ABOUT 'BEAT YOUR A-FIB'...


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

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

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

Dr. Wilber Su Cavanaugh Heart Center, Phoenix, AZ

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

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



ABOUT A-FIB.COM...


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

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

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

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

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

Terry Traver, former A-Fib patient

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

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


PACs/PVCs

PVC-Free After Successful Ablation at Mayo Clinic by Dr. Mulpuru

John and Marcia Thornton-Personal A-Fib story at A-Fib.com

John and Marcia Thornton

A-Fib Patient Story #84

PVC-Free After Successful Ablation at Mayo Clinic by Dr. Mulpuru

By John Thorton, as told to Steve Ryan, December 2015

In September, John Thornton wrote us about his successful ablation at the Mayo Clinic in Rochester, MN:

“Well, I am now home from the Mayo Clinic. I cannot give high enough praise to the way Mayo treated me. The nurses were outstanding, and the delivery of care exceptional. The Mayo philosophy and attitude is far superior to the way the local hospital does things.”

Difficult Ablation with Multiple A-Fib, Flutter and PVC Spots

On July 27, 2015, John had his ablation procedure at the Mayo Clinic.

Besides A-Fib and A-Flutter, a particular problem for John was PVCs. Premature Ventricular Contractions (PVCs) are premature beats that occur in the ventricles, i.e., the heart’s lower chambers. (Premature beats that occur in the atria, the heart’s upper chambers, are called premature atrial contractions, or PACs.)

John’s ablation turned out to be quite an extensive procedure. Dr. Siva A. Mulpuru found two sources of PVCs, two spots A-Fib was originating from,  and one where atrial flutter was found.

The ablation took six hours which was much longer than a typical pulmonary vein ablation/Isolation (PVA/I).

High Density PVCs and Low Ejection Fraction

John Thornton: “According to Mayo, if PVCs are over 20% of your heart beats, they are dangerous. Mayo calls that level ‘high density PVCs”.  High density PVCs cause your heart muscle to weaken.

My high density PVCs were 30% of my heart beats, and my ejection fraction was down to 41%.

[An ejection fraction (EF) below 50%, means your heart is no longer pumping efficiently to meet the body’s needs and indicates a weakened heart muscle.] 

After the ablation, my PVCs were down to 15% of my heart beats, and my ejection fraction was back up to 64%.”

[Spot on! A normal ejection fraction is in the range of 50 – 65%.]

My Heart is Beating Normally Now!

“It’s now December 2015 and I am still A-Fib free. I do have occasional PVCs still, but no where near the extent of what I had prior to the ablation. I am almost completely without symptoms of any rhythm problems.  I’m still on a beta blocker and a blood pressure med.

Lessons Learned

Lessons Learned graphic with hands 400 pix sq at 300 resDo NOT listen when doctors say PVCs are harmless.

The local MDs (about a half dozen different ones), cardiologists, EPs, and other local specialists, all told me stuff like, “Everyone has PVCs” and “PVCs are benign” and “It is just anxiety” and “You just need to learn to live with it” which was completely WRONG.

Be Assertive, Even Aggressive: I had to set up my own appointment at Mayo to get evaluated there.  It was a lot of work, by me alone, to get in to see the doctors at Mayo, but it was worth it.

I honestly believe that had I not gone to Mayo I would have suffered some major heart event, or possibly death.

Follow-up and Changing MDs: Many of the local MDs are not receptive to me now. I had to change my local cardiology group to one where they would listen to the recommendations from Mayo.

I had to interview local doctors to find one willing to listen to Mayo’s staff and order follow-up tests for me.  Simple things like ECGs, lab test, etc…

I am planning all my major follow-ups back at Mayo because of the stress between the locals (with the one exception) and the people at Mayo.

One Final Thought: If in doubt, go to the Mayo Clinic and get checked out.  They know what they are doing and are the real experts.

Feel free to email me if you have questions about PVCs and/or the Mayo Clinic.”

