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"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


Persistent

Persistent A-Fib: ECGI Insights to Finding Additional Drivers by Dr Jais

AF Symposium 2015

Pierre Jais MD

Pierre Jais MD

Persistent A-Fib: Insights into Finding Additional Drivers May Shorten Ablation Procedures with Fewer Lesions

By Steve s. Ryan, PhD, July 2015

Dr. Pierre Jais of the French Bordeaux/LIRYC group gave a presentation on “The Spectrum of Atrial Tachycardias Following Ablation of Drivers in Persistent AF.”

He described a study of the ablation of 50 persistent A-Fib patients using ECGI to map and ablate A-Fib signal drivers.

A-Fib was terminated in 79% of patients, with 10% returned to sinus rhythm and the remaining 69% in tachycardias (but with no A-Fib).

For those still in arrhythmia, ECGI was used to map, analyze and diagnose the locations of the arrhythmias signals, and additional ablation lesions were performed. Identified were 25 macro-reentry circuits and 14 focal/localized-reentry circuits.

The reentry circuits found by ECGI were:

• common atrial flutter in 14 patients
• perimitral flutter in 9 patients
• roof dependent flutter in 2 patients

Dr. Jais showed many slides and videos of how ECGI mapped and analyzed where these arrhythmias were coming from and how they were ablated.

Dr. Jais’ Conclusions

Dr. Jais stated that the study data revealed, “the focal/localized-reentry were adjacent to drivers at 0.9cm from the core of driver with low voltage (0.5 mV)”.

To clarify, this means that the drivers of the remaining arrhythmias were located very close (adjacent) to the drivers previously mapped by ECGI.

Therefore, when ECGI locates an area of rotors and drivers, it is highly likely this is where the source of additional arrhythmias will most likely be found. This insight reduces or eliminates the need (and time) to search other areas of the heart thereby shortening procedure length and decreasing the number of lesions needed.

Editor’s Comments:
ECGI mapping and ablating is changing our understanding of and our techniques for ablating persistent A-Fib. If a patient has continued arrhythmias after the initial ablation, ECGI often can re-map and identify where the remaining arrhythmias are coming from, usually very near previously identified driver locations. This is a valuable insight for doctors doing ablations.
For patients, it may mean a shorter procedure time with fewer burns needed to eliminate the sources of A-Fib signals.

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Last updated: Thursday, August 6, 2015

FAQs A-Fib Treatments: Medicines and Drug Therapies

FAQs A-Fib Treatments: Medicines and Drug Therapies

Drug Therapies for Atrial Fibrillation, A-Fib, Afib

Drug Therapies for Atrial Fibrillation

Atrial Fibrillation patients often search for unbiased information and guidance about medicines and drug therapy treatments. These are answers to the most frequently asked questions by patients and their families. (Click on the question to jump to the answer.)

1. Which medications are best to control my Atrial Fibrillation?” “I have a heart condition. What medications work best for me?

2. “Is the “Pill-In-The-Pocket” treatment a cure for A-Fib? When should it be used?”

3. “I take atenolol, a beta-blocker. Will it stop my A-Fib.”

4. I’ve been on amiodarone for over a year. It works for me and keeps me out of A-Fib. But I’m worried about the toxic side effects. What should I do?”

5. Should everyone who has A-Fib be on a blood thinner like warfarin (Coumadin)?”

6. Which is the better anticoagulant to prevent stroke—warfarin (Coumadin) or aspirin?

7. What’s the difference between warfarin and Coumadin?

8. I’m on warfarin. Can I also take aspirin, since it works differently than warfarin? Wouldn’t that give me more protection from an A-Fib (ischemic) stroke?

9. “What are my chances of getting an A-Fib stroke?

10. “I’m worried about having to take the blood thinner warfarin (brand name Coumadin). If I cut myself, do I risk bleeding to death?

