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Warfarin Users: NOACs now First-line Therapy
The use of warfarin (Coumadin, Jantoven) to prevent clots is no longer recommended for most A-Fib patients. With a superior safety profile, NOACs (Novel Oral Anticoagulants) are now recommended as first-line therapy for suitable A-Fib patients. NOACs include dabigatran (Pradaxa), rivaroxaban (Xarelto), Apixaban (Eliquis) and edoxaban (Savaysa).
A-Fib treatment guidelines were updated in 2019 by the American Heart Association/American College of Cardiology/Heart Rhythm Society (AHA/ACC/HRS).
The guidelines recommend that Coumadin no longer be used to treat A-Fib except for a limited, specific group of patients. Instead, guidelines strongly recommend using NOACs (DOACs).
“New scientific studies show that NOACs may be safer for patients because there is less risk of bleeding, and they may also be more effective at preventing blood clots than warfarin,” said Craig T. January, MD, PhD, FACC, co-chair of the focused update.
NOACs (or DOACs) Guidelines
The guidelines instead encourage the use of “novel [direct] oral anticoagulants” (NOACs or DOACs) which are better at preventing stroke and have fewer side effects. I’ve written about the NOACs several times:
…Eliquis (apixaban) tested the best and is the safest. But all NOACs are considered high risk drugs and should only be taken if there is a real risk of stroke. (Warfarin vs. Pradaxa and the Other New Anticoagulants)
For example, if you’ve been cured of A-Fib and are A-Fib free by a catheter ablation, you normally don’t have to take NOACs. You aren’t in danger of having an A-Fib stroke if you don’t have A-Fib. NOACs are not like taking vitamins. (Blood Thinners After Ablation)
High Cost of NOACs: Co-Pay Card and Patient Assistance Discounts
I know NOACs are much more expensive than Coumadin. And I understand if you and your doctor may choose to continue using Coumadin because of the high cost of a NOACs.
But don’t give up so fast. There are resources to save on prescription cost. For example, here are two resources on Eliquis to check:
• Drugs.com has a very informative page about the NOAC, Eliquis. For example, see Eliquis Prices, Coupons and Patient Assistance Programs
• Eliquis Customer Connect: Bristol-Myers Squibb offers an Eliquis Co-pay card and program which might work to reduce your cost. See ELIQUIS Costs, Savings and Support.
“Eliquis Co-pay Card: Eligible patients may pay no more than $10 per 30-day supply for up to 24 months with an annual savings of $3800; for additional information, contact the program at 855-354-7847.”
Other NOAC drug companies may have similar discount plans. We offer these links to help you get started:
• Pradaxa (dabigatran), see PRADAXA Savings & Support
• Xarelto (rivaroxaban), see Get Savings and Support for XARELTO
• Savaysa (edoxaban), see The SAVAYSA Savings Card
If you are 65 or older, you may qualify for Senior Discounts.
Talk to Your Doctor if You’re on Warfarin
If you’ve on warfarin (Coumadin, Jantoven) to prevent blood clots, you know that this powerful drug can save your life. But warfarin treatment is a careful balance, and certain factors can tip the balance, increasing the risk of bleeding.
If you are taking warfarin, talk to your doctor about the NOACs and whether you should change from warfarin.
Taking an anticoagulants (and which one) is one of the most difficult decisions you and your doctor must make.
Medical ID: If you’re on any blood thinner, it’s a good idea to carry some kind of medical ID. If you have an accident involving bleeding, EMTs can call ahead to the ER and get the staff ready to help you. To print your own I.D. see: Print a free Medical Alert I.D. Wallet Card
Copy of FAQs Coping with A-Fib: Pacemaker for Too Slow a Heart?
FAQs Coping with A-Fib: Pacemaker
“Now my doctor says I need a pacemaker, because my heart rate is too slow and because I’m developing pauses.
I’m an athlete with A-Fib and have a naturally slow heart rate. Since I developed A-Fib, I was put on atenolol (a beta blocker) which really slows down my heart rate. What should I do?”
Get a second opinion. It’s crazy to go through the risks and lifestyle disruptions of having a pacemaker implanted just to be able to continue taking atenolol.
Because you are an athlete, your heart rate is naturally slow. But it’s normal for you.
As long as you feel fine and aren’t fainting from lack of blood flow, don’t be talked into getting a pacemaker. A slow or even very slow heart rate usually doesn’t cause any harm. As for heart rates, “normal” is indeed a wide swath.
In the words of Dr. John Mandrola:
“Do not implant pacemakers in patients with nonsymptomatic bradycardia (slow heart rate).The same holds for pauses, though they are certainly of more concern than a slow heart rate. Nonsymptomatic slow heart rate or pauses don’t justify exposing patients to the risks of implanting a pacemaker.”
Do not implant pacemakers in patients with nonsymptomatic bradycardia. This includes the wide spectrum of sinus node dysfunction (SND), asymptomatic pauses in patients with permanent AF, and young patients with medication-induced bradycardia. Humans exhibit tremendous variation of heart rate, and impressively slow heart rates frequently cause patients no harm. As for heart rates, ”normal” is indeed a wide swath. Unlike the more sinister high-degree AV block, SND is not immediately fatal. In 2012, there exist many strategies for the treatment of arrhythmia that do not include exposing patients to the risks of implanting a permanent intravascular device.
Back to FAQs: Coping with Your A-Fib
Last updated: Wednesday, August 26, 2020
Lorrie’s Catastrophic Mini-Maze Surgery and Its After-Math
Lorrie was an informed Atrial Fibrillation patient. She did everything right.
Lorrie C.
She researched her disease, she studied the choices of surgical treatments. With input from her EP, she thoughtfully decided on a Mini-Maze surgery.
She chose a highly skilled cardiac surgeon with an outstanding reputation. She and a companion interviewed the surgeon and asked loads of questions—twice. And chose one of the top 100 hospitals in the country for her surgery.
It’s a shame she had to endure so many complications.
