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2022 AF Symposium: Challenging Cases: The Patient has the Last Say
My new report from the 2022 AF Symposium is about one of the “Challenging Cases” presentations. This is when some of the world’s leading Electrophysiologists (EPs) describe the most difficult Atrial Fibrillation cases they had to cope with through the year. Frankness prevails.
Dr. Erik Prystowsky of St. Vincent’s Hospital, Indianapolis, IN, described a 65-year-old man with Atrial Fibrillation, shortness of breath, and a critically low Ejection Fraction (10%). And a severely enlarged left atrium (5.4 cm).
The patient was offered a catheter ablation procedure but would not accept even after the most persuasive attempts to convince him—it would likely fix his A-Fib, improve his Ejection Fraction, and reduce the size of his left atrium. To learn how this patient’s health evolved over the next 5-6 years, read my full report: Challenging Cases—The Patient has the Last Say.
2022 AF Symposium Challenging Cases in AF Management: The Patient has the Last Say
2022 AF Symposium
Challenging Cases: The Patient has the Last Say
In the “Challenging Cases” presentations, some of the world’s leading Electrophysiologists (EPs) describe the most difficult Atrial Fibrillation cases they had to cope with through the year. I find it one of the best learning experiences of the AF Symposium. (But for reasons I frankly don’t understand, it’s always the least attended. This year was no exception.)
Frankness prevails. The presenters don’t hesitate to discuss challenging situations, possible mistakes, or embarrassing moments. I’m always surprised to see such a lack of ego among this group of the best Electrophysiologists in the world.
The panelists this year were:
▪ Dr. David Keane of St. Vincent’s Hospital, Dublin, Ireland, Moderator
▪ Dr. John Camm of St. George’s Medical Center, London, UK
▪ Dr. John Day of the Intermountain Heart Institute, Murray, UT
▪ Dr. Young-Hoon Kim of Korea University Medical Center, Seoul, South Korea
▪ Dr. Gregory Michaud of Vanderbilt University Medical Center, Memphis, TN
▪ Dr. Eric Prystowsky of St. Vincent’s Hospital, Indianapolis, IN
Dr. Erik Prystowsky: The Patient Has the Final Say
One of the most challenging type of case EPs have to deal with was recalled by Dr. Erik Prystowsky of St. Vincent’s Hospital, Indianapolis, IN.
A 65-year-old man had Atrial Fibrillation and shortness of breath. His Ejection Fraction was an astonishingly 10% (critically low). He was on a beta-blocker and was cardioverted successfully.
Dr Eric Prystowsky
He was sent to Dr. Eric Prystowsky and became his patient. The patient was put on amiodarone and for several months was asymptomatic. His Ejection Fraction actually improved to 50%. He was found to have a severely enlarged left atrium (5.4 cm).
Questions Posed To the Panel: Dr. Prystowsky posed the following questions concerning this patient and asked panelists’ opinion about the best strategy for treating him:
1. Catheter ablation?
2. Switch from amiodarone to dofetilide (Multaq)? (Dr. Prystowsky said he does this frequently, probably because of the long-term toxicity of amiodarone.)
3. Continue on amiodarone?
The general consensus seemed to be to offer the patient a catheter ablation. (This would likely fix his A-Fib, improve his Ejection Fraction, and reduce the size of his left atrium.)
Offered a Catheter Ablation
The patient was offered a catheter ablation procedure. But the patient would not accept an ablation even after the most persuasive attempts to convince him otherwise. (Dr. Prystowsky practices in Indiana, where perhaps people are more conservative in medical choices.)
Dr. Prystowsky continued the patient on amiodarone but had him return to the office every six months.
Two Years Later…
Two years pass. The patient is now symptomatic and had sinus bradycardia (slow heart rate). He still refused a catheter ablation but did get a dual chamber pacemaker for his slow heart rate.
…Three Years After That
Three more years pass and his pacemaker now showed his Atrial Fibrillation had progressed to Persistent A-Fib. His Ejection Fraction was in the 25%-30% range (low). His heart rate was 150 bpm (high). He was again cardioverted back to sinus, but this only lasted a week. So he was once again cardioverted and put on lisinopril (an ACE inhibitor used primarily for high blood pressure and heart failure).
