Doctors & patients are saying about 'A-Fib.com'...


"A-Fib.com 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


Treatments

A Primer: What is the Typical Progression of an Ablation for A-Fib?

In his AF Symposium presentation, Dr. Pierre Jais, of the French Bordeaux group made a reference to the ‘typical progression of a catheter ablation procedure.‘ Readers may ask, what does he mean? What is the typical progression of an ablation procedure?

The Goals of Catheter Ablation for A-Fib: Let’s start by looking at the two main goals of a catheter ablation for A-Fib:

Restore the heart to normal sinus rhythm
Eliminate the symptoms of A-Fib

Additional benefits: Achieving these goals also relieves the patient from the associated risks such as blood clot formation, stroke and increased risks of dementia and mortality.

The EP Lab: Typical Ablation for Persistent A-Fib

We know that Atrial Fibrillation is not a ‘one-size fits all’ type of disease. Every operating electrophysiologist (EP) caters each catheter ablation to the specific patient’s needs. In this simplified example we are looking at the progression of a typical ablation for Persistent A-Fib:

Dr Ali Sovari in EP lab, Oxnard, CA at A-Fib.com

Dr Ali Sovari in EP lab, Oxnard, CA

1. Mapping: First, the sources of the rogue A-Fib electrical signals are mapped using a computerized system.

2. Ablation/Isolation: The tip of the catheter is then maneuvered to the various sources of the A-Fib signals (usually starting with the openings to the pulmonary veins). Using RF energy (or Cryo) a tiny burn or lesion is made at each location to disrupt (or ablate) the electrical pathway.

3. Rogue signals terminate or transition: As the series of lesions progress, more and more of the A-Fib signals stop. Or, A-Fib signals may transition into Atrial Flutter which is a more stable and less erratic heart rhythm.

4. Re-Mapping/ablation: At this point it is not uncommon for some A-Fib signals to continue. So, one or more rounds of mapping and ablation may be required to stop any remaining sources of arrhythmic signals.

 5. NSR or Tachycardia: Finally, the heart typically transitions to either normal sinus rhythm (NSR) or a stable atrial tachycardia (a regular but fast heartbeat).

Outcomes After the Ablation

NSR: After their ablation, many patients will be in normal sinus rhythm (NSR). Hurray! Obviously, this is the best outcome.

Stable Atrial Tachycardia: A second good outcome is being in stable atrial tachycardia, i.e., a regular but fast heartbeat. It’s not NSR, but being in atrial tachycardia instead means the patient is NO LONGER in A-Fib.

Graphic: Cryoablation heat withdrawl at A-Fib.com

Graphic: Cryoablation heat withdrawl

Why is stable atrial tachycardia still a good outcome? Typically, your heart will heal itself over the following months—called the ‘blanking period’ and, on its own, return to normal sinus rhythm (NSR). (That’s why you should wait for the 3+ months blanking period before you decide if your ablation is a success.)

Benefits from Failed Ablation? When the patient doesn’t return to NSR (or tachycardia), researchers who studied the follow-up data, found a few ‘side’ benefits to a ‘failed’ ablation. Some patients found their A-Fib symptoms were less intense or shorter in duration. Some patients found they could take certain medications that prior to their ablation had been ineffective.

Conclusion: So, either way, a catheter ablation offers benefits. You may still reap some substantial benefits from the previous “failed” ablation even if you need a second (or third) ablation.

Atrial Fibrillation PVI: Can the Need for Multiple Ablations be Forecasted?

Could the necessity for multiple ablation procedures be predicted? According to a research study, the answer is YES!

In a study of patients who had catheter ablation of the Pulmonary Veins (PVs) for paroxysmal (occasional) A-Fib, 8% had to have more than two ablations to be A-Fib free.

The only independent predictor of the need for multiple procedures was the presence of non-PV triggers. According to this research, electrophysiologists (EPs) should check for non-PV triggers such as at the ligament of Marshall.

Illustration of RF ablation at A-Fib.com

Illustration of RF ablation

The lesson to be learned from this study: When having an ablation, make sure your Electrophysiologist (EP) is experienced at tracking down (mapping) and ablating (isolating) non-PV triggers.

For example, I reviewed the an O.R. (Operating Room) report of a patient who, after isolating the PVs, was still in A-Fib. Instead of looking for non-PV triggers, the EP just electrocardioverted the patient back into sinus rhythm. This does sometimes work. But not in this case. The ablation failed.

This is particularly important for EPs doing CryoBalloon ablations.

Graphic: Cryoablation heat withdrawl at A-Fib.com

Illustration: Cryoablation heat withdrawl

Find EPs Experienced at Ablating Non-PV Triggers

When getting a CryoBalloon ablation, you need to find an EP who is willing to do more than just isolate your PVs—someone who will put out the extra effort to find and ablate non-PV triggers such as at the ligament of Marshall.

To do this, your EP may have to replace the CryoBalloon catheter with an RF catheter to ablate these non-PV triggers. This may require mapping and ablation skills not all EPs have.

What to Ask Prospective EPs

To find the right EP for your CryoBalloon ablation ask:

What do you do if I’m still in A-Fib after you do the CryoBalloon ablation?

(You want to hear they’ll search for and ablate non-PV triggers.)

For more about Ablating Non-PV Triggers, see my article: CryoBalloon Ablation Study: 30% of Patients Required RF to Achieve Isolation

Note: This research study was conducted before the widespread use of Contact Force sensing catheters, whose use is another contributor to the reduction of recurrence and need for multiple ablation procedures.