11. “I am on Coumadin (warfarin) to thin my blood and prevent A-Fib blood clots. Do I now need to avoid foods with Vitamin K which would interfere with the blood thinning effects of Coumadin?” UPDATED

12. “The A-Fib.com web site claims that an A-Fib stroke is often worse than other causes of stroke. Why is that? If a clot causes a stroke, what difference does it make if it comes from A-Fib or other causes? Isn’t the damage the same?

13. “I just had an Electrical Cardioversion. My doctor wants me to stay on Coumadin for at least one month. Why is that required? They mentioned something about a “stunned atrium.” What is that?

14. Are natural blood thinners for blood clot treatment as good as prescription blood thinners like warfarin?”

15. “How long do I have to be in A-Fib before I develop a clot and have a stroke?

16. I have to be on aspirin for stroke prevention. Which is better—the low-dose baby aspirin (81 mg) or a high dose (325 mg)? Should I take the immediate-release (uncoated) or the enteric-coated aspirin?

17. I don’t want to be on blood thinners for the rest of my life. I’ve had a successful catheter ablation and am no longer in A-Fib. But my doctor says I need to be on a blood thinner. I’ve been told that, even after a successful catheter ablation, I could still have “silent” A-Fib—A-Fib episodes that I’m not aware of.  Is there anything I can do to get off of blood thinners?

18. “My last cardiologist had me on Pradaxa. My new cardiologist wants me to switch to Eliquis. Is Eliquis easier to deal with if bleeding occurs?

19. “My doctor told me about the Tikosyn drug option that I want to consider in getting rid of my 5-month-old persistent A-Fib. That seems like something that should be discussed on your web site.

20. “I hate taking Coumadin. Is there a way to get off blood thinners all together? I know I’m at risk of an A-Fib stroke.”

21. “I”ve read about a new anticoagulant, edoxaban, as an alternative to warfarin (Coumadin) for reducing risk of stroke. For A-Fib patients, how does it compare to warfarin? Should I consider edoxaban instead of the other NOACs?

22. “Do you have information about Hormone Replacement Therapy (HRT) and if it might help or hinder my atrial fibrillation?

23. Are Anticoagulants and blood thinners the same thing? How do they thin the blood?

24. I have A-Fib, and my heart doctor wants me to take Xarelto 15 mg. I am concerned about the side effects which can involve death. What else can I do?

25. “Is the antiarrhythmic drug Multaq [dronedarone] safer than taking amiodarone? How does it compare to other antiarrhythmic drugs?”

Last updated: Wednesday, May 25, 2016

Back to FAQs by Patients with Atrial Fibrillation

FAQs Understanding A-Fib: Questions from Patients

FAQs Understanding Your A-Fib A-Fib.comFAQs: Understanding Atrial Fibrillation

Atrial Fibrillation patients often have loads of “Why?” and “How?” questions. Here are answers to the most frequently asked questions by patients and their families. (Click on the question to jump to the answer.)

1. Why does so much Atrial Fibrillation come from the Pulmonary Vein openings?

2. Is my Atrial Fibrillation genetic? Will my children get A-Fib too? Updated!

3. Why do older people get Atrial Fibrillation more than younger people?

4. Is Atrial Fibrillation (A-Fib) different from what doctors call Paroxysmal Supraventricular Tachycardia?

5. What is the difference between “Adrenergic” and “Vagal” Atrial Fibrillation? How can I tell if I have one or the other? Does it really matter? Does Pulmonary Vein Ablation (Isolation) work for Adrenergic and/or Vagal A-Fib?

6. What causes Paroxysmal (occasional) A-Fib to turn into Persistent (Chronic) A-Fib?

7. I’ve heard about ‘stiff heart’ or diastolic dysfunction. When you have A-Fib, do you automatically have diastolic heart failure? What exactly is diastolic dysfunction?