Another Year Later…
The cardioversion lasted about a year with a slightly improved Ejection Fraction, and he was asymptomatic. He complained of lightheadedness. He seemed to improve with an adjustment to his pacemaker taking him off of bi-ventricular pacing. After all this, he still refused to have a catheter ablation.
Bottom Line: The Patient has the Final Say
Dr. Prystowsky talked to the panel and attendees about the dangers of Tachymyopathy (impairment of left ventricular function) which many people never recover from. He stressed how important it was to try to keep patients in normal sinus rhythm, even in difficult cases like this.
In spite of all his problems, this patient feels relatively well and is still adamant about not having a catheter ablation.
As Dr. Prystowsky stated, “The patient has the final say!”
Editor’s Comments
Dr. Prystowsky is one of smartest, most persuasive EPs around. But as frustrating as it must have been for him, he had to let this patient make the final decision.
This is a life-lesson all too many EPs have to come to grips with during their careers. No matter how much education and experience an EP has, even though they know how to fix problems like this patient has, there is only so much an EP can do.
After all, the patient does have the final say.
If you find any errors on this page, email us. Y Last updated: Tuesday, February 22, 2022
Return to 2022 AF Symposium Reports
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, Update December 2022
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
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
Addendum: December 2022
Cecelia Hender writes in an update that she had a Watchman implanted February 2022 at Brigham and Woman’s Hospital in Boston, MA.
“Now I am off of the Tikosyn (dofetilide) and also off of Eliquis. No more blood thinners. I am feeling well. The implant placement was a breeze, and I came home the same day. I had a wonderful team there.
I think God for all of this. Just wanted to bring you up to date.”
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: Thursday, May 4, 2023
Tony Rejects Drug Therapy: Says to Ask Questions, None are Stupid
Tony Hall, Evansville, IN, was 54 years old when he develped Atrial Fibrillation in January 2014. After confirming his diagnosis at the hospital, he wrote:
“I sit in the passenger seat feeling like a pet heading to a kennel. Suddenly things are different. I no longer have that “healthy as a horse” attitude.”
He started drug therapy. Then came a cardioconversion, but that didn’t keep him in normal sinus rhythm for long. He was in and out of A-Fib, and by August was in persistent A-Fib.
Learning His Treatment Options
Tony didn’t passively accept everything he was hearing from doctors and others.
He and his wife, Jill, read as much as they could and critically waded through the information they found. (I’m continually amazed at how much mis-information there is about A-Fib on the internet and in the media.)
5-months post-ablation, Tony and Jill after 10K race.
After doing his research, educating himself about treatment options and learning what his health insurance would cover, he chose to have a catheter ablation at the Mayo Clinic in December 2014.
During his three month blanking period, he had some sporadic fluttering and early on a couple of brief A-Fib episodes.
Off all medication and A-Fib-free, in March 2015 he completed a 10K race beating his time from the previous year by a fraction.
Becoming his Own Best Patient Advocate
Tony and Jill are great examples for all A-Fibbers of how to become your own best patient advocate. He rejected endless trials of various drug therapies. Instead he opted for a catheter ablation just shy of a year after his initial A-Fib diagnosis.
In his A-Fib story, he shares this advice to others considering a catheter ablation:
“Make sure, if you desire to have an ablation, that your reasoning is sound and that you have a good argument as to why drug therapy is not the way you want to go.
Having an ablation as front line treatment for A-Fib is not embraced by every EP, and many are reluctant to ablate until drug therapy has failed.
Be persistent and move on [to another doctor] if you are met with resistance.”
For Tony Hall’s personal experience story, see: Very Active 54-Year Old Became His Own Patient Advocate; Chose Ablation as First Line Treatment.
My Top 5 Picks: Advanced-Level Atrial Fibrillation Videos
The A-Fib.com Video Library is for those readers who learn visually through motion graphics, audio, personal interviews and animations.
These are my top 5 picks of advanced-level videos. For the reader wanting a more in-depth look inside the EP lab and surgery, and at advanced topics relating to atrial fibrillation.