References for this article

New Video: EKG of Actual Heart in Atrial Fibrillation

We’ve added a new video to our Library of Videos & Animations. A graphic display of actual heart in Atrial Fibrillation. How it could look to your doctor on an EKG/ECG monitor; (Your EKG may look different, but will be fast and erratic). Includes display of the changing heartbeat rate in the lower left.

For comparison, we’ve included a graphic comparing the tracing of a heart in normal sinus rhythm vs. a heart in A-Fib.

Share with you family and friends when you talk about your A-Fib. (:59 sec)  Go to video->

EKG tracing

How to Interpret an ECG Signal

A-Fib is fairly easy to diagnose using EKG. The ECG signal strip is a graphic tracing of the electrical activity of the heart.

An electrocardiogram, ECG (EKG), is a test used to measure the rate and regularity of heartbeats. To learn more, see our article, Understanding the EKG Signal.

Video: EKG of Heart in Atrial Fibrillation on Monitor

Graphic display of actual heart in Atrial Fibrillation. How it could look to your doctor on an EKG/ECG monitor; (Your EKG may look different, but will be fast and erratic). Notice the changing heartbeat rate in the lower left. Compare to normal ECG below.

Share with you family and friends when you talk about your A-Fib. (:59 sec) Posted by jason king, Published on Aug 24, 2017.

Graphic: ECG of Heart in Normal Heart Rhythm and in Atrial Fibrillation

In the case of Atrial Fibrillation, the consistent P waves are replaced by fibrillatory waves, which vary in amplitude, shape, and timing (compare the two illustrations below).

How to Interpret an ECG Signal

EKG signal components at A-Fib.com

EKG signal components

An electrocardiogram, ECG (EKG), is a test used to measure the rate and regularity of heartbeats, as well as the size and position of the chambers, the presence of any damage to the heart, and the effects of drugs or devices used to regulate the heart.

The ECG signal strip is a graphic tracing of the electrical activity of the heart. To learn more, see our article, Understanding the EKG Signal.

If you find any errors on this page, email us. Y Last updated: Friday, September 8, 2017

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In-Depth: Mini-Maze Surgery: Inside the O.R. with Dr. William Harris, Cardiovascular Surgeon

Cardiovascular Surgeon, Dr. William Harris describes the Mini-Maze surgery for Atrial Fibrillation. In the Mini-Maze the heart is accessed through small incisions in the chest.

Of interest to A-Fib patients who can not tolerate blood thinners and thus do not qualify for a Catheter Ablation. The Mini-maze surgery is a highly effective with an 85%–95% success rate. Dr. Harris is with Baptist Medical Center, Jackson, Miss. (4:49 min.)

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: Friday, September 15, 2017

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VIDEO: Step-by-Step: Cardioversion Demonstration of by ER Staff

Emergency room medical personnel demonstrates the equipment, pads placement and procedures of cardioversion for a patient with Atrial Fibrillation. Close-up of the equipment display. Uploaded on Jan 5, 2012 (2:10 min.) by Alfred Sacchetti.

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: Wednesday, August 30, 2017

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VIDEO: Your Heart’s Ejection Fraction (EF): What You Need to Know

In the following three short videos, cardiac electrophysiologist, Dr. Robert Fishel, discusses the ejection fraction (EF) a measurement of the pumping efficiency of the heart and why cardiac patients should know their EF.

Video 1: What is an Ejection Fraction? (:34 sec.)

Video 2: What is considered abnormal or low EF levels? (:44 sec.)

Video 3: Who should know their EF? (:54 sec.)

Dr. Fishel is Director of Cardiac Electrophysiology at JFK Medical Center in West Palm Beach; Uploaded on Jun 22, 2011.

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: Thursday, August 31, 2017

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VIDEO: The Lariat Procedure for Left Atrial Appendage Closure

Dr. Eric Pena, cardiac electrophysiologist at Rogue Regional Medical Center, discusses the risk of clots and stroke in A-Fib patients not on anti-coagulation drug therapy. The Left Atrial Appendage (LAA) of the heart is known to be a major source of these clots.

He describes the LARIAT procedure, a lasso-shaped suture used to tie off  the LAA and why at-risk A-Fib patients may consider the LARIAT. EP lab footage and animation. 2:41 min. Published by Asante on Apr 11, 2013.

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: Friday, September 1, 2017

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VIDEO: Watchman Left Atrial Appendage Closure—How it Works and Who is a Prime Candidate

Electrophysiologist, Dr Drew Pickett of Saint Thomas Health, discusses closure of the Left Atrial Appendage using the Watchman device to reduce the risk of clots and stroke. He explains how it works and who is a prime candidate, the installation process and length of procedure, and why a patient may consider the Watchman.

Includes EP lab footage and animation. 3:28 min. Published by Saint Thomas Health; July 13, 2015.

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: Friday, September 1, 2017

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New Video Posted: Dr. Bruce Janiak’s Cardioversion from Atrial Fibrillation

Dr. Bruce Janiak

Dr. Bruce Janiak, a 74 year old full-time emergency medicine physician, videotaped his cardioversion from atrial fibrillation in order to demonstrate both the ease and safety of this procedure.

