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This is not Dr Natale responding; however, your history sounds like you would benefit greatly from catheter ablation. Conventional teaching is that as long as your heart rate is controlled, the heart muscle is unlikely to be weakened; however this is not always true. Heart rate irregularity and a rapid response to exercise may partly be the reason why.

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It is difficult to provide useful advice without a detailed review. I would suggest a consult with an experienced EP.

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There exists a risk of an embolic event – the passage of a clot into the circulation – occurring soon after restoration of sinus rhythm and the magnitude of this risk is related to the duration of atrial fibrillation. This is considered to become significant when the duration of atrial fibrillation exceeds 48 hours, the underlying hypothesis being that the longer the atrial fibrillation, the greater the stasis of blood in the atria with a higher risk of forming clots. The restoration of sinus rhythm is considered to dislodge the clot from the atria into the circulation. Even without conversion to sinus rhythm, the presence of continued atrial fibrillation is also associated with an embolic risk. A long flight is thought to possibly increase the risk of forming clots in the veins of the legs (not in the heart) and this risk can be controlled or minimised if you are taking Coumadin adjusted to an INR of 2-3.

Answer:

Based on what you have written, you should be a good candidate for catheter ablation. Although there is no urgency, the success rates for catheter ablation drop off noticeably once the atrial fibrillation becomes persistent and/or associated with enlargement of the left atrium. Without seeing the actual tracings, I cannot comment on their significance.

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Major surgery in the setting of anticoagulant treatment has certain risks: of bleeding as well as clot formation, but this is a reasonably well known situation. A common strategy for this situation would be replace Warfarin preoperatively with heparin (typically by injection subcutaneously, once or twice a day) which is then stopped a few hours before surgery, and then restarted usually 48 to 72 hours after surgery. Finally, warfarin is restarted before discharge and the heparin stopped when an effective INR level is reached with Warfarin. With this type of strategy, even major surgery can be performed without a significant elevation of bleeding/clotting risks.

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The placement of a permanent pacemaker generally does not obviate the need for continued Coumadin (for embolic protection in the context of AF).

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Yes, based on what you have written, you can certainly exercise despite the AF. I would suggest a progressive regime.

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I am not aware of any clinical evidence that maintaining sinus rhythm with anti-arrhythmic drugs prior to the procedure improves the outcome of catheter ablation. Though there is some related animal data, this is difficult to apply to humans undergoing catheter ablation of atrial fibrillation. With regards to the supplements, one would need to know all the ingredients to decide about the likelihood of interactions with other drugs. Finally, I cannot help you with specific recommendations.

Answer:

It is possible that you have been in AF during that entire period or you have been going back and forth as you suggest with shorter bursts of AF.