1. Step-by-Step: Cardioversion Demonstration by ER Staff
The goal of electrocardioversion is to convert the patient’s rhythm from atrial fibrillation back to normal sinus rhythm.
In this video, emergency room medical personnel demonstrate the equipment, pads placement and procedures of cardioversion. The video describes where pads are properly placed on the patient; how medication is chosen to produce deep sedation; and how after the shock is delivered, a successful cardioversion is confirmed by viewing a normal sinus rhythm on the cardiac monitor.
Close-up of the equipment is shown along with the monitor display. (2:10 min.) Uploaded by Alfred Sacchetti. Go to video->
2. Your Heart’s Ejection Fraction (EF): What You Need to Know
In the following three short videos, cardiac electrophysiologist, Dr. Robert Fishel, discusses the ejection fraction (EF) a measurement of the pumping efficiency of the heart and why cardiac patients should know their EF percentage.
Video 1: What is the ejection fraction? (:54 sec.) Cardiac Ejection Fraction (EF) is the percentage of blood pumped from the heart’s main chamber during each heartbeat, and why it’s important.
Video 2: Who should know their ejection fraction (EF)? (:34 sec.) Measurement of your Ejection Fraction (EF) is an important test and why A-Fib patients need to know their EF number.
Video 3: How is an ejection fraction measured? (:56 sec.) Ejection Fraction (EF) can be measured by various techniques including an echocardiogram.
Videos hosted by Share.com. Go to videos->
3. Mini-Maze Surgery In-Depth: Inside the O.R. with Dr. William Harris, Cardiovascular Surgeon
Cardiovascular Surgeon, Dr. William Harris describes the Mini-Maze surgery for Atrial Fibrillation. In the Mini-Maze the heart is accessed through small incisions in the chest.
Of interest to A-Fib patients who can not tolerate blood thinners and thus do not qualify for a Catheter Ablation. The Mini-maze surgery is a highly effective with an 85%–95% success rate. (4:49 min.) Dr. Harris is with Baptist Medical Center, Jackson, Miss. Go to video->
4. Pulmonary Vein Isolation In-Depth: Step-by-Step Inside the EP Lab Using Mapping & CT Scan
Cardiac Electrophysiologist Dr. James Ong begins with a brief tour of the EP lab and control room; Dr. Ong explains how pulmonary vein isolation is done with radiofrequency ablation to cure atrial fibrillation.
Included are: Mapping technology; the Virtual Geometrical shell of the heart displayed next to the CT scan; Placement of the catheter, real time tracking; the Complex Fractionated Electrogram (CFE) Map used to identify and eliminate the extra drivers (aside from the pulmonary veins). (6:01 min.) From a series of videos by Dr. Ong, Heart Rhythm Specialists of Southern California. Go to video->
5. Long-Standing Persistent A-Fib: A Live Case of Catheter Ablation Through 3D Mapping & ECG Images
Presented entirely through 3D mapping and ECG images, a live demo of ablation for long-standing, persistent A-Fib is followed from start to finish. Titles identify each step (no narration).
3D mapping and ECG images show the technique of transseptal access, 3D mapping, PV isolation, and ablating additional drivers of A-Fib. (8:03 min.) With Dr. James Ong, Heart Rhythm Specialist of Southern California. Go to video->
Note: These videos may require basic understanding of cardiac anatomy and A-Fib physiology.
Visit our A-Fib.com Video Library
for more Advanced-Level Videos
STEVE RYAN VIDEOS:
We’ve edited Steve’s most interesting radio and TV interviews to create several short (3-5 min.) videos. Check out Videos Featuring Steve S. Ryan, PhD, publisher of A-Fib.com.
VIDEO: Step-by-Step: Cardioversion Demonstration of by ER Staff
The goal of electrocardioversion is to convert the patient’s rhythm from atrial fibrillation back to normal sinus rhythm.
In this video, emergency room medical personnel demonstrate the equipment, pads placement and procedures of cardioversion. The video describes where pads are properly placed on the patient; how medication is chosen to produce deep sedation; and how after the shock is delivered, a successful cardioversion is confirmed by viewing a normal sinus rhythm on the cardiac monitor. Close-up of the equipment is shown along with the monitor display.
Uploaded on Jan 5, 2012 (2:10 min.) by Alfred Sacchetti.