8. A-Fib and Flutter—I have both. Does one cause the other?” 

9. “My surgeon wants to close off my LAA during my Mini-Maze surgery. Should I agree? What’s the role of the Left Atrial Appendage?” 

10. “I’ve read about stem cells research to regenerate damaged heart tissue. Could this help cure A-Fib patients?”

11. What is the heart’s ejection fraction? As an A-Fib patient, is it important to know my EF? 

12. “I read that the local anesthesia my dentist uses may trigger my A-Fib. Why is that?”

13. “How can I determine or measure how much fibrosis I have? Can something non-invasive like a CT scan measure fibrosis?

14. “I have paroxysmal A-Fib with “pauses” at the end of an event. Will they stop if my A-Fib is cured? My cardiologist recommends a pacemaker. I am willing, but want to learn more about these pauses first.

15. “I have paroxysmal A-Fib and would like to know your opinion on which procedure has the best cure rate”

16. “I am 69 years old, in permanent A-Fib for 15 years, but non-symptomatic. My left atrium is over 55mm and several cardioversions have failed. My EP won’t even try a catheter ablation. I exercise regularly and have met some self-imposed extreme goals. What more can I do? NEW!

Last updated: Friday, December 9, 2016

Return to Frequently Asked Questions: Coping with A-Fib

FAQs Understanding A-Fib: Paroxysmal to Persistent A-Fib, What Causes the Progression?

 FAQs Understanding A-Fib: Paroxysmal to Chronic

FAQs Understanding Your A-Fib A-Fib.com6. What causes Paroxysmal (occasional) A-Fib to turn into Persistent (chronic) A-Fib?

Researchers are still working to find the answer(s) to this question. We do know that some patients remain paroxysmal (usually with anti-arrhythmic therapy), while a large proportion progress to persistent A-Fib. (In a study of 5,000+ A-Fib patients, 54% of those on rate control meds went into permanent A-Fib in one year.)

The main trigger seems to be increased pressures in the left atrium that causes the muscle fibers around the pulmonary vein openings to start beating on their own.

Uncontrolled blood pressure, untreated sleep apnea and diabetes, or a worsening cardiomyopathy seem to be key factors that make people progress from Paroxysmal to Persistent A-Fib. Research tells us that even after a successful ablation for Persistent A-Fib, “the long term success rates depend mostly on treatment of hypertension and obstructive sleep apnea.”

What does this mean to you? The longer you have Atrial Fibrillation, the harder it can be to cure it. Consider working aggressively to stop your A-Fib as with antiarrhythmic meds or with a minimally-invasive Pulmonary Vein Ablation or a Mini-maze surgery. You don’t want to be part of the 54% whose A-Fib becomes permanent.

Go back to FAQ Understanding A-Fib

Atrial Remodeling and the Transition From Paroxysmal to Persistent AF by Dr Jose Jalife-2014 Boston AF Symposium

Jose Jalife, MD

Jose Jalife, MD

2014 Boston AF Symposium

Experiments in Atrial Remodeling in Sheep and the Transition From Paroxysmal to Persistent A-Fib

By Steve S. Ryan, PhD

Dr. Jose Jalife of the Center for Arrhythmia Research of the University of Michigan described his experiments inducing A-Fib in sheep by pacing their hearts. He is trying to discover the mechanisms underlying the transition from paroxysmal to persistent A-Fib.

Background: Some patients remain paroxysmal (usually with anti-arrhythmic therapy), while a large proportion progress to persistent A-Fib. (In a study of 5,000+ A-Fib patients, 54% of those on rate control meds went into permanent A-Fib in one year.)1
Previous presentation summary: This talk was a continuation of Dr. Jalife’s 2013 Boston A-Fib Symposium presentation on his experimental studies with sheep. (See A-Fib Produces Fibrosis—Experimental and Real-World Data.) He implanted pacemakers in the hearts of sheep; then induced A-Fib by pacing for 6-30 seconds, then stopped, then paced again, etc. He continued this sequence until the sheep were in persistent A-Fib. He left them in A-Fib for about a year. Dr. Jalife also had a control group of sheep who were monitored but not paced into A-Fib.

