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

Closure of the Left Atrial Appendage (LAA) vs Anticoagulants

The Left Atrial Appendage (LAA) is the source of many non-pulmonary vein A-Fib signals. So, when irregular heart rhythm signals persist after a catheter ablation, Atrial Fibrillation patients (like myself) look to closure or removal of the Left Atrial Appendage (LAA) rather than spending a lifetime on anticoagulants. Is this the wiser choice?

 The term “non-inferior” is used in a study to mean the new treatment is not worse than an active treatment.

Prague Research Study

In a four-year study from Prague (PRAGUE-17), determined that Left Atrial Appendage (LAA) closure was “non-inferior” (i.e., not worse in comparison) to Novel Oral Anticoagulants (NOACs) for preventing major neurological, cardiovascular, or bleeding events in high-risk patients with A-Fib.

Two LAA occlusion devices

The anticoagulant most used in the study was apixaban (Eliquis) in 95% of cases. To close off the Left Atrial Appendage (LAA), electrophysiologists (EPs) used either the Amplatzer™ Amulet™ LAA Occluder or the Boston Scientific Watchman occlusion device.

The study also examined device-related complications finding “significant procedure/device-related complication was similar between the two treatment groups” (NOAC vs LAA Closure).

Bleeding risks: Furthermore, subsequent non-procedural bleeding was significantly reduced with LAA closure.

Anticoagulant risks: Patients taking anticoagulants for four years had a significantly greater risk of bleeding complications.

Danish Study Confirms Prague Results

NOACs vs DOAC? The term Novel oral anticoagulants (NOACs) is no longer “novel”; Preferred term is “DOAC,” which stands for direct oral anticoagulant.

In a study from Denmark using the Danish National Patient Registries, patients receiving the Amulet Left atrial appendage (LAA) closure device with a history of ischemic stroke were compared to similar patients receiving DOACs.

Risk of major bleeding events: The risk of major bleeding and all-cause mortality was significantly lower in the Amulet group. This study indicated similar stroke prevention effectiveness but significantly lower risk of major bleeding events with Left atrial appendage occlusion (LAAO) therapy compared with DOAC.

Editor's Comments about Cecelia's A-Fib storyEditor’s Comments

LAA Closure as Effective as Anticoagulants…Studies show that LAA Closure is just as effective as anticoagulants in preventing A-Fib stroke and other cardiovascular problems (stroke, transient ischemic attack, cardiovascular death, and clinically-relevant bleeding.
But Anticoagulants Increase Bleeding: As one would expect, having to take anticoagulants for four years did increase bleeding. For more, see Anticoagulants Increase Risk of Hemorrhagic-Type Strokes.
The Bottom Line: If you have a choice, this research indicates a Left Atrial Appendage closure device like the Watchman is better than having to take anticoagulants for the rest of your life.

Many people hate taking anticoagulants. Now you don’t have to! LAA occlusion devices like the Watchman are a most welcome alternative to having to take anticoagulants for life.

Steve Ryan with Dr. Natale and surgical nurse, before ablation August 2021.

On a Personal Note: A Watchman is in my future.

As many readers know after 21 years, my A-Fib returned. Not to worry. I’m once again A-Fib free after two catheter ablations by Dr. Shephal Doshi and Dr. Andrea Natale.

But Dr. Natale and Dr. Doshi both recommended I close off my Left Atrial Appendage (LAA). So in a few months, I’ll be getting the Watchman FLX occlusion device. I’ll write about the experience.

References
• Osmancik, P. et al. Left Atrial Appendage Closure versus Non-Warfarin Oral Anticoagulation in Atrial Fibrillation: 4-Year Outcomes of PRAGUE-17. J Am Coll Cardiol. 2021 Oct 27;S0735-1097(21)07895-5 https://pubmed.ncbi.nlm.nih.gov/34748929/ doi: 10.1016/j.jacc.2021.10.023.

• Korsholm, K. et al. TCT-94 Clinical Outcomes of Left Atrial Appendage Occlusion Versus Direct Oral Anticoagulation in Atrial Fibrillation Patients With Previous Ischemic Stroke. J Am Coll Cardiol. 2021 Nov, 78 (19_Supplement_S) B39. https://www.jacc.org/doi/full/10.1016/j.jacc.2021.09.944. 

How to Reduce Post-Surgery A-Fib Inflammation?

A friend of mine (with no history of Atrial Fibrillation) recently had quintuple bypass surgery. Afterwards he developed A-Fib. Subsequently, he was then put on the dreaded drug amiodarone. This happens all to often. 