YouTube video playback controls: When watching this video, you have several playback options. The following controls are located in the lower right portion of the frame: Turn on closed captions, Settings (speed/quality), Watch on YouTube website, and Enlarge video to full frame. Click an icon to select.
If you find any errors on this page, email us. Y Last updated: Monday, January 15, 2018
New Video Posted: Dr. Bruce Janiak’s Cardioversion from Atrial Fibrillation
Dr. Bruce Janiak, a 74 year old full-time emergency medicine physician, videotaped his cardioversion from atrial fibrillation in order to demonstrate both the ease and safety of this procedure.
In a very low-key, conversational manner, Dr. Janiak and the hospital staff conduct his cardioversion. Dr Janiak discusses his previous experiences with chemical conversions. He shares before and at the conclusion of the procedure. 15:08 min. Published by Augusta University, Medical College of Georgia. Go to video->
Silent Persistent A-Fib: A Proactive Patient’s 3-Year Journey to Burden Relief
By Frances E. Koepnick, Athens, GA, June, 2017
Frances, now A-Fib free after 3 yrs.
“I was diagnosed with atrial fibrillation (A-Fib) in April 2014, at age 69, while undergoing a pre-operative physical examination prior to hip replacement surgery. This was a surprising development since my A-Fib was completely “silent” with no symptoms.
My A-Fib was diagnosed as being ‘persistent’ rather than ‘paroxysmal’. These two forms of A-Fib are quite different. However, both types of A-Fib are usually treated initially with prescription drugs. I was given the beta blocker atenolol to reduce my heart rate and the anti-coagulant Eliquis to prevent the formation of blood clots.
Family History of Atrial Fibrillation
Unlike many other stories on A-Fib.com, I was familiar with Atrial Fibrillation. I am the third person in my family with A-Fib after my mother and older sister. However, they both had paroxysmal A-Fib while I was diagnosed with persistent A-Fib.
On-going studies indicate that there may be a genetic link to A-Fib. Consequently, if someone in your immediate family has been diagnosed with A-Fib, then your risk of developing it in the future may be increased.
Six Cardioversions: Not a Long-Term Solution
Eventually, I underwent a total of six cardioversions in an attempt to return my heart to normal sinus rhythm. Three of these procedures were electrical cardioversions and three were by means of intravenous drugs. I soon learned that cardioversion is rarely effective for maintaining normal sinus rhythm over a significant period of time.
Consequently, I did not consider it to be a long-term solution for my A-Fib.
The First Two Cardiologists Advised: ‘Just Take Your Medications and Live with A-Fib’―No! No! No!
I eventually consulted a total of five cardiologists―three in the state of Georgia, one in Manhattan and one in Bordeaux, France. I have a background in anatomy/physiology as well as microbiology, so I asked a lot of questions and managed to irritate several physicians.
The advice of the first two cardiologists was to “just take my medications and live with A-Fib”.
If your cardiologist recommends this treatment regimen, I urge you to get a second, third or even fourth opinion.
More Interviews: Three Electrophysiologists & Lots of Questions
After my first electrical cardioversion in March 2015, my heart remained in normal sinus rhythm for only 12 hours. At that time, I had been in persistent A-Fib for one year, and was re-classified as long-term persistent A-Fib. That motivated me to pursue a catheter ablation.
I ultimately discussed an ablation procedure with three different Electrophysiologists and consequently learned to ask lots of questions such as:
- What is the percentage rate of successful ablations performed by this cardiologist/electrophysiologist?
- What is the risk of serious complications?
- How many ablations does this cardiologist/electrophysiologist perform at his/her facility annually? (My opinion is: “the more, the better”.)
- What type of instrumentation is used for electrical cardiac imaging? (My opinion is the CardioInsight or ECGI/ECVUE imaging system; FDA-approved for the USA in February 2017.)
I finally located a cardiologist/electrophysiologist (EP) at a regional medical center who performed ablations for long-term persistent A-Fib.
