Wishing you good health and lots of NSR,
Hans

ABSTRACTS

BORDEAUX, FRANCE. In 1998 Dr. Michel Haissaguerre and colleagues at the Hopital Cardiologique du Haut- Leveque in Bordeaux reported that 94% of the points (foci) triggering paroxysmal atrial fibrillation were to be found inside the pulmonary veins (about 2-4 cm from where the veins exit into the left atrium)[1]. This discovery led to the techniques of pulmonary vein ablation (ablation of foci inside the vein), pulmonary vein isolation (isolation of the veins from the atrium through the placement of ring-shaped lesions around each vein), and more recently, circumferential pulmonary vein ablation (Pappone method) where ablation lines are drawn so as to encircle the left pulmonary veins within one ring of scar tissue and the right veins with a separate ring – the two rings are connected with a line on the back wall of the left atrium.

Since 1998 Dr. Haissaguerre and his team have continually refined their pulmonary vein isolation (PVI) procedure and have now performed several thousand procedures on patients with paroxysmal, persistent or permanent atrial fibrillation. Dr. Haissaguerre recently outlined the details of his procedure in an article published in the Journal of Cardiovascular Electrophysiology. Following are the highlights:

• Patients are considered for ablation if they have suffered frequent afib episodes for more than one month and have proven resistant to at least two class I (propafenone, flecainide, disopyramide) or class II (amiodarone, sotalol, dofetilide) antiarrhythmics. Patients are accepted for treatment whether their afib is paroxysmal, persistent or permanent and are not excluded based on the presence of structural heart disease, left ventricular dysfunction, enlarged left atrium, prior stroke or advanced age.

• All antiarrhythmic drugs are discontinued at least 5 half-lives prior to the ablation except for amiodarone which must be discontinued 3 months prior to the procedure. All patients are anticoagulated to an INR of between 2 and 3 for at least a month prior to the procedure and a check for left atrial thrombi (blood clots) is performed via transesophageal echocardiography (TEE) in the week prior to ablation. The oral anticoagulation is replaced with heparin 48 hours before and all anticoagulation is withdrawn 6 hours before the procedure.

• The first step in the procedure, following appropriate sedation, involves the insertion of three catheters through sheaths inserted in the right femoral vein. A quadripolar steerable catheter is placed in the coronary sinus, a circumferential mapping (Lasso) catheter and a 4-mm-tip externally irrigated ablation catheter (Celsius Thermocool) are advanced through the septum into the left atrium. Different navigation systems such as the LocaLisa, NavX and CARTO systems are used to help in navigation and reduce fluoroscopy exposure.

• Once the left atrium, specifically the area around the pulmonary veins, has been mapped the ablation catheter is used to create rings of lesions around each pulmonary vein outlet usually at least 1 cm from the edge so as to avoid pulmonary stenosis. The RF generator is limited to deliver a maximum of 30-35 W when ablating outside the veins and the maximum allowable temperature is 50oC. Ablation is also performed at the cavotricuspid isthmus (in the right atrium) and a lesion line is drawn between the left inferior pulmonary vein and the neck of the mitral valve in cases where simple PVI and cavotricuspid ablation do not prevent atrial fibrillation from recurring after pacing.

• In a recent series of 368 patients, the total procedural time for PVI and cavotricuspid ablation was about 70 minutes, of which about 44 minutes involved fluoroscopy exposure and 35 minutes involved the application of RF energy.

• The overall success rate for the initial ablation (no afib, no drugs) was 69% for paroxysmal afibbers undergoing just PVI and cavotricuspid ablation and 87% for patients having the added mitral isthmus ablation. The procedural time with the added mitral isthmus ablation was about twice that of the basic procedure.

• Severe symptomatic pulmonary vein stenosis (more than 70% narrowing) has been observed in 0.2% of over 2000 patients. No deaths or strokes were reported.

Hocini, M, et al. Techniques for curative treatment of atrial fibrillation. Journal of Cardiovascular Electrophysiology, Vol. 15, December 2004, pp. 1467-71

Editor's comment: I can highly recommend this article to anyone contemplating a RF ablation. Dr. Haissaguerre's original 1998 paper also provides fascinating insights into the original research leading to today's PVI procedures.