Read why I write “dreaded”, see Amiodarone: Most Effective and Most Toxic

A-Fib Common After Heart Surgery

After cardiac procedures such as bypass, 20%-40% patients develop A-Fib. It’s quite a disturbing development for patients. So, in addition to trying to recover from the trauma of heart surgery, their heart is in Atrial Fibrillation which they didn’t have before the surgery.

For A-Fib patients seeking a catheter ablation, I often refer them to a Master Electrophysiologist (EP) who uses the medication, Colchicine, to reduce post-surgery inflammation especially in non-paroxysmal and older patients. (Colchicine suppresses protein complexes that are responsible for activation of inflammatory signaling in the body).

Historic Colchicine: Treatment for Pain and Swelling

One of oldest known medications Colchicine is mentioned in ancient Egyptian documents (1550 bc) in which it’s described as a treatment for pain and swelling. It’s one of the few medications known from that time which is still being used today.

One of the best known biologically active compounds from ancient times.

In modern times, Colchicine (pronounced: kol’ chi seen) is primarily used to treat gout (which can be very painful) for its broad anti-inflammatory effects. During cardiac surgery, Colchicine is used to treat pericarditis, the swelling and irritation of the thin, saclike tissue surrounding your heart (pericardium).

Because it reduces inflammation, some EPs are now using Colchicine to treat A-Fib.

Colchicine and Cardiac Disease Research

Colchicine is being investigated to prevent and treat cardiovascular disease. Inflammation plays a key role in the development and propagation of a range of cardiac illnesses. Many of the inflammatory mechanisms that are targeted by colchicine play a role in the development of coronary artery disease.

Anti-inflammatory therapies such as colchicine have shown benefits in reducing recurrence of A-Fib after surgery or catheter ablation.

• In a meta-analysis of 6 randomized trials, colchicine was shown to significantly reduce post-cardiac procedure A-Fib compared to a placebo (Salih M. et al).

• In another study colchicine use was associated with a 49% relative risk reduction of MI (heart attack), stroke, and transient ischemic attack compared to patients who did not use colchicine, as well as a 73% relative risk reduction in all-cause mortality (Slobodnick, A. et al).

In patients who underwent pulmonary vein isolation, Colchicine has been shown to help prevent early recurrences of paroxysmal A-Fib.

• The Colchicine for the Prevention of the Postpericardiotomy Syndrome (COPPS) AF Substudy found that the administering of colchicine appears to be safe and efficacious in the reduction of postoperative AF, which could potentially halve the complication and reduce the time a patient stays in the hospital.

Research has shown that the administration of colchicine in patients who underwent pulmonary vein isolation helped to prevent early recurrences of paroxysmal AF. (Rosenthal, L.)

What This Means For A-Fib Patients

Blood test vial

C-reactive protein (CRP-hs) blood test measures inflammation.

Learn About Your Inflammation Level. Why? The higher your inflammation the more you are at risk of developing heart disease and recurrent A-Fib.

The most common way to measure inflammation is to do a blood test for C-reactive protein (hs-CRP), which is a marker of inflammation. Another method is to measure homocysteine levels to evaluate chronic inflammation.

When you have your regular physical examination by your family doctor, they will usually draw blood to measure your C-reactive protein (CRP-hs) which ought to be less than 2. (Mine was 0.7.)

If Undergoing Any Kind of Heart Surgery, does Your Surgeon have a plan to deal with A-Fib after your surgery? If you are scheduled for heart surgery (of any kind), check with your surgeon to see if they have a protocol or procedure to deal with A-Fib after surgery.

Don’t settle for generalities. If they can’t cite specific steps they are prepared to take, maybe you should get a second opinion. The last thing you want is for your heart to go into A-Fib while you’re trying to recover from the trauma of heart surgery. Surgeons can also administer medications before surgery to prevent patients from developing A-Fib after the surgery.

A Key to Fighting the Inflammation of Atrial Fibrillation?

Isn’t it amazing that a medication at least centuries old is now used to combat inflammation in A-Fib and cardiac disease? Could colchicine and other anti-inflammation treatments become the key to stopping A-Fib from developing in the first place?

(Thanks to Anne Richard for alerting us to this use of colchicine in A-Fib.)

References
• Slobodnick, A. et al. Update on colchicine, 2017. Rheumatology, Volume 57, Issue suppl_1, January 2018, Pages i4-i11. https://doi.org/10.1093/rheumatology/kex453

• Zhou, X. et al. Evidence for Inflammation as a Driver of Atrial Fibrillation. Frontiers in Cardiovascular Medicine, April 29, 2020. https://doi.org/10.3389/fcvm.2020.00062

• Salih, M. et al. Colchicine for prevention of post-cardiac procedure atrial fibrillation: Meta-analysis of randomized controlled trials. Int J Cardiol. 2017; Sept 15:243:258-262. doi: 10.1016/j.ijcard.2017.04.022.