Look for the Best EP―and Ablate Sooner Rather Than Later
At this point I had been in A-fib for 17 months. The first 7 months of this time frame was necessary due to my need for two total hip replacements which were performed 5 months apart. However, the additional 12 month delay was due to my procrastination in seeking a third opinion from another EP. That was definitely a mistake. This additional delay reduced my success rate for a successful first ablation to approximately 65% and it also increased the chance that I might need a second ablation in the future. (I anticipated I might need a 2nd ablation because of this.)
Ablation for Persistent A-Fib is More Difficult
There are many competent electrophysiologists in the USA who have been successful with ablations for paroxysmal A-Fib. However, ablations for persistent and long-term persistent A-Fib are more difficult, require a higher level of expertise, and are performed less frequently in the USA.
Bordeaux, France: Consequently, in September, 2015 I decided to have my ablation for long-term persistent A-Fib performed in Bordeaux, France. I chose this location because it’s internationally known for its cardiologists/Electrophysiologists as well as for its use of the computerized CardioInsight or ECGI imaging system. [They cured Steve Ryan’s A-Fib back in 1998.]
This arrhythmia group is headed by Dr. Michel Haissaguerre and Dr. Pierre Jais, and they perform ablations for paroxysmal, persistent and long-term persistent A-Fib. Of course, French citizens are first priority for admission, but out-of-country patients can be wait-listed.
Fran’s EP: Pierre Jais MD
Not Covered by My Insurance: I do need to mention that the decision to travel to Bordeaux, France, was financially significant. My medical treatment was not covered by insurance.
The Hopital Haut Leveque-Cardiologique in Bordeaux is not an impressive building. It was most likely built in the 1970s, the patient rooms are not air conditioned, and the parking lot is gravel rather than pavement. However, the French government obviously invests their health care funds in medical research, excellent physicians, quality hospital staffing, and state-of-the-art medical equipment.
The physicians and most of the hospital staff speak English, so there really isn’t a significant language barrier problem. I did purchase an English/French app with medical terminology for my smartphone, and it was helpful on occasion. [In Bordeaux they have broken ground on the new LIRYC Institute which is intended to become one of the premier research institutions in Europe.]
Difficult Six-Hour Ablation at Bordeaux, then Electrical Cardioversions
My first ablation by Dr. Pierre Jais was a difficult procedure requiring six hours for completion. [Not only were her Pulmonary Vein openings isolated, but in addition, non-PV triggers were identified, mapped, and isolated using the CardioInsight ECGI mapping system.]
Fran wearing the mapping vest.
During the three-week time period following this ablation, two electrical Cardioversions were also required. This was later explained to me by Dr. Jais as the interior of the atria needed to heal sufficiently so that scar tissue would successfully block abnormal electrical signals.
After this ablation, I continued to take the anticoagulant Eliquis and was also put on the anti-arrhythmic drug amiodarone for six months.
Normal Sinus Rhythm for 11 Months, then Atypical Flutter
I knew at the time of my first ablation that I most likely would require a second ablation due to my predicted one-year success rate of 65%.
My heart actually stayed in normal sinus rhythm (NSR) for a total of 11 months. Then I experienced three episodes of atypical atrial flutter over a two-week period, and each of these episodes resulted in an admission to the emergency room. After three intravenous drug Cardioversions, I was placed back on amiodarone to maintain a normal sinus rhythm.
Suspected Sleep Apnea
After my third ER admission, I suspected that these episodes might have been triggered by obstructive sleep apnea (OSA). I was waking up during the night with an extremely uncomfortable dry mouth even though my head was elevated while sleeping.
I consulted my dentist, and he referred me to a cardiologist/sleep specialist who ordered a sleep study. This study confirmed that my OAS was “severe” during periods of rapid eye movement sleep (REM).
Sleep Apnea and A-Fib: I would like to emphasize that OSA is a significant “trigger” for A-Fib. A recent study found that 43% of individuals with A-Fib also had a diagnosis of OSA.
This means that all individuals diagnosed with A-Fib need to be screened with a sleep study. If OSA is confirmed, it needs to be addressed immediately so that any future treatment for A-Fib is not compromised.
OSA can be controlled by continuous positive airway pressure (CPAP) machines whereby you wear a face mask at night when sleeping. I decided instead to have a custom oral appliance (FDA-approved TAP3) made by a sleep dentist. This oral appliance prevents my lower jaw from moving out of position when sleeping and thereby ensures that my airway remains open.
