afib questions

Dr. Mandrola

by AgentX86 - 2019-06-17 23:47:02

Forget you heard that name!  He's known as a quack, more interested in promoting Dr. M than helping people.  He even says that ablations are unnecessary and dangerous, even though he does them himself.  I wouldn't have him treat a gold fish for a common cold.  If you want a stronger reaction to his name, just drop it in the Afib forum at stopafib.org.

Why would the EP not suggest an ablation?  At 50% burden, it's not a slam dunk, to be sure, but it really is the only way out.  All of the antiarrhythmic drugs are toxic and have a limited efficacy and lifetime before they don't work, or worse (some actually become pro-arrhythmic).  They're all toxic to the heart, liver, kidneys, thyroid, and some to even the eyes (though not a high probability).  One of them got to my thyroid and another is the reason for my pacemaker (SSS).

It's not a matter of how good "blood thinners" (anticoagulants) are, it's the fact that without them the chances of a stroke are greatly elevated.  Anticoagulants better the odds significantly.  The modern anticoagulants are much safer than the old standby, warfarin (rat poison ;-).  They're not cheap, however.  The full-boat price of these can be $400/mo, but insurance covers it (Medicare donut holes aside).'

The reason for beta blockers is to avoid tachycardia.  Afib, by itself, is not dangerous.  It certainly can be a royal PITA but it's not life threatening.  Strokes, of course, are so anticoagulants are an absolure necessity.  The other issue is tachycardia.  Any sustained heart rate above 100bpm is an invitation to cardiomyopathy, so beta blockers are used to surpress the heart rate.  Of course, if it's already low this becomes a balancing act.  Indeed, sometimes a pacemaker is needed to keep the rate up while, at the same time using a beta blocker to keep it low.  Managing heart rate is critical.

You're absolutely right about passing out.  This isn't acceptable.  The near syncope episode I had got my EPs attention.  He didn't think that was acceptable, either so had me fitted with an event monitor for a month to track it down.  Fortunately (or un- depending on your POV), they found an 8-second asystole on the third night home.  They actually found a 5-second one while I was in the hospital but explained it away as equipment malfunction (was sleeping on the EKG leads).

I also agree with you that an ablation is preferable to drugs.  Ablations are simple procedures (I've had three) and given the right EP, have a high success rate.  It's critical to choose the EP correctly, however.  There is a vast difference in the skill level between EPs.  The EP doing the work should have done thousands of such procedures.  It may be worth travelling to the the best.  Ablations aren't like any other surical procedure.  There is definitely an art to it.

For more information, I highly recommend the Afib forum at stopafib.org.

To ablate or not to ablate, that is the question?

by Selwyn - 2019-06-18 12:11:50

Ablation for atrial fibrillation is not without complications, some life changing. Clint Eastwood says as DIrty Harry,"Are you feeling lucky, punk?" Perhaps some things to think about...

There is a real risk of stroke following the procedure of atrial fibrillation ablation.

There is a real risk of open heart surgery for complications of the procedure.

There is a real risk of recurrance of the AF after ablation ( this may depend on how long the AF has already been present) 

Sometimes AF is without symptoms, even then, there is a risk of stroke.

Beta blockers are not the sole treatment for symptoms associated with AF- other, additional and alternative medications are available. 

Sometimes pacemakers are fitted to offset the effects of drug therapy if that therapy is important to the patient. 

Personally, I have tried many different medications for AF. 

I opted out of the offer for atrial fibrillation ablation and had a flutter ablation as the risk of stroke from the procedure is about 10 times less. 

Subsequently, I could not tolerate various medications and I had an atrial fibrillation ablation.  Luckily for me I did not wake up with a stroke, or having had open heart surgery following the serious complications that can ensure ( although my hospital does cater for emergency opening of the chest etc.)  That ablation was unsuccessful! I chanced my luck again and had another ablation.  I still get ocassional AF. I do not take any medication for AF. I remain on blood thinners with all the benefits and risks.

