Afibs -and- Left Atrial Enlargement

Many people live with permanent AF as long as the rate is low. They use medications to keep the rate low. This doesn’t work for everyone.

Another option is what is called pace and ablate where they ablate the AV node and insert a pacemaker. The pacing helps preserve the heart’s structure as the rate can no longer go high.

My 82 year old husband has had a-fib on and off since 2004. Treatment has been amiodarone and an anti-coagulant, then cardio-versions and ablations. He has had about 10 cardio-versions and 3 ablations. He is currently in normal sinus rhythm after the last ablation but is still taking 200mg amiodarone and Xeralto daily. His cardiologist said she will not do any more ablations if he goes back into a-fib and the next step would be a pacemaker.

Atrial fibrillation is dangerous, but it's not generally lethal. Instead, it is the other subsequent outfall events that can be very serious, and these include stroke due to the risk of clotting in the Left Atrial Appendage (LAA), atrial enlargement, ventricular enlargement, mitral valve prolapse, and what is known as 'remodeling', the latter meaning the heart's substrate, the underlying myocardial tissues, begin to develop collagen deposition and fibrosis. Eventually, with all that change and degradation, the heart moves into 'heart failure', which is really heart insufficiency. It doesn't literally 'fail'. So, the less time spent in fibrillation, the better. AF begets AF...that's the aphorism in the medical community. The more AF you experience, the more your heart wants to be in AF...IOW, 'remodeling.' The same is true for atrial flutter, incidentally.
The best EPs in the land will do multiple ablations on the same patient, but with consideration of history, prognosis, current physical condition, etc. The two top EPs that I know of are Dr. Andrea Natale at the Texas Cardiac Arrhythmia Institute in Austin, and Dr. Pasquale Santangeli at Cleveland Clinic. Those two are wizards who will take a close look and assessment of each case and tell you if he can do better than the previous attempt. I know of several people who went to them last, after multiple ablations, and they fixed them up. One had five (5) ablations, but Natale corrected his arrhythmia and he is now 6 years free of AF. So, the skills and experience of the EP matter much more than the technique they use.
As forensicfairy has said, the last attempt to correct the AF is to 'nuke' the AV node, also via ablation (so your husband gets at least one more ablation no matter what...), and with that they implant an ICD or a pacemaker that 'paces' his heart's rhythm so that it is coherent and not chaotic. However, and this is important to know; AV node ablation with pacemaker implantation does not necessarily correct AF. Some patients stay in AF anyway, the odd cases.
If you have the resources and the time, I would advise consulting Natale or Santangeli. Natale practices at his clinic in Austin, but also does procedures at Los Robles and La Jolla, and occasionally other hospitals (yes, he is in that much demand, and is a very busy, and successful, guy!).

I have A-fib,I've had 4 cardioversions and after each one except so far the 4th one,came back sooner and sooner. I just had my 4th in April. In recovery A-fib was trying to come back. My heart rate was in the 30's so they had to keep me longer until it reached a safe rate to be discharged. Although as soon as the cardiologist came into the room he said that my heart is huge. I said the atria,he said yes. So far I've only had a few pains in my chest,but no signals of A-fib..yet. I'm so fatigued and at times short of breath. I'm tired of it. I had SVT for many yrs.and in 2019 it turned into A-fib after my partner died in her sleep. My cardiologist is in Cathloic Medical Heart and Vascular Hospital in Manchester,NH. It's a great place! Any suggestions???

You have extensive enlargement of your left atrium, and quite possibly some enlargement of your left ventricle (?). The former is the most worrisome because it usually leads to mitral valve prolapse, and that CAN cause AF. It also works the other way around: AF can lead to atrial enlargement, and at the same time collagen deposits, and fibrosis, and those can cause mitral valve prolapse.
I'm sorry to see that your partner died when neither of you could say a last goodbye, although I guess dying in her sleep beside you is a pretty decent way to have it all end considering the other myriads of ways possible. And no wonder you lurched into AF at that time.
I would counsel you to consult a really good, busy, and experienced electrophysiologist and have an ablation done if he/she thinks it's a good idea. You really want your AF to stop so that your heart can commence at least some reparation. It has been established that an enlarged left atrium will often reduce in size substantially once it is not under the stresses it experiences when being inflated all the time by the powerful ventricle below it.

