Northside Hospital Gwinnett Family Medicine Residency Program, Strickland Family Medicine Center, Lawrenceville, GA (Dr. Osayande); Northside Hospital Cardiovascular Institute, Atlanta, GA (Dr. Sharma) amimi.osayande@northside.com
Dr. Osayande reported no potential conflict of interest relevant to this article. Dr. Sharma received a grant from Biotronic in 2019 to support an educational conference; was provided with honoraria in 2019 for serving on the speakers’ bureaus of Pfizer and Bristol Myers Squibb; and received financial support for education and training from Medtronic (2018) and from Abbott, manufacturer of the EnSite Precision Cardiac Mapping System described in this article (2018 and 2019).
Cardiac examination is significant for an irregular rhythm without murmurs, rubs, or gallops. His lungs are clear bilaterally; his abdomen is soft and nondistended. His extremities show no edema.
Testing. You obtain an electrocardiogram, which demonstrates a controlled ventricular rate of 88 bpm and AF. You order a complete blood count, comprehensive metabolic panel, tests of hemoglobin A1C and thyroid-stimulating hormone, lipid panel, echocardiogram, and a chest radiograph.
Results. The chest radiograph is negative for an acute cardiopulmonary process; cardiac size is normal. Aspartate aminotransferase and alanine aminotransferase levels are higher than twice the normal limit. The echocardiogram reveals an estimated left ventricular ejection fraction of 55% to 60%; no structural abnormalities are noted.
In which AF patients is catheter ablation indicated?
Ablation is recommended for select patients (TABLE 13,6) with symptomatic paroxysmal AF that is refractory to AAD or who are intolerant of AAD.3,6 It is a reasonable first-line therapy for high-performing athletes in whom AAD would affect athletic performance.3,10 It is also a reasonable option in select patients > 75 years and as an alternative to AAD therapy.3 Finally, catheter ablation should be considered in symptomatic patients with longstanding persistent AF and congestive heart failure, with or without reduced left ventricular ejection fraction.3
CASE
You inform Mr. Z that his symptoms are likely a result of symptomatic paroxysmal AF, which was refractory to flecainide and amiodarone, and that his abnormal liver function test results preclude continued use of amiodarone. You propose Holter monitoring to correlate timing of symptoms with the arrhythmia, but he reports this has been done, and the correlation confirmed, by his previous physician.
You explain that, because the diagnosis of symptomatic paroxysmal AF refractory to AADs has been confirmed, he is categorized as a patient who might benefit from catheter ablation, based on:
the type of AF (ie, paroxysmal AF is associated with better ablation outcomes)
persistent symptoms that are refractory to AADs
his intolerance of AAD
the length of time since onset of symptoms.
Mr. Z agrees to consider your recommendation.
Continue to: What are the benefits of catheter ablation?