The first part of Lorrie’s Atrial Fibrillation story was written in 2012 from her hospital room upon re-admission after Mini-Maze surgery. She then jumps to the present and writes about the aftermath. She begins:
“As I sit in my hospital bed on my seventh consecutive day of my second admission, I have finally mustered the strength and clarity of mind to write about my exasperating experience of an elective surgery… .
My A-Fib started when I was in my early 60’s with only a few episodes a year. The story of my Mini-Maze surgery began about four years later when my electrophysiologist felt it was time to put an end to my increasing episodes of Atrial Fibrillation.
Due to having paroxysmal A-Fib (meaning every now and then for unknown reasons) as well as my good health and stamina, at 66 years of age I was the perfect candidate for either a catheter vein ablation or Mini-Maze surgery. Because I was only having about 3 episodes a year and in good health, my EP felt that I would have a success rate of over 95%.
After much research, I decided the Mini-Maze would be the best procedure for me. (My EP felt it would be a better choice than an ablation, for he felt I would have a good outcome, which I did not.)
He also warned me that the Mini-Maze wouldn’t be a “walk in the park.” That was an understatement! …
…Continue reading Lorrie’s story about her mini-maze surgery and learn her advice to others with A-Fib.
Atrial Fibrillation and a Catastrophic Mini-Maze Surgery
By Lorrie C., August 2020
Lorrie C.
The first part of Lorrie’s Atrial Fibrillation story was written in 2012 from her hospital room upon re-admission after Mini-Maze surgery. She then jumps to the present and writes about the aftermath.
As I sit in my hospital bed on my seventh consecutive day of my second admission, I have finally mustered the strength and clarity of mind to write about my exasperating experience of an elective surgery.
My A-Fib Gets Worse
My A-Fib started approximately 10 years ago when I was in my early 60’s with only a few episodes a year.
The story of my Mini-Maze surgery began about four years later when my electrophysiologist felt it was time to put an end to my increasing episodes of Atrial Fibrillation. (Atrial fibrillation, or A-Fib, is an irregular heart rhythm caused by the quivering of heart muscles of the atria.)
Years ago, many physicians regarded A-Fib as “just a nuisance.” It is now known that clots form during an episode and may cause a stroke when the patient returns to a normal sinus rhythm.
As one grows older, the A-Fib episodes can become more frequent and stretch the atria. Once it stretches beyond the criteria for surgical correction, there is nothing more that can be done, and the patient may eventually suffer from persistent A-Fib and simply have to live with the feeling of “squirrels in the chest.”
Catheter Ablation or Mini-Maze?
Due to having paroxysmal A-Fib (meaning every now and then for unknown reasons) as well as my good health and stamina, at 66 years of age I was the perfect candidate for either a catheter vein ablation or Mini-Maze surgery. Because I was only having about 3 episodes a year and in good health, my EP felt that I would have a success rate of over 95%.
With both the catheter ablation and the Mini-Maze, the electrophysiologist or cardiothoracic surgeon creates lesions by cauterizing around the pulmonary veins to hopefully stop [interrupt] the erratic electrical signals which cause A-Fib.
After much research, I decided the Mini-Maze would be the best procedure for me. (My EP felt it would be a better choice than an ablation, for he felt I would have a good outcome which I did not.)
About Mini-Maze Surgery
As I understand it, three incisions are made under the arm on each side of the chest. The lungs are somewhat deflated, and the surgeon has a clear view of the heart to see exactly where the lesions are being made.
My EP told me he would be there to do mapping. (Whether he was for sure or not, I do not know. I can only assume he was.) [It is not standard practice for an EP to be present during a Mini-Maze surgery.]
One advantage of the Mini-Maze over a catheter ablation is that the left atrial appendage, where most clots form, is stapled off thereby reducing the risk of stroke by 80%.
For more about the Mini-Maze, see my article:“When to consider a Mini-Maze surgery instead of a Catheter Ablation?”
Warned that Mini-Maze Won’t be a “Walk in the Park”
My electrophysiologist agreed with my decision, although he warned me that the Mini-Maze wouldn’t be a “walk in the park.” That was an understatement!
I chose a well-known cardiothoracic surgeon from a very well-known hospital to perform my surgery and hopefully end my A-Fib forever.
Interviewing the Surgeon―Many Questions
My daughter, Lisa, accompanied me to my initial visit, and we were both armed with questions. When I asked the surgeon, what were the risks of the surgery, he said the two major risks were phrenic nerve damage or bleeding.
We questioned him vigorously, and he was very patient answering all questions. He said I would be “in and out of A-Fib” for the first two or three months due to inflammation. I am sorry to say the one thing we didn’t ask was what complications could be encountered during or after the surgery.
To be sure I was making the right decision, I met with the surgeon a second time and drilled him again. He said his success rate was 80%; however, I would most probably be in the 90% and above bracket.
Selecting a cardiac specialist can be a daunting task, to learn how, see our page: Finding the Right Doctor for You and Your A-Fib.
The Day of My Mini-Maze Surgery Arrives
My Mini-Maze was performed on September 1, 2012, at one of the top 100 hospitals in the country with one of the best cardiothoracic surgeons at the helm. Contrary to what my electrophysiologist had warned, I was confident this surgery would be a “walk in the park.”
The surgery took approximately 4 ½ hours. My husband and my friend anxiously awaited the results from the surgeon. He told them my surgery went perfectly, and that I was doing very well.
My Recovery―Three Days in the Hospital
I spent the first day in the Intensive Care Unit on heavy duty pain meds as well as a nerve block, so I don’t remember much the first couple of days.
I vaguely remember the surgeon telling me I developed fluid around the outside of my right lung, but it would probably be absorbed. If not, I would have to come back to the hospital to have a drain tube inserted and stay overnight.
On the third day after the surgery, I had an eight-hour episode of A-Fib (which was to be expected).
I was discharged on the sixth day and was delighted to be home again.
Back Home, but Daily A-Fib Episodes―Breathing Problems
Much to my disappointment, I began to experience daily A-Fib episodes lasting anywhere from eight hours up to twenty hours. I knew this was to be expected, but it could not be happening to me―after all, I am Super Woman!
My breathing began to worsen, and I had to move my post op visit up a week.