John Thornton, Sioux Falls, SD
johnthornton(at)sio.midco.net

Editor’s Comments
To learn more about PVCs, see my article: FAQs Coping with A-Fib: PVCs & PACs
Like John, don’t be afraid to fire your doctor! To learn how to interview doctors, see our page: Finding the Right Doctor for You and Your A-Fib.
PVCs aren’t always benign and, especially for people with A-Fib, should be taken seriously. Often they precede or predict who will develop A-Fib. They can increase chances of a fatal heart attack or sudden death. Sites in the heart that produce PVCs can be mapped and ablated just like A-Fib signals.
Kudos to John for being his own best patient advocate, for taking the bull by the horns and dealing with his PVCs which were destroying his life and driving him crazy. In spite of what he heard from everyone else, he persevered and went to probably the best center in the US for treating PVCs—the Mayo Clinic. Now he’s A-Fib free and only has occasional PVCs. Way to go, John!

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Top 10 List #6 Be courageous. Be aggressive 600 x 530 pix at 300 res

Updated Answer to FAQ About Coping with PVCs & PACs

New Article icon - red-heart-negative 75 sq at 96 resWe’ve update our answer to the Frequently Asked Question: I have a lot of extra beats and palpitations (PVCs and/or PACs) which are very disturbing and frightful. They seem to proceed an A-Fib attack. What can or should I do about them?

We’ve added:

Sometimes PVCs Aren’t Always Benign

In patients with other heart problems like Coronary Artery Disease (CAD), frequent PVCs often aren’t “benign.” They can increase chances of a fatal heart attack or sudden death. PVCs have been implicated in the development of cardiomyopathy and LV (Left Ventricular) dysfunction.

But catheter ablation or antiarrhythmic pharmacological agents appears to reverse this cardiomyopathy and LV dysfunction. RF ablation for frequent PVCs in patients without structural heart disease has been shown to completely reverse cardiomyopathy in numerous studies.

To read the entire answer, go to: FAQs Coping with A-Fib: PVCs & PACs.

New A-Fib Patient Story: Serious Pradaxa Side Effects

Jeff Patten, Ashby, MA

Jeff Patten, Ashby, MA

Jeff Patten’s A-Fib started briefly in 2000, then returned in 2010 when his father-in-law died. The emotional upset, high summer heat, stress and accumulated age, followed closely by a bout with appendicitis, put him back into A-Fib .

In 2012, came a successful CryoBalloon ablation. But Jeff’s post-ablation recovery on Pradaxa turned into “alimentary torture” and burning diarrhea. Later came a Right Atrium Catheter Ablation for PACs/PVCs. Learn how Jeff emerged in 2015 healthy and A-Fib free.

 

Jeff Patten A-Fib Patient Story

A-Fib Patient Story #78

Jeff Patten

15 years in A-Fib: CryoBalloon Ablation, Pradaxa Problems, Second Ablation (RF) for Flutter

By Jeff Patten, Ashby, MA, January 2015

My A-Fib started about fifteen years ago.

That warm September day in 2000, I was tired, had a lot of coffee and was trying to finish a heavy shrub transplanting job. Sweating and breathing heavily, I noticed my heart was not doing what it should.

Alarming! Dehydration?? A couple of hours in ER and it normalized on its own.

After a couple more brief episodes, I decided to get back in better shape – slowly and judiciously! I’d always been active and couldn’t understand why the ole’ ticker was failing me now. They called it lone paroxysmal atrial fibrillation, so there was nothing else wrong.

Flecainide “Pill-In-The-Pocket,” Propafenone, Then CryoBalloon Ablation

The next decade saw no more episodes.

Then, in 2010, my father-in-law died. The recipe of emotional upset, high summer heat, stress (there was a lot of heavy “estate” to handle), and―as they tell me―accumulated age put me back on the A-Fib merry-go-’round.

My A-Fib was very symptomatic with erratic chest pounding, weakness and breathlessness. I took Life easier, and the A-Fib eased―until that autumn’s bout with appendicitis!

My EP put me on flecainide as a pill-in-the-pocket. That seemed to work for a while―until it didn’t

Time to see an electrophysiologist. My newly acquired EP put me on flecainide as a pill-in-the-pocket. That seemed to work for a while―until it didn’t. Episodes got worse. I was put on propafenone and warfarin while waiting for my ablation.

