The Patient’s History and Clinical Information

The patient is a 68 year-old male diagnosed with paroxysmal atrial fibrillation.

He shows unstable angina with normal coronography.

Patient initially suffered acute myocardial infarction and was treated with primary PTCA (angioplasty).

He later experienced the onset of paroxysmal atrial fibrillation episodes which were treated with Amiodarone, which was stopped due to bradycardia.

Subsequently, Flecainide was used as therapy, but was found to be ineffective.

Due to the occurrence of episodes almost on a daily basis, the patient had a cardiologist visit following an ECG Holter. This showed tachyarrhythmia as a result of atrial fibrillation and numerