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Decisions About Treatment Options: Which is Best for Me?

Decisions About Treatment Options - Atrial Fibrillaton

Decisions About A-Fib Treatments

Atrial Fibrillation is not a “one-size fits all” type of disease.

After your initial diagnosis and stroke risk assessment, you need to develop a personalized treatment plan with both short-term and long-term treatments. Your treatment choices will depend on your type of A-Fib and your treatment goals.

Here we offer you some treatment guidelines for symptoms as described by patients. Select and read one (or more) that best describes your A-Fib. Then discuss these treatment options with your doctors.

Remember: Your treatment plan should be a ‘team effort’, a decision you and your doctors will make together.
  1. My A-Fib just started.”
  2. My A-Fib is occasional (Paroxysmal) with no or mild symptoms (sometimes referred to as “silent’ A-Fib).”
  3. I have infrequent, short episodes of symptomatic A-Fib.”
  4. I have Paroxysmal (occasional) A-Fib but am in good health overall.”
  5. I have Paroxysmal (occasional) A-Fib but also have serious heart and/or other health problems.”
  6. My A-Fib is Persistent or Chronic (all-the-time).”
  7. I have Persistent or Chronic (all-the-time) A-Fib but no symptoms (‘silent’) A-Fib.”
  8. I have A-Fib but am allergic to Coumadin, Heparin, Lovenox and most blood thinners. I’m also very overweight. And I’ve already had one stroke.”
  9. I’ve had two failed left atrium ablations and have tried many different medications.”

 1.   “My A-Fib just started.” 

See our library of videos about Atrial FibrillationVIDEO: Electrical Cardioversion of Dr. Bruce Janiak; Observe the ease and safety an of actual procedure recorded by his ER staff. Go to video->
You might be helped by a Electrical Cardioversion and/or Chemical Cardioversion. Doctors can perhaps shock your heart back to beating normally. Antiarrhythmic meds may also be used for several months to train your heart to stay in normal sinus rhythm. Ideally after cardioversion, your heart won’t go back into A-Fib. But don’t delay. This treatment seems to work best in cases of recent onset A-Fib.

The main problem with Electrical Cardioversions is for many the results only last a week to a few months. Some patients have had multiple cardioversions.

2.   “I have occasional (Paroxysmal) A-Fib with no or mild symptoms (sometimes referred to as “silent‘ A-Fib).”

Doctors may have discovered you had A-Fib during a routine examination, but you weren’t aware of anything wrong and feel generally OK.

Since you’ve probably had A-Fib for a while, an Electrical Cardioversion may not have as good a chance of getting you back into normal sinus rhythm. But it might be worth trying.

Another option might be to just live with the A-Fib, since it doesn’t seem to affect you very much. You still need to talk with your doctor about whether or not you should be on blood thinners, since with “silent” A-Fib you are at risk of an A-Fib stroke. Your doctor may also prescribe Rate Control medications to make sure your heart doesn’t beat too fast.

However, this option of just living with A-Fib may eventually cause you problems. A-Fib is a progressive disease that tends to get worse. Your episodes become longer and more frequent. You are at greater risk of stroke and heart failure. You may feel more pounding or fluttering in your chest. Because blood isn’t being pumped properly to your body and brain, you may feel more tired and listless. You may experience more shortness of breath, weakness, chest pain, fatigue, dizziness or fainting. You may not be able to think properly.

Over time A-Fib tends to stretch and weaken the heart often leading to other heart problems and heart failure. An enlarged atrium (approximately over 55 mm) may limit your options. Some centers won’t accept patients for a PVA(I) procedure if they have an enlarged heart, because the heart walls have been stretched thin and are easily perforated and burnt through by an RF ablation catheter.

Also, A-Fib over time may lead to decreased mental abilities and even dementia, because blood isn’t being pumped properly to the brain and other organs.

If you choose the option of just living with your A-Fib, it is important to monitor you closely; for example, your atria should be measured periodically to see if they are being stretched and enlarged, and your cognitive abilities should be tracked over time. But you may be able to live for years with occasional “silent” A-Fib episodes which don’t progress to anything worse.

The use of antiarrhythmic medications with their risk of bad side effects may not be justified when your A-Fib is “silent” and infrequent. The same holds for a Pulmonary Vein Ablation (Isolation) procedure. (Many doctors won’t perform a PVA(I) on someone relatively A-Fib symptom free.)

3.   “I have infrequent, short episodes of symptomatic A-Fib.”