In December 2012, I had a pulmonary vein isolation (PVI). My EP used the newly approved CryoBalloon catheter.

Recovery: A-Fib free, but Pradaxa “Alimentary Torture” and Burning Diarrhea, Switch to Xarelto

After my ablation, I was put on a double dose of the proton pump inhibitor omeprazole (Prilosec), which is done on the theory it will help prevent the very unusual but deadly side effect of PVI known as atrioesophageal fistula by reducing erosive inflammation.

Since my INR numbers on warfarin were hard to control and there was concern about warfarin’s deleterious effect on vascular calcium through its action on vitamin K, I was put on dabigatran (Pradaxa) as an alternative.

Pradaxa comes in a special container to control moisture. The pills must be tossed if not used in four months once opened. They are awkwardly large. They must be taken twice a day. They are formulated with tartaric acid to help absorption. Everyone who takes Pradaxa must contend with all this.

Pradaxa was alimentary torture. Burned on the way down. Burned in my stomach and belly. Burned with diarrhea on the way out.

For me, Pradaxa was alimentary torture. Burned on the way down. Burned in my stomach and belly. Burned with diarrhea on the way out. The label suggests you’ll accommodate.

After six days I called for help and was switched to rivaroxaban (Xarelto). This is a small pill. Tiny, really. No particular moisture issues. No unusual expiration. Once a day. No burning. But the diarrhea continued for more than a couple of months.

Lymphocytic Colitis: From Taking Omeprazole (Prilosec) and/or Pradaxa?

As soon as my ablation was deemed ‘successful’, meaning that I was able to come off my doses of propafenone and Xarelto and omeprazole, I had a colonoscopy to check out the continuing diarrhea.

Diagnosis: lymphocytic colitis. I did a bit of research on this and discovered that very little is conclusively known about this increasing public problem. It is understood that there is an association between this colitis and the use of proton pump inhibitors among other meds such as non-steroidal anti-inflammatories. The diarrhea gradually subsided.

This Pradaxa/omeprazole story is one anecdote. No scientific conclusions can be drawn. I know what I personally conclude about it, however!

Ectopic Beats Turn into Flutter, RF Ablation

The ectopic beats following the ablation got worse.

PACs and PVCs are supposed to be normal and benign. Sometimes mine seemed to string themselves together for a bit. Then in July 2013, they didn’t quit. A heart rate of 130 at rest sent me to the E.R. where I got a diagnosis of atrial flutter, a successful cardioversion, and an appointment for another ablation.

An ablation in August addressed three flutter ‘circuits’. Careful electrical mapping was used this time, and RF-energy was used to break the ‘circuits’.  Apparently flutter such as this often follows on the heels of an A-Fib ablation. Not fully understood.  Yet.

So far, so good. I’ll let you know if anything more of interest happens.