Second Ablation by Dr. Vivek Reddy Using CardioInsight ECGI
Dr Vivek Reddy, Mt Sinai Hospital
My second ablation was performed by Dr. Vivek Reddy at Mount Sinai Hospital in Manhattan, New York in March 2017.
I had been referred to Dr. Reddy by my doctors in Bordeaux. It was fortuitous that Mount Sinai Hospital had just obtained the FDA-approved CardioInsight (ECGI) imaging system which was previously only available in Europe.
The physicians, staff and facilities at Mount Sinai Hospital are absolutely excellent. The arrhythmia group there is headed by Dr. Reddy, and I found him to be professional, personable and comfortable answering my questions.
My second ablation was another difficult, six-hour procedure, but ultimately successful. [If interested in Dr. Reddy’s O.R. Report on Frances’ ablation, see my comments below.]
I recommend that you go online to the Mount Sinai Hospital website and then watch short informative videos on A-Fib which are presented by Dr. Reddy himself. See What Do I Need to Know About Atrial Fibrillation? (21:29).
Success & Lessons Learned
My 3-year journey with A-Fib has included numerous Cardioversions, two ablations and a belated diagnosis of underlying obstructive sleep apnea (OSA).
It’s now about three months since my second ablation, and I am doing well. I no longer am taking the anti-arrhythmic drug amiodarone, but continue on the anticoagulant Eliquis.
My recommendations: Look locally, regionally, nationally and perhaps internationally in order to identify the best option for a successful ablation. (Yes, consider traveling to find the best EP for you.)
It is also important to seek an ablation sooner rather than later as a delay may decrease your chance of a successful procedure.
Seek up-to-date information : I highly recommend the website, www.A-Fib.com for up-to-date information on A-Fib. This website is run by Steve Ryan, Ph.D. and―although he is not a medical doctor― he is an A-Fib expert who explains A-Fib in terms readily understood by the average person.
Steve also attends the AF International Symposium held annually in the USA, and his synopses of conference presentations contain the latest in A-Fib research. Steve was and continues to be my “A-Fib coach”.
Smartphone app: Finally, I recommend the AliveCor Kardia device ($99) and app for smartphones. This app determines your heart rate in beats per minute (BPM) and also records a 30-second electrocardiogram (ECG) using two electrodes attached to the back of your phone. Kardia’s software interprets your ECG as “normal” or as “possible A-Fib”, and you can email a copy of an ECG directly to your cardiologist.” [Also see our 2016 Update: AliveCor Kardia Review by Travis Van Slooten]
Added 1/12/21: Dr. Reddy had to ablate at Frances’ Left Atrial Appendage (LAA) which did terminate her A-Fib. But electrically isolating the LAA can result in the LAA no longer contracting and pumping out properly. This could result in clots forming in the LAA and the development of an A-Fib stroke. Frances had to be put on anticoagulants. Dr. Reddy said she would need a Watchman device installed within 90 days to close off the LAA due to this increased risk of stroke.
But Frances discovered she is allergic to nickel, a primary component of the Watchman device. Many people have this nickel allergy, especially women who wear jewelry. Frances obviously didn’t want to suffer an A-Fib stroke. She also didn’t want to have to take anticoagulants for the rest of her life. She found she didn’t have a lot of options. After extensive research, she decided on the second generation AtriClip (nickel free) which can be installed by a surgical heart operation. See https://a-fib.com/considering-a-laa-occlusion-closure-watch-out-for-nickel-allergy/ One major advantage of the AtriClip is that it essentially eliminates the LAA which can be a significant source of A-Fib signals. But the AtriClip didn’t work anatomically for Frances, because the blind end of her LAA had attached itself to the surface of her heart.
I welcome your email,
Frances Koepnick
fek67@hotmail.com
Editor’s Comments:
We’re most grateful to Frances for her story. She’s a great example of a proactive patient. When told to ‘just take her meds and live with A-Fib’, she said NO! Even though she was relatively symptom-free, she knew how destructive A-Fib can be over time.