In a very low-key, conversational manner, Dr. Janiak and the hospital staff conduct his cardioversion. Dr Janiak discusses his previous experiences with chemical conversions. He shares before and at the conclusion of the procedure. 15:08 min. Published by Augusta University, Medical College of Georgia.  Go to video->

VIDEO: The Lariot Procedure: Closure of the Left Atrial Appendage Technique 2

How and why the LARIAT is inserted. For some high-risk patients, the LARIAT procedure is used to tie off the left atrial appendage thereby eliminating this source of clots. The heart’s left atrial appendage, is known to be a major source of blood clots that can lead to strokes. Features Dr. Eric Pena of the Asante Rogue Regional Medical Center. (1:24 min. excerpt.) Published by Asante on Apr 11, 2013.

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: Wednesday, August 30, 2017

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VIDEO: The Watchman Device: Closure of the Left Atrial Appendage Technique 1

Animation of how the Watchman is inserted. For some high-risk A-Fib patients, the WATCHMAN Left Atrial Appendage Closure device is implanted at the opening of the left atrial appendage (LAA) to trap blood clots before they exit the LAA. (The heart’s left atrial appendage is known to be a major source of blood clots that can lead to strokes.) (1:04 min.) Published by jonathan penn on Feb 22, 2014.

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: Wednesday, August 30, 2017

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Hybrid Surgery/Ablation Procedure: An Introduction with Dr. Robert Joy

Dr. Robert Joy gives a short overview of the hybrid procedure to treatment for Atrial Fibrillation in which a cardiothoracic surgeon and an electrophysiologist work together in a single procedure; How it opens up a new opportunity for A-Fib patients with difficult cases of Atrial Fibrillation (1:26 min.) Published by Ellis Medicine, 2012. Dr. Robert Joy is an an Interventional Cardiologist with Ellis Medicine.

Note: The genius of the Hybrid approach seems to be its complementary nature: the surgeon works on the outside the heart and the EP on the inside of the heart to eliminate the Atrial Fibrillation signals.

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: Friday, September 1, 2017

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VIDEO: Introduction to Anticoagulant Therapy—Living with Warfarin

Excellent introduction for A-Fib patients to anticoagulant therapy with warfarin (Coumadin). Practical issues associated with taking warfarin are discussed by patients and medical professionals (clinical nurse, doctors, a pharmacist  and clinical dietitian). (16:22 min.)

Produced by Johns Hopkins Medicine and posted Mar 7, 2011.

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If you find any errors on this page, email us. Y Last updated: Friday, September 1, 2017

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Eleven Things I Know About A-Fib Drug Therapy: Seldom a Lasting Cure

Anti-arrhythmic drugs are certainly better than living a life in A-Fib. They are useful for many patients. But Dr. Peter Kowey, Lankenau Heart Institute, describes them as a stopgap, i.e., they don’t deal with the underlying cause, and are seldom a lasting cure for A-Fib.

Eleven Things I Know About A-Fib Drug Therapy

Peter R. Kowey MD

P. Kowey MD

About Dr. Peter Kowey: An internationally respected expert in heart rhythm disorders, his research has led to the development of dozens of new drugs and devices for treating a wide range of cardiac diseases. (Summary of his 2014 American Heart Association (AHA) Scientific Session presentation.)

Fact #1 “An anti-arrhythmic drug is a poison administered in a therapeutic concentration.” Like most meds, anti-arrhythmic drugs, (AADs), are a trade-off between the unnatural and possible toxicity with the power to alleviate our A-Fib symptoms.

Fact #2 “Amiodarone is by far the most effective of the antiarrhythmics but is also the most toxic.” Amiodarone has never been reviewed or approved by the FDA for the treatment of A-Fib (this is called “off label” use).

Fact #3 “Doctors choose anti-arrhythmic drugs based on their relative chances of harm, not comparative efficacy.” That is. the least dangerous anti-arrhythmic first, rather than the drug most likely to suppress A-Fib.

Fact #4 “Anti-arrhythmic drug therapy is highly empiric (based on observable evidence), and exposure-related.” In practice, doctors don’t monitor how much of a drug is actually in a patient’s blood, but instead use a patient’s response to adjust dosage.

Fact #5 “Antiarrhythmics drugs require surveillance of varying intensity.” An example is Amiodarone requires intense surveillance—lungs, thyroid, eyes, liver, skin and heart.

Fact #6 “Anti-arrhythmic drugs with multi-channel effects may be more effective than those that target single channels or receptors.” For instance, in one study, ‘Pill-In-The-Pocket’ didn’t reduce A-Fib symptoms but did significantly reduce emergency room visits and hospitalizations.

Fact #7 “Anti-arrhythmic drug therapy of A-Fib is imperfect.” It’s treatment without dealing with the underlying cause and not total eradication of symptoms.

Fact #8 “Anti-arrhythmic drug therapy can be creative.” Such as, a strategy like Pill-In-The-Pocket.

Fact #9 “Anti-arrhythmic drugs may supplement the effectiveness of other interventions like catheter ablation.” For instance, used during the 3 month blanking period following a catheter ablation.

Fact #10 “Taking anti-arrhythmic drugs does not preclude the need for stroke prevention.” For example, withdrawal of anti-coagulation therapy after a successful ablation.

Fact #11 “The holy grail is prevention.” But there is no proof that any treatment is conclusively effective.

Dr. Kowey’s Conclusions

• If doctors made better and more intelligent use of anti-arrhythmic drugs, patients would fare better and there’d be fewer ablations.

• Intelligent use requires an in-depth knowledge of pharmacology and familiarity with all aspects of clinical use, especially dosing.

• Anti-arrhythmic therapy is not perfect, but it can improve quality of life and functionality for a significant percentage of A-Fib patients.