Jeff Patten
jedapatten@yahoo.com

Editor’s Comments
Pradaxa and Stomach Problems: It’s unfortunately not unusual to experience the intestinal tract problems Jeff had when taking Pradaxa. Pradaxa’s own fact sheet states the common side effects of Pradaxa include:
• Indigestion, Upset Stomach, or Burning
• Stomach Pain
In Pradaxa’s clinical trials, nearly two out of five people (35%) could not tolerate Pradaxa, which is a high rate of adverse reactions. In an earlier post I wrote “Based on the clinical trial data, there is a danger that Pradaxa over time may cause long-term damage to the gastrointestinal system.” (See The New Anticoagulants [NOACs], 2013 Boston Atrial Fibrillation Symposium). This may be what happened to Jeff when he developed lymphocytic colitis, but we can’t say this for sure.
It’s unusual to be put on a double dose of omeprazole (Prilosec).
Switch from Pradaxa to Eliquis or Go Back to Warfarin: I’d recommend to anyone taking Pradaxa to switch to a different anticoagulant or go back to warfarin if it worked for you. Not only is Pradaxa associated with intestinal tract problems, but it’s been associated with people bleeding to death in the ER. There’s no reversal agent or antidote for Pradaxa as there is for warfarin. (See Stop Prescribing or Taking Pradaxa). Eliquis tested better than the other new anticoagulants and is safer.
With the new anticoagulants (NOACs) now available, no one probably should be taking warfarin anymore. Warfarin produces arterial calcification, and also puts patients at increased risk of osteoporosis and bone fractures. (See Stop Taking Warfarin [Coumadin]!!! Switch to Eliquis [Apixaban].)
Flutter after A-Fib ablation: Many EPs include a Flutter ablation along with an A-Fib PVI. It’s relatively easy to do compared to a left atrium PVI and only adds around 10 minutes to the ablation procedure. It involves making an ablation line in the right atrium (Caviotricuspid Isthmus line) either before or after entering the left atrium. But other EPs are reluctant to make any ablation burns in the heart that aren’t medically necessary. If someone isn’t in right atrium flutter, they wouldn’t do a Flutter ablation. (Personally if I had a choice, I’d ask the EP to do a right atrium Flutter ablation as long as they were already ablating inside my heart anyway.)
However, Jeff had three Flutter circuits which probably meant that some of these Flutter circuits did come from the left atrium. Flutter can develop after an A-Fib ablation or be found later after the inflammation of the ablation scarring settles down. That’s why Jeff needed a second ablation which was RF rather than CryoBalloon.

Oct 2015: FDA Aproves Reversal Agent Praxbind® for the Anticoagulant Pradaxa

The FDA granted “accelerated approval” to Praxbind®, a reversal agent (antidote) to Pradaxa®. Praxbind is given intravenously to patients who have uncontrolled bleeding or require emergency surgery.

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FAQ Minerals & Supplements: Natural Remedies for PVCs & PACs

FAQ Minerals Deficiencies: PVCs & PACs 

Minerals & Supplements for a Healthy Heart

Minerals & Supplements

 3. “I have annoying PVCs and PACs with my A-Fib. Are there natural remedies to reduce these extra beats and palpitations? My doctor says to ignore them.”

Doctors generally consider Premature Ventricle Contractions (PVCs) and Premature Atrial Contractions (PACs) as benign and not something to worry about. Everyone gets them occasionally. But for people with A-Fib, PVCs and PACs seem to be more frequent and often seem to precede an A-Fib attack

Dr. Stephen T. Sinatra in his book, The Sinatra Solution—Metabolic Cardiology, recommends the following natural “cocktail” for suppressing PACs and PVCs, what he calls the “awesome foursome”:

L-carnitine. A derivative of the amino acid lysine which helps to turn fat into energy. It promotes energy metabolism and enhances cardiac function. Some consider it the single most important nutrient in cardiac health. It reduces PVCs. Dosage: Daily: 750-2000 mg of L-Carnitine Fumerate (250 to 500 mg three to four times a day).

Coenzyme Q10 (Ubiquinone), A naturally occurring enzyme, part of the quinone chemical group, that is found in every cell in the body. It produces energy in the mitochondria and energizes the heart. 95% of the body’s energy is generated by CoQ10, which generates energy in the form of ATP. It prolongs the action potential and helps maintain sinus rhythm. It improves heart rhythm problems. Dosage: 100-300 mg daily in divided doses with meals. 

D-ribose. A five-carbon sugar that is a regulator in the production of ATP. The only compound used by the body to replenish depleted energy stores. Ribose increases tolerance to cardiac stress, improves exercise tolerance and physical function, provides cardiac energy needed to maintain normal heart function, increases cardiac efficiency, lowers stress during exercise, and maintains healthy energy levels in heart and muscle. Dosage: Daily: 7-10 grams of Ribose powder. Take in divided doses with meals or just before and after exercise.

Magnesium. A vital mineral used by the enzymes that make energy synthesis and recycling possible. Adequate intracellular magnesium is essential to normal tissue and organ function. Low magnesium is associated with cardiac abnormalities, fibrillation, and vascular and muscle spasms, and is seen in cardiac failure. Dosage: A recommended goal is a minimum 600 mg/day, preferably 800 mg. (For example, 200mg three times a day and 200 mg at bedtime.)