Don’t Just Live in A-Fib: Leaving patients in A-Fib overworks the heart and leads to remodeling and fibrosis which increase the risk of stroke, and also doubles the risk of developing dementia. For more read: ‘Drug Therapies’: Rate Control and A-Fib Doubles Risk of Dementia. If you hear someone tell you to just live with A-Fib, get a second opinion (or third, or fourth!).
Educate Yourself About A-Fib―Be Proactive: Frances knew she would be a more difficult case to fix. She researched who were the best EPs for her case. She asked all the right questions of the EPs she interviewed. (See Selecting a New Doctor? 10 Questions You’ve Got to Ask.) She even went to Bordeaux, France, on her own dime.
Find the Best EP You Can: All Electrophysiologists are not equal. Like Frances, don’t just settle for the nearest EP. Consider traveling to the best, most experienced EP you can afford, particularly if you have progressed to persistent A-Fib which is harder to fix. (See Finding the Right Doctor for You and Your A-Fib.)
Silent A-Fib: If You’re 65 or Older, Get Yourself Tested: Frances is lucky. She could have easily been one of the 25% of stroke victims who only discover their silent A-Fib after having a stroke. Everyone 65-years-old or older, should be tested for silent A-Fib.
Sleep Apnea: Most EPs today will insist you get tested for sleep apnea before performing a catheter ablation. Why? Patients with untreated sleep apnea have a greater risk of their A-Fib reoccurring even after a successful ablation. Also, for a lucky few, just getting rid of sleep apnea restores them to normal sinus rhythm (NSR). To learn more, see Sleep Apnea: When Snoring Can Be Lethal
CardioInsight ECGI/ECVUE System: The CardioInsight ECGI/ECVUE mapping system is probably the most significant, game changing improvement in mapping A-Fib, particularly for people with persistent A-Fib. To learn more, see Bordeaux New ECGI Ablation Protocol—Re-Mapping During Ablation.
Frances’ O.R. Report: Using the CardioInsight system, Dr. Reddy found 5 A-Fib drivers in Frances’ atria. (In typical persistent cases, 4 driver regions are usually identified. 7 drivers is the maximum found in more difficult cases.) (For you technical types, the 5 A-Fib drivers were found: at the base of the Left Atrial Appendage (LAA), the Ostium of the Coronary Sinus (CS), the posterior Left Atrium (LA), the Right Atrial Appendage (RAA) and the lateral Right Atrium (RA).)
When Dr. Reddy ablated at the base of the LAA, Frances’ A-Fib terminated. (That’s the ideal result when A-Fib terminates during the ablation.) But then Dr. Reddy checked to see if there were any other regions in her heart producing A-Fib/Flutter signals. By pacing her heart, he was able to induce Atrial Flutter (CL 380msec). Using activation mapping, he found the re-entry atrial flutter circuit was coming from the anterior inferior RA. Ablating this area terminated her Flutter.
For more about O.R. reports, see my free report: How to Read Your Operating Room Report.
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If you find any errors on this page, email us. Y Last updated: Saturday, May 20, 2023
Now A-Fib Free: A Personal A-Fib Story 23 Years in the Making
It’s been a 23-year ordeal for Charn Deol who’s from Richmond, British Columbia, Canada. He was 43 in August of 1993 when he was aware of a few skipped heartbeats. He had just returned to Canada after working for years in Southeast Asia. A week later, the irregular heart beating got worse in duration.
Charn Deol, BC, Canada
At the same time, Charn’s story is complicated by two other medical problems. First, simultaneous with the start of his A-Fib, a dull aching pain started in the left chest region the size of a 50-cent piece. Second, he was discovered to have very high levels of mercury in his blood.
Mercury Cleared, Atrial Fibrillation Stops!
By 2000, through chelation therapy treatments, the mercury was finally out of his system. And surprise! His atrial fibrillation stopped too. (It is known mercury can concentrate in nerve tissue.) While it’s only a correlative relationship―mercury out of system―his atrial fibrillation did stop.
For 10 years He had No Atrial Fibrillation
In 2010, while starting a hike, the atrial fibrillation began again. The A-Fib would last 6-8 hours and occur an average of 2 times per week. He was immediately tested for heavy metals again…continue reading Charn’s A-Fib story…