My husband 77 has enlarged left atrium. I’ve learned that can cause Afibs, or vice versa. Sadly no rhythm methods - ablations, cv, Amiodarone- worked for him. Possibly due to flutters? EP says next step is Rate control with meds or pacemaker. What to do?

My understanding is that atrial enlargement is a response to high blood pressure. High blood pressure can be a systemic problem, maybe related to reduced kidney function (the kidneys are key in controlling BP), or it can be a problem with the left ventricle, or even slow/stiff valves that the ventricles are trying to force the needed volume of blood through. If the left atrium is what is enlarged, chances are that it is being 'blown back' or 'blown up' by the powerful left ventricle below it. The mitral valve between them is meant to be a one-way valve. The left atrium receives oxygenated blood from the lungs, and pumps it one way through the mitral valve into the left ventricle. That's the 'lub' in the 'lub-dub' of a heartbeat. The left ventricle receives its electrical stimulation a fraction of a second after the atrium does, and it contracts forcefully. Sometimes too forcefully and it may enlarge in time as a result. But let's deal with the enlarged atrium: the ventricle contracts, and like any fluid, the blood will flow into the path of least resistance. In a normal heart, mitral valve in good order, the blood surges up into the aorta, curves as the aorta curves, and branches off blood to the various arteries coming off the aorta. When the mitral valve is compromised, it leaks. It doesn't keep the surge of pressurized ventricular blood from being flushed back into the atrium. The atrium is trying to refill with venous blood from the lungs (yes, 'venous' because all blood flowing to the heart is 'venous', meaning the pulmonary veins return oxygenated blood to the heart, which everyone needs to happen). But the ventricle is also forcing blood back into the atrium through the weakened/prolapsed mitral valve. If the left atrium is beating out of rhythm due to AF, it might beat at the same time that the ventricle beats. Guess who wins! The larger and more powerful ventricle inflates the left atrium as if it were a balloon! Eventually, it literally enlarges. But, in many cases, with corrected AF, the left atrium can reduce in size a significant degree. This is good!
A pacemaker is not a guarantee that he will be free of AF. What it might do is to reduce the rate AND the frequency quite a bit, which will help. It also can pace the left ventricle to not be out of sequence so often, or to not speed up with what is called 'rapid ventricular response' (you can google that phenomenon).
Lastly, please note that I am not an expert in this: I have no formal training.

Hi
I have Rapid & Persistent AF. Now at 6 years. 2 years 3 months on BBs two separately did not lower my H/R enough.
A Private Cardiologist finally immediately put me CCB Diltiazem CD. 180 CD mg with Biso too much at 1/2.
Today no Bisoprolol. Diltiazem 120 CD only taken early afternoon. So Diltiazem took me down dramatically. From 165 to 51 in 2 hours!
CCBs there are a number of them which differ for various conditions. I had an enlarged LA. But with fast Venticular response. Systolic working function normal.
Hope this helps.
Remember to separate a CCB & BB by 12 hours.
cheri JOY

Thanks.
My husband had been taking Diltiazm which controlled his high BP. EP switched him to Amiodarone after ablations followed by CV but he’s still in afib/irregulars/flutters. So he just switched out dangerous Amiodarone to CCB Norvasc. I’m hoping that establishing rate control will keep him from fatigue and no appetite. Then might be pacemaker? Sigh.

Thanks so much for your helpful explanation.

He’s still in afib/irregulars/flutters after ablations & CV . So EP just switched out Amiodarone to CCB Norvasc. I’m hoping that establishing rate control will keep him from high fatigue and no appetite. Then might be pacemaker? Sigh.