In extreme cases where the extra beats are very disturbing and damage one’s quality of life, Electrophysiologists (EPs) can perform an ablation for them similar to an ablation for A-Fib. But this is a specialized procedure that not all EPs perform or are willing to perform.

References for this Article

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FAQs: Mineral Deficiencies & Supplements for a Healthy Heart

FAQs: Mineral Deficiencies & Supplements for a Healthy Heart

A-Fib patients often look for non-drug approaches to ease or prevent the symptoms of their Atrial Fibrillation. Here we share answers to the most often asked questions about minerals deficiencies and the use of supplements.

1. I’m scared of getting dementia. Can the right minerals help? I’ve read about the link with A-Fib. What does research reveal about this risk?

2.How can I tell if I’m lacking in Vitamin D? I’m concerned because Vitamin D deficiency has been tied to both A-Fib and Dementia. What is a normal level of Vitamin D?

3. “I have annoying PVCs and PACs with my A-Fib. Are there natural remedies to reduce these extra beats and palpitations? My doctor says to ignore them.”

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

5. The supplement BCAA+G helps builds muscle. Is it a natural remedy that could help my A-Fib? Are A-Fib patients BCAA-deficient?

6. What’s the best way to take supplements—at the same time each day or spread throughout the day? In one lot or in divided doses?

7. “I’m anemic. Is too little iron in the blood (anemia) a cause of Atrial Fibrillation? Any advice on how A-Fib patients can deal with iron deficiency?”

8. “Can excess iron in the blood (Iron Overload Disease, IOD) cause Atrial Fibrillation? How do I know if I have IOD? What can I do about it?

9. “Where can I find reliable, unbiased research and information on specific vitamins and supplements? (I want an independent resource, not some site trying to sell me their products.)

10. “What does ‘chelate’ or ‘chelated formulas’ mean when talking about vitamin and minerals? Is it important?

11. “Regarding Magnesium, can supplementing and restoring Mg to healthy levels reverse my A-Fib? I’m about to schedule a catheter ablation. But if supplementing can cure my A-Fib, why do an ablation?

12. “Can I take the supplement CoQ10 while on Eliquis for Atrial Fibrillation? On your site it says CoQ10 could be helpful. But on my bottle of CoQ10, it says “do not take if you are on blood thinners.

13. “I’m taking Eliquis for my risk of A-Fib stroke. I’m interested in the supplement, Krill Oil, that has natural blood thinning properties. Is It OK to take Krill Oil along with Eliquis?

Last updated: Tuesday, June 14, 2016

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FAQs Coping With Your A-Fib Day-to-Day Issues

FAQs A-Fib afibFAQs Coping With Your Atrial Fibrillation: Day-to-Day Issues

Coping with your Atrial Fibrillation means a patient and their family have many and varied questions. Here are answers to the most frequently asked questions about dealing with the day-to-day issues of having Atrial Fibrillation. (Click on the question to jump to the answer.)