Editors Comments:
Dr. Kowey’s statement that “an anti-arrhythmic drug is a poison administered in a therapeutic concentration” should set off alarm bells for patients. In the US, we’ve been conditioned to think “ if we’re sick, just take a pill”.
But today’s anti-arrhythmic drugs have poor success rates (often under 50%), often have unacceptable side effects, and when they do work they tend to lose their effectiveness over time.
In general, anti-arrhythmic drugs are toxic substances which aren’t meant to be in our bodies―so our bodies tend to reject them.
References for this Article

At Age 13, Treatment for Acne Reveals Need for a Cardiologist! A-Fib Hits Early

Warren D.

By Warren Darakanada, Los Angeles, CA, August 2017

“As I write about my A-Fib, I am 23 and just starting my adult life as a financial and economic consultant. But my cardiac story actually starts about ten years ago.

At age 13, I got a severe acne breakout that brought me to the doctor’s office. While waiting to see the doctor, a nurse decided to take my vitals and blood pressure. While the diastolic pressure was normal, the systolic was above 140 mmHg. Without a doubt, I needed to see a cardiologist.

Further investigation revealed that I also had an elevated cholesterol level. Luckily, my blood glucose level was normal. I went through a series of tests to rule out causes of secondary hypertension. Luckily or unluckily, nothing was found.

Since I was a low-risk patient who could benefit from lifestyle modification, and given my age, I was not prescribed any medication or procedure.

At Age 18, A Shock to be Diagnosed with A-Fib!

Over the next years, I had several EKGs, but it was not until a routine cardiologist visit when I was 18 that I was diagnosed with atrial fibrillation. I think I had A-Fib for some time prior to my diagnosis, but had no idea my heart beat was irregular.

I was 18, and in shock! I didn’t know what to do. I didn’t know what to think or feel.

I was in shock! I didn’t know what to do. I didn’t know what to think or feel. The attending cardiologist called in medical residents and fellows to show them that “this is what atrial fibrillation sounds like” through the stethoscope.

Referred to an electrophysiologist, I was put on a beta-blocker and warfarin. Given my young age and the perpetual nature of atrial fibrillation, I knew I was headed toward a cardiac ablation.

[For someone as young as Warren, it’s unthinkable to leave him taking dangerous A-Fib drugs for a lifetime (60 or 70 years). In addition, a catheter ablation was his most reasonable option with a high success rate in young people like Warren.]

Suffers Most from Mental and Psychological Effects

While I had few A-Fib symptoms, what I found hard to endure and most debilitating was the mental and psychological effects. I would ask myself:

‘Why is this happening to me and not anybody else?
Why can’t I go back to college and enjoy my freshman year with my friends?
Given all these circumstances, is my life worth living?’

These questions may sound stupid to a mature person in good mental condition. But that wasn’t me. Remember, I was only 18 years old and just starting college, and college students are prone to depression for various reasons. (See Seven Ways to Cope with the Fear and Anxiety of A-Fib)

My solution: Instead of staying home and pondering about these life problems, I decided to keep myself busy with activities, online classes, and occasional meet-ups with friends.

In hindsight, that helped tremendously.

My Catheter Ablation

It was roughly 3 months between my diagnosis and my ablation in March 2013. So, I only “knowingly” lived with A-Fib for a few months before my ablation.

The day of my RF catheter ablation came just as any other day. I had been admitted the night before. Except for not eating after 9 pm, I did nothing to prepare myself for it. I think the procedure lasted about 1 1/2 hours. I stayed in the hospital overnight.

As a child, I had had many surgeries, so hospitalization was not a big deal. (To keep this short, I’ll skip my childhood medical history.)

Post Ablation

After the procedure, I was almost always in sinus rhythm. But my atrial fibrillation would come back intermittently. Most episodes were really short with the frequency decreasing over time. [This is common during the three-month ‘blanking period’ following an ablation.]

However, because my heart rate was not well controlled and because of the risks of recurrences, I was put on diltiazem, a calcium channel blocker.

Because of my hypertension and high cholesterol (added risk factors of atrial fibrillation), I am also on Cozaar and a statin.

Now A-Fib-Free 

Since I started diltiazem, I’ve not had an episode…except one time after being under general anesthesia. The cardiologist believes that was a side effect of propofol [used to help you relax before and during general anesthesia for surgery].

It would be great if I could live without my various medications, but taking them, honestly, is not a big deal.

Lessons Learned

Emotionally Stronger and Healthier: I feel the entire A-Fib/ablation process has made me an emotionally stronger person. I also started to work out and take care of my own health more. (But that’s also a function of becoming more mature with age rather than the ablation alone.)

In the process, I have learned to enjoy and appreciate life in the way most people my age could never do.

I have learned to enjoy and appreciate life in ways others my age could never do.

Atrial Fibrillation―It Comes in a Package: By that I mean, cardiovascular disorders often come “packaged” together, often congenitally and genetically.

I’m trying to suggest that people with A-Fib/arrhythmia often have other cardiovascular risk factors. For instance, I have hypertension and high cholesterol and a family history thereof.

Moreover, cardiovascular diseases are also risk factors of diseases for other organs, such as the kidneys and liver.

My advice for younger patients diagnosed with Atrial Fibrillation:

Exercise: I would suggest that young adults work out more, at least 3 times a week for one hour each time.

Seek Help for Mental Health: For those suffering from A-Fib, make sure that you have a good attitude. Seek counseling if you have mental conditions from A-Fib.

Evaluate & Reduce Other Risk Factors:  Young A-Fib patients should also see general cardiologists to evaluate A-Fib related risk factors.