[1] Haissaguerre, M, et al. Spontaneous initiation of atrial fibrillation by ectopic beats originating in the pulmonary veins. New England Journal of Medicine, Vol. 339, September 3, 1998, pp. 659-66

AARHUS, DENMARK. There is impressive evidence that fish oils (eicosapentaenoic acid [EPA] and docosahexaenoic acid [DHA]) can materially reduce the risk of sudden cardiac death (cardiac arrest). Researchers at the University of Washington found that men and women who consumed fatty fish just once a week reduced their risk of cardiac arrest by 50%. They believe that fatty fish consumption increases the levels of EPA and DHA in the membranes of red blood cells, which in turn, reduces platelet aggregation and the risk of fatal ventricular arrhythmias. Other researchers have confirmed the protective effect of fish oils against ventricular fibrillation, but very few, if any, studies have investigated the association between fish/fish oil intake and the development of atrial fibrillation.

A group of Danish researchers recently set out to fill in this gap in our knowledge. Their study included 22,528 men and 25,421 women (average age of 56 years) who were free of endocrine and cardiovascular diseases at baseline. All participants completed a detailed semi-quantitative food- and drink-frequency questionnaire and were then followed for an average of 5.7 years. At the end of the follow-up period 374 men (1.7%) and 182 women (0.7%) had been diagnosed with either atrial fibrillation or atrial flutter. About 10% of all participants were being treated for hypertension. Somewhat surprisingly, the researchers found that participants with a high consumption of fatty fish (herring, mackerel, sardines, trout, and salmon) had a significantly higher incidence of new-onset atrial fibrillation than did participants who rarely or never ate oily fish. After adjusting for age, gender, height, BMI, smoking, alcohol consumption, total daily energy intake, systolic blood pressure, treatment for hypertension, cholesterol level, and level of education, the researchers concluded that participants whose daily fish oil intake averaged 1290 mg had a 34% greater risk of developing AF than did those whose intake averaged only 160 mg/day. The difference was statistically significant (p=0.006). The researchers point out that the lack of an observed beneficial effect could have been because the consumption of fish oil was insufficient to prevent arrhythmias. They also say, "We cannot exclude the possibilities that fish oil may prevent the development of atrial fibrillation in patients with symptomatic heart disease or that fish oil may prevent relapses of atrial fibrillation in patients with paroxysmal atrial fibrillation."

Finally, they point out that they did not collect information regarding the use of fish oil supplements and also emphasize that they do not know whether fish oil would have a protective effect against the development of AF in populations with a low intake of fatty fish (such as the United States). Their overall conclusion was that, "Consumption of omega-3 fatty acids from fish is not associated with a reduction in the risk of developing atrial fibrillation or flutter."
Frost, L and Vestergaard, P. n-3 fatty acids consumed from fish and risk of atrial fibrillation or flutter: the Danish Diet, Cancer, and Health Study. American Journal of Clinical Nutrition, Vol. 81, January 2005, pp. 5-54

Editor's comment: The conclusions of the Danish study are fully in line with the results of the two LAF surveys, which investigated the association between afib severity and fish oil intake. None of our surveys have ever found that a high fish oil intake is associated with fewer or shorter episodes. This, as pointed out by the Danish researchers, could be due to the fact that the fish oil intake was not high enough to provide a benefit. However, this would seem unlikely since the highest intakes were well above those required to provide excellent protection against ventricular fibrillation. The finding that heavy fish consumers have a statistically significant 34% greater risk of developing atrial fibrillation or flutter is worth noting. It is possible that this could be due to the higher mercury intake associated with higher fish consumption. Several studies have shown that people with a high consumption of certain fish have higher mercury levels in their blood and toenails. The lesson here is that the safest way to obtain a high intake of EPA and DHA is through the consumption of a high quality, molecular distilled fish oil supplement. In conclusion then, even though there may be no scientific evidence that fish oils can prevent the development of AF, there are still numerous reasons for ensuring an adequate intake (1-2 grams/day). The evidence that they help prevent cardiac arrest, reduce triglyceride levels, combat inflammation, and help prevent stroke and heart attack makes fish oils a must supplement for all, whether an afibber or not.