1.  I like my cardiologist, but he has not talked about me seeing an Electrophysiologist. Should I ask for a second opinion from another cardiologist?”
2. Is there any way to predict when I’m going to have an A-Fib attack?”
3. Should I exercise when in A-Fib or skip it and rest? Can I damage my heart if I exercise in A-Fib?”
4. How long do I have before I go into chronic or permanent A-Fib? I know it’s harder to cure. My A-Fib episodes seem to be getting longer and more frequent.”
5. They want to do an Atrial Flutter-only ablation, will that help if I possibly have A-Fib as well?”
6.  Is smoking medical marijuana or using Marinol going to trigger or cause A-Fib? Will it help my A-Fib?
7.  “During an A-Fib episode, when should I call paramedics (911 in the US) and/or take my husband to the hospital? I’m petrified. I need a plan.”
8. I have a lot of extra beats and palpitations (PVCs or PACs) They seem to proceed an A-Fib attack. What can or should I do about them?”
9.   “How do I know which is the best A-Fib treatment option for me?”
10. When my husband has an Atrial Fibrillation episode, what can I do for him? How can I be supportive?”
11. How can I tell when I’m in A-Fib or just having something like indigestion?”
12.What kind of monitors are available for atrial fibrillation? Is there any way to tell how often I get A-Fib or how long the episodes last?”
13. I’m an athlete with A-Fib and have a naturally slow heart rate. My doctor says I need a pacemaker because my heart rate is too slow.”
14. Can excess iron in the blood cause Atrial Fibrillation? How do I know? If I have Iron Overload Deficiency (IOD), what can I do about it?”
15. Can too little iron in the blood (Anemia) cause Atrial Fibrillation? What can I do about iron deficiency?”
16.Is it possible to have a single A-Fib attack and not have any others? I had a single episode of A-Fib and was successfully converted in the ER with meds.”
17. “My mom is 94 with A-Fib. Are there consumer heart rate monitors she can wear to alert me at work if her heart rate exceeds a certain number?”
18. Can I have A-Fib when my heart rate stays between 50-60 BPM? My doctor tells me I have A-Fib, but I don’t always have a rapid heart rate.”
19. I’m in Chronic A-Fib. Can I improve my circulation, without having to undergo a Catheter Ablation or Surgery?”

20. “In one of your articles it said that having an ablation was better than living in A-Fib. I’ve been taking 75 mg of propafenone 3X/day for seven years and have only had 5 A-Fib attacks in 7 years. If your article means all types of A-Fib [including Paroxysmal], then I will consider an ablation.

21. “Both my uncles and my Dad have Atrial Fibrillation. I’m 50 years old and so far I don’t have A-Fib (yet), but I’m worried. How can I avoid developing A-Fib? Can dietary changes help? Or lifestyle changes?

22. In case I have a stroke, what does my family need to know to help me? (I’m already on a blood thinner.)  What can I do to improve my odds of surviving it?”

Last updated: Sunday, March 27, 2016
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Cellular Remodeling and Mapping – 2014 Boston AF Symposium

Sanjiv Narayan

Sanjiv Narayan MD

2014 Boston AF Symposium

Cellular Remodeling and Mapping of A-Fib

Report by Dr. Steve S. Ryan, PhD

Dr. Sanjiv Narayan of the University of California, San Diego gave a presentation entitled “Cellular Remodeling and Spatial Mapping of Human AF.” Dr. Narayan is known for inventing the FIRM mapping/ablation system (Topera). (For a discussion of the FIRM system, see BAFS 2013: FIRM [Focal Impulse and Rotor Modulation] for Catheter Ablation of A-Fib by Dr. Narayan of UC San Diego).

Background: Understanding the Firm System. Because the FIRM system uses a proprietary, patented algorithm to identify A-Fib producing spots in the heart, it’s hard to understand and evaluate it. (In a private conversation with someone from Topera, this algorithm is a closely guarded secret like the secret recipe for Coca Cola.) If you’re the type of person who likes to look under the hood of your car and understand the mechanics of how it operates, the FIRM system may be very frustrating. (Continued below)1

SUSTAINING MECHANISMS, SUBSTRATES, CFAES

Dr. Narayan began his presentation by discussing Sustaining Mechanisms (Substrate, CFAEs). (CFAEs are Complex Fractionated Atrial Electrograms [an electrogram is a picture of the electrical activity of the heart as sensed by a pacemaker or catheter in the heart]. They are low voltage electrical signals with very short cycle lengths used to identify areas in the heart that need to be ablated.) (For an in-depth discussion of CAFEs, see BAFS 2011: Using CAFEs in Ablating Persistent A-Fib )

Dr. Narayan identified four different types of non-localized sustaining mechanisms―Collision, Block, Pivot Point and Slow Conduction (see graphic online). But these CFAEs have no discrete target. “Localized ablation can’t work.”

Whereas what Dr. Narayan described as Spatially Localized (”Drivers”) are identifiable A-Fib targets. When one ablates these “(true) sources,” A-Fib is eliminated.

