51 Year Old Man Undergoing Pulmonary Vein Isolation

The patient is a 51-year-old man with history of hypertension and hyperlipidemia who presented with several weeks of progressive fatigue and four days of shortness of breath, dyspnea on exertion, orthopnea, and lower extremity edema. He was diagnosed by history and examination with congestive heart failure. Transthoracic echocardiography left ventricular dilatation (end-diastolic internal dimension 6.7 cm) with severe global systolic dysfunction (EF 22%), severely depressed right ventricular function, a severely dilated left atrium, and moderate mitral regurgitation. Right heart catheterization showed elevated filling pressures, with a pulmonary arterial occlusion pressure of 31 mmHg, and depressed cardiac index of 1.8 L/min/m2. Coronary angiography showed 20% stenosis of the mid-LAD and no other significant epicardial coronary disease. Cardiac MRI showed a small focal endocardial area of delayed gadolinium enhancement in the mid-inferior wall.

Figure 2: 51 Year Old Man Undergoing Pulmonary Vein Isolation

He was treated for newly diagnosed non-ischemic cardiomyopathy and congestive heart failure with aggressive afterload reduction and diuresis, and he was discharged on hospital day 4 in good condition. He presented to the clinic 2 weeks later with increasing exertional fatigue, intermittent nausea, and “agitation.” He denied chest discomfort or palpitations. The EKG from the clinic visit is shown in Figure 1.

He was admitted for initiation of anticoagulation and TEE-guided cardioversion, performed without complication. He was discharged on enoxaparin and warfarin. Symptomatic atrial fibrillation recurred within one week, and amiodarone therapy was initiated. A second cardioversion was performed, again with early recurrence of symptomatic atrial fibrillation. After a discussion of the potential risks and benefits, he was referred for pulmonary vein isolation.

The patient remained on warfarin, and on the morning of the procedure the following studies were obtained:

Laboratory Values:

Table: Laboratory Values
Sodium: 138 (134 - 149 mEq/L) WBC: 9.0 (3.5 - 11 x103/uL)
Potassium: 4.1 (3.3 - 4.7 mEq/L) Hgb: 13.9 (13.5 - 17.5 g/dL)
Serum creatinine: 1.3 (0.5 - 1.4 mg/dL) Platelets: 305 (150 - 450 x103/uL)
Magnesium: 2.2 (1.6 - 2.5 mg/dL)
PT: 24.6 (12.1 - 14.9 secs) INR: 2.1 (0.9 - 1.1)

Transesophageal Echocardiogram:

Figure 1: 51 Year Old Man Undergoing Pulmonary Vein Isolation

Left ventricular performance severely reduced. Right ventricular performance moderately reduced. No intracardiac mass or thrombus, but spontaneous echo contrast noted in the left atrium. Mitral annular dilation with moderate-severe mitral regurgitation. Mild-moderate tricuspid regurgitation.

Electrophysiology Procedure:

Heparin bolus and continuous infusion was administered prior to double transseptal puncture to achieve an activated clotting time (ACT) >350 seconds (secs). During electroanatomic mapping, the ACT was noted to have fallen to 260 secs. Intracardiac echocardiographic (ICE) imaging from that time is shown in Figure 2 and the accompanying video.

Based on the above information and findings, the next best step in management would be:

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