Recurrent AFib Shortly After Pulmonary Vein Isolation
A 62-year-old man presented to the emergency department 3 weeks after a pulmonary vein isolation procedure complaining of severe palpitations continuously for the last 24 to 30 hours. He has a history of hypertension and a 2 year history of symptomatic paroxysmal atrial fibrillation, which occurs 3 times weekly and last for 6 to 10 hours. He had been free of symptoms since the ablation.
In the recent past rhythm control was attempted with flecainide, which was discontinued due to an unbearable metallic taste and dronedarone, which was discontinued immediately before ablation due to gastrointestinal side effects.
Rivaroxiban 20 mg once daily, carvedilol 25 mg twice daily, lisinopril 5 mg once daily. Patient has not missed a dose of medication since procedure.
Vital signs: pulse 105bpm irregularly irregular, blood pressure 89/60 mmHg.
Adult male, no apparent distress but looks concerned.
Clear lungs to auscultation.
Cardiac exam: irregularly irregular rhythm, tachycardic. No murmurs.
No lower extremity edema.
Ancillary data is remarkable for:
Prior EKG with normal sinus rhythm and left bundle branch block.
Recent echocardiogram showing normal LV systolic function and LV hypertrophy.
Normal serum creatinine, normal D-dimer, normal TSH.
EKG in the ED is shown in Figure 1.
Of the following choices, the best recommendation for the management of this patient is: