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I have persistent atrial fib / flutter and HCM. Is it better to try a repeat ablation or try new medicines? 

I am a 55 year old female; I had cryoablation pvi locally Oct 2012. For 12 years, I have been under care of a cardiologist for HCM [hypertrophic cardiomyopathy]. Stress echoes normal. Two maternal uncles died from HCM arrhythmia in 1970s. My brother has HCM, atrial flutter, VT, and both my parents have afib. I have experienced intermittent short bursts ( 5 -90 minutes) of SVT [supraventricular tachycardia] for 4-5 years. RVR rate mid 160s always, probably 1-2 times monthly. I am a CV ICU nurse and was able to capture a long run on telemetry strip and short asymptomatic runs captured on a 24-hour Holter monitor. Longer episodes were symptomatic; experienced as profound fatigue with irregular palpitation. I was on Metoprolol for a couple of years. . . . The only trigger I knew was dehydration. I did stop all caffeine and alcohol.  July 2012 it was as if something flipped a switch and I began having 4-20 runs of arrhythmia every day. . . . No effect at all from diltiazem, started on sotalol and anticoagulation with warfarin . . .  with sotalol, I started having chest tightness, dyspnea, and exercise intolerance. I am still on the sotalol 120 mg BID. It did slow rvr rate to 120-130 due to variable conduction. It was then obvious my symptomatic arrhythmia was atypical atrial flutter. . . . Ablation went well. I had no arrhythmia till day 8 then fast symptomatic. I remain on sotalol and warfarin during the blanking period and still having some arrhythmia, improved overall. My symptoms from sotalol have not improved. I do not want to stay on it. I see my EP in 2 weeks and he is planning on output telemetry monitoring. I do not want to take amiodarone and would agree to second ablation before taking it. My questions are: 1. Is it a good idea to try to change meds at this point? If the best thing is to grind through another 3-4 months on sotalol, I will force it. 2. Is it likely to be of benefit to wait 6 months to reconsider repeat procedure? [Edited for brevity.]

submitted by Connie from Ohio on 12/7/2012


by Texas Heart Institute cardiologist, Ali Massumi, MD    

Ali Massumi, MDAntiarrhythmic choices for someone with HCM are limited. Dofetilide and an old medicine, disopyramide, can be alternatives to sotalol. Final results of ablation should have been completed in 4 to 6 months. Another ablation is a an option if your arrhythmia is suitable for that. If you don't have prolonged atrial fib for several hours, then the benefits of repeat ablation procedure are questionable.   

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Updated January 2013
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