McHale: Here are some good references (below). One thing I didn't mention is the most reliable predictor of fibrosis progression is increasing age. Maybe there is no clear cut answer on the fibrosis issue at this point. As an aside, there is a study going on at the U of Utah regarding fibrosis reversal with Pradaxa! Yup. Pradxa reduces pulmonary fibrosis and they think it might work in atrial fibrosis! Not saying its a definite, but it sure is intriguing. Another aside... they found out that post people with afib have Utah scores of 2 and 3 (not 1 or 4). As you probably know, the Utah scoring system measures fibrosis progression. For me, I would need a clear cut answer to move forward with an ablation if that was my criteria. Again, quality of life/symptom reduction and high probability of success/young age are great reasons for ablation from what the experts say.



http://www.webmd.com/heart-disease/atrial-fibrillation/radiofrequency-catheter-ablation-for-atrial-fibrillation
Many people think that having ablation means they'll be able to stop taking an anticoagulant (also called a blood thinner), such as warfarin, every day to prevent stroke. But that is only true if your risk of stroke is low. Studies haven't shown that ablation for atrial fibrillation lowers your risk of stroke. So you'll still need to take an anticoagulant if your risk of stroke remains high. Your doctor can tell you about your stroke risk.
http://heartdisease.about.com/cs/arrhythmias/a/ablateafib.htm
Even with patients who appear to be ideal candidates for ablation of atrial fibrillation, the arrhythmia recurs in at least 15 - 20% within one year, and in 25 - 50% within three to five years. Furthermore, even when an ablation procedures appears to be successful, the risk of stroke (the most dreaded complication of atrial fibrillation) remains elevated. So it is important to continue with therapy to prevent strokes.
http://www.stopafib.org/newsitem.cfm/NEWSID/402/Cleveland%20Clinic%20atrial%20fibrillation%20experts/afib%20chat%20transcript
sidepocket: Specifically, how is cure defined regarding ablation for AFIB?
Dr Walid Saliba: A significant decrease in episodes of atrial fib to a level that is satisfactory to the patient.
Sadiegrey: Is it true that if your afib only lasts approximately 3-8 hrs there is no chance of you forming a blood clot that is the worry of stroke? Could I just be on aspirin instead of Coumadin, which I don't like to take. I've had 15 bouts of afib in 14 mos and most were back in rhythm with iv diltiazem within 3-7 hrs. I'm 70 female
Dr David Van Wagoner: No, this is not accurate. Even brief episodes of AF are associated with increased risk of stroke. However, the risk of thrombus formation is time dependent, so the risk is greater for 24 hours AF than for 5 minutes of AF.


petey

"most" not "post"

Pete,
Yep everything you posted is right on and i am fully aware of all of it hence the reason I haven't moved forward with an ablation. My symptoms are are pretty a symptomatic at this point but I know when I'm out of wack like right now it's just uncomfortable......don't even know if its AFIB. I know of a top rated doctor that had a unfortunate death with someone with laser ballon ablation during the first few tries .......I won't name the hospital....they probably used too much energy or burned too long. Being I was a CHADS 0 before my TIA an ablation with a top EP would have kept me Afib free for the most part and off blood thinners so now that's changed. An ablation will cut down on stroke risk which is my concern especially when I must go off them for elective procedures or major surgery. Also hopefully stop the progression to persistent or permanent. Problem is they still don't know a damn thing about this disease as was evident with regards to the recently discovered info on fibrosis.....maybe

Pete you're right basically a patient's desire to stop taking anticoagulants, such as Coumadin (warfarin) or Pradaxa (dabigatran), is not a factor in the clinical decision for whether a patient is a candidate for catheter ablation. With that said most do not go on or stay on these blood thinners so many opt for ablation.
It's important to seek treatment sooner rather than later, particularly if you are still having afib episodes while taking antiarrhythmic medication . That's because atrial fibrillation is a progressive disease. If afib is not treated, patients can transition from paroxysmal atrial fibrillation to persistent atrial fibrillation and eventually to longstanding persistent atrial fibrillation. The greater the severity of atrial fibrillation, the harder it is to cure.
Also the guidelines have recently changed and ablation can now be considered a first line of defense. So if one is a symptomatic do you opt out of treatment whether it be anti arrhythmic or ablation and just get on anticoagulation?

It's a hard decision especially if you're not symptomatic.......