Post-Surgery Visit Sooner Than Planned
After having a chest x-ray and an examination, the surgeon told me I had to be admitted the next day to have a drain tube inserted – the fluid around my right lung was not being absorbed and had to be drained.
The fluid was causing a pneumothorax (collapsing of the lung) and that was the reason I was so short of breath. (Complication #1)
Re-Admitted to Hospital
Drainage Tube Inserted: I was admitted to the hospital and the chest tube was inserted…but without anesthetic. And let me tell you, it was the most painful experience next to childbirth! (Complication #2) That evening, a CT scan of the chest was done to see if there was proper placement of the drain tube. The CT revealed something that I was not prepared for….
Undisclosed Fractured Rib: The next morning, my husband and I were taken aback when the surgeon told us he had fractured a rib during the surgery and he had removed a portion of the middle of my rib, then stitched muscle in place to fill the gap.
…and a Lung Hernia: He explained that after surgery, my excessive coughing tore those stitches. I now had a hernia that had to be surgically repaired as soon as the lung surgeon was available. (The hernia was my lung popping out of the space where the piece of rib had been removed!) (Complication #3)
Fortunately, when the lung surgeon viewed my CT and examined me, he didn’t feel emergency surgery was necessary, for he said it was a small hernia and it may repair itself. [If not, and it became worse or bothered me, he could do the repair, but it was not an emergency.
Overnight Stretches to a Week in the Hospital: My overnight stay became a week due to going in and out of A-Fib. I was on Coumadin and waiting for my INR to be at a therapeutic level so I can be discharged.
Home, Sweet Home
Cellulitis from Infected IV: It has been difficult writing this saga in long hand, for I have developed cellulitis [red, swollen, bacterial skin infection] in my right hand from an infected IV. (Complication #4)
…and a Respiratory Tract Infection: I am now at home, still coughing away. It’s due to an upper respiratory tract infection I caught the first couple of days in the hospital. (Complication #5)
Thankfully, the cellulitis is much improved, and I am able to type my story as I am going in and out of A-Fib.”
Fast-Forward to 2020: The After-Path of a Catastrophic Surgery
Today, I have no A-Fib episodes. I still go into atrial tachycardia [the atria beats too quickly] and have frequent PVC’s [extra heartbeats from a ventricle] and bradycardia.[slower than normal heart rate].
No doctor has said anything about my lung hernia. I assume once you have one, it will always be there unless you have surgery.
Another result of my mini-maze was paralyzed diaphragm [from surgical trauma, causes reduction in lung capacity]. I still have some shortness of breath from the paralyzed diaphragm “but it’s something I can live with.”
That, along with my right lung being raised above my left lung. It was not like that before the surgery and the surgeon could not explain why.
I still take a low dose of amiodarone (200 mg). I do know the dangers of amiodarone, and I do have had some thyroid issues. But my EP and cardiologist monitor my labs for the effects and feel the low dose is okay for me.
Lesson Learned
My advice to other A-Fib patients? Due your homework. Get second opinions.
About choosing a Mini-Maze vs Ablation? Listen to the advice of your doctor, but always get a second opinion.
Make sure the surgeon has done a lot of this type of surgery. My surgeon was a prominent, skilled heart surgeon, but I don’t believe he had much experience in performing the mini-maze. (At the time this surgery was not yet popular in my geographical area.)
And finally, if you are going to have any type of surgery, please ask your surgeon what “complications” you may encounter, not just the risks.
Thank you for reading!
Lorrie C.
Editor’s Comments
Lorrie was an informed patient. She did everything right.To find A-Fib specialists in your area or country, see A-Fib.com Directory of Doctors and Facilities
She researched her disease, she studied the surgical treatments. She thoughtfully chose to have a Mini-Maze surgery. She chose a highly skilled cardiac surgeon with an outstanding reputation. She and a companion interviewed the surgeon and asked loads of questions—twice. And chose one of the top 100 hospitals in the country for her surgery. It’s a shame she had to endure so many complications.
I Don’t Understand: Why didn’t the surgeon tell Lorrie’s family that he had fractured and perforated her rib during the Mini-Maze? That’s a long-term complication that could affect Lorrie for years and cause major, lasting pain.
It’s hard to comprehend why on her re-admission, the surgeon used no anesthetic when he inserted the drainage tube into Lorrie’s chest. It’s also unusual for Lorrie to have so many A-Fib attacks right after her Mini-Maze.
Caution: Mini-Maze Not Recommended for First Timers. In general, catheter ablation is recognized in current guidelines as a first option treatment for A-Fib (Class IIa). Whereas surgical treatments such as the Mini-Maze are generally not a first option (Class IIb), (The exception is special circumstances such as intolerance to anticoagulants.)
It’s less traumatic and you are often home the same day or the day after. And it can be repeated, if needed.
Mini-Maze Surgery has Limitations: The standard Mini-Maze only isolates the Pulmonary Veins (PVs). If you have A-Fib signals coming from other parts of the heart untreatable by a Mini-Maze (such as Flutter from the right atrium), you’ll need a catheter ablation with advanced mapping to find and isolate these A-Fib spots.
Is Mini-Maze Really “Minimally Invasive”? To the average patient, a Mini-Maze is still heart surgery with the potential risks and complications. On the upside, more surgeons now are accessing the heart less invasively through the diaphragm rather than through the ribs as in Lorrie’s case. But it’s still not a “walk in the park.”
Ablation vs. Mini-Maze Trial: There are few clinical trials comparing the Mini-Maze to Catheter Ablation. One was the SCALAF trial which found that patients undergoing the Mini-Maze had nearly a one-in-four chance of having a major complication (unacceptable for most patients). To learn more, see my article: Catheter Ablation vs Surgery For A-Fib: Finally an Apples-to-Apples Comparison.
Controversy about Removal of Left Atrial Appendage (LAA): Lori mentioned that the Mini-Maze surgery includes removal of the LAA. The LAA is not a useless appendage. Some medical professionals question the need of removing the LAA if the goal of the surgery is to no longer be in A-Fib. To learn more, see my article: The Role of the Left Atrial Appendage (LAA) & Removal Issues.