• Rosenthal, L. et al. Medscape. When is colchicine indicated in the treatment of atrial fibrillation (Afib) (AF)? Nov 18, 2019 (update). https://www.medscape.com/answers/151066-4179/when-is-colchicine-indicated-in-the-treatment-of-atrial-fibrillation-afib-af

• Imazio M, et al, for the COPPS Investigators. Colchicine reduces postoperative atrial fibrillation: results of the Colchicine for the Prevention of the Postpericardiotomy Syndrome (COPPS) atrial fibrillation substudy. Circulation. 2011 Nov 22. 124 (21):2290-5. https://reference.medscape.com/medline/abstract/22090167

• O’Riordan M. Colchicine postablation reduces early AF recurrences. Heartwire from Medscape. October 4, 2012; Accessed: October 15, 2012. http://www.medscape.com/viewarticle/772079.

• Deftereos S, et al. Colchicine for prevention of early atrial fibrillation recurrence after pulmonary vein isolation: a randomized controlled study. J Am Coll Cardiol. 2012 Oct 30. 60 (18):1790-6. https://reference.medscape.com/medline/abstract/23040570  

Abbott’s LAA Closure Device Amplatzer Amulet FDA Approved for A-Fib

Atrial Fibrillation patients now have a second effective way to close off the Left Atrial Appendage (LAA) to prevent strokes and to no longer be required to take anticoagulants for life. Abbott’s Amplatzer Amulet Left Atrial Appendage closure device was approved by the FDA in August 2021.

Amulet Clinical Trial

In a clinical trial sponsored by Abbott, the Amplatzer Amulet was compared head-to-head with the earlier version of the Watchman device, (not with the more recent Watchman FLX commonly in use today).

Amplatzer Amulet Occluder device positioned in Left Atrial Appendage (LAA)

The Amplatzer Amulet device features a lobe which fills the body of the Left Atrial Appendage (LAA) and a disc to close off the opening into the LAA.

In the Amulet LAA Occluder clinical trial, 80% of Amulet patients were discharged without anticoagulant therapy. Only 20% were discharged on anticoagulants (usually dual antiplatelet therapy, clopidogrel plus aspirin). The FDA-approved label recommends this to prevent clot formation before the device is completely closed off by heart tissue growing over the device (reendothelialization).

In this study most Watchman patients (82%) were discharged requiring anticoagulant therapy. The Watchman usually requires a short course (45 days) of warfarin followed by dual antiplatelet therapy anticoagulants (usually clopidogrel plus aspirin) until 6 months after LAA closure.

Major Advantage of Amulet Over Watchman

Why is the Amulet important for some Atrial Fibrillation patients? The Amulet doesn’t usually require the use of anticoagulants after it is inserted. (Some patients can’t take anticoagulants, others don’t want to be on anticoagulants, even for a short period.)

No Data Yet on Amulet vs. Newest Watchman FLX

The Amulet did close off the LAA better than the 2015 version of the Watchman, but not by much (98.9% vs. 96.8%).

We don’t have data comparing the current Watchman FLX to the Amulet.

Editor's Comments about Cecelia's A-Fib story

Editor’s Comments

Atrial Fibrillation patients considering an Amulet should probably wait till after they are free of Atrial Fibrillation and after a thorough mapping and isolation of all non-PV triggers, especially those coming from the LAA.
Metal Exposure: The Watchman FLX features reduced metal exposure, whereas the Amulet outside disc is a large protruding piece of metal inserted into the heart. (I personally would not want that huge piece of metal disc in my heart.)
Occluders: Watchman on left; Amplatzer Amulet on right

Occluders: Watchman on left; Amplatzer Amulet on right

What if one’s LAA continues to produces A-Fib signals? It’s difficult or impossible to isolate the LAA if the Amulet disc covers the LAA opening. The Watchman doesn’t protrude into the heart like the Amulet does.

No or Reduced Need for Anticoagulants with Amulet: The Amulet doesn’t usually require anticoagulants. This is great news for those who can’t tolerate anticoagulants. One of the major motivations to getting one’s LAA closed off is to no longer have to take anticoagulants which are high risk drugs.