When young people get A-Fib, they could be living with it for possibly more than 50 years. Take actions to reduce your risk factors and take care of your body.

Positive Attitude Trumps All: I’m dealing with my ‘package’ of conditions. While getting rid of my ‘package’ once and for all might not be an option for me, I can choose to live with a positive attitude.

I welcome your emails.”

Warren Darakananda
warrenddara(at)gmail.com

Editor’s Comments:
We are most grateful to Warren for his frank discussion of how A-Fib affected him psychologically and emotionally. He was only 18 years old when diagnosed with A-Fib and just starting college. He’s learned the hard way how to develop a “positive attitude.”
Psychological Distress:  For Warren, the psychological effects were hard to endure, much more so than his physical symptoms.
Recent research indicates that “psychological distress” worsens A-Fib symptoms’ severity. For many patients the anxiety, fear, worry and depression can become debilitating.
To learn how to deal with the psychological aspect, see my article, Seven Ways to Cope with the Fear and Anxiety of A-Fib.
A-Fib Support Volunteers: I’m pleased to welcome Warren to our group of A-Fib Support Volunteers. He hopes to be a resource for those patients closer to his age. (He’s one of our youngest volunteers.)
We are blessed to have many generous people who have volunteered to help others get through their A-Fib ordeal. Most A-Fib Support Volunteers are not medical personnel. They come from widely different backgrounds. But you can be sure they care about you and understand what you are going through. Visit our A-Fib Support Volunteers page to learn more.

Personal Story: Urology Test Led to A-Fib Diagnosed at Age 66

Larry Stichweh tells us about his 8 year journey with Atrial Fibrillaiton. It all started with his high blood pressure.

“It was taking an increasing level of meds to keep my blood pressure in check. At a routine office visit, I suggested to my doctor that we should look at possible causes of my high blood pressure.

My doctor agreed, and as a starting point, sent me to an urologist to look for a kidney stenosis problem. The ultrasound proved negative, but the urologist listened to my heart and noted an irregular beat. I had no known prior history of heart problems.

The urologist sent me down the hall for an ECG with instructions to have the technician give the chart to me to take back to him. He took one look at it, took me to his office, and said he was admitting me to the hospital right then and there. He put me in a wheel chair (even though I felt no symptoms) and off I went.

He said I had no “P” wave and was in A-FIB. Thus, began my A-FIB history.” Continue reading Larry’s story.

Major Coumadin Problems, on Sotalol For 8 Years, Then Cryoballoon Ablation at Age 74

By Larry Stichweh, Lacey, WA, August 2017

Larry Stichweh, Lacey, WA

Many of the shared personal A-FIB experiences on A-Fib.com describe a long and complicated path to a cure. But mine, not so much.

But it did involve these issues: a bad experience with Coumadin, effective long-term use of Sotalol (Sotalol becoming an important component of my blood pressure control), significant congestion side effect of Eliquis, and a single successful cryogenic PVI ablation with no complications.

I hope my story is more typical of those who experience A-FIB (except for the Coumadin issue).

High Blood Pressure for 20 Years

My story begins at age 66 in 2008. I am a retired chemical engineer and was living in Pensacola FL. I had been successfully treated for high blood pressure for at least 20 years, working progressively through many hypertensive drugs and drug combinations. Up to this point my blood pressure was controlled near 120/80.

Urology Test Led to A-Fib Diagnosed at Age 66

It was taking an increasing level of meds to keep my blood pressure in check. At a routine office visit, I suggested to my doctor that we should look at possible causes of my high blood pressure.

He took one look at my ECG, took me to his office, and said he was admitting me to the hospital right then and there.

My doctor agreed, and as a starting point, sent me to an urologist to look for a kidney stenosis problem. The ultrasound proved negative, but the urologist listened to my heart and noted an irregular beat. I had no known prior history of heart problems.

The urologist sent me down the hall for an ECG with instructions to have the technician give the chart to me to take back to him. He took one look at it, took me to his office, and said he was admitting me to the hospital right then and there. He put me in a wheel chair (even though I felt no symptoms) and off I went.

He said I had no “P” wave and was in A-FIB. Thus, began my A-FIB history.

Hospitalized 6 Days: Started Arrhythmic Drug

I do not know how long I was in A-FIB at that point as I did not recognize any symptoms except for a bit of fatigue. My best guess was less than two weeks prior to discovery. I spent 6 days in the hospital while I was introduced to the arrhythmic drug, Sotalol, which requires a few days of monitoring at the start to watch for undesirable reactions.

I do not know how long I was in A-FIB at that point as I did not recognize any symptoms except for a bit of fatigue.

I also began anticoagulation therapy which starts with injected heparin and then migrates to Coumadin.

After 6 days in the hospital I was feeling well (though bored) but still in A-FIB. I requested a electroconversion. During the prep and anesthesia, I self-converted [back into sinus rhythm] and was sent home to begin adjusting the Coumadin level.

Weeks Spent Adjusting Coumadin Dosage

Now the “fun” begins.  I left the hospital taking 160mg Sotalol/day and 5.0 mg Coumadin with an INR of about 2.5 on April 29, 2008.  I had to report to a “Coumadin lab” every few days while they adjusted the Coumadin dosage to the target INR level.

Here is the history of the adjustments, as prescribed by the clinic technician, working toward a target INR of 2.5:

Date    INR    Adjusted Coumadin mg/day

4/29     ~2.5     5.0 as discharged from hospital
5/2       4.1       4.0
5/8       4.3       4.4 I do not know why this increase was prescribed
5/16     3.8       4.0
5/30     3.6       3.0

[SSR: These INR levels are too high for someone on Coumadin.] I spent the better part of a month above the target of 3.0.

