Answer:

Research studies have suggested that the atria undergo structural and functional changes during fibrillation that might make future episodes of fibrillation more frequent or sustained. The catchphrase invented by researchers is “atrial fibrillation begets atrial fibrillation.” According to this line of thinking, intervening earlier in the course of the disease (for example, with antiarrythmic drugs or ablation) might have a higher chance of success than waiting until the atrial fibrillation is persistent. However, there is no convincing clinical trial evidence yet that suggests every patient with atrial fibrillation should have ablation early on. The guidelines of the Heart Rhythm Society still recommend ablation be considered for symptomatic atrial fibrillation only after an unsuccessful trial of an antiarrhythmic medication. Catheter ablation for atrial fibrillation has been practiced successfully for years now, but your husband is correct that techniques and equipment are constantly improving. Ultimately, the decision about whether and when to pursue ablation is a highly individual one that requires weighing the risks and benefits of the procedure, as well as the severity of the symptoms from atrial fibrillation.

Answer:

Because you have symptoms from atrial fibrillation that have not been controlled with rate-lowering medications (e.g. metoprolol) alone, your physician is considering a different treatment approach, aimed at keeping you in sinus rhythm instead of just keeping the heart rate controlled during fibrillation. Flecainide and other antiarrhythmic drugs do work for some patients, but their long-term effectiveness is probably only 50% or less. Catheter ablation is a procedure in which thin tubes are threaded through the veins in your legs or neck to the heart’s upper chambers, and energy is applied to specific areas to create small burns inside the heart. These burns can prevent rapid heart beats from triggering episodes of atrial fibrillation. For a first-time ablation, usually the pulmonary veins are electrically isolated from the left atrium, which is effective in preventing episodes of atrial fibrillation in many patients with otherwise normal hearts. If the heart’s chambers are enlarged, or the atrial fibrillation is persistent for months or years, this pulmonary vein isolation is usually not successful, and more areas in the atria need to be ablated. Depending on the patient, success rates for atrial fibrillation ablation can range from 30% to 90%, and about one-third of patients will require a second ablation procedure. Some patients will continue to have episodes of atrial fibrillation, but less often, for a shorter time, or with less severe symptoms. Besides antiarrhythmic drugs and catheter ablation, the other commonly used treatment for atrial fibrillation is surgery, but this is most often done in conjunction with another cardiac surgery, or after catheter ablation has failed. As of now, there are no good trials showing benefits of food supplements or holistic medicine in the treatment of atrial fibrillation.

Answer:

For all treatments, including antiarrhythmic drugs, catheter ablation, and arrhythmia surgery, success rates are highest for paroxysmal AF and lowest for long-standing persistent (or permanent) AF. The most invasive, and arguably the most effective, treatment for atrial fibrillation is the full Maze procedure, but this is not often recommended to patients without another indication for cardiac surgery. The “keyhole” approach you mention, minimally invasive surgical epicardial pulmonary vein isolation, has shown good results in experienced centers. A recent published series by Edgerton et al (Ann Thorac Surg 2008;86:35-39) showed more than 80% of patients with paroxysmal AF, and 50% of those with persistent AF, had no episodes of AF greater than 15 seconds during 6 months of postoperative rhythm monitoring. Repeat minimally invasive surgery is possible, but pericardial scarring might limit access or visibility in the second operation. Catheter ablation is less invasive than either of these approaches, and in selected patients, especially those with paroxysmal AF and no structural heart disease, has shown success rates of 80% or greater, with some patients requiring a second procedure. Serious complications can occur with any procedure for treating atrial fibrillation; risk is generally on the order of 1-2%.

Answer:

There is no clear benefit to waiting for a “natural” return to sinus rhythm. In fact, there are some theoretical disadvantages to staying in atrial fibrillation for more time, including possibility that remodeling will make future episodes more likely, and possibly longer periods might make it more likely that blood clots can form in the heart. If you have no risk factors for complications from flecainide, you should continue using it as prescribed by your doctor. This approach has been studied and found to be safe in a study by Alboni and colleagues (N Engl J Med. 2004 Dec 2;351(23):2384-91).