An Electrical Cardioversion might be worth trying, though it generally has the best chance of success with early onset A-Fib.

The option of just learning to live with your A-Fib may not be acceptable to you, depending on how bad your A-Fib symptoms are. Not only do you have to deal with the A-Fib symptoms, but also with the psychological trauma and fear of knowing an A-Fib attack is always possible.

Since your A-Fib episodes are relatively infrequent, antiarrhythmic meds may keep your heart in normal sinus rhythm. But watch out for bad side effects. There is a fine line between giving your body time to adjust to the antiarrhythmic med, and recognizing that the medication is causing you unacceptable side effects.

Some people have had success with the antiarrhythmic drugs flecainide (brand name Tambocor) or the newer meds dofetilide (Tikosyn) and Rhythmol SR.

Because your symptoms are infrequent, you may have a simpler, more easily fixed type of A-Fib; i.e. your A-Fib may come from only one or two spots in the heart which a Pulmonary Vein Ablation (Isolation) has a good chance of curing. However, many doctors and medical centers are hesitant to perform a PVA(I) on someone with relatively infrequent A-Fib episodes. You may have to be assertive. But current guidelines give you the right of choosing to have a PVI rather than having to spend time trying various antiarrhythmic drugs.

You may also want to try the Pill-in-the-Pocket drug therapy where you carry an antiarrhythmic drug with you, but only use it when you have an A-Fib attack.

4.   “I have Paroxysmal (occasional) A-Fib but am in good health overall.”

An Electrical Cardioversion may be effective for you, though it generally has the best chance of success with early onset A-Fib.

Antiarrhythmic meds may help in the short term, but they tend to lose their effectiveness over time. In general, don’t expect an antiarrhythmic med to be a permanent cure for your A-Fib.

You have perhaps the best odds of being cured by a Pulmonary Vein Ablation (Isolation) procedure. Doctors may use both Electrical Cardioversion and Chemical Cardioversion during and after a PVA(I) to help your heart stay in normal sinus rhythm.

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5.   “I have Paroxysmal (occasional) A-Fib but also have serious heart and/or other health problems.”

An Electrical Cardioversion may not be an option for you, depending on your other heart and/or health problems.

The antiarrhythmic Class III drugs Sotatol, Dofetilide, and Azimilide appear to be safer to use if you have structural heart disease. Amiodarone is also a Class III drug, but it often has more serious bad side effects even though it is probably the most effective antiarrhythmic med. (See Drug Treatments for more info.)

A PVA(I) can  be very effective; however, you need to prioritize and take care of your most serious heart and health problems first. A successful PVA(I) may improve your overall heart functions such as ejection fraction.

If your heart problems require surgery, you may want to consider going to a surgeon who can perform a Maze operation at the same time.

6.   “I have Persistent or Chronic (all-the-time) A-Fib.”

People with Persistent or Chronic A-Fib often have more than one or two spots in the heart producing A-Fib signals. These A-Fib signal sources often have gotten stronger over time and are less likely to be affected by Electrical Cardioversion. Antiarrhythmic meds may also be less effective.

Until recently your chances of being cured of Chronic A-Fib by a PVA(I) were less than if you had Paroxysmal (occasional) A-Fib. Doctors have to work harder to find and ablate the many A-Fib signal sources often found in Chronic A-Fib patients. Some centers have rules such as not accepting patients who have had Chronic A-Fib for over a year. However, a study by the French Bordeaux group reported a 95% success rate in curing Chronic A-Fib after two ablation procedures.

If you have Chronic A-Fib, you have to be prepared to have at least two ablation procedures.

People with Chronic long-standing A-Fib were generally thought not to benefit from a Maze operation such as the Radial Maze. But recent developments in the Maze operation offer new hope to Chronic A-Fib-ers.

The Mini-Maze operations probably aren’t a satisfactory option if you have Chronic A-Fib, since they currently can’t reach or block all areas of the heart where A-Fib signals are found.

7.   “I have Persistent or Chronic (all-the-time) A-Fib but no symptoms (‘silent’) A-Fib.”

You may want to consider just learning to live with the A-Fib. You will have to be on blood thinners or have a Watchman device installed to keep from having an A-Fib stroke. You will probably have to take rate control meds to keep your heart from beating too fast. Your heart isn’t pumping out properly, but you can compensate to some extent by exercise. You may be able to lead a close-to-normal life in silent Chronic A-Fib. It’s hard to justify the effort and risk necessary to fix Chronic A-Fib if you have no A-Fib symptoms.