Dangers of Long-term Amiodarone: While Amiodarone is the most effective of the antiarrhythmic drugs, it’s also the most toxic. Normally people are on Amiodarone for only a few months or less. To learn more see: Amiodarone: Most Effective and Most Toxic. And especially this tragic, heartbreaking story of a doctor who died on Amiodarone: Toxic Effects of Amiodarone—What Could Have Prevented this Death?
Thank you, Lorrie! We are grateful to Lorrie for sharing her cautionary tale about the possible complications of Mini-Maze surgery.
Learn about sharing your A-Fib story.
Return to: Personal A-Fib Stories
If you find any errors on this page, email us. Y Last updated: Saturday, August 22, 2020
AVNRT Diagnosed, 2nd Ablation—Finally A-Fib Free
Prior to 2015, I was an active 67-year old male who had taken up running in my late 30’s…I had never experienced any heart issues. Late in September 2015, my heart was racing and a local Spokane hospital ER informed I was experiencing atrial fibrillation. Approximately 12 hours later, with meds, I was back in normal sinus rhythm.
Bob Thompson, Spokane, WA
Over Three Years A-Fib, Bouts Become More Frequent
Over the next few years, I went into A-Fib over 50 times with each bout lasting on the average 10 to 12 hours.Taking metoprolol while in A-Fib, got me back in normal sinus rhythm. I never needed to have a cardioversion.
After dealing with A-Fib for over three years and with the occurrences becoming more frequent, I opted to have a heart catheter ablation in September 2018. Result: the ablation was a complete failure. The EP was only able to ablate three of the four pulmonary veins.
Ablation Fails—Exploring Mini-Maze Procedure
After my failed ablation, my occurrences of A-Fib rapidly increased. I began to explore another option, a mini-maze procedure.
I met with a cardiac surgeon in Spokane who suggested I try one more catheter ablation before I opted for the mini-maze procedure. The surgeon informed me that the best EP in Spokane was Dr. Mark Harwood whom he would be seeing later in the day.
Best EP in Spokane Calls Me the Next Day!
One day after meeting with the cardiac surgeon, I received a call from Dr. Harwood’s office. Upon meeting with Dr. Harwood, he informed me that he was confident of his ability to ablate all four of my pulmonary veins.
Scheduled for Ablation But Stress Test Reveals AVNRT
I was scheduled to have my second ablation in March 2019, but it was contingent on the results of a stress test.
A few days later, at the end of the stress test, I went into A-Fib. An irregularity (tachycardia) was detected requiring an AVNRT Ablation as well. Continue reading Bob’s story…->
A Failed Ablation, then AVNRT Diagnosed and 2nd Ablation—Now Finally A-Fib Free
Bob Thompson, Spokane, WA
By Bob Thompson, Spokane, WA, August 3, 2020
Prior to 2015, I was an active 67-year old male who had taken up running in my late 30’s. I had been diagnosed with Essential Tremor [involuntary shaking or trembling] early in my life but otherwise was considered to be very healthy. I had never experienced any heart issues. Little did I know how much my life was about to change.
Late in the evening of July 11, 2015, I began to feel like my heart was racing and immediately went to a local Spokane hospital ER. After a short period of time, I was informed that my heart was experiencing atrial fibrillation.
Since I was already taking the beta blocker metoprolol for my Essential Tremor, the ER staff intravenously gave me some additional metoprolol. Approximately 12 hours later, I was back in normal sinus rhythm.
Surprised by A-Fib―Researching on the Internet
But what was atrial fibrillation? I had never heard of this diagnosis before the summer of 2015. As is my custom when I am unfamiliar with something, I went to the internet and began to research A-Fib.
I discovered Steve Ryan’s website, A-Fib.com and almost immediately ordered a copy of his book, Beat Your A-Fib. Both Steve’s website and book have been invaluable resources in my quest to deal with my A-Fib.
A-Fib Attacks Continue Lasting 10-12 Hours―Tries Drug Therapy
Over the next few years, I went into A-Fib over 50 times with each bout lasting on the average 10 to 12 hours. Increasing my dosage of metoprolol while in A-Fib, resulted in being able to get back into normal sinus rhythm, and I never needed to have a cardioversion.
My first electrophysiologist (EP) recommended that I take flecainide whenever I went into A-Fib (the so-called Pill-in-the-Pocket treatment), but I found that particular drug did nothing but cause extreme stomach discomfort.
The EP also recommended I try some additional drugs such as sotalol and amiodarone, but I resisted because of the likely side effects that would result. I did, however, agree to take the blood thinner Eliquis.
After Three Years, Time for a Catheter Ablation―Disappointing Failure
After dealing with A-Fib for over three years and with the occurrences becoming more frequent, I opted to have a heart catheter ablation on September 15, 2018.
Result: the ablation was a complete failure. The EP was only able to ablate three of the four pulmonary veins.
A-Fib Occurrences Increase, Exploring Mini-Maze Procedure
Subsequent to the ablation, my occurrences of A-Fib rapidly increased. I began to explore another option, a mini-maze procedure. I met with a cardiac surgeon in Spokane who suggested I try one more catheter ablation before I opted for the mini-maze procedure.
The surgeon informed me that the best EP in Spokane was Dr. Mark Harwood whom he would be seeing later in the day. I informed the surgeon I was aware of Dr. Harwood’s reputation, but I was never able to see him because the EP who had performed the first ablation was part of the same practice of EPs.
Dr. Harwood’s Office Calls Me the Next Day!
One day after meeting with the cardiac surgeon, I received a call from Dr. Harwood’s office informing me that Dr. Harwood could see me the next day. Upon meeting with Dr. Harwood, he informed me that he was confident of his ability to ablate all four of my pulmonary veins.
However at the completion of the stress test, I went into A-Fib. Dr. Harwood detected an irregularity (Tachycardia) that lead him to also perform an AVNRT Ablation.
Another Ablation in March 2019
As scheduled, I had an atrial fibrillation ablation on March 15, 2019. Unlike my first ablation, Dr. Harwood was able to successfully ablate all four pulmonary veins.