But A-Fib remodeling often leads to ‘substrates’ (CFAEs) that are spatially localized.

ROLE OF PACS

Dr. Narayan discussed the role of PACs (Premature Atrial Contractions) in A-Fib remodeling (‘Substrate’, CFAEs). In describing the findings from his own studies of fibrosis and Stiles’ “Reduced Voltage areas”2, PACs trigger A-Fib. But they don’t in patients without A-Fib.

Advanced or cellular remodeling may be due to APD (Action Potential Duration) Oscillations at slow rates in a rotor pattern, and they enable PACs to trigger A-Fib. In mapping these signals, A-Fib is sustained by spatially reproducible rotors.

DR. NARAYAN’S CONCLUSIONS

• Remodeling is the “rosetta stone” linking basic science with clinical observations of A-Fib.

• Remodeling is spatially non-uniform and regional, that explains clinical observations, A-Fib ‘substrates’.

Editor’s Comments:
We still don’t understand how the FIRM system algorithms actually work. We can only speculate that the FIRM mapping system identifies Sustaining Mechanisms (Substrate, CFAEs) that produce rotors and filters out others that don’t. However, unless someone “leaks” the algorithms, we’ll probably never know and be able to compare and evaluate the FIRM system.
Dr. Narayan’s findings about PACs (Premature Atrial Contractions) is most important for A-Fib patients. Doctors tend to dismiss PACs because everyone gets them. But as many people with A-Fib know all too well, PACs often precede an A-Fib attack. Dr. Narayan’s studies show that PACs trigger A-Fib attacks, but they don’t in people without A-Fib. And PACs can be very disturbing, even if they don’t trigger A-Fib, particularly in people who’ve had a successful catheter ablation and are A-Fib free.
Can ablation techniques or meds be developed to eliminate PACs and thereby eliminate going into A-Fib? Should EPs ablate for PACs even without A-Fib? (I know of one EP who does ablate for PACs, even in the absence of A-Fib/Flutter.)
Many EPs map and ablate CAFEs (Sustained Mechanisms, Substrates) when trying to “cure” patients in Persistent A-Fib. But according to Dr. Narayan, ablating these areas is ineffective “Localized ablation can’t work,” because there is no discrete target as there is for areas producing rotors. (The ECGI system also seems to identify foci and rotors as compared to CFAEs.) For patients, Dr. Narayan’s observations may result in much less unnecessary burning and scarring of the heart during an ablation procedure.

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Last updated: Wednesday, September 2, 2015 

 

References    (↵ returns to text)
  1. But here’s a possible way the FIRM system could possibly be evaluated. Take a standard Lasso mapping catheter or a system like ECGI and meticulously identify every possible A-Fib producing spot in, for example, an animal or human heart in long-term persistent A-Fib. Such a heart usually has many different A-Fib producing spots. Carefully mark the exact location of every foci, rotor, potential, CFAE or any spot producing possible A-Fib signals. Then immediately afterwards, use the FIRM mapping system on the same heart and compare the results. The FIRM system usually finds only one or two A-Fib signal sources in each atria. The FIRM algorithm probably filters out a lot of other A-Fib signal sources as noise. What does the FIRM system filter out? What does it select?

    In the live satellite case presented at the 2014 Boston A-Fib Symposium in Orlando, the Bordeaux group using the ECGI system found many different foci and rotors in a patient in persistent A-Fib. But these were clustered in predominantly three areas. Would they show up in the FIRM system as only three foci/rotors?

    Patent Law: The algorithms to analyze MRI slices, such as used by Dr. Marrouche, or the algorithms to map electrophysiology, such as used by Topera, have to be kept secret. Dr. Marrouche and Topera really have no choice. According to current US patent law (which I highly disagree with), you can’t enforce a patent on a medical technique. But you can for a surgical technique. For you legal types, the statute reads “35 USC 287(c) (1) With respect to a medical practitioner’s performance of a medical activity that constitutes an infringement under section 271(a) or (b) of this title, the provisions of sections 281 , 283 , 284 , and 285 of this title shall not apply against the medical practitioner or against a related health care entity with respect to such medical activity.” This law effectively makes any patent on a medical technique worthless. (Thanks to David Pressman, Patent Attorney for this important observation.)

