Recurrent AF After Ablation
A 52-year-old Asian-Indian man presented to the clinic for follow-up after undergoing pulmonary vein isolation by radio frequency ablation for his paroxysmal atrial fibrillation (AF) 3 weeks ago. The patient's medical history was notable for hypertension, chronic obstructive pulmonary disease (COPD), dyslipidemia, and obesity class I (body mass index = 34 kg/m2). He complained of palpitations and progressive fatigue. The patient's current medications included metoprolol 25 mg daily, lisinopril 10 mg daily, rivaroxaban 20 mg daily, aspirin 81 mg daily, albuterol 2.5mg/3ml nebulizer solution, and atorvastatin 40 mg daily.
During the patient's physical exam, his vital signs were a heart rate of 80 bpm, irregularly irregular pulse, respiratory rate of 22 breaths per minutes, and blood pressure of 140/90 mm Hg, SaO2 = 88%. He had a short, thick neck (neck circumference = 18 inches), his breath sounds were diminished, and his heart sounds were distant. He had no evidence of jugular venous distention or lower extremity edema.
An electrocardiogram showed AF with ventricular response ranging about 59-83 bpm and borderline R wave progression (Figure 1). Low voltage was present diffusely, which is a nonspecific finding that might be seen with obesity.
In the echocardiogram, the left ventricular ejection fraction appeared to be 50-55%. The left ventricle appeared to be normal in size, but the right ventricle was severely dilated. The right and left atrium were also severely dilated. Right ventricular systolic pressure was moderately elevated (45.4mm Hg), and there was severe tricuspid regurgitation (Figure 2).
Which of the following is the best course to prevent recurrence of AF?