Pacing Sheep into A-Fib

Once pacing started in the sheep, it took around 5.5 days to produce the first A-Fib episode. It took around 7-9 weeks of pacing for the sheep to move from Paroxysmal to Persistent A-Fib. At that point the sheep stayed in Persistent A-Fib without any further need of pacing. Dr. Jalife’s sheep developed two major types of atrial remodeling:

  • Structural Remodeling (Fibrosis)
  • Electrical Remodeling (ion channel expression changes)
(In humans, remodeling usually also results in atrial dilation. Dr. Jalife’s sheep once in A-Fib also developed significant Atrial Dilation compared to a control group of sheep.)

Unlike humans, the sheep didn’t develop heart failure, left ventricle dilation and dysfunction, or tachycardia-induced cardiomyopathy despite being in A-Fib for more than a year. This is possibly because sheep have a very good AV Node (unlike most humans) which filters the A-Fib pulses from affecting the ventricles and keeps the ventricular rate low.

Genetic Differences in Sheep

But there were differences in the sheep. Some sheep transitioned into persistent A-Fib fast (<40 days) while others needed more pacing to transition into persistent A-Fib (>40 days). Sheep from the same herd would have the same diet, environment, etc. But genetically they must have been different in their ability to hold out from transitioning into persistent A-Fib.)

Structural Remodeling

All ventricular parameters remained normal in the paced sheep, except for atrial dilation and the markers of fibrosis which increased progressively as the sheep went from paroxysmal to persistent A-Fib. Fibrosis appeared in the right atrium, left atrium and the posterior left atrium. This fibrosis was the result of collagen deposition in the atria which is a permanent remodeling effect of A-Fib.

Dr. Jalife showed slides of a normal pig’s heart compared to a pig in persistent A-Fib. Well over ½ the atria seemed fibrotic.

Mechanisms of Electrical Remodeling

As expected, sustained A-Fib shortened the atrial action potential duration and refractory period. Also, rotor frequencies were increased. For example, in one sheep the dominant frequency of the first episode of paroxysmal A-Fib was 7.3 Hz, but increased progressively to 10.3 Hz during the transition to persistent AF. When AF in that sheep became persistent, the dominant frequent had stabilized at 11.3 Hz and remained constant for up to a year.

Dr. Jose Jalife 2014 Boston AFib Symposium

Graphic used with permission

In perhaps the most important findings of Dr. Jalife’s experiments, the rate of increase in dominant frequency correlated strongly with the time at which AF stabilized. In other words, although the progression from paroxysmal to persistent A-Fib varied from one animal to another, the rate of dominant frequency increase could be used to forecast the time at which AF became persistent.

 In other words, although the progression from paroxysmal to persistent A-Fib varied from one animal to another, the rate of dominant frequency increase could be used to forecast the time at which AF became persistent.

Dr. Jalife and his team also identified the mechanisms of electrical remodeling in sheep, which ion channels in the heart are responsible for transitioning sheep from paroxysmal to persistent A-Fib. Sodium and calcium heart electrical currents were lowered, while potassium and IK1 currents were increased. These electrical changes were associated with gene expression changes “in the alpha subunits of the L-type calcium (CACNA1C) and sodium (SCNSA) channel protein.”

  1. “Sustained AF reduces L-type calcium (Caᵥ1.2) and sodium (Naᵥ1.5) protein expression”
  2. “Sustained AF reduces the rapid sodium inward (INa) and L-type calcium (ICaL) currents”
  3. “Sustained AF reduces the transient outward current (Ito)”
  4. “Sustained AF increases the inward rectifying potassium current (IK1)  and protein expression of the Kir2.3 channel”

Conclusions

The sheep model explains the structural and electrical remodeling that occurs in humans.

