flutter at the same time even though they appeared to only have A-Flutter.

Some A-Flutter may originate in the left atrium, or the A-Flutter may mask A-Fib which may appear later after a successful A-Flutter ablation.

As many as half of all patients ablated for A-Flutter may later develop A-Fib.

In a small research study, patients did much better if they had an ablation for both A-Fib and a A-Flutter at the same time even though they appeared to only have A-Flutter.

What Patients Need to Know

But right now we can’t say for sure if one causes the other. We do know that A-Flutter usually comes from the right atrium, while A-Fib usually comes from the left atrium.

Resources for this article

Live Case: Non-Contact Ultrasound Basket Catheter Dipole Density Mapping

2017 AF Symposium

Live Case: Ablation Using Non-Contact Ultrasound Basket Catheter Dipole Density Mapping

Illlustration: Acutus Medical Non-Contact Dipole basket catheter with multiple electrodes.

Acutus Medical Non-Contact Dipole basket catheter with multiple electrodes.

Video streaming of an ablation from Na Homolce Hospital in Prague, the Czech Republic with Drs. Peter Neuzil, Jan Petru, and Jan Skoda.

The doctors used a new high resolution mapping system from Acutus Medical to identify in real time where his A-Fib signals were coming from.

Patient background: A 68-year-old man in paroxysmal A-Fib had a CHA2DS2-VASc score of 4 with hypertension and a pulmonary embolism. He had had a PVI in January 2011 and a repeat PVI to fix gaps in April 2011. His A-Fib recurred in 2014. Electrical cardioversions didn’t work.

Non-Contact Mapping with Ultrasound-Electrode Catheter

VIDEO: For a more detailed explanation of the Non-Contact Dipole Density AcQ Imaging and Mapping, see the video from Acutus Medical.(1:54)

The Acutus Medical Non-Contact Dipole Density AcQ Imaging and Mapping catheter uses a basket catheter with multiple electrodes and ultrasound anatomy reconstruction.

‘Non-contact’ means the basket catheter can float freely in the left atrium and doesn’t have to be applied to the surface of the heart to generate A-Fib maps.

The basket catheter has six splines each with eight nodules that contain 48 ultrasound transducers and 48 electrodes. The ultrasound pings the atrium wall and rapidly produces a 3D left atrium anatomy.

Electrical Measurement: Dipole Density vs Voltage

For over one hundred years, voltage has been the major electrical measurement in cardiac medicine. The limitation with using voltage in electrophysiology is that the reading includes both the localized charge (Dipole Density) as well as the sum of the surrounding sources providing a broad, blended view of cardiac activity.

According to Acutus Medical, by eliminating these surrounding sources, and using dipole density (instead of voltage) the field of view becomes sharper and narrower.

This more precise electrical activation is displayed as a Dipole Density map on a 3D ultrasound reconstruction of the heart.

Acutus Medical Illustration: localized charge (Dipole Density) with the sum of the surrounding sources

Acutus Medical Illustration: localized charge (Dipole Density) with the sum of the surrounding sources

Live Streaming Video: Ablation from Prague

In the live case, the EPs used the non-contact basket catheter to generate a 3D anatomy of the patient’s left atrium.

They produced propagation maps which looked like rotor action seen in other mapping systems, but sharper and with high resolution.

During the ablation, they used the basket catheter to re-map the left atrium. This showed that there were gaps in the ablation of one of the right vein openings which they corrected. When they made a mitral isthmus line, the patient’s A-Fib terminated which restored him to normal sinus rhythm.

What Patients Need To Know

May Replace Contact Mapping: Non-contact mapping is a significant innovation in catheter ablation and may eventually replace existing contact mapping catheters and make ablations easier. It also seems to require less technical skill than in a traditional contact mapping system.

“Non-contact mapping is a significant innovation and may eventually replace existing contact mapping catheters.”—Steve Ryan

No Radiation & Instantaneous: Using ultrasound to produce a 3D rendering of the heart is innovative and could change the way the anatomy of the heart is generated for an ablation. And unlike a CT scan, it doesn’t use radiation. Also, unlike a CT scan, the ultrasound images of the heart are generated instantaneously in real-time.

Higher Resolution: Dipole Density mapping may prove to be a higher resolution system than current mapping systems.

Not Yet Available in U.S.: But don’t expect the Acutus Medical System to become available in the U.S. any time soon. It isn’t yet FDA approved or available for sale in the U.S.

