Failure of Antiarrhythmic Medications

68-year-old male without a significant cardiac history was diagnosed with atrial fibrillation (AF) 12 years ago (at age 56). Initially the episodes were 3-4 times/year but over the next few years the paroxysms increased to weekly. No precipitating factors identified. Initially treated with beta blockers with moderate success and approximately 5 years ago propafenone was added which suppressed most of the episodes. However, six months ago the paroxysms of AF returned and propafenone was changed to amiodarone. Unfortunately, the AF continued. The episodes last from 1-4 hours. He was referred to the Atrial Fibrillation Center for management.

Figure 1: Failure of Antiarrhythmic Medications
PMHx: hypercholesterolemia, BPH

Medications: amiodarone 200 mg/day, aspirin 325 mg/day, atorvastatin 40 mg/day

SHx: retired physician, exercises 3X week for 30 min on an elliptical, no smoking, alcohol averages 4 drinks/week

PEx: BP 124/74, P 45. CV: regular rhythm without murmurs Lungs: clear Ext: no edema with 2+ distal pulses

Labs: WNL (CBC and chemistry)

Echocardiogram: LV function is normal; no valvular abnormalities; LA size 4.0 cm

ECG: NSR (See Figure 1)

What is the next most appropriate step in the management of his atrial fibrillation?

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