CENTO, ITALY. The on-demand or "pill-in-the-pocket" approach is now used by many paroxysmal afibbers to quickly and effectively terminate afib episodes and return to normal sinus rhythm. This approach involves swallowing 450 mg of propafenone (Rythmol) or 200 mg of flecainide (Tambocor) with water within 5 minutes of the onset on an episode. The dosages are increased to 600 mg and 300 mg respectively for patients weighing more than 70 kg (154 lbs). It is recommended that patients rest (in a supine or sitting position) until palpitations have stopped or at least 4 hours have passed. The on-demand approach was originally tested in patients with supraventricular tachycardia (SVT) and its use among afibbers was first reported in 2002 in Lone Atrial Fibrillation: Towards A Cure.

A group of researchers from 8 Italian hospitals now report that the on-demand approach is safe and effective and that its use is associated with a very significant decrease in hospitalizations and visits to the ER. Their study involved 268 AF patients who had undergone chemical cardioversion in the hospital using either propafenone or flecainide. Two hundred and ten of these patients (average age of 59 years, 118 lone afibbers) were selected to participate in the study involving the on-demand approach at home. During a mean follow-up of 15 months, 165 patients experienced a total of 618 episodes. The majority (92%) was self-treated within about half an hour after the onset of symptoms and the treatment was successful in 94% of cases. The average time to conversion was 2 hours (113 minutes). Adverse events, mostly nausea and anxiety, were reported in 12 patients.

The effect of the use of the on-demand approach on health care resources was remarkable. Although there was no difference in the overall number of episodes experienced in the group before and after instituting this approach, there was a great difference in the use of ER facilities (45.6 visits/month before vs 4.9 visits/month after) and hospitalizations (15/month vs 1.6/month). The researchers caution that patients who do not convert within 6 hours should go to the ER.
Alboni, P, et al. Outpatient treatment of recent-onset atrial fibrillation with the "pill-in-the-pocket" approach. New England Journal of Medicine, Vol. 351, December 2, 2004, pp. 2384-91

Editor's comment: Some practicing cardiologists feel it is safe to repeat the initial dose if conversion is not achieved after 5 hours, but the applicability of this approach clearly needs to be firmly established between doctor and patient.

CLEVELAND, OHIO. Dr. Andrea Natale and his team at the Cleveland Clinic Foundation have, by now, performed several thousand radiofrequency (RF) ablations with the purpose of curing atrial fibrillation. Their technique has evolved rapidly over the past few years and is now producing impressive results with very few adverse effects. Dr. Natale recently outlined his latest pulmonary vein isolation procedure in an article published in the Journal of Cardiovascular Electrophysiology. Here are the highlights:

• Patients are considered for pulmonary vein isolation or, more specifically, pulmonary vein antrum isolation (PVAI) if they have symptomatic atrial fibrillation and have not responded to at least one antiarrhythmic drug. Patients are accepted regardless of whether AF is of the paroxysmal, persistent or permanent variety and advanced age, enlarged left atrium or low left ventricular ejection fraction are not causes for exclusion.

• All antiarrhythmic drugs are withdrawn at least 5 days prior to the procedure except in the case of amiodarone which must be discontinued at least 4 months before, because it interferes with the accuracy of mapping. All patients are anticoagulated with warfarin to an INR of 2-3 for 6 to 8 weeks prior to the procedure. More recently, an INR range of 2.0-2.5 has been targeted with no significant complications. Warfarin is stopped 2 days before the procedure.

  All patients have a 12-lead ECG, 24-hour Holter monitoring, and an echocardiogram (transthoracic) prior to the procedure. Some patients also have a CT scan of the left atrium to determine the anatomy of the pulmonary veins, but this is not mandatory. Patients who are in AF the day before undergo transesophageal echocardiography (TEE) to ensure the absence of a blood clot (thrombus) in the left atrial appendage. If a clot is found, the procedure is postponed for 3-4 weeks during which time anticoagulation is resumed.

• Heparin is injected before the procedure and as required during to maintain an activated clotting time of 350-400 seconds. After the procedure, patients are again anticoagulated with warfarin for at least 4 months (twice the usual dose is given for the 3 days immediately following the procedure).