In addition, at the same time, Dr. Harwood also performed an AVNRT (Atrioventricular Node Reentrant Tachycardia) ablation which he felt was needed after detecting an irregularity in the EKG during the earlier stress test. [For more about AVNRT, see my Editor’s Comments below.]
Success! A-Fib Free Since March 2019
Subsequent to my 2019 ablation procedures, I have had no recurrences of A-Fib. I no longer need to take the blood thinner Eliquis.
In other words, after almost four years, I am A-Fib free, and I and my wife now have our lives back.
Lessons Learned: My Advice
Here is my advice to others who are battling A-Fib:
1. Never give up in trying to find a cure for this insidious disease. Do not accept the words “Learn to Live with It”.
2. Do not settle for seeing the first available EP which is a mistake I made. Talk to other physicians and medical professionals and ask them for recommendations.
3. It is normal to have anxiety when dealing with A-Fib. My digestive system was a complete mess until I was finally convinced to take some anxiety medication.
4. Try to avoid being tired. Looking back at the chart I kept for my A-Fib incidences shows a definite pattern of going into A-Fib after excessive exercise or work.
5. If you have doubts as to whether or not you are experiencing A-Fib, go to a local fire station that has a paramedic on site. You will be able to have an EKG at no cost.
In Gratitude
In conclusion, I will be forever grateful to Dr. Mark Harwood of Providence Spokane Cardiology-North, for going beyond the parameters of a normal ablation of the pulmonary veins and performing the AVNRT ablation which likely resulted in my cure.
In addition, I am so thankful for the input I have received from Steve Ryan from his website and book as well as one-on-one correspondence.
You can contact me at easychatt@aol.com.
Bob Thompson
Spokane, WA
Editor’s Comments
All EPs Are Not Equal: It’s a shame that Bob’s first EP wasn’t able to isolate all of his PVs. Unfortunately, all EPs are not equal. One of the hardest tasks A-Fib patients face is finding the right EP.
Don’t be afraid to get a second (or third) opinion. Don’t just go with an EP who happens to work near you. Be prepared to travel. Go to the best, most experienced EP you can find, afford, and to where you can reasonably travel.
Search Out the Best EP You Can Find: One of the best ways to find a good EP is what Bob did: talk to doctors, nurses, or support staff who work in the field. They can often tell you who is the best and whom to avoid. But getting this kind of inside info isn’t easy and isn’t possible in many cases.
How Do You Find the Right EP for You? To learn how electrophysiologists differ and how to find the right EP for you, see two of my articles:
• A Tale of Two Ablations and Why All EPs Are Not Equal
• Considering a Catheter Ablation? Know Complication Rates When Choosing Your Doctor.
Bob’s Persistence: What’s inspiring about Bob’s story is his persistence in getting to the best EP in Spokane. God bless the wonderful surgeon who recommended that Bob see Dr. Harwood, even though that surgeon might lose a patient for his own Mini-Maze surgery.
Heart in AVNRT: Instead of a single path, an extra (re-entry]) circuit is shown from the Sinus node and within the AV node.
Technical Description of Bob’s Ablation
Kudos to Dr. Harwood for discovering that Bob had AVNRT and an extra circuit (from the Sinus node and within the AV Node).The ablation for ANVRT is a somewhat unusual procedure.
AVNRT stands for Atrioventricular Node Reentrant Tachycardia.
Normally, the AV Node electrically connects the atria and ventricles and is normally a single electrical road. But in AVNRT, there is a re-entry [extra] circuit within or adjacent to the AV Node.
Catheter Ablation of Pulmonary Veins
Bob’s Left Superior Pulmonary Vein [RSVP] needed to be ablated at the roof, and the Left Inferior Pulmonary Vein [LIPV] needed to be ablated at the ridge.
After isolating Bob’s PVs, Dr. Harwood administered adenosine to confirm entrance and exit block. He then waited 30 minutes to re-confirm that all PVs remained blocked/isolated.
AVNRT illustration: The extra path creates cardiac conduction with both a Fast signal and a Slow signal that disrupts normal sinus rhythm.
Ablation for AVNRT
Next Dr. Harwood used atrial pacing on isoproterenol to induce Supraventricular Tachycardia [SVT].
Then he ablated this extra pathway or circuit which eliminated Bob’s re-entrant tachycardia without damaging Bob’s normal AV Node circuit/pathway.
In effect, he found and engaged Bob’s “Slow Pathway” circuit which was adjacent to his normal AV Node circuit.
After 50 years of Irregular Heartbeats and PVCs, Finally an A-Fib Diagnosis and Treatment
Cecelia Hender, 72, shares about her life with Atrial Fibrillation. She writes that heart arrhythmias have been a part of her life since she was a young woman.
I was about 20 years old when I first experienced irregular heartbeats. My doctor back then told me it was “nerves” and to relax.
This was how most women were treated by doctors back then. Everything was “nerves”.
Cecelia Hender from Abington, MA with her granddaughter.
In my 30’s, I told another doctor how my heart would take off like a race horse, I could not breathe. He said, “try not to think about it.” What????
I fought with these irregular heartbeats for many years. I was never told to see a cardiologist or have a doctor investigate just what was going on.
Sent to a Cardiologist Almost By Accident
About 15 years ago, I worked for a medical facility, and one day a young doctor came in and was waiting for an interview…when he said he was an electrophysiologist [cardiac specialist], I asked about my irregular heartbeats.
He was so kind and intelligent…It was this young doctor who told me that I should see a cardiologist. So, I did. And I was treated with medications and wore many heart monitors.
Hard to Document the Arrhythmia
But it was always hard to catch the arrhythmias on an ECG or heart monitor.
Finally, in 2017 I had another [heart] monitor, and it showed a series of irregular heartbeats.
But on this one particular day, I had a very irritating rhythm. It was very fast, then irregularly fast, and I could barely breathe. I went to my PCP [Primary Care Physician] office where they did an EKG and said, “You are in A-Fib”.