It’s Great for A-Fib Patients to Now Have a Choice of LAA Closure Devices: It’s amazing how research has improved for patients with A-Fib. Who would have thought that we would now have two effective ways to close off the LAA to prevent strokes−with no requirement of anticoagulants therapy for life?
Which is Better―the Amulet or Watchman? Which Should I Choose? Unless you can’t tolerate anticoagulants for 6 months, stick with the Watchman FLX. We know it works in the real world after years of experience. While the Amulet is used in Europe, it has just been FDA approved in the US. We need more real-world experience with it.

On a Personal Note: As many readers know after 21 years, my A-Fib returned. Not to worry. I’m once again A-Fib free after two catheter ablations by Dr. Shephal Doshi and Dr. Andrea Natale. But Dr. Natale did recommended I close off my Left Atrial Appendage (LAA). So in a few months, I’ll be getting the Watchman FLX occlusion device. I’ll write about the experience.

Additional reading: Don’t Want to Take Anticoagulants? Three Alternatives for A-Fib Patients; and Anticoagulants Increase Risk of Hemorrhagic-Type Strokes

References
● Lakkireddy, D. et al. Amplatzer amulet left atrial appendage occluder versus watchman device for stroke prophylaxis (amulet ide): a randomized controlled trial. Circulation, august 30, 2021. https://www.ahajournals.org/doi/abs/10.1161/CIRCULATIONAHA.121.057063

● Todd. FDA Approves Next-Generation Watchman FLX Device for LAA Occlusion. TCTMD News, July 22, 2020. https://www.tctmd.com/news/fda-approves-next-generation-watchman-flx-device-laa-occlusion

A-Fib & Anticoagulants: Bleeding Risk If combined with OTC meds, Supplements

More than a third (33%) of people taking anticoagulants also take at least one nonprescription drug daily or most days of the week. This combination can cause dangerous side effects.

If you are taking an anticoagulant, such as Eliquis, Xarelto, Pradaxa or Savaysa, be aware that taking it along with some over-the-counter drugs and supplements can cause dangerous internal bleeding.

These over-the-counter drugs include painkillers such as aspirin, Advil (ibuprofen), and Tylenol (acetaminophen) and dietary supplements such as fish oil, turmeric, ginger and other herbs.

Internal Bleeding Risk: NOACs/DOACs Hard to Measure

The older anticoagulant, warfarin, required regular blood tests of INR (International Normalized Ratio) to measure how much warfarin was actually working in a patient’s blood to prevent a stroke.

But the newer anticoagulants (NOACs, DOACs), such as Eliquis, Xarelto, Pradaxa or Savaysa, aren’t normally measured by anticoagulation clinics or health care professionals using standardized tests such as INR. (The FDA, under pressure for new anticoagulants, approved the NOACs without there being any established or universally recognized method of determining their clot preventing effectiveness.)

Be aware that your doctor probably doesn’t test to see how much your NOAC is actually working in you. They hope it is, but doesn’t know for sure. Blood levels of your NOAC depends on factors such as how well or how poorly your kidneys are functioning.

Not all of your NOAC may actually be working for you. Pradaxa, for example, is 80% cleared by the kidneys. This means there may be lower anticoagulant levels in your blood stream, and a lot of your clot prevention is being flushed away by your kidneys. (Eliquis, Xarelto and Savaysa fare better with only 25%, 33% and 35% being cleared by the kidneys, respectively.)

Check With Your Doctor About Increased Internal Bleeding Risk

If you take an anticoagulant along with over-the counter drugs and supplements, ask your doctor which combinations to avoid. But be aware that many doctors are clueless about natural dietary supplements.

(Don’t ask them how effectively your NOAC is working in you. They probably don’t know and can’t easily test for that.)

References
• Tarn, D.M. et al.   Prevalence and Knowledge of Potential Interactions Between Over-the-Counter Products and Apixaban. The American Geriatrics Society, 2019. 68:155-162. https://agsjournals.onlinelibrary.wiley.com/doi/pdf/10.1111/jgs.16193

• Tarn, Derjung M.  More Than A Third of Patients On Blood Thinners Take OTC Products That Can Cause Dangerous or Fatal Interactions. Thailand Medical News, Oct. 29, 2019. https://www.thailandmedical.news/news/more-than-a-third-of-patients-on-blood-thinners-take-otc-products-that-can-cause-dangerous-or-fatal-interactions-

• Tarn, Derjung M., Beware of blood thinner danger. Bottom Line Health, February 2020.

 

A-Fib Free Again: My 3rd Ablation for “Very Late Recurrence” by Dr Natale

The return of my A-Fib was captured by my Medtronic Reveal LINQ loop recorder. I was asymptomatic, often referred to as Silent A-Fib. (For more about my recurrence, see my earlier post: My A-Fib’s Back: Need a Touch-Up This Week)

A Medtronic Reveal LINQ Insertable Cardiac Monitor (ICM) is one of the world’s smallest cardiac monitors—inserted just under the skin near the heart.