Treatment by ablation when it causes life changing complications would be something of a bad choice. When all goes smoothly, it is a helpful way to avoid medication side effects and therefore improve quality of life. 

Such decisions need a careful balance of considerations of how the AF affects the quality of life and how much risk you are willing to take.

I remember one ex sergeant-major from the Royal Guards going for surgery and waking up with a dense left hemiplegia, he said to me, " I've been in battle, doctor, I have seen men take risk, and I accept that. I took a risk, and that is the way it is". We had his car adapted so that he could drive with one arm and one foot.  

more

by Tracey_E - 2019-06-18 15:22:36

She's on one of the super expensive new anti-coagulants.

She doesn't feel bad from the afib very often. If her rate gets too high, she has something that she takes to bring it down, but again, that doesn't happen often either. 

Thanks for the feedback and additional info. I'm still waiting to find out how low she got overnight but it sounds like it might be best to leave well enough alone. My concern was stroke risk, hearing she's in afib half the time freaked me out a bit. She's coming to visit in a few weeks so I can judge for myself if she's feeling as good as she says she does. Fortunately she gets more amused than annoyed when I turn the tables and go all mom on her. 

Update, she called while I was typing this.  She got to 36 for less than a minute, got to 128 once, but average overnight was 70. 

afib

by ROBO Pop - 2019-06-18 17:32:50

First, a Beta Blocker does not reduce the heart rate it lowers the blood pressure so the heart doesn't work so hard.

Afib is generally just an annoyance and the real risk is blood clots which of course can lead to stroke. There are quite a number of meds for Afib as well as other options such as cardioversion, (a Jesus Jolt) and Ablation. I've had both and neither worked for me. Ablation is about 70 - 75% successful on the first attempt and only increases slightly on successive attempts. The downside of Ablation is the potential of heart attack, stroke, and even death. I think you need to determine whether the risk is worth the possible reward. Again, I have Afib and yes it can be annoying at times but so are children.

By the way, I take plavix plus baby aspirin for clots and have far more risk factors for clotting. I understand your concern but weigh the pluses and minuses. Afib often returns even after a successful Ablation. Pretty sure, though theres no proof, my ablation lead to a whole slew of arrhythmias I never had before that procedure.

Mom's afib and bradycardia

by Marybird - 2019-06-18 18:47:26

Wondering if the EP gave your mom reasons he wouldn't recommend an ablation if she were his mom? Does she have comorbidities that might make ablation more complicated? Might he figure your mom's afib hasn't negatively affected her quality of life enough for the risks and vicissitudes of afib ablation? 

As for her intermittent or occasional bradycardia, could be your mom's headed for sick sinus syndrome- tachy-brady type. Afib is often a player there. As I understand it that progresses over time. What happens is that an afib/high heart rate plays out, stops and is followed by a pause while the dysfunctional sinus node gets its act together to go into sinus rhythm. If that pause is more than a couple seconds long the person may pass out. There may also be sinus bradycardia. 

As I understand it, the bradycardia and pauses must be documented and correlated with symptoms occuring at the same time. Passing out with a documented pause, or significant bradycardia will do it, but bradycardia must be associated with symptoms such as dizziness, lightheadedness, confusion, etc. to justify a pacemaker. 

While it sounds cavalier of your mom's cardiologist to instruct her to come back if she's dizzy or lightheaded, that's what he is telling her. Your mom's bradycardia may be intermittent or infrequent at this point, but if its the beginning of tachy-brady syndrome, I'd think he'd want to put her on an event monitor to see if they can catch the brady or tachy-brady events and correlate those with symptoms.

My sister has afib, and about six months ago got up at night and passed out cold. The paramedics found her heart rate was 38, took her to the hospital where they tried to bring up her HR but only got it to 42. They put in a pacemaker. They explained to her that the med she takes to control her afib-diltiazem, probably at least contributed to her bradycardia, but since it was essential to control her afib, she needed the pacer. If your mom got a pacer, she'd be in that same boat as it's likely the sotolol may at least be contributing to the bradycardia, but she needs a heart rate control med to control the afib. 