Answer:

Patients report a wide variety of triggers for their episodes of atrial fibrillation. Less common is your case, in which two distinct triggers operate at different times in the same patient. It is likely that your autonomic nervous system, which plays an important role in swallowing and eating, is related to the current symptoms. One possibility is that the vagal reflex during swallowing is causing extra atrial beats, which then go on to trigger episodes of atrial fibrillation. Your physician is considering a second ablation procedure because reconnection is commonly seen in the pulmonary veins of patients with recurrent AF after ablation. If your current episodes, like the ones before ablation, are also caused by extra beats originating in the pulmonary veins, a second ablation procedure has a good chance of offering some symptomatic benefit. However, it is very difficult to know before the procedure whether these triggering beats are coming from the pulmonary veins or another part of the heart. One approach might be to look for reconnection in the pulmonary veins and repeat the ablation if necessary, then look for other triggering sites during the procedure.

Answer:

Atrioesophageal fistula is a rare but serious complication of atrial fibrillation ablation. It occurs when ablation at the back of the left atrium, which is directly adjacent to the esophagus, causes heat injury to the esophagus and its blood vessels. When this heals, it may form an abnormal connection between the heart and the esophagus, allowing blood to enter the esophagus, or air, food material, and bacteria to enter the bloodstream. This can result in infection inside the heart or the chest, stroke, and often death. To prevent this complication during atrial fibrillation, we use several techniques to identify the location of the esophagus and avoid ablating near it, and monitor the temperature inside the esophagus. I have managed this complication (when patients with this complication were sent to us from other centers). However, I have not personally experienced this complication, but it is important to remember that it is a risk for any physician performing atrial fibrillation ablation.

Answer:

PACs (premature atrial contractions) are extra beats arising from the heart’s upper chambers. They are quite common in the weeks following pulmonary vein ablation, probably as the result of inflammation in the recently damaged tissue. The PACs should become less frequent over time. There is a possibility that they will trigger another episode of atrial fibrillation, but early recurrence after ablation does not necessarily predict long-term failure of the ablation. A second ablation to target the PACs is probably not indicated; ablation is rarely performed unless the atrial arrhythmia is sustained (atrial tachycardia or recurrent atrial fibrillation.)

Answer:

The shocks you describe after singing are not common among patients with ICDs. If the device is delivering a shock, it’s because the circuits are seeing electrical activity that suggest your heart rate is dangerously high. There are a few possibilities for why this occurs after you sing. Least likely is that you have true life-threatening arrhythmias that are provoked by the stress of singing. Another possibility is that singing in front of a group increases your adrenaline levels and you have the usual sinus tachycardia that we all get when nervous or exercising. Sometimes the heart rate can be high enough in these situations that the ICD is “fooled” into treating it as a life-threatening arrhythmia with a shock. Finally, it could be the result of electromagnetic interference that is misinterpreted as electrical activity in your heart. Although microphones do not commonly cause this, other devices (welding torches, high-voltage electrical equipment, etc.) have been shown to cause such interference. The best way to sort this out is to have your device interrogated at the pacemaker clinic, and have your electrophysiologist look over the tracings from the time just before the shocks. You can also try to remove things that might be contributing. For instance, sing at home by yourself, or sing without the microphone, and see if the same thing happens. It is very likely that the settings on your device can be changed in a way that will allow you to keep singing without fear of shocks.

Answer:

You have a complicated arrhythmia history, with 4 previous ablations and persistent symptoms. It is reasonable to consider all the alternatives before proceeding with AV nodal ablation and pacemaker implantation, since that is an irreversible commitment to permanent 100% pacing. Also, since that procedure would not prevent more episodes of Afib, it is not guaranteed to prevent symptoms. It would, however, prevent rapid and irregular heartbeats during the Afib episodes. Many patients have undergone more than one PVI, and the complication rate on repeat procedures is generally similar to that of first-time PVI. However, given your multiple prior atrial arrhythmias and ablation procedures, it is likely that your current episodes of Afib are not purely arising from extra beats in the pulmonary veins, and that a more extensive repeat ablation would be required. I would recommend discussing other treatment options with your EP, especially medical therapy. Multiple antiarrhythmic drugs have been used for atrial flutter and fibrillation; this might be a good opportunity to try a medication that you have not taken in the past to see if it might reduce your symptoms. If medications are unsuccessful, you can then discuss a fifth attempt at atrial ablation versus AV node ablation and pacemaker.