  2. Stiles MK, John B, Wong CX, et al. Paroxysmal Lone Atrial Fibrillation Is Associated With an Abnormal Atrial Substrate: Characterizing the “Second Factor”. J Am Coll Cardiol. 2009;53(14):1182-1191. doi:10.1016/j.jacc.2008.11.054.

Premature Atrial Contractions (PACs) Predict A-Fib

Premature Atrial Contractions (PACs) Predict A-Fib

PACs Predict A-Fib

by Steve S. Ryan, PhD

Premature Atrial Contractions (PACs) are generally considered benign. Everybody gets them, not just people with A-Fib.

However, studies indicate that PACs often precede or forewarn of an A-Fib attack. A-Fibbers seem to have more problems with these extra beats than normal people. An important study from Dr. Boon-Hor Chong and others from China shows that frequent PACs (more than 100 beats/day) actually predict who will develop A-Fib.

Frequent PACs also predicted who would develop ischemic stroke, congestive heart failure, and death.

The study: 428 patients without A-Fib but with palpitations, dizziness or syncope (fainting) were divided into four groups according to how many PACs they experienced.

The top quartile (107 patients) with more than 100 beats/day were considered to have frequent PACs. (Some patients in this top quartile had much higher rates of PACs than 100 beats/day. The mean number of PACs was 533.5.)

There were no significant differences in gender, diabetes, hypertension or coronary artery disease. But patients with frequent PACs were older and more likely to be smokers. Frequent PACs predicted that someone in the 6.1-year follow-up would develop A-Fib.

Frequent PACs also predicted who would develop ischemic stroke, congestive heart failure, and death. (Other predictors were age, male gender, hypertension, diabetes, and coronary artery disease, as previous studies have demonstrated.) More patients with frequent PACs developed congestive heart failure or died.

Editor’s Comments:
This study is a major medical breakthrough for A-Fib patients. A-Fib is often not diagnosed till it is too late, till complications such as ischemic stroke, congestive heart failure, and death occur. Up to 25% of patients were first diagnosed with A-Fib only at the time they had a stroke. But now we have a documented method of predicting who is more likely to develop A-Fib. (We previously knew that older people and people with coronary artery disease were more prone to develop A-Fib.)

A catheter ablation, in addition to removing A-Fib producing spots in the heart, can also map and ablate areas producing PACs/PVCs.

It’s relatively easy for doctors, using today’s sophisticated and low effort monitoring devices, to determine if someone has a lot of PACs/PVCs. It should become part of a routine physical exam when one turns 50 to monitor for frequent PACs/PVCs. Then preventive measures can be taken such as natural remedies like magnesium, anticoagulants, devices to close off the Left Atrial Appendage where 90%-95% of A-Fib strokes come from, antiarrhythmic meds, ”Pill-In-The-Pocket” therapies, or a catheter ablation.
A catheter ablation, in addition to removing A-Fib producing spots in the heart, can also map and ablate areas producing PACs/PVCs. Frequent PACs can be as damaging and troublesome as A-Fib. Ablations are done not just to fix A-Fib, but also  for the sole purpose of freeing someone from frequent PACs. They are an option patients with frequent PACs should be aware of.
But one question this study didn’t fully address is how often someone with frequent PACs develops A-Fib (and other heart problems). Frequent PACs is a definite predictor. But how many people or what proportion of people with frequent PACs will definitely develop A-Fib? If you have frequent PACs, what are the odds that you will develop A-Fib, or how soon will you go into A-Fib? (The editor has written Dr. Chong and asked him this question.)
If you have frequent PACs, you shouldn’t try to play the odds and hope you don’t develop A-Fib. Instead you should face the reality that you are on the road to developing A-Fib and act accordingly. Talk with your doctor about what you should do, what preventive measures you can take.
(A special thanks to David Young for calling attention to this research and pointing out its importance for A-Fib patients.)

References for this Article

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Last updated: Sunday, February 15, 2015

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