They sent me immediately to my cardiologist who confirmed this. I was put on a different kind of med (Metoprolol at first and also Coumadin). And “fingers crossed” I would convert on my own. It took almost two weeks…Continue to read how two ablations brought Cecelia Hender relief from A-Fib and PVCs, and about a recent setback ->
“Your A-Fib is Just Nerves”…”Try Not to Think About It”; At 72 Finally A-Fib & PVCs-Free After 2 Ablations, But Then a Setback
By Cecelia Hender, July 2020
Cecelia Hender and granddaughter
I have been asked to write my story about my journey with A-Fib. I have had arrhythmias since I was a young woman. I was about 20 years old when I first experienced irregular heartbeats. I had gone to my doctor back then and was told it was “nerves” and to relax. This was how most women were treated by doctors back then. Everything was “nerves”.
Time passed, and the irregular heartbeats seemed to get worse at times.
In my 30’s, I remember going to another doctor and told him that when my heart would take off like a race horse, I could not breathe. And when it stopped, I felt I could climb a mountain again. He said, “try not to think about it.” What ????
I fought with these irregular heartbeats for many years. I was on different blood pressure meds that also helped with heartbeats, but I was never told to see a cardiologist or have a doctor investigate just what was going on.
Once or twice, when I was younger, a doctor had me wear a heart monitor. It was a 24-hour monitor. And when it showed nothing for that period of time, he said I was fine.
Sent to a Cardiologist Almost By Accident―Hard to Document the Arrhythmia
I worked for a medical facility, and one day about 15 years ago a young doctor came in for an interview. He sat in my office for a good amount of time while they were preparing for the interview. During this time, I got to talk to him a lot.
When he said he was an electrophysiologist [cardiac specialist], I asked about my irregular heartbeats. He was so kind and intelligent and gave me a lot of information to think about.
It was this young doctor who told me that I should see a cardiologist. So, I did. And I was treated with medications and had many heart monitors.
But it was always hard to catch the arrhythmias on an ECG or heart monitor.
“You are in A-Fib”―Two Weeks of A-Fib Hell…
Finally, in 2017 I had another [heart] monitor, and it showed a series of irregular heartbeats.
But on this one particular day, I had a very irritating rhythm. It was very fast, then irregularly fast, and I could barely breathe. I went to my PCP [Primary Care Physician] office where they did an EKG and said, “You are in A-Fib”.
They sent me immediately to my cardiologist who confirmed this. I was put on a different kind of med (Metoprolol at first and also Coumadin). And “fingers crossed” I would convert on my own.
…Then Blessed ‘Normal Sinus Rhythm!’
It took almost two weeks, but I remember like it was yesterday, the moment my heart decided to go back into normal sinus rhythm.
The feeling was like a major blessing had just descended on me. I was so happy and felt so strong in that very moment. I cried.
Dr. Seth McClennen―Successful Ablation! But PVCs Major Issue
I met with Dr. Seth McClennen, an Electrophysiologist, who decided I was a good candidate for ablation. I was so thrilled.
Finally, someone was going to help me be normal!
My whole life was spent afraid and never going anywhere alone for fear that my heart would act up and I’d be stranded someplace unable to breathe – unable to move. Finally, I found some help.
Dr. Seth McClennen is a well-known and most beloved Electrophysiologist here in the Boston area. He is the best in my book.
He told me all that I needed to know about ablation, and off I went for my very first A-Fib ablation in June 2017.
It was successful! I went almost two years without an episode of A-Fib at all whatsoever.
However, my PVC’s were a major issue. They still kept me house-bound for the most part. Afraid to go anywhere alone. Although PVC’s don’t carry the risk of stroke that A-Fib has, they were just as debilitating.
A Second Ablation for PVCs―Without General Anesthesia―No Big Deal
Dr. McClennen suggested a second ablation for the PVC’s in January 2019. He said that it would be best if I could go through this without anesthesia, because with sedation, the PVC’s would “hide,” and the ablation would be difficult.
So, I did it … my trust in Dr. McClennen and his wonderful team outweighed any fear or apprehension on my part.
My second ablation was in April 2019. The ablation without sedation was no big deal at all. Now I am talking about a PVC ablation. Seth McClennen was right there working, and I could talk to him any time. He kept me informed as to what was going on.
At one point he said, “Think of something that irritates you so we can get these to come out, and I can follow the path.” So something that irritates me or causes stress will bring these out …. Well, it worked, and he was able to ablate these PVC’s.
Successful PVCs Ablation―Living Without Fear
For the first time in my whole life, I was able to move about without fear.
I could go to the store and feel normal—I was not worried that my heart would go crazy and I would be left in a puddle somewhere with no one to help me.
(Being a widow, it is very hard to continue life alone especially where your health is concerned. My husband died eight years ago when he was only 60 years old. I have never recovered.)
A Setback: Respiratory Infection Triggers A-Fib
Life was good as far as my heart was concerned. For three months I had no A-Fib or PVC’s. Then suddenly in April 2019, I got an upper respiratory infection which kicked off an episode of A-Fib. Oh no!!!…This familiar awful feeling was something I remembered.
It woke me up, and I immediately took my heart rate. It was 198. No one to take me to the hospital. And with my nerves, I did not want to call an ambulance. That was a BIG MISTAKE. I won’t do that again….
Anyway, a few hours later, my cousin came and took me to the Emergency Room.
They tried Cardioversion TWICE, but it did not work; so, I was put on the antiarrhythmic Tikosyn (dofetilide).
Tikosyn Works, But “Can I Have Another Ablation?”
I had to stay in the hospital for a week to level out and make sure this antiarrhythmic would be okay for me. It got my heart in perfect order, but I don’t want to stay on this forever.
So, my next question for my wonderful Dr. McClennen was “Can I have another ablation”? He answered, “Yes, we will discuss it in the Fall.”
Is Another Ablation on the Horizon?
So, I am waiting eagerly for Fall 2020 when we can discuss another A-Fib ablation. In the mean time, let me share what I’ve learned so far about treating Atrial Fibrillation.