Medtronic Reveal LINQ insertable heart monitor

Medtronic Reveal LINQ IHM

Each night my Reveal Linq wireless monitor transmits that day’s data by wireless connection to my EP, Dr. Shephal Doshi.

I’m 80 years young and a very active runner, high jumper and weightlifter. While many EPs would likely prescribe A-Fib drugs, I chose a third “touch-up” ablation instead.

Very Late Recurrence: This ablation was for the condition called “Very Late Recurrence” where someone who has been A-Fib free for years develops A-Fib again. (Previously these cases were considered very difficult or even impossible to fix.)

Why does A-Fib sometimes recur many years later? We can only speculate. Perhaps the evolution or development of A-Fib silently continues during the years of being A-Fib free. Is it age-related? Does genetics play a role? Obviously more research needs to be done in this area.

Pre-ablation, Steve Ryan with Dr. Natale and his surgical nurse.

But thanks to the excellent research of Dr. Andrea Natale and his colleagues, “Very Late Recurrence” can now be fixed.

To learn more about Very Late Recurrence, see our article: After Two Years A-Fib Free, What Causes ‘Very Late Recurrence’ in Post-Ablation Patients?

My Third Ablation: My re-do catheter ablation was on August 19, 2021 and was performed by Dr. Andrea Natale at Los Robles hospital in Thousand Oaks, CA.

Research has shown that “very late recurrence” of A-Fib is primarily driven by non‐pulmonary vein triggers especially from the left atrial appendage and coronary sinus. Isolation of these triggers results in a high success rate.

Beautiful quilt, Los Robles Hospital Cardiac admittance; Handmade by two staff nurses.

During my ablation, this is exactly what Dr. Natale found. Therefore, he isolated both my left atrial appendage and my coronary sinus to eliminate the locations of these triggers. (My pulmonary veins had remained isolated.) He also made a roof line and an “infero-posterior” line with RF to isolate the posterior wall of the left atrium. He  found non-PV electrograms/potentials in the left atrial septum, the floor of the left atrium, the left atrial lateral wall, and the anterior roof of the left atrium which he eliminated with RF ablation.

I was in the hospital overnight. Everything went fine. The only complication I had was irritation of the throat from being intubated. I had to return to the Los Robles emergency room, but they took care of that with medication.

A-Fib Free (Again): I’m temporarily on Multaq and of course the anticoagulant Eliquis.

I am in the three-month blanking period. This is the period when my heart is learning to beat normally again.

For now, I’m A-Fib free.

 

After Two Years A-Fib Free, What Causes ‘Very Late Recurrence’ in Post-Ablation Patients?

Even though catheter ablation is remarkably successful in restoring most paroxysmal A-Fib patients to normal sinus rhythm, a small number of these patients do have relapses (recurrences) sometimes many years out.

The main objective of this study was to understand why Atrial Fibrillation relapses years after successful electrical isolation of the pulmonary veins (PVs) in paroxysmal patients and whether the presence of comorbidities influence recurrence.

These are the questions Dr Andrea Natale and his colleagues at the Texas Cardiac Arrhythmia Institute were looking to answer.

Study Parameters

In this observational study, researchers at Texas Cardiac Arrhythmia Institute looked at 1,633 of their paroxysmal patients who had been A-Fib free for two years after their first or second catheter ablations, then suffered recurrences years later  (i.e., Very late recurrent).

What does 'Very Late Recurrent' mean?
It’s one of three way to describe the timeframe of A-Fib recurrence after ablation:
• Early recurrence = During the 1-3-month “blanking period”;
• Late recurrence = 3–12 months after ablation;
• Very late recurrent = 12+ months after ablation.

The patients were divided into two groups based on the presence or absence of comorbidities (presence of two or more diseases). The groups were:

Group 1: 692 patients with no comorbidities
Group 2: 941 patients with comorbidities

Comorbidity (co·mor·bid·i·ty) means presence of two or more diseases or medical conditions in a patient.