Return to 2017 AF Symposium Reports
If you find any errors on this page, email us. Last updated: Thursday, March 2, 2017

Reference for this Article

2017 AF Symposium: Three New Reports—Genetic A-Fib and LIVE Streaming Video Ablations

Live Streaming Video from AF Symposium at

To my 2017 AF Symposium Overview, I added how we observed in-progress A-Fib procedures via streaming video from five locations spanning the globe, and heard from the EPs performing the ablations. Continue to the Video Overview…

Report 11: LIVE! Ablation Using CardioFocus Laser Balloon

CardioFocus HeartLight Laser Balloon catheter

CardioFocus HeartLight Laser Balloon catheter

Video streaming from Na Homolce Hospital in Prague, The Czech Republic. Drs. Peter Neuzil, Jan Petru and Jan Skoda did an ablation using the CardioFocus HeartLight Endoscopic Visually Guided Laser Balloon (FDA approved April 4, 2016).

The doctors showed how they could directly see the Pulmonary Vein opening they were ablating (unlike RF and CryoBalloon systems). The center of the catheter has an endoscopic (looking inside) camera.

(To me, this is a major advantage and ground-breaking improvement for patients.)

Read more of my report, and see a short video clip with an actual view of the pulmonary veins during an ablation. …Continue reading my report….

Report 10: LIVE! Two Procedures—but Different Left Atrial Appendage Occlusion Devices

Featuring the Amplatz Amulet from St. Jude Medical and the LAmbre from LifeTech Scientific.

Amplatz Amulet occlusion device by St. Jude Medical -

Amplatz Amulet occlusion device by St. Jude Medical

Live from Milan, we watched the doctors insert an Amplatz Amulet into the LAA of a 78-year-old women who had a high risk of bleeding.

These doctors did something I had never seen before. They made a physical model of the woman’s LAA, then showed how the Amplatz Amulet fit into the model. This helped AF Symposium attendees see how the Amplatz Amulet actually worked. …Continue reading my report…

Report 9: World-Wide Studies on Genetic A-Fib

DNA: Double helix graphic at

Dr. Patrick Ellinor of Mass. General Hospital, Boston MA, reported the biggest news is that A-Fib genetic research is increasing exponentially. The AFGen Consortium website lists 37 different studies and world-wide institutions studying A-Fib genetics with over 70,000 cases. Within the next 10 years, Dr. Ellinor and his colleagues hope to identify over 100 different genetic loci for A-Fib.

Dr. Ellinor reported that using a genetic “fingerprint” of A-Fib helps to identify those patients at the greatest risk of a stroke. (There’s a 40% increased risk of developing A-Fib if a relative has it.)…Continue reading my report…

About the Annual AF Symposium

The annual AF Symposium brings together the world’s leading medical scientists, researchers and EPs to share recent advances in the treatment of atrial fibrillation. You can read all my summary reports on my 2017 AF Symposium page.

Videos: Arrhythmias Animations by St. Jude Medical

Three short animations: Atrial Flutter, Pacemaker, and Implantable Defibrillator (ICD) treatment options from St Jude Medical.

Atrial Flutter: Fast Heartbeat Arrhythmia (00:28)

Pacemaker Treatment Option (too slow of heart beat) (:49)

Implantable Defibrillator (ICD) Treatment Option (too fast heart beat) (:57) 

If you find any errors on this page, 
email us. Y Last updated: Sunday, February 19, 2017

Return to Instructional A-Fib Videos and Animations

Video: A Live Case of Catheter Ablation for Long-Standing Persistent A-Fib Through 3D Mapping & ECG Images

Presented entirely through 3D mapping and ECG images, a live demo of ablation for long-standing, persistent A-Fib is followed from start to finish. Titles identify each step. No narration, music track only (I turned down the volume as the music track was distracting.)

3D mapping and ECG images show the technique of transseptal access, 3D mapping, PV isolation, and ablating additional drivers of AF in the posterior wall and left atrial appendage. (8:03) Produced by Dr. James Ong, Heart Rhythm Specialist of Southern California.

NOTE: Before viewing this video, you should already have some basic understanding of cardiac anatomy and A-Fib physiology.

YouTube video playback controls:
When watching this video, you have several playback options. The following controls are located in the lower right portion of the frame: Turn on closed captions, Settings (speed/quality), Watch on YouTube website, and Enlarge video to full frame. Click an icon to select.

If you find any errors on this page, email us. Y Last updated: Sunday, February 19, 2017 Return to Instructional A-Fib Videos and Animations

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