On June 3, 2016 I was sitting at my computer in the morning when I noticed my blood pressure increasing rather rapidly from my normal systolic of about 130mm to 200mm.

I had my wife drive me to the emergency room where I was monitored due to the high blood pressure, and they noted I had been taking Coumadin.

Back to Hospital with High Blood Pressure Crisis

By midafternoon I was sitting in the ER and noted my vision was fading out to all white. The dropping blood pressure brought the staff in to put my head down and feet up which brought back my sight and consciousness.  At this point the ER doctor said he had no idea what my problem was, and I was admitted to a hospital room. I seemed to be somewhat stabilized at this point but very weak.

That night a bowel movement was very large and resembled fresh asphalt which I informed the attendant of the next morning [sign of intestinal bleeding]. This information apparently did not make it into my record, a major oversight. No one ever asked about this possibility while I was there, and I was in no shape to think clearly.

The next three days I did not have the energy to sit up or eat any solid food. They ran many tests including a CT scan and frequent blood tests.

None of these produced any clue as to my problem.

That is until day four. After I had been drinking only water, my morning hemoglobin results came back at 7.0 (normal is 14) now that my blood volume was back to normal due to the water intake. I had lost 5 pints of blood.

My Small Intestine Bleeding Linked to Coumadin

At this point the several doctors on my case knew what to do, and three units of blood brought my hemoglobin up to 11.5. They concluded that the intestinal bleed had stopped on its own with the discontinuation of Coumadin and that I could be discharged.

With the discontinuation of Coumadin, the intestinal bleed had stopped on its own.

Poor Opinion of Hospital Care: This sequence of events does not reflect well on the hospital and staff and their record keeping. My wife was also not happy with the lack of communications with the cardiologist managing my case. I do not remember any discussions with any of the doctors.

A follow-up colonoscopy and endoscopy eliminated the back and front end leaving the small intestine as the default source of the bleed. At this point it was concluded that I should avoid Coumadin until such time as this problem in my small intestine is identified and corrected, if ever.

Switched to Aspirin: The newer anticoagulants, not requiring INR monitoring, were not yet available [in 2008]; so I was left on 81mg aspirin for anticoagulation.

Next 8 Years: Paroxysmal A-Fib Gets Worse

As time progressed my A-FIB was clearly paroxysmal with episodes lasting between 1 and 2 days with 8 episodes over the next 8 years. The interval between episodes ranged from 0.6 months to 22 months. This calculates out that I was in A-FIB only 1% of the time.

Symptoms were minimal, consisting of slight fatigue with the loss of the atrial pumping action and the noted irregular heartbeat.

I could not identify any thing that triggered or ended an A-FIB event. I always self-converted and had to pay attention to even note when the sinus rhythm returned.

When the last A-FIB attack lasted three weeks, it was time to consider an ablation.

Arrhythmic Drug: Sotalol dosage was adjusted between 160 and 240 mg/day with reductions when needed to increase the resting heat rate or increased as the A-FIB frequency and duration eventually began to increase.  Fortunately, this A-FIB frequency meant that anticoagulation therapy was likely of little value in my case. [Some say that clots can form and cause an A-Fib stroke in only 24 hours.]

A-FIB Frequency and Duration Increase: Sotalol and other antiarrhythmic drugs typically are effective for only a few years at most, but in my case, Sotalol worked for 8 years before the A-FIB frequency and durations began increasing.

When the last A-FIB attack lasted three weeks, it was time to consider an ablation at age 74.

Elects CryoBalloon Ablation at Age 74

By this time [2016] cryogenic balloon ablations had become readily available in major medical centers in the US, and I was now living in the Seattle area. This was a major improvement over the RF burning ablations for the Pulmonary Veins, the most common sources of A-FIB.

My local cardiologist referred me to Dr. Derrell S. Wells with the Swedish Heart and Vascular Clinic at Cherry Hill in Seattle. (I had noted his listing on the A-Fib.com directory of doctors.)  My local cardiologist had an echocardiogram done and forwarded it to Dr. Wells who reviewed my echocardiogram and medical history. He concluded I was a good fit for a cryogenic PVI ablation.

My EP Skilled in Both CryoBalloon and RF Ablation Techniques

My left atrium was enlarged but still within the acceptable range. He could also do RF ablations at the same time if other active electrical sites were found.  Dr. Wells looked at my Coumadin adjustment experience and commented that it was no wonder I had a bleeding problem.

My EP could also do RF ablations at the same time if other active electrical sites were found. 

Surprisingly, there was only a 6-week waiting time between the initial appointment and the ablation procedure. The day before, I reported for x-rays and an MRI to create a three-dimensional model of my heart for use in the procedure. The clinic had at least two MRI units and at least one was a 3 Tesla unit.

Stopping Sotalol Causes Problems

Three days before the ablation I was to stop the Sotalol. (During the procedure, they do not want a drug suppressing any A-FIB tendency.)

Stopping the Sotalol proved to be a significant problem for me. Two days after stopping the Sotalol, I reported for the MRI and a checkup by Dr. Well’s nurse practitioner.

My heart rate was above 100, blood pressure was high, and I had the “shakes” so much that I could not sign my name in a recognizable script.

The nurse said if I thought it necessary, I could take a Sotalol which I did.  One hour later I was back to normal.

CryoBalloon Ablation: Successful 2.5-hour Procedure

The next morning, I was prepped for the catheter procedure.