A-Fib and Common Comorbidities

The Group 2 patients had one or more of the following illnesses/conditions (comorbidities):

• Moderate to severe sleep apnea
• Diabetes mellitus
• Body mass index 30 kg/m² or higher (obese)
• Hypertension treated with multiple anti-hypertensive agents
• Low left ventricular ejection fraction (lower than 45%; normal is 50% to 75%)

Quality of Previous Ablations

The patients who experienced recurrences had been previously well ablated (one or two procedures.) Standard ablation procedures included PVI plus isolation of the left atrial posterior wall and the Superior Vena Cava (SVC):

• Their pulmonary veins were completely isolated of all PV potentials as confirmed by entrance and/or exit block. The electrical isolation was extended to the posterior wall contained between the PVs.
• Posterior wall isolation was performed using multiple ablation points covering the whole posterior wall.
• The SVC was mapped and isolated circumferentially in all patients. The atrial myocardial sleeves extend into the SVC for up to 2 to 5 cm. thus harboring ectopic pacing cells that provide the substrate for atrial arrhythmia. The Superior Vena Cava (SVC) is a known source on non-PV triggers.

Superior Vena Cava (SVC) is a known source of non-PV triggers.

Patient Follow‐up

Follow‐up was performed at 1, 3, 6, and 12 months with office visits, cardiology evaluation, 12‐lead electrocardiogram (ECG) and 7‐day Holter monitoring at 1, 6, and 12 months. After 1 year, patients were followed up annually with a 7‐day Holter and were asked to check their pulse regularly to monitor rate.

Ablation success was defined as absence of arrhythmia off antiarrhythmic drugs.

Ten-Year Recurrence Findings

At 10 years of follow-up, median time to recurrence was 7.4 years. The recurrence rate among the study patients was:

• Group 1 patients: 31.1% experienced recurrence (215 of 692)
• Group 2 patients: 51% experienced recurrence (480 of 941)

Redo Ablations

Patients with recurrence of their A-Fib, underwent a ‘re-do’ ablation:

• 201 in Group 1 patients
• 456 in Group 2 patients

Ablations targets at re-do:

• 561 patients received isolation of the Left Atrial Appendage (LAA) and Coronary Sinus (CS); 96 patients received left atrial lines and flutter ablation; 9 patients received re‐isolation of PVs;
• PV reconnection was not noted in any of the patients with two prior procedures. The SVC was found to be permanently isolated in 642 (97.7%) and no reconnection of posterior wall in 611 (93%) cases.

Top: Representative images showing a patient’s lesion sets during initial ablation. Bottom: 5 years later during the same patient’s re-do ablation.

Two-Year Results After Redo Ablation

At 2 years, 91.1% (134) of Group 1 and 94.4% (391) of Group 2 remained arrhythmia free! These patients received left atrial appendage (LAA) and Coronary Sinus (CS) isolation.

Of those who received left atrial lines and flutter ablation, results were poor with around 7% arrhythmia free.

Study Conclusions

The main objective of this study was to understand why Atrial Fibrillation relapses years after successful PV catheter ablation in paroxysmal patients and whether the presence or absence of comorbidities influence very late recurrences.

Despite permanent pulmonary vein isolation (PVI), very late recurrence was primarily driven by non‐pulmonary vein triggers especially from the left atrial appendage and coronary sinus. Ablation of these triggers resulted in high success rate (regardless of the comorbidity profile.)

The median time to recurrence was significantly shorter in patients with cardiovascular comorbidities.

Editor's Comments about Cecelia's A-Fib storyEditor’s Comments

These study results are remarkable! The study findings reinforce the crucial role of non-PV triggers in the relapse of A-Fib. Knowing how comorbidities shorten the timeline to A-Fib recurrence can motivate patients to improve their overall health.
If You’re Having an Ablation or Re-do Ablation: Besides isolating the Pulmonary Veins, talk with your doctor about mapping and isolating non-PV triggers i.e., from the Left Atrial Appendage (LAA) and Coronary Sinus (CS).
How can You Avoid Recurrence? Get rid of comorbidities. Even after the establishment of sinus rhythm, comorbidities contribute to the progression of A-Fib and its recurrence.
Very late recurrence was primarily driven by non‐pulmonary vein triggers especially from the left atrial appendage and coronary sinus.
While patients in Group 2 (with comorbidities) were able to be cured and restored to sinus rhythm just as well as patients without comorbidities, recurrence occurred sooner (5.6 years versus 7.4 years).
To postpone or avoid recurrence of your A-Fib, do what you can to get healthier. Lose weight if needed, get treatment if you have sleep apnea, address hypertension issues, manage your diabetes, stop smoking, moderate your  consumption of alcohol.
Why Does A-Fib Sometimes Recur Many Years Later? We can only speculate. Perhaps the evolution or development of A-Fib silently continues during the years of being A-Fib free. Is it age-related? Does genetics play a role? Obviously more research needs to be done in this area.
Last Thoughts: Have researchers like Dr. Andrea Natale discovered how to cure even the most difficult A-Fib cases? Isolating the LAA and the CS seems to be the key.