Lessons Learned
Ablation is a Blessing and Low Risk―Better Than Living in Fear
Why do I feel excited about ablation? I truly feel that having an ablation is a blessing. And this is why I am writing this story for you.
I know there are risks and I know people are afraid of ablations, but the risks are nothing compared to living each moment of your life afraid to live.
Find a Great Doctor!
The trick is finding a great doctor. Not just a good doctor, but a great doctor. What makes a great doctor? Well, to ME … it’s someone who listened to me. Dr. Seth McClennen listened. He cared. He even wants me to email him when I have a concern or question. He always answers me. Always.
Kardia Device a Great Help
Using Kardia with tablet; under $100.
I have a Kardia machine – it’s that little EKG tag that you can email to your doctor. I have sent Dr. McClennen my EKG when I’ve had a question. More so now, with this antiarrhythmic drug, I am always tempted to take an EKG and send it to say “How am I doing?” Some days I just need to know my heart is in good order.
Find a Great Pharmacist As Well
It helps greatly to have a wonderful pharmacist too. Someone you can confide in and who will help you. The particular drug I am on interacts with so many things that I have to check everything with the pharmacist. Lisa Cohen Szumita is a wonderful pharmacist who is there to answer all my questions.
So, my advice is to have a great doctor – and a wonderful Pharmacist who has that rare quality these days of “Caring” for their patients.
Your Attitude is Your Greatest Weapon
As far as ablations go…your attitude is your greatest weapon.
If you are told you need an ablation, be blessed. Be thankful and blessed.
It’s what we AFIBBERS have to help us live a normal life. Thanks be to God! When you are going to have your ablation, go into that hospital thanking God and asking Him and His angels to surround you.
Ask all of us here on the A-Fib.com website to hold you in prayer and good thoughts. That is what we are called to do.
Leave fear behind you – don’t bring fear into your procedure. Bring FAITH and JOY and PEACE. I went into that A-Fib ablation with such excitement—to finally live a life where I was not afraid to be in the store alone. A simple thing … but I was unable to do it. After ablation, my life was restored.
I was so very upset that an upper respiratory infection brought me down. But I am on the right track again. So for the time being, I will take this antiarrhythmic. (Please don’t send me any scary emails about what I take.) I’ve heard it all. I did all the reports at work that had any and all of these drugs listed. I know all about it. But for now, it’s what I have to do
When the Fall comes, if my cardiologist says I’m good for another ablation …. Well, thanks be to God !! …. And so it is.
P.S. I’ll update my story when I have something to share. If you want to write me, send an email to Steve and he will forward it.
Cecelia Hender
Abington, Massachusetts
Editor’s Comments
I can’t help but get angry reading Cecelia’s story. After repeated heart rhythm complaints to her doctors, I can’t believe she wasn’t referred to a cardiologist.
She’s not alone with doctors dismissing women’s symptoms.
Other female patients have reported being told: “You’re experiencing a type of panic disorder.” “You’re exaggerating.” “A-Fib is no big deal.” “Take a Valium.” “Just take your meds and get used to being in A-Fib.”
Consequences of Gender Bias: If you are female, be prepared to experience gender bias in the medical field (but less so among Electrophysiologists [EPs]).
Beware of condescending behavior. You don’t have to accept or put up with that kind of attitude. Anticipate gender bias! Don’t let it deter you! (For more see: Women with A-Fib: Mother Nature and Gender Bias—Or—Get Thee to an EP ASAP.)
Don’t Just Live with A-Fib: Educate Yourself! Cecelia had irregular heartbeats for decades before she learned she should consult a specialist, a Cardiologist (an electrophysiologist to be exact).
Thankfully Cecelia finally got her Atrial Fibrillation diagnosed. She then found one of the best electrophysiologists (EP) in her area. She learned about A-Fib. She got the best and most up-to-date advice and treatment. She had lived in fear of her A-Fib but found her cure in spite of her fears.
Catching the Arrhythmias: Cecelia describes very well her frustration when doctors tried and failed to document her A-Fib. All too often when you have occasional (paroxysmal) A-Fib, you’ll be in the doctor’s office and your heart is in normal sinus rhythm (NSR). If you’re not in A-Fib, they can’t document it with an ECG. Frustrating!
(I remember spending all morning in a doctor’s office waiting for an A-Fib attack so that an EKG can document it. But no luck. Then when I went downstairs for lunch, that‘s when I had an A-Fib episode.)
iRhythm Zio patch
Advancements in Heart Monitoring. Today doctors have any number of monitoring and data recording devices to “catch” A-Fib episodes.There are patches such as a Zio Patch which looks like a big Band Aid and which you wear for 1 or 2 weeks.
Medtronic Reveal LINQ
Another is an implantable loop recorder like the Medtronic Reveal LINQ which is inserted under your skin in a very simple, fast procedure. (I’ve had one for the last 1 1/2 years). It lasts for three years and tells doctors (and you) what’s going on in your heart 24/7.
Today your doctors are much more likely to “catch” and document your irregular heartbeats.
Dealing with PVCs: We’re most grateful to Cecelia for describing how Dr. McClennen fixed her PVCs which are a major issue for some people with A-Fib.
Maybe the key to ablating PVCs is no sedation or conscious sedation rather than general anesthesia. (I’ll try to get more info on Dr. McClennen’s methods of ablating PVCs.)
Learn about sharing your A-Fib story.
Return to: Personal A-Fib Stories
If you find any errors on this page, email us. Y Last updated: Friday, October 16, 2020
2020 AF Symposium Challenging Case: 75-Year-Old, A-Fib Increases, Develops Bradycardia, 12-sec Heart Pause
2020 AF Symposium: AF Management
Challenging Case: 75-Year-Old, A-Fib Increases, Develops Bradycardia, 12-sec Heart Pause
by Steve S. Ryan
One of the most interesting sessions at the AF Symposium is the “Challenging Cases in AF Management: Anticoagulation, Arrhythmic Drugs and Catheter Ablation for AF” where leading doctors discuss very frankly their most difficult cases that year.
While several cases were discussed, here I summarize just one case.