• After appropriate sedation, 4 catheters are placed in the heart. One (a 14-pole, non-deflectable recording catheter) is inserted through the right internal jugular vein and placed in the coronary sinus; one (a 64-element phased-array ultrasound catheter) is inserted through the left femoral vein and is positioned in the middle of the right atrium; one (a 10-pole Lasso mapping catheter) is inserted through the right femoral vein and advanced through the septum into the left atrium. The fourth and last catheter (an 8-mm-tip ablation catheter) is inserted through the right femoral vein and advanced through the septum into the left atrium.

• Once all catheters are in place the mapping to establish electrically active areas (PV potentials) in the pulmonary veins using the 10-pole Lasso catheter begins. Once an active area has been located its pathway to the left atrium is ablated guided by the ultrasound (ICE) catheter. The ablation is performed as close as possible to the outside edge (antrum) of the junction between the pulmonary veins and the atrial wall. The mapping and ablation can be done during sinus rhythm, atrial fibrillation or artificial pacing. RF energy is set at 30 W and 55oC and is increased by 5 W every 5 seconds until satisfactory lesion formation is obtained or microbubbles (a sign of overheating) are observed on the ICE monitor.

• All four pulmonary veins as well as the superior vena cava (in the right atrium) are isolated during the procedure. When isolation is deemed complete another round of Lasso catheter mapping is performed in order to ensure that no PV potentials have been missed.

• The procedure is deemed a success if there are no further afib episodes and no antiarrhythmic drugs required beyond the first 2 months after the procedure. During the 2 months immediately following, afib episodes are common while the heart heals. Patients with an original diagnosis of persistent or permanent AF are placed on sotalol (Betapace) or dofetilide (Tikosyn) for the 2 months immediately following the procedure. The current success rate of the initial procedure is about 80% with higher rates in young, paroxysmal afibbers. A second (touch-up) procedure brings the final success rate to 90-94%. The success rate among afibbers with previous heart surgery or an impaired ejection fraction is somewhat lower at about 73%.

• Patient follow-up involves 24-hour Holter monitoring on the day following the procedure as well as 3, 6 and 12 months after. An event monitor is used for the first 3 months after the procedure and a contrast-enhanced multi-slice CT scan of the left atrium is performed 3 months after to check for stenosis.

• The rate of moderate-to-severe stenosis has been 0.25% for the last 400 cases, the rate of thromboembolic complications 0.8%, and the rate of cardiac tamponade (penetration of the heart wall) 0.5%. No cases of atrial-esophageal fistula have occurred.

Verma, A, et al. Pulmonary vein antrum isolation: intracardiac echocardiography-guided technique. Journal of Cardiovascular Electrophysiology, Vol. 15, November 2004, pp. 1335-40

Editor's comment: An excellent description of the PVI procedure currently used at the Cleveland Clinic can be found at www.clevelan dclinic.org/heartcenter/pub/atrial_fibrillation/pulmonaryvein_ablation.htm

MONTREAL, CANADA. The prolonged use of some antiarrhythmic drugs such as sotalol (Betapace) and amiodarone (Cordarone) has been associated with the development of bradycardia (excessively slow heart rate) and the subsequent need for a pacemaker implantation. Researchers at McGill University now report that the risk of bradycardia development associated with amiodarone use is highly dependent on the initial loading dose as well as on the maintenance dose.

Their study involved 1340 patients with AF and a prior heart attack who were given a first prescription for amiodarone. The patients (63% male) were all over the age of 65 years with an actual average age of 76 years. They were followed from their first exposure to amiodarone to the first of pacemaker implantation, death or end of follow-up at March 31, 2001 (an average of 1.8 years). During the follow-up, 53 patients received a permanent pacemaker. The incidence of implantation was significantly greater (5.2% per person-year) during the first 90 days of amiodarone exposure. The incidence of implantation was found to be 3 times higher during the first 90 days for patients whose daily dosage exceeded 200 mg and, over the whole study period, patients taking more than 200 mg/day had twice the incidence of pacemaker implantation than did patients taking 200 mg/day or less.

