Answer:

It is often difficult to determine the mechanism of atrial fibrillation in an individual patient. You are correct in stating that digoxin enhances vagal tone, and might not be helpful in a patient with vagally mediated atrial fibrillation. However, for most patients with atrial fibrillation, digoxin is a reasonable choice for controlling the heart rate during an episode (without actually preventing the atrial fibrillation). If the Betapace keeps you in sinus rhythm most of the time, and the heart rate is controlled during episodes of atrial fibrillation, there does not seem to be a compelling indication to take digoxin. Other rate-control and antiarrhythmic drugs are also available. Most episodes of atrial fibrillation are not life-threatening and do not require admission to the hospital. Also, most resolve without specific treatment, but sometimes cardioversion is necessary to restore normal heart rhythm. You should discuss with your doctor regarding the need for anticoagulation.

Answer:

I would like to preface this answer by stating that everyone’s technique has evolved rapidly over the past few years and it is hard to accurately compare one “technique” to another. The original procedure describe by Dr. Pappone involved ablating circumferentially around each pair of pulmonary veins. Additional lesions were then delivered to the region of the mitral annulus, the septum, and the left atrial roof. Our current procedure varies with the patient’s type of atrial fibrillation. For patients with paroxysmal atrial fibrillation, we perform circumferential ablation followed by a second transeptal puncture to allow us to map the ostium of each pulmonary vein. This second transeptal insures electrical isolation of each vein. In patients with persistent Atrial fibrillation, we perform the identical lesion set as described for paroxysmal fibrillation, and then sequentially map both the left and the right atria for areas of electrical fractionation. Then sequential ablation is performed at these sites in an attempt to change the Atrial fibrillation into organized tachycardias and ultimately map and ablate these tachycardia resulting in normal sinus rhythm. We have certainly learned that the procedures need to be individualized for each patient.

Answer:

If the second catheter ablation is unsuccessful, there are many options still available to you. The first is the strong possibility that medical therapy may be effective after ablation even though it failed initially. Other available options include AV Node ablation and pacemaker implantation, an attempt at epicardial ablation through surgical techniques, or finally, more aggressive attempts at adequate rate control alone. Many patients have achieved success after a third procedure as well. I do not believe that your apparent cardiac rotation is a significant factor in the treatment of your Atrial fibrillation. Isometric exercise, as performed with strength training, may well exacerbate Atrial fibrillation by increasing pulmonary and intracardiac pressures. Cardiovascular fitness training would be preferable.

Answer:

Periodic exacerbations and remissions of atrial fibrillation are very common. The history that you describe is quite typical and your current stabilization will be for a limited period of time only. Your recurrent episodes despite multiple attempts at antiarrhythmic therapy would suggest that catheter ablation may be the only means of long term control of your arrhythmia. As such, if you are very symptomatic during episodes than I would proceed with the ablation as planned. There are advantages to waiting if the episodes are of recent onset or relatively infrequent. This includes improvement in the technology used in the procedures or operator experience. However, frequent and prolonged episodes of AF may significantly impact the long term success of ablative therapy.

Answer:

If your recent monitoring has revealed atrial arrhythmias but you are asymptomatic, then continuing your current medical regimen may be all that is required. Based on the recent observations, if you were to proceed with ablation, then BOTH atrial flutter and fibrillation would have to be addressed during the procedure. An ablation for atrial flutter alone is unlikely to result in long term suppression of your rhythm disturbance. At the present time, ablation is only indicated for symptomatic patient or those intolerant to medical therapy.

Answer:

WPW is a result of an accessory or additional muscular connection between the atrium and the ventricle. A left bundle branch block is an obstruction in the hearts normal electrical conduction system. If there is confusion in the diagnosis on the electrocardiogram, an electrophysiologic study performed by your electrophysiologist will accurately make the diagnosis. If you do have WPW and an ablation is necessary, then the likelihood of requiring a pacemaker after the procedure is very small. The risk is dependent on the location of the pathway and the proximity to the normal conduction system. We would estimate the risk at approximately 1%.

Answer:

You certainly are eligible for another ablation and there is no evidence that your recurrence would make a second procedure unsuccessful. In fact, the success after a second procedure is quite good. However, if the drugs are “working well” and you are minimally symptomatic, there is no compelling need to change at the present time. At some point, the fibrillation is likely to recur and then ablation would be an excellent alternative to more medication and their toxicities.

Answer:

I would certainly consider another ablation as the frequency of Cardioversions will only increase as time goes on. An alternative would be to consider antiarrhythmic medication for a period of time and then observe for AF recurrence. The success after a second procedure is quite good and you have an excellent chance of controlling your arrhythmia long term. At the present time there are many centers very experienced in Atrial Fibrillation ablation and my first choice is always on the basis of the experience and skill of the operator.

Answer:

Other than an increased incidence of bleeding, there are few common side effects with Coumadin. The symptoms you describe are likely related to the atrial fibrillation as they improved with Beta Blockers. Additional medical management of the fibrillation may further ameliorate your symptoms.