Dr Eric Prystowsky
Patient History: 75-Year-Old Female
Case presented by Dr. Eric Prystowsky, St. Vincent Hospital, Indianapolis, IN
Dr. Prystowsky described the case of a 75-year-old female with A-Fib of at least three years duration. Before she came to Dr. Prystowsky, she was on Sotalol 40 mg 2/d and aspirin.
She was doing fine until a few months before when her A-Fib attacks became more frequent and with a more rapid rate. She also developed bradycardia and had a 12-second pause in heart beat.
Pacemaker and Pericardial Effusion: She had a pacemaker installed (but not by Dr. Prystowsky). During the implanting of the pacemaker, she developed a pericardial effusion (bleeding from the heart into the pericardium sac). She was not on anticoagulants.
Two weeks after implanting the pacemaker, she felt lousy with recurring palpitations.
Treatment by Dr. Prystowsky
Flecainide added: Dr. Prystowsky put her on flecainide 100 mg 2/day. She had slightly elevated blood pressure. She was also on aspirin, metoprolol, and Atorvastatin (to lower blood pressure by treating high cholesterol and triglyceride levels).
The patient had repeatedly been offered a catheter ablation, but she declined each time.
Reset Pacemaker: The pacemaker was controlling her atrium 93% of the time. Her Ejection Fraction was 55%-60% (a good range).
Dr. Prystowsky reprogrammed her pacemaker to change her AV interval. He stopped the aspirin, and put her on apixaban (Eliquis) 5 mg 2/d. He ordered a stress echo test to check her heart.
She felt better for 5 days.
Moderate Pericardial Effusion; Medications Adjusted
The patient then developed a moderate (“significant”) pericardial effusion.
Dr. Prystowsky stopped the apixaban (probably the cause of the pericardial effusion). Because she still had some symptomatic episodes of A-Fib (although much better), he then increased the flecainide to 150 mg.
Contributing Role: Referring to the cause of the patient’s pericardial effusion, Dr. Prystowsky faced the fact that “I did it.”
She experienced bad side effects with the increased dosage of flecainide. He put her on 100 mg 3/day to reduce the side effects.
The patient had repeatedly been offered a catheter ablation, but she declined each time.
Minimizing Pacing; Medication Adjusted
The patient’s ventricular pacing produced a wide QRS which Dr. Prystowsky said “worried the hell out of me.” He tried to minimize the pacing she received.
A CT scan revealed that her pacemaker incisions were fine, and that she had no more pericardial effusion. He re-started apixaban. She felt great.
He wound up putting her on amiodarone 200 mg which she tolerated well (previously she didn’t react well to Sotalol).
Dr. Prystowsky’s Lament
He described what he called his “shpilkes” index (Yiddish for anxiousness). When he talks to his fellows, “If you go home and worry about your patient at midnight, you ought to re-think everything.”
One Year Later and Lesson Learned
A year later she came in complaining of palpitations. Her pacemaker revealed that she only had 2 minutes of A-Fib in six months. Dr. Prystowsky told her, “I can’t do better than that.”
Dr. Prystowsky told the attendees that he would never again put a woman of her age on flecainide 150 mg.
He wrote me that it’s been over a year, and the patient is doing great.
If you find any errors on this page, email us. Y Last updated: Saturday, May 2, 2020
Return to 2020 AF Symposium Reports
2020 AF Symposium Abstract: Combination Device to Both Electrically Isolate and Occlude the LAA
2020 AF Symposium Abstract
Combination Device to Both Electrically Isolate and Occlude the Left Atrial Appendage (LAA)
by Steve S. Ryan
Heart showing location of Left Atrial Appendage (LAA)
Researchers in this study described the Left Atrial Appendage (LAA) as the 5th Pulmonary Vein. It plays a similar role as the PVs in generating A-Fib signals, but is the source of many clots that lead to stroke. Currently implanting an LAA occlusion device is a stand-alone procedure.
How the AuriGen Combination Device Works
An abstract by AuriGen Medical described a study with dogs of a very innovative device which both closes off and electrically isolates the Left Atrial Appendage (LAA) in a one-shot procedure.
The AuriGen Ablation, Delivery and Occlusion System consists of an LAA implant which closes off the LAA with a PET (polyethylene terephthalate) membrane, and an RF Ablation System to circumferential ablate the ostium of the LAA with an RF electrical array. Once implanted, the catheter electrodes are removed through a self-closing access conduit, leaving the occluder in play.
On day 7, the dogs underwent surgery to open the chest (thoracotomy) and observed that the LAA occluder device hadn’t moved. This also indicated that the ablation may have resulted in permanent electrical isolation of the LAA.
Editor’s Comments:
One can’t help but admire how A-Fib researchers and device manufacturers are developing innovative devices to improve A-Fib patient treatment.
From a patient’s perspective, it’s important that doctors and researchers recognize the importance of the LAA as a source of A-Fib signals (potentials). It seems to me that all too many EPs either ignore or put a low priority on mapping and ablating the LAA. Whereas other EPs such as Dr. Andrea Natale, after ablating the PVs, then focus on the LAA before examining any other areas of the heart. They recognize that the LAA often plays a major role in triggering A-Fib signals
Brilliant Idea to Combine LAA Closure with Electrical Isolation: The AuriGen combination occluder/LAA ablation device probably won’t be used in simple, recent onset, paroxysmal A-Fib cases because just isolating the PVs is usually enough to return patients to normal sinus rhythm (NSR).
Instead, the AuriGen combination device would be very useful in more complex cases where patients have had A-Fib for longer periods or who are more at risk of developing LAA clots. The AuriGen device can both close off and isolate the LAA in one procedure.
Practical Use by EPs: It’s is a long way from being available for A-Fib patients.
When and if the AuriGen device becomes available for patients, in practice EPs will probably first do a PVI to isolate the PVs, then proceed to use the AuriGen combination device to close off and isolate the LAA in the same procedure.
This will increase the effectiveness of ablation particularly in cases of persistent A-Fib. And, more importantly for patients, both procedures can be done at the same time.
If you find any errors on this page, email us. Y Last updated: Wednesday, August 26, 2020
Return to 2020 AF Symposium Reports
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