It is common to use high concentrations of amiodarone (660-1000 mg/day) in an initial "loading phase" when amiodarone therapy is first begun. Based on their findings of an exceptionally high incidence of pacemaker implantation during the first 90 days, the researchers question the wisdom of this practice at least when it comes to atrial fibrillation. They suggest that patients with paroxysmal AF or rate-controlled permanent AF may be better served by loading and maintenance dosages of 200 mg/day or less. This would apply particularly to elderly patients with a previous heart attack.
Essebag, V, et al. Effect of amiodarone dose on the risk of permanent pacemaker insertion. PACE, Vol. 27, November 2004, pp. 1519-25

Editor's comment: Other researchers have found that the benefits of amiodarone can be attained at significantly reduced dosage levels if the drug is taken with meals. Amiodarone has many more potential adverse effects than the development of bradycardia, so this is definitely one area where doctor and patient need to work closely together to establish the minimum effective dosage for the individual patient.

NEW YORK, NY. For the last few years manufacturers of pacemakers and implantable cardioverter defibrillators (ICDs) have made great strides in miniaturizing their products so as to make the implant less noticeable. This size reduction has, however, to a large extent come from the use of smaller and less durable batteries. Researchers at the Albert Einstein College of Medicine in New York recently completed a survey to determine if patients would prefer a smaller implant with a smaller battery and a commensurate shorter period before battery replacement surgery or a larger device with longer battery life.

The answer to the survey involving 156 patients was pretty unanimous – 90% preferred a larger device with a battery life of 5-9 years rather than a smaller one with a battery life of 3-7 years. There was no significant different in preference between men and women nor between younger and older patients, nor between patients with a first or replacement implant. The researchers conclude that the message is clear. Device longevity is more important than size.
Wild, DM, et al. Pacemakers and implantable cardioverter defibrillators: device longevity is more important than smaller size. PACE, Vol. 27, November 2004, pp. 1526-29

Results of LAF Survey VIII – Part 2

Part 1 of our 8th LAF survey covered the outcome of RF ablation and was published in the December 2004/January 2005 of The AFIB Report. This second part covers other surgical and catheterization procedures for eliminating afib. A total of 18 afibbers underwent other procedures as detailed below:

• Cryoablation (left atrium) - 2 respondents
• Maze procedure - 10 respondents
• ICD or pacemaker implantation - 4 respondents
• AV node ablation + pacemaker - 2 respondents
• Flutter ablation - 2 respondents

Cryoablation

Two male afibbers (ages 62 and 50 years) underwent cryoablation in March 2004 and April 2001 respectively. The March 2004 procedure was performed in Maastricht, The Netherlands (AZM) by Drs. Rodriguez and Timmermans and was 100% successful. Details about this particular procedure can be found in the November 2004 issue of The AFIB Report.

The procedure done in April 2001 was only partially successful and was followed by a touch-up RF ablation in January 2002, which was again only partially successful. The afibber involved is still experiencing episodes (12 episodes in the last 3 months lasting an average of 12 hours each); however, this frequency and duration is a substantial improvement over the near constant afib experienced prior to the ablations. This afibber is still taking antiarrhythmics and warfarin.

Thus, one out of two reported cryoablations was successful, the other partially successful. None of the ablatees were found to have any signs of stenosis. It is clear that much more data is required before I can draw any valid conclusions about the relative merit of cryoablation versus RF ablation, especially since cryoablation has been primarily done at European centers so far, and is just now beginning to become available in the United States.

Maze Procedure

The conventional maze procedure involves open-heart surgery, i.e. making a foot long incision through the sternum so that the ribs can be pushed aside and the heart exposed. The procedure is performed under general anesthesia and the use of cardiopulmonary bypass (heart/lung machine). The surgeon creates lesions (with a scalpel) on the heart wall so as to channel the electrical impulses across the atria from the SA node to the AV node and also creates lesions to prevent the chaotic electrical activity characterizing atrial fibrillation. The procedure has a high success rate, but does entail a much longer recovery time than do RF and cryoablations. The maze procedure is often done in conjunction with other open-heart surgery such as bypass operations, mitral valve repair, and valve replacement.

More recently, minimally invasive procedures have been developed in which the lesions are created with RF energy rather than with a scalpel. Doing the maze procedure this way avoids the necessity for a large incision to open up the rib cage and also eliminates the need for the use of the heart/lung machine. An excellent demonstration of one variant of the procedures, the Wolf mini-maze can be found at www.or-live.com/healthalliance/1217/

Ten afibbers responding to the survey had undergone either the full maze or a minimally invasive procedure. Their data and results are presented below.