As in humans, there is a variable progression in time from paroxysmal to persistent A-Fib.

The rate of dominant frequency increase during such a progression predicts the time at which AF stabilizes and becomes persistent, reflecting changes in Action Potential Duration and densities of ICaL, IK1, INa and Ito.

Predicting the transition from paroxysmal to persistent A-Fib is feasible, at least in some patients, by measuring the increase in dominant frequency over time.

Editor’s Comments:
No one seeing Dr. Jalife’s presentation could doubt that A-Fib produces fibrosis. (Though even among sheep in the same environment, diet, etc. and with a similar gene pool, there were differences in how fast the individual sheep progressed to persistent A-Fib.) As patients with A-Fib, we have to base our medical decisions on the conclusion that A-Fib produces fibrosis; that if we stay in A-Fib over a significant period of time, we will progressively develop fibrosis which is currently irreversible and can lead to a host of other heart problems.

A common strategy today…is to leave you in A-Fib but control your heart rate by the use of beta-blockers, etc. But leaving you in A-Fib produces fibrosis which is irreversible and very damaging to the heart.

A common strategy today for treating A-Fib is to leave you in A-Fib but control your heart rate by the use of beta-blockers, calcium-channel blockers, etc. But leaving you in A-Fib produces fibrosis which is irreversible and very damaging to the heart. If your doctor wants to leave you in A-Fib, Dr. Jalife’s experiments would recommend that you get a second opinion, and ASAP.
One of the major advantages of a successful catheter ablation (and surgery) is it probably reverses the electrical remodeling effect of A-Fib. This makes intuitive sense. A heart beating in normal sinus rhythm (NSR) doesn’t usually produce those weird ion channel currents. But more research needs to be done before we can conclude this. However, a successful catheter ablation does not reverse fibrosis (structural remodeling), though it may reduce atrial dilation.
By identifying the actual mechanisms of electrical remodeling, Dr. Jalife’s ground-breaking experiments may lead to new therapies and drugs to combat not only the transition from paroxysmal to persistent A-Fib, but how to prevent patients from developing A-Fib in the first place. And using dominant frequency to predict when a patient is transitioning to persistent A-Fib, can be an invaluable tool for doctors (and reassuring for patients).
One of the scariest parts of Dr. Jalife’s presentation was how fast he could pace those sheep into persistent A-Fib. Obviously sheep aren’t people. But we know that for most people, there is a relatively short window of time when they progress from paroxysmal to persistent A-Fib (about a year). When you have A-Fib, you can’t count on genetics, diet, life style, environment, etc. to protect you from progressing to persistent A-Fib. Right now we just don’t know why some people stay paroxysmal for years, while most become persistent after a relatively short time. Worst case scenario, you have about a year. Act accordingly.

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Return to Index of Articles: AF Symposium: Steve’s Summary Reports

Last updated: Wednesday, September 2, 2015 

References    (↵ returns to text)

  1. Peykar, S. Atrial Fibrillation. Cardiac Arrhythmia Institute/Sarasota Memorial Hospital website. Last accessed Jan 5 2013. URL:http://caifl.com/arrhythmia-information/atrial-fibrillation/

Steve’s Lists of A-Fib Doctors by Specialty

Steve's Lists of Doctors by Specialty - Atrial Fibrillation, afib, a fib, A-Fib

Doctors by Specialty

Steve’s Lists of A-Fib Doctors by Specialty 

Steve has prepared these lists of doctors treating atrial fibrillation patients by specialty to help you find doctors with a particular expertise.