Are we close to a time where even the most difficult cases of A-Fib can be cured by the right EPs using the right ablation techniques at the right time?

Resource for this article
Mohanty, S. et al. Natural History of Arrhythmia After Successful Isolation of Pulmonary Veins, Left Atrial Posterior Wall, and Superior Vena Cava in Patients With Paroxysmal Atrial Fibrillation: A Multi-Center Experience. Journal of the American Heart Association, 2021;10:e020563. https://www.ahajournals.org/doi/10.1161/JAHA.120.020563. https://doi.org/10.1161/JAHA.120.020563

My A-Fib’s Back: Need a Touch-Up This Week

On August 19 I’m scheduled for a touch-up ablation by Dr. Andrea Natale at Los Robles hospital in Thousand Oaks, CA.

Dr. Shephal Doshi and Steve Aug 1 2019

I’m symptom free. But my Medtronic Reveal LINQ loop recorder shows I still have some A-Fib after a catheter ablation by Dr. Shephal Doshi at St. John’s hospital in Santa Monica 24 months ago (August 2019).

Background: My first catheter ablation was in 1998 by Drs. Michel Haïssaguerre, Pierre Jais, and Dipen Shaw in Bordeaux, France. Though it was relatively primitive compared to what EPs are doing today, it kept me A-Fib free for 21+ years.

Steve with Dr Häissaguerre who cured Steve in 1998.

Left Atrial Appendage: During the touch-up ablation, my Left Atrial Appendage (LAA) may have to be electrically isolated. If that’s done, and my LAA doesn’t empty of blood properly, I may have to have a Watchman device inserted to mechanically close off my LAA. As an enthusiastic runner/sprinter, I don’t want to have my LAA closed off as it can reduce blood flow. But at 80 years old, I may have little choice. I’ll post again after my redo ablation.

A “re-do” catheter ablation is nothing to be frightened of. My procedure this week, like last time, will be as an out-patient. For my 2019 touch-up procedure, I arrived at the hospital at 5am and was back home at 5pm. In and Out. Lickety-split!

Magnesium IV to Stop A-Fib

We have long advocated the benefits of Magnesium for A-Fib. (See Magnesium Long-Life Insights for A-Fib Patients.)

Intravenous Delivery: A recent randomized controlled double-blind study found that Magnesium delivered directly into the bloodstream (Intravenous, i.e., IV) can produce both rate and rhythm control when used for A-Fib patients in the emergency room (ER).

The Good News: This study from the University of Monastir, Tunisia, found Magnesium IV is the fastest way to improve Magnesium levels and is very effective in restoring A-Fib patients to normal sinus rhythm.

The Bad News: In U.S. emergency rooms, Magnesium IV is not a standard treatment for A-Fib patients (though it may be used prior to cardioversion). (Dr. Julian Whitaker in Newport Beach, CA performs this therapy (www.drwhitaker.com).)

One of our Advisory Board members wrote me about his large facility’s experience with Magnesium IVs, “A few years ago we tried and stopped because of futility.”

Bottom Line: So it’s an interesting research study, but don’t look for a Magnesium IV if you end up in the ER with an A-Fib episode.

Resource for this article
Bouida, W. et al. Low-dose Magnesium Sulfate versus High Dose in the Early Management of Rapid Atrial Fibrillation: randomized controlled double-blind study. (LOMAGHI Study). Acad Emerg Medi. 2019;26(2):183-191. https://www.onlinelibrary.wiley.com/doi/full/10.1111/acem.13522 doi.org/10.1111/acem.13522

Side Effects of Flecainide: An A-Fib Patient’s Perspective

Carol, from Salem, Oregon, wrote me to share how taking the antiarrhythmic drug, flecainide, affected her.
Flecainide, an antiarrhythmic medication, works by slowing electrical signals in the heart to stabilize the heart rhythm.

“When I initially started taking flecainide for my A-Fib, I experienced annoying visual disturbances, especially when there was a difference between a light and dark environment such as a stage or when going from a light to a dark room. I would see afterimages, many of them. For example, in a theater I’d see my hands clapping, but I’d see many of them as if in a time lapse still photo. Over time that effect got better.

But other side effects developed.

…Here it goes again. I plan to call the Cardiologist as soon as the office opens. I have the following symptoms:

Irregular heartbeat
stomach discomfort (bloating)
rash and hives
hair loss
anxiety (my shoulders are practically making contact with my ears)
sleep problems
increased sweating
annoying visual disturbances

These are all listed on the package insert as possible side effects. 