Dr. Wells used conscious sedation, but I was totally unaware of anything during the 2.5-hour procedure. All four pulmonary veins were ablated using two freeze-thaw cycles for each vein.  Electrical isolation was confirmed.

No Significant Bleeding/No Complications: No other A-FIB sources could be identified, and an arrhythmic event could not be chemically induced. Total fluoroscopic time was 11.5 minutes, a relatively low time. No significant bleeding issues were experienced at the catheter insertion point. Dr. Wells said that my case was a “text book” case with no complications during the procedure.

Blood Pressure/Heartrate Alarm: Later that evening my blood pressure and heartrate increased significantly as I had not taken a Sotalol for 30 hours. I asked the nurse to give me 120mg of Sotalol which he did after consulting the on-call doctor. Again, that solved the problem within the hour.

I was discharged the following morning.

Most Patients Not on Sotalol for 8 Years: Dr. Wells said he had not seen a case where Sotalol had provided a significant contribution to blood pressure control, but then most patients have not been taking it for 8 years.

Recovery―Replacing Eliquis with Pradaxa

Over the next several months the Sotalol was gradually replaced by another blood pressure medication (Carvedilol added to Losartan and Torsemide).

Eliquis caused me significant congestion, trouble breathing, and wheezing. It was replaced by Pradaxa with no issues.

Eliquis was prescribed for at least three months after the ablation to avoid blood clots while the heart tissue healed. Eliquis caused me significant congestion, trouble breathing, and wheezing. It was replaced by Pradaxa with no further issues.

I should also note that I had been taking 20mg/day of Omeprazole for 6 years for gastritis which may have helped me tolerate the Pradaxa, but this is pure conjecture.

After One Year Still A-Fib Free

During the three months [blanking period] following the ablation I experienced no A-FIB events. But I did observe a few missed heart beats ranging from 1 to 10 that gradually diminished to zero.

There were no irregular heartbeats as experienced with A-FIB. After three months, I was given a wearable battery powered cardiac monitor for two weeks which was then mailed off for analysis.

Off Pradaxa: The results came back in a normal range, and Dr. Wells gave me permission to discontinue the Pradaxa. Almost one year later I continue to be A-FIB free.

Self-Monitoring of Blood Pressure & Pulse: I monitor my blood pressure frequently, and the unit I use will also detect an irregular heartbeat. I can also feel the pulse in my wrist. This takes about 5 seconds to do, requires no equipment and can be done anywhere and at any time. It was obvious when I was in A-Fib.

Lessons Learned:

I guess the point of my story is that even if your symptoms are minimal and paroxysmal, do not hesitate to consider an ablation if you begin moving toward persistent A-FIB.

Success Rate diminishes: As your A-Fib becomes more persistent, the lower your success rate of a permanent cure.

Don’t Delay Too Long: The rapid advances in ablation procedures over the last 20 years suggest delaying if possible, but not beyond the point of a diminishing probability of a successful cure.

Larry Stichweh
lastic1(at)live.com

Editor’s Comments:
Larry’s Easily Cured Case: We’re grateful to Larry for sharing his A-Fib story of being cured by a single, short CryoBalloon ablation, which is similar to the experience of most A-Fib patients (unlike many of the stories in A-Fib.com which tend to be unusual and often heroic).
Success with Sotalol: Larry had remarkable success with the antiarrhythmic drug Sotalol which also has beta-blocker properties.  But don’t count on any antiarrhythmic drug to control or eliminate A-Fib for 8 years. Most antiarrhythmic drugs tend to lose their effectiveness over time, as Sotalol eventually did for Larry.
Anticoagulants are Considered High Risk Drugs: Coumadin and all anticoagulants are considered high risk medications. They work by causing or increasing bleeding. Even though they are certainly preferable to having an A-Fib stroke, they carry their own set of risks.
Larry could have died from his internal bleeding. He will have to monitor and watch out for GI bleeding probably for the rest of his life.
But on the other hand, Larry was having A-Fib episodes longer than 24 hours which can cause clots and strokes. One of the most difficult decisions you and your doctor have to make is whether or not to be on an anticoagulant and which one to take. And that decision may change as you do.
Continued Monitoring: Larry will see Dr. Wells or his colleagues for at least once a year (but, like me, probably for the rest of his life).
He may want to make sure he doesn’t slip back into silent A-Fib, so he may use DIY monitors at home to check himself regularly.

In your 80s? Are You Doomed to a Life in A-Fib or Can You Still Have a Catheter Ablation?

If you’re in your 80s, you’re not automatically doomed to a life in A-Fib and on A-Fib drugs. You most likely can still have a catheter ablation. The research by Dr. Pasquale Santangeli is very hopeful and encouraging.

Study of Octogenarians Who Had a Catheter Ablation (PVI)

Dr. Pasquale Santangeli and his colleagues at the Texas Cardiac Arrhythmia Institute in Austin, TX examined data from 103 octogenarians who had an RF catheter ablation between 2008 and 2011. They compared this older group to younger patients who underwent the same procedure.

 If you’re in your 80s, you’re not automatically doomed to a life in A-Fib and on A-Fib drugs.

• There was no difference in the rate of success between the octogenarians and the younger group (69% vs. 71%).

• The rate of procedure-related complications was also not significantly different between the two groups, even when looking at different types of A-Fib such as paroxysmal and non-paroxysmal A-Fib.