  1. US EPs with FHRS-designation performing A-Fib ablations: Listed by State/City
  2. US EPs Using Cryoballoon Ablation
  3. US EPs Installing the Watchman Device
  4. US Surgeons performing Maze and Mini-Maze operations
  5. US Centers performing the Hybrid Surgery/Ablation procedure
  6. EPs Specializing in Persistent/Long-Standing Persistent A-Fib (US and International)
  7. EPs using Contact Force sensing catheters

Return to Directory of Doctors Treating A-Fib: Medical Centers and Practices

Notice: unlike other directories, A-Fib.com offers no preferential listings or placement. No doctor or facility pays, provides services, etc. to be listed. We accept no fee, benefit or value of any kind for listing a specific doctor or medical center. A-Fib.com is not affiliated with any practice, medical center or physician.

If you know the name of the doctor or practice, use the “Search our site” box (upper right on this page) to get to the right Directory page. Then, open your browser’s ‘Find on Page’ feature (‘CTRL+F’) to locate the name on the page.

Disclaimer: this directory is provided for informational purposes only. We make no endorsement of a specific physician or medical facility. Choosing a physician is an important decision and should be based upon your own investigation of each physician’s training, education and experience. These listings offer you the opportunity to locate and contact a healthcare professional directly. 

A-Fib.com is your independent source of unbiased information about Atrial Fibrillation, resources and treatments.

Last updated: Tuesday, September 6, 2016

EPs Specializing in Persistent/Long-standing Persistent A-Fib (US and International) a List from A-Fib.com

Steves List logo 200 pix at 96 resDoctors Specializing in Persistent/Long-standing Persistent A-Fib (US and International)

Persistent A-Fib and Long-standing Persistent A-Fib are often difficult to cure. If you are highly symptomatic, you may need a highly skilled, experienced specialist. This list is a starting point for you.

HOW TO FIND THE CONTACT INFO

Return to Steve’s Lists of A-Fib Doctors by Specialty

DOCTOR OR MEDICAL CENTER US CITY/STATE OR COUNTRY COMMENT
The French Bordeaux Group Bordeaux, France Step wise ablation technique with 95% success rate in curing Chronic A-Fib after two ablations.
Dr. Robert A. Schweikert Akron, OH  —
Dr. Fred Morady Ann Arbor, MI Developed Ablation Frontier’s Multi Electrode catheters for Chronic A-Fib still in clinical trials (11/20/09)
Dr. Patrick M. Hranitzky Durham, NC Uses stepwise approach.
Dr. Kevin J. Makati Tampa, FL  —
Dr. Andrea Natale
Dr. J. David Burkhardt
Austin, TX  —
Dr. Andrea Natale
Dr. Steven C. Hao
Dr. Rick Hongo
San Francisco, CA  —
Dr. James Ong Tarzana, CA  —
Dr. Carlo Pappone Cotignola, Italy Uses step wise technique, though different than Bordeaux group.
Dr. Sidney Peykar Sarasota, Florida Uses Bordeaux step wise technique and trained in Bordeaux.
Dr. Robert Eckart Sarasota, Florida
Dr. Vivek Reddy New York, NY Uses step wise technique, though different than Bordeaux group.
Dr. Darryl S. Wells Seattle, WA Does CryoBalloon ablation.
Dr. William H. Sauer
Dr. Ryan G. Aleong
Aurora, CO Modified step-wise approach.
Dr. J. Marcus Wharton Charleston, SC  —
Dr. Wilber Su Phoenix, AZ  —
NOTICE: we offer no preferential listings. We accept no fee, benefit or value of any kind for listing a specific doctor or medical center. A-Fib.com is not affiliated with any practice, medical center or physician.

HOW TO FIND THE CONTACT INFO: Use the “Search our site” box (upper right on this page) to get to the right Directory page. Then, open your browser’s ‘Find on Page’ feature (‘CTRL+F’) to locate the name on the page.

Disclaimer: this directory is provided for your convenience only.  We make no endorsement of a specific physician or medical facility. Choosing a physician is an important decision and should be based upon your own investigation of each physician’s training, education and experience. This directory offers you the opportunity to locate and contact a healthcare professional directly.

♦ ♦ ♦

Last updated: Saturday, May 14, 2016

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