Flecainide is pronounced as (flek’ a nide)

However, I am not ready to say they were caused by flecainide as I have had lifelong problems with allergies and digestive issues. Except for the visual disturbances…

I was on flecainide for 12 years―and it mostly worked well―until it didn’t anymore.”

Carol Baumann,
Salem, Oregon

Editor’s Comments

Editor's Comments about Cecelia's A-Fib story
One of the most frequently prescribed antiarrhythmic drugs is flecainide acetate (Tambocor). Flecainide has been around a long time (1985) and is only available as a generic drug.
Instead of a daily dose, fecainide can be used as a “Pill-In-The-Pocket” treatment i.e., taking an antiarrhythmic med at the time of an A-Fib attack.
Flecainide carries an FDA “Black Box Warning” which is the most serious the FDA issues. A Black Box Warning alerts doctors and patients that a drug has potentially dangerous effects.

Lookup fecainide at MedlinePlus.gov

As with almost all antiarrhythmic drugs, flecainide is known for bad side effects.
To read a detailed description of flecainide, its uses and side effects, see fecainide at MedlinePlus/Drugs, Herbs and Supplements (U.S. National Library of Medicine).

Don’t Want to Take Anticoagulants? Three Alternatives for A-Fib Patients

With Atrial Fibrillation, you are 4–5 times more likely to have an A-Fib (ischemic) stroke. Taking an anticoagulant helps prevent an A-Fib stroke and may give you peace of mind.

The negative side is that all anticoagulants are high-risk medications and inherently dangerous. You bruise easily, cuts take a long time to stop bleeding. You can’t participate in any contact sports. Bleeding events are common complications. There is an increased risk of developing a hemorrhagic stroke and gastrointestinal bleeding. See Risks of Life-Long Anticoagulation.

Be advised that no anticoagulant or blood thinner will absolutely guarantee you will never have a stroke. Even warfarin [Coumadin] only reduces the risk of stroke by 55% to 65%.

(Most EPs are well aware of the risks of life-long anticoagulation.)

Don’t want to take anticoagulants? What’s the alternative? Remove the reason you need an anticoagulant!

Three Alternatives to Taking Anticoagulants

Anticoagulants are used with high-risk Atrial Fibrillation patients for the prevention of clots and stroke.

The best way to deal with the increased risk of stroke and side effects of anticoagulants is to no longer need them. Here are three options:

RF Catheter ablation

#1 Alternative: Get rid of your A-Fib.

As electrophysiologist (EP) and prolific blogger Dr. John Mandrola wrote: “…if there is no A-Fib, there is no benefit from anticoagulation.”

Action: Request a catheter ablation procedure. Today, you can have an ablation immediately (called ‘first-line therapy’). You don’t have to waste a year on failed drug therapies. See Catheter Ablation Reduces Stroke Risk Even for Higher Risk Patients

Placing Watchman in LAA

#2 Alternative: Close off your Left Atrial Appendage (LAA).

The Left Atrial Appendage is where 90%-95% of A-Fib clots originate. Closing off the LAA provides similar protection against having an A-Fib (ischemic) stroke as being on an anticoagulant.

Action: Request a Watchman device. The Watchman device is inserted to close off your LAA and keep clots from entering your blood stream. See Watchman Better Than Lifetime on Warfarin

Natural blood thinners

#3 Alternative: Consider non-prescription blood thinners

Perhaps you can benefit from an increase in natural blood thinners such as turmeric, ginger and vitamin E or, especially, the supplement Nattokinase.

Action: Ask your doctor about your CHA2DS2-VASc score (a stroke risk assessor). If your score is a 1 or 2 (out of 10), ask if you could take a non-prescription approach to a blood thinner. See FAQ: “Are natural blood thinners as good as prescription blood thinners?” 

If you decide to take an DOAC, ask your doctor about taking Eliquis. It tested better than the other DOACs and is considered safer. 

Bottom Line

Whether or not to take anticoagulants (and which one) is one of the most difficult decisions you and your doctor must make. To stop taking an anticoagulant, talk to your doctor about alternatives:

• Catheter ablation
• LAA closure (Watchman device)
• Non-prescription blood thinners

These options may help you to no longer need an anticoagulant. As Dr. John Mandrola wrote: “…if there is no A-Fib, there is no benefit from anticoagulation.”

As an A-Fib patient, don’t settle for a lifetime on anticoagulants or blood thinners. Remember: You must be your own best patient advocate.

Resource for this article
Weng Y, et al. Nattokinase: An Oral Antithrombotic Agent for the Prevention of Cardiovascular Disease. Int J Mol Sci. 2017;18(3):523. Published 2017 Feb 28. doi:10.3390/ijms18030523

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