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.
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Figure 1
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Medications:
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.
Physical Exam:
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.
The correct answer is: C. Urgent Electrical Cardioversion and antiarrhythmic therapy.
Recurrence of atrial fibrillation (AF) or atrial flutter shortly (within three months) after pulmonary vein isolation ablation (PVI) is common and does not warrant urgent repeat ablation. Joshi et al.1 reported up to 50% atrial arrhythmia recurrence during this period, which often resolves. Management should be tailored to the patient's clinical presentation.2 The best recommendation from the options above is to proceed with electrical cardioversion (DCCV) with or without the use of an antiarrhythmic drug (AAD) (option C). There is some thought that recurrences post PVI ablations should be addressed promptly and sinus rhythm should be reestablished. Oral et al.3 reported that patients post PVI who underwent DCCV within 30 days of recurrence had a better chance of remaining in sinus rhythm compared to delayed DCCV (beyond 30 days). DCCV delivered in the emergency department promptly resolved symptoms. Hypotension also resolved and an echocardiogram was not performed to look for delayed cardiac tamponade related to the ablation procedure. The patient was sent home the same day.
Atrio Ventricular node ablation and pacemaker implant is premature during an early period post-ablation. Adding more rate control medications and waiting for spontaneous termination is reasonable, but not for this patient (option D) since he is highly symptomatic and diltiazem may further aggravate hypotension.
The use of an AAD temporarily after discharge for AF recurrence post PVI is common and while it reduces early recurrence, it does not change the long term success rate of the procedure.4 The highly symptomatic nature of this patient's clinical presentation makes him a candidate for pharmacotherapy to reduce recurrences until the success of the ablation could be formally evaluated outside the first 3 months. This patient was started on amiodarone, which was discontinued at 4 months post ablation, and has been free of symptoms 10 months post ablation.
References
- Joshi S, Choi AD, Kamath GS, et al. Prevalence, predictors, and prognosis of atrial fibrillation early after pulmonary vein isolation: findings from 3 months of continuous automatic ECG loop recordings. J Cardiovasc Electrophysiol 2009; 20:1089 –1094.
- Calkins H, Kuck KH, Cappato R, et al. 2012 HRS/EHRA/ECAS expert consensus statement on catheter and surgical ablation of atrial fibrillation: recommendations for patient selection, procedural techniques, patient management and follow up, definitions, endpoints and research trial design. Heart Rhtyhm 2012; 9:632-696.e21.
- Baman TS, Gupta SK, Billakanty SR, et al. Time to cardioversion of recurrent atrial arrhythmias after catheter ablation of atrial fibrillation and long-term clinical outcome. J Cardiovasc Electrophysiol 2009;20:1321–1325.
- Leong-Sit P, Roux JF, Zado E, et al. Antiarrhythmics after ablation of atrial fibrillation (5A Study): six-month follow-up study. Circ Arrhythm Electrophysiol 2011; 4:11–14.
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