None of the above demographic parameters were significantly different from those observed for afibbers undergoing RF ablation, nor was the number of episodes, their average duration or the total afib burden prior to the procedure significantly different between the two groups.

Success rate
Seven (70%) of the maze procedures are known to be fully successful. These procedures were performed between 1998 and 2001. One robotic maze procedure performed in March 2004 had not been successful as the afibber was still experiencing episodes, although far fewer than before. The remaining two procedures were performed early in 2004 (January and March). The patients have experienced no episodes, but are still on antiarrhythmics and warfarin, so it is too early to tell whether the procedures were entirely successful or not.

The successful procedures were performed at the following facilities:

• Cleveland Clinic - Dr. Patrick McCarthy
• Ohio State University Hospital - Dr. James Cox
• OSF St. Francis Medical - Dr. Dale Geiss
• Texas Heart Institute - Dr. Massumi
• Mayo Clinic, Rochester - Dr. Dearani

The success rate quoted for the maze procedure in the medical literature is 95-97%. Our very limited data would indicate a rate between 70 and 90%, most likely closer to 90%, and thus not significantly different from that obtainable with RF ablation performed at a top-rated facility.

Stenosis is unlikely to be a problem with the maze procedure and none was observed.

Recovery and adverse effects
Six out of the seven completely successful respondents regained consistent normal sinus rhythm immediately upon completion of the procedure, while one took a month to do so. One patient has been in consistent sinus rhythm since April 1998.

The time to full physical recovery was generally about 2 months, but one respondent reported a recovery time of 6 months and another a recovery time of 36 months. Only one of the 10 respondents still needed to avoid some triggers.

There were no serious side effects reported, but in one case the breastbone took longer than normal to heal because of a persistent cough.

There were no indications that blood pressure or heart rate were significantly changed due to the procedure.

Medication use
All respondents were taking antiarrhythmics and beta- or calcium channel blockers prior to the procedure. After the procedure only 3 out of 10 were doing so. None of the successful patients were on warfarin after the procedure.

Satisfaction with procedure
All respondents felt (subjectively) that the procedure had been a success and 9 out of 10 would recommend the procedure.

Implantable Pacemakers/Defibrillators

Pacemakers have long been used to assist ailing hearts in maintaining a steady beat. The most common reason for implanting a pacemaker is because the heart's own pacemaker (the sino-atrial node) has become too slow because of heart disease, age or the use of heart medications. Pacemakers are also used to provide a regular electrical impulse directly to the ventricles in case the AV (atrioventricular node) is blocked. A pacemaker can only increase the heart rate; it cannot slow it down.

The pacemaker consists of a small metal housing containing a battery and a small computer and is connected to one or two leads (wires) that are threaded through a vein beneath the collar bone and positioned in the heart using an x-ray monitor. The pacemaker itself is placed in a pocket beneath the skin just below the collarbone. The entire installation procedure takes about an hour or two and is performed under local anaesthesia.

From its original application as a means of supporting ailing hearts, the pacemaker has now emerged as a viable means of preventing cardiac arrhythmias. Their first application was in the prevention and termination of potentially fatal ventricular arrhythmias, but they are now also used in the prevention of atrial fibrillation. Some later models also have the capability of terminating fibrillation episodes by rapid bursts of pacing or by delivering an internal shock to the heart at much lower energy levels than what is required for the conventional external cardioversion procedure. These new devices are called implantable cardioverter-defibrillators or ICDs and are highly sophisticated and expensive electronic devices.

A typical, modern ICD acts as a miniature Holter monitor, has electronic circuitry that will provide precisely-timed impulses to the atria, thus preventing afib from beginning, and if an episode does start has the capability to terminate it. The ICD works in two ways to prevent arrhythmia. It continuously senses the heart beat and if it drops below a certain rate transmits electrical impulses to one or more electrodes implanted in the heart and connected to the ICD. This speeds up the heart beat and prevents bradycardia (dangerously slow heart beat) and the subsequent compensatory atrial fibrillation. This approach would work particularly well for vagal afibbers whose episodes are almost always preceded by bradycardia.

The ICD also continuously senses the heart rhythm and quickly notices the occurrence of PACs (premature atrial complexes) that often are a prelude to an afib episode, particularly among mixed and adrenergic afibbers. When the ICD senses PACs it speeds up the heart rhythm in a step-wise fashion until the PACs no longer appear. It then slowly reduces the heart rate to its original level and leaves the heart to do its own pacing again.