I'm in a different section of that tachy-brady boat, I guess. I have atrial tachycardia, not afib. I've had it for years and taken metoprolol to control it (along with diltiazem in the past) in varying doses. No problems till about two years ago I began having bradycardia that increased and became symptomatic over time, along with the tachycardia becoming less controlled with the meds. Referred to an EP, who called the atrial tach, diagnosed sick sinus syndrome after reading various monitor results documenting symptomatic bradycardia ( lightheadedness and near syncope with HR in the low 40's). He discouraged ablation, explaining that success rates for AT can be less than stellar due to the nature of the beast. He suggested tapering off and discontinuing the metoprolol, starting diltiazem for the tachy and implanting a pacemaker if the diltiazem didn't resolve the bradycardia and control the tachy. It didn't, so he (strongly) suggested the pacer, and put it in on June 12. And my reason for it is basically the same as for my sister, the pacer enables treatment of medical conditions ( in my case AT and drug resistant hypertension) for which there are no substitutes. 

And if your mom got a pacer ( which might not be needed if she had her afib ablated and it was successful), that would be her reason as well.

Mary

Afib

by islandgirl - 2019-06-19 09:21:59

I had afib ablation about 4 years ago after frequent and long runs of very life-disrupting afib.  I now occasionally have runs of afib and aflutter, the most recently lasting about 3 hrs (felt like a pingpong ball bouncing in my chest),  also shown on my ICD interrogation.  My EP told me that there are new afib ablation techniques that have improved outcome.  My EP has told me that the more/longer you are in Afib, the less chance of a cure.  I in no way have enough afib that I would, nor would my EP, consider an ablation.  Before the ablation, the EP checks for clots in the heart by a TEE and leaves the TEE in place throughout the ablation.  If there are clots, they won't do the ablation.  I don't know about age factors regarding afib ablation.  A friend's husband had successful ablation about a year ago in his mid 70s.  He's thrilled he had it and remains afib free.  Also look at the long-term effects on the heart and brain with afib.  

Good luck!

Karen

everyone is different

by Violet West - 2019-06-21 10:33:40

How much AFIB is okay? 

I think this depends on how much it's disrupting one's life.  When I first looked up AFIB (after I landed in the hospital) it said many people experience no symptoms.  I was like - what? Because I SURE had symptoms. I was nearly incapacitated and unable to do myh ADLs for long stretches of the past 4 years, and it just got worse and worse.

I think ablation is worth the risk if the AFIB is bad and the EP is a good one and is confident it can help,    Alblations can actually cure AFIB -- nothing else will. 

I had two ablations.  They didn't help. Before the end I was in AFIB 100% of the time and had an average bpm of 128. The final, AV Node ablation with pacemaker did, but that was a last resort for severe and intractable AFIB because the docs were worried about heart failure and wanted to get me off toxic Amiodarone. It was a "last resort."

I still have AFIB/AFlutter.  I just can't feel it.  But I do have to take a blood thinner for the rest of life to minimize stroke risks.

I don't know how old your mom is or what her life situation is.  At 50% AFIB, maybe ablation is not worth the risk.  I don't know, I'm not a doc. Maybe it's time for a second opinion.  I got one, and felt better for it.

good luck!

A-fib

by bgarza - 2019-07-23 22:16:47

Tracey, so nice to see your posts. I truly appreciated your advice 10 years ago when I got my first pacemaker. About 5 years ago I developed a-fib and was controlled with medication flecainide for a year. I opted for an ablation, went well lasted a couple of years, was cardio-converted that lasted 3 days. 2nd ablation 6 months later and that lasted 3 months. I'm in permanent A-fib now. Good days and some not so good but I'm still working and grateful I'm still active. I do take metropolol and Eliquis. I'm on pacer #2 which is now a 3 lead and 100% dependent. Again, thank you for being so supportive.