Chronic A-Fib is harder to fix and often requires at least two ablations. An unintended consequence of a successful ablation for Chronic A-Fib is your A-Fib may be improved so that you are only Paroxysmal (occasional). But Paroxysmal A-Fib may be more debilitating and troublesome than being in Chronic A-Fib. At least in Chronic A-Fib you don’t have to worry about having an A-Fib attack.

A Cox Radial Maze to fix Chronic A-Fib is open heart surgery which is very traumatic and risky. It’s hard to justify open heart surgery if you’re feeling OK. The Mini-Maze operations probably aren’t a satisfactory option if you have Chronic A-Fib, since they currently can’t reach or block all areas of the heart where A-Fib signals are found.

Another factor to consider is your age. If you’re 40 years old, it’s probably worth the effort to get your silent Chronic A-Fib fixed. Chronic A-Fib over time will probably damage your heart, brain, and other organs. But if you’re in your 70s, you can probably live the rest of your life in a satisfactory, fulfilling manner even with silent Chronic A-Fib.

However, having had A-Fib, I know how wonderful it is to be in normal sinus rhythm. Even though you have silent Chronic A-Fib and in general feel OK, you may want and need to get rid of your Chronic A-Fib. Most doctors understand this need to have a heart that beats normally and will work with you, as long as you understand the risks and challenges. See the options in the above question: “I Have Chronic A-Fib”.

8.   “I have A-Fib but am allergic to Coumadin, Heparin, Lovenox and most blood thinners. I’m also very overweight. And I’ve already had one stroke.”

You might be a good candidate for a Mini-Maze operation, since you don’t have to be on blood thinners during and after a Mini-Maze operation. (See Treatments/Maze/Mini Maze for more.)

A Mini-Maze is possibly a better option if you have had a stroke or are more in danger of having a stroke during a catheter ablation.

The Mini-Maze is sometimes a better choice if you are “morbidly obese.” With current fluoroscopic imaging systems used in catheter ablation, it’s more difficult to see a clear image of the heart if someone is overweight. And greater doses of radiation often have to be used.

The Radial Maze might be an option you should consider, though an allergy to blood thinners may influence whether or not the surgeon takes your case and may affect elements of the operation. If your left atrium is larger than 6.0 cm or you’ve been in A-Fib for over five years, the long term success of the “Cut and Sew” Maze operation is under 80%.

9. “I’ve had two failed left atrium ablations and have tried many different medications.” 

You can go for a third left atrium ablation, but you need to go to the best, most experienced A-Fib doctors you can find. You are a special case and deserve special treatment.

The Mini Maze operations probably wouldn’t work for you because of the reasons mentioned above (see Treatments/Maze/Mini Maze.)

A Cox Radial Maze operation may work for you. 

(An alternative to the full Cox (Radial) Maze surgery, is a variation of Mini-Maze operation called the “Five-Box Thorascopic Maze Surgery” or Total Thorascopic Maze (TTM) which was developed by Dr. John Sirak. According to Dr. Sirak’s web site, it has a “cure rate in excess of 95%.”)

A last option is Ablation of the AV Node with Pacemaker implanted. Though you are still in A-Fib and have to continue taking blood thinners and probably rate control meds, your ventricles are no longer affected by A-Fib. In general people report a better quality of life than when A-Fib made their heart race.

References for this article
• Camm, “Clinical Relevance of Silent Atrial Fibrillation: Prevalence, Prognosis, Quality of Life, and Management.” Journal of Interventional Cardiac Electrophysiology 4, 369-382, 2000, p. 376.

• Haines D., “Atrial Fibrillation: New Approaches in Management.” Un. of Virginia multi-media presentation, 1999, p. 4.

• Haïssaguerre, et al. “Catheter Ablation of Long-Lasting Persistent Atrial Fibrillation: Clinical Outcome and Mechanisms of Subsequent Arrhythmias.” Journal of Cardiovascular Electrophysiology, Vol. 16, November 2005, pp. 1138-47.

• Romano, M. A. et al. Atrial reduction plasty Cox maze procedure: extended indications for atrial fibrillation surgery. Ann Thorac Surg 2004;77:1282-1287.

• Han, F.T. et al. Heart Rhythm, “Minimally invasive surgical atrial fibrillation ablation: Patient selection and results.” Vol 6, No 12S, December Supplement 2009, P. 575.

• Andy C. Kiser, MD. FirstHealth Arrhythmia Center, Pinehurst, NC.

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If you find any errors on this page, email us. Y Last updated: Friday, August 11, 2023

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