A 65-Year-Old Male With Symptomatic Paroxysmal and Persistent AFib

A 65-year-old male has symptomatic episodes of paroxysmal AF despite treatment with sotalol 80 mg twice daily or flecainide 150 mg twice daily. When he elected to discontinue antiarrhythmic medication, atrial fibrillation episodes were persistent.

Figure 1: A 65-Year-Old Male With Symptomatic Paroxysmal and Persistent AFib
His past medical history was significant for orthopedic injuries and corrective surgery, in addition to AF for the last 15 years, typically initiated after big meals and during sleep. Cardiac imaging revealed a structurally normal heart. ‎His brother and father both had AF.

CHADS-Vasc score is 1 based on age.

Medications: Flecainide 150 mg PO BID, Verapamil 180 mg PO daily, Aspirin 81 mg PO daily and Simvastatin 20 mg at PO qHS.

ECG: Sinus rhythm with a right bundle-branch block and left anterior fascicular block, PR interval is 200 milliseconds.

Cardiac MRI: Four pulmonary vein ostia were normal sized (range 18 - 27 mm). LVEF 58% with normal LV size and function. The late enhancement images showed no evidence of prior infarct, inflammation or infiltration of the LV myocardium. The LA antero-posterior dimension was 38 mm.‎‎

Based on the above information, the best initial catheter ablation approach for this patient is:

Show Answer