Modern ICDs are programmable just by holding a special wand in front of them, and the built-in Holter monitor, which can store lengthy heart beat records, can be read in the same way. They are indeed highly sophisticated devices and, as such, take extremely competent cardiologists to install and program.

Four survey respondents had had a programmable pacemaker installed in order to control their afib. Two reported complete control of episodes for 6 months or more and a much improved quality of life. Attaining this desirable state was, however, only achieved after considerable experimentation with the settings of the pacemaker, and, in one case, partial ablation of the AV node was required.

An excellent description of one afibber's journey to successfully ridding himself of afib is given in the April 2004 issue of The AFIB Report. One afibber with an ICD was able to remain afib-free with the aid of 2 x 100 mg/day of flecainide and one was still experiencing very brief episodes about every month or so. The improvement in the latter patient's condition only came about after the ICD was adjusted to provide only atrial pacing rather than dual pacing (both atria and ventricles).

Although it is impossible to draw any valid conclusions from just 4 responses, I see no evidence that an implantable pacemaker would be a better option for lone afibbers than a PVI carried out at a top-rated facility. Of course, in cases where access to such a facility is not available, the implantation of an anti-arrhythmia pacemaker would certainly be an option, particularly if supplements, lifestyle change, and medications have not worked.

Pacemaker Implantation with AV Node Ablation

Another approach to eliminating the effects of the fibrillation of the atria on ventricular performance is to isolate the AV node (the ventricular beat controller) from any extraneous impulses and feed it its "marching orders" from an implanted pacemaker. This procedure is considered a last resort only and is (or should be) reserved for afibbers with no other options. The procedure has five major drawbacks.

• It is irreversible.
• It does nothing to stop the fibrillation of the atria, which, in itself, can be quite uncomfortable, and necessitates continuing anticoagulation (warfarin) therapy.
• It makes the patient entirely dependent on the pacemaker. If it malfunctions or the batteries run out, the patient dies.
• It does nothing to remedy the fatigue and reduced exercise capacity caused by the fibrillation of the atria.
• It actually worsens the prognosis since it tends to convert paroxysmal afib to the persistent or permanent type.

The procedure itself is relatively safe and a Swedish study reported that recipients of the procedure reported an improvement in their quality of life.

Two survey respondents (one 76-year-old female and one 51-year-old male) reported that they had undergone AV node ablation and pacemaker implantation in February 2004 and October 2000 respectively. The procedure performed in February 2004 (permanent female afibber) was deemed successful by the recipient. She no longer experiences noticeable afib, is not taking antiarrhythmics or beta-blockers, and does not need to avoid any triggers. She is, however, still on warfarin. She would only recommend the procedure if medication does not work.

The procedure performed in October 2000 was not successful and was later followed by the open-heart maze procedure. This procedure was successful in eliminating afib, but the patient is still on antiarrhythmics and beta- or calcium channel blockers. He has been taken off warfarin.

The results of only two procedures clearly do not provide adequate information as to the viability of AV node ablation and pacemaker implantation. However, I see no evidence that would contradict current medical opinion that this procedure should only be used as the very last resort.

Flutter Ablation

Most cases of atrial flutter are associated with a conduction abnormality in the lower right atrium and can be successfully treated with a relatively simple ablation procedure that does not include penetrating the septum separating the right and left atrium. Both atrial flutter and atrial fibrillation may be at least partially due to an enlarged atrium and the two conditions can coexist in the same patient and one may convert to the other.

Two survey respondents (a 57-year-old male vagal afibber and a 61-year-old male mixed afibber) had experienced both afib and atrial flutter prior to their flutter ablations in May 2004 and March 2001 respectively. The ablations successfully eliminated flutter episodes, but afib episodes still occur unless controlled by medication.

This concludes the evaluation of the responses obtained in our 8th LAF survey covering surgical and catheterization approaches to dealing with afib. Radiofrequency ablation is clearly the most popular option and has an excellent success rate if performed by a highly skilled EP at a top-rated facility. The success rate for the maze procedure is also excellent. Insufficient data is available to gauge the success rate of cryoablation and pacemaker implantation with and without AV node ablation.