• Octogenarians with paroxysmal A-Fib had more non-pulmonary vein trigger sites, and consequently required longer procedural time to effectively isolate such non-pulmonary vein areas. (Dr. Santangeli suggested a hypothesis that the underlying pathology of A-Fib in older patients might be different from younger patients.)

In practice, octogenarians have been largely excluded from clinical trials of catheter ablation. Current guidelines are also very conservative, because there has been a lack of adequate clinical studies in this area. Dr. Santangeli’s report is a step in the right direction.

When Old Isn’t Necessarily Old

In the real world old isn’t necessarily old. People in their 80s may indeed have ‘excellent functional and health status” which would make them good candidates for a catheter ablation. Most healthy 80-year-olds aren’t so frail that they can’t have a catheter ablation.

You can still have a catheter ablation but you need to find an EP Experienced in Non-PV Triggers.

After all, a catheter ablation is a non-invasive procedure. It isn’t like open heart surgery which is incredibly taxing and physically demanding. You don’t have to be a ‘Johnny Atlas’ muscleman to have a catheter ablation. Most healthy 80-year-olds aren’t so frail that they can’t have a catheter ablation.

In your 80s? Find an EP Experienced in Non-PV Triggers

If you’re in your 80s, you most likely can still have a catheter ablation. But, you need to find the right electrophysiologist (EP).

Make sure you select an EP with a proven track record of finding and isolating non-PV triggers. (Dr. Santangeli’s research found that octogenarians have more non-pulmonary vein trigger sites.) Some EPs can’t or won’t make the extra effort to map and ablate non-PV triggers.

(I’ve read O.R. reports where the patient was still in A-Fib after the EP had ablated their PVs. Instead of trying to map and ablate non-PV triggers, the EP simply electrocardioverted [shocked] the patient back into sinus rhythm. After a short time, the patient went back into A-Fib.)

Questions to Ask a Prospective EP

When interviewing a prospective EP, ask:

 “What do you do if I’m still in A-Fib after you’ve ablated my pulmonary veins?” (You want a reply such as “I use mapping to search for non-PV triggers in other areas of the heart”.)

We are indebted to Dr. Santangeli and his colleagues for showing that octogenarians can have a successful, safe ablation, and shouldn’t be excluded from a catheter ablation simply on the basis of their age.

To learn more: read my related article: FAQs A-Fib Ablations: Is 82 Too Old for a PVA?  

References for this article

Does a Successful Catheter Ablation Have Side Benefits? How About a Failed Ablation?

Are there additional dividends from a successful catheter ablation for A-Fib—beyond being back in normal sinus rhythm (NSR)? Research says, yes!

Additional Benefits of Successful Catheter Ablation

“The benefit of catheter ablation extends beyond improving quality of life…If successful, ablation improves life span,” says, lead author Dr. Hamid Ghanbari, an electrophysiologist at U.of Mich. Frankel Cardiovascular Center.

Illustration of RF ablation

His comments are based on a study that examined 10 years of follow-up medical data on over 3,000 adults who received RF catheter for paroxysmal or persistent atrial fibrillation. Researchers found that staying in normal sinus rhythm (NSR) was associated with a 60% reduction in the expected rate of cardiovascular mortality (risk of death from stroke and other cardiovascular events).

In another study (Anselmino), a meta-analysis of 26 studies involved 1,838 A-Fib patients who had undergone a catheter ablation. Post-ablation follow-up averaged 23 months. Examining the patient follow-up data, researchers found a significant 13% improvement in left ventricular ejection fraction (EF), i.e., the heart’s blood pumping efficiency.

In addition, there was a significant reduction in the number of patients who formerly had an ejection fraction of less than 35% (more patients improved their EF ratio out of the life-threatening range). Blood pressure levels were also improved.

Summary of Research Findings: These studies reveal some of the real benefits to patients after a successful catheter ablation that go beyond being in normal sinus rhythm (NSR):

• improved quality of life
• significantly lower risk of cardiac-related mortality
• better heart pumping efficiency for more patients (ejection fraction, EF)
• improved blood pressure levels

You may ask, do these side-benefits depend on the catheter ablation eliminating the patient’s A-Fib?

Ever Wonder If There Are Benefits from a Failed Ablation?

Catheter ablation from Cleveland Clinic

VIDEO: Catheter ablation, Cleveland Clinic

Researchers have studied the follow-up data of failed ablations and found a few ‘side’ benefits.

A clinical trial (Pokushalov) showed that, when ablation fails to eliminate paroxysmal atrial fibrillation, a second try is more successful in returning the patient to sinus rhythm than medication alone; it also slows the progression from paroxysmal A-Fib to persistent A-Fib.

In addition, some patients found their A-Fib symptoms were less intense or shorter in duration. (Might be attributed to an improvement in left ventricular ejection fraction.)

Other patients found they could take certain medications that prior to their ablation had been ineffective.

Summary of Research Findings: These studies reveal some of the real benefits to patients even if their catheter ablation doesn’t return them to normal sinus rhythm:

• second ablation is more successful than medication alone
• second ablation slows progression from paroxysmal to persistent A-Fib
• symptoms were shorter or less intense
• certain medications worked that didn’t work before

A catheter ablation can profoundly change one’s life, even if you need a 2nd ablation.

Conclusion

A catheter ablation can profoundly change one’s life, even if you need a 2nd ablation. 

So, either way, a catheter ablation offers benefits to Atrial Fibrillation patients. Even if you need a second ablation (or a third), know that you may still reap substantial benefits from the previous “failed” ablation.

For more about the benefits of ablation, see Live Longer―Have a Catheter Ablation!

References for this article

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