I don't believe making 55-70 is the answer which I'd done for a routine PVI. But the again many have been "cured" With only paroxysmal AFIB done at top tier hospitals and EPs like Natale.
That's why I'm hoping and believe FIRM without PVI is the answer!

Where's the Edit!

55-70 Burns vs 7-15 or FIRM only

McHale:

Thanks for the good discussion... it is great to bounce things back and forth. Being an asymptomatic, longstanding persistent (chronic) afibber whose rate is well controlled, I have thought long and hard about what the "damage" is by staying in afib. Here is what I came up with: Although I'd like this whole thing to go away, it isn't likely to happen. I also learned that I will not live forever. Prior to afib, I thought I was. So the path I am taking is the safest one even if I lived 3 months less on the 90 year old end (God, if you are listening, I'd still like the 3 months).

Let's say fibrosis increases your stroke risk... strangely, it is not on CHGADS risk factor... but let's use logic... maybe it should get 1 point as being structural heart disease. So how far does it move the risk really? ... and with Pradaxa, about 90% of the risk is eliminated.

Next... heart failure risk... with rate control, your risk of this is minimal. My EP, of course, checks my ejection fraction twice a year.

Atrial size... mine decreased significantly (6 cm) to a good size since I was treated with rate control.

This is a conservative approach. I feel that the ablation techniques will improve such that chronic afibbers will do well with ablation at some point. As far as reversal agents are concerned... they are close to having them ready for the public... it is coming... they exist... just not approved.

So I'm thinking, what if I stay in afib until they have something available that really cures afib with less risk? Seems reasonable to me. For that reason, I think my decision is easier. For a young person with symptoms and paroxysmal afib, there is a greater need... More active life (theoretically), greater expectations from their bodies (still doing aggressive sports), longer time to be in afib and potentially more "damage", more time to have a stroke (or live with its consequences), life limiting symptoms, and "on and off" afib that makes drug management more difficult for rate control.

I really feel that taking an anticoagulant, exercising, controlling weight, eating well, taking whatever supplements that improve heart health, and keeping a healthy mental attitude can reduce the stroke risk also.

Do what you can... and live every day.

petey

CHADS, not CHGADS.

... and you know, FIRM ablation may be the answer for chronic afibbers... we will see.
petey

Once again I'm both impressed and very grateful for the information you share here.

Your point about the loss of contraction in the atria post-ablation raises a question for me. My nuclear stress test results from a few weeks ago measured my ejection fraction at 67%. Would that number likely be higher if I had not undergone the PVI ablation? Would loss of contraction be measurable? I know the ventricles are responsible for the pumping but how much of ejection is dependent upon the atria? These are questions I will pose to my EP but thought I'd get your take on it.

The heart is an extraordinary muscle(hearty-no pun intended), capable of healing extremely well. This is likely a contributing factor for some post-ablation patients several years down the road, combined I'm sure with residual or naturally-progressive remodeling. 20 years from now so much more concrete data will be available on this subject and that's great news for the next generation of Afibbers.

I'm sure anyone that's had an ablation wonders about the long term and I'm in complete agreement that the procedure should not be considered THE treatment for every patient, it's aggressive and invasive. As treatments are improved upon every person that underwent a PVI will likely wonder if they made the right choice at the right time. The FIRM procedure is the perfect example. Only time will tell so I won't lose sleep worrying or wondering, I've done enough of that.

Pete,very excellent discussion and I'm glad you see things from the different vantage points in regards to age, paroxysmal vs persistent/permanent, remodeling etc......
What do I do? Im Paroxysmal have AFIB AFIB every 7-10 days but I think lately it's been a little more frequent. My left atrial diameter last year was 3.0 after 13 months on Flecainide down from 4.6 and 4.4 the prior 2 years. Those numbers with the enlarged atrium I believe I was in some kind of arrhythmia definitely the 4.6cm number was AFIB so was that atrial stretching which is a temporary condition or did Flec truly prevent or reverse electrical and structural remodeling as was tted in the Europace paper? My last stress test was excellent with a high degree of exercise tolerance. If my next stress shows in a few months an enlargement again do I go for it before it becomes more difficult to ablate? I really want FIRM without PVI . Dr Reddy and Dr Stinberg turned me down last year for FIRM but not sure why and if it included a PVI.? This is what my dilemma is?

Steve,
67% is an excellent ejection factor! I'm sure that during the test and a normal resting EJ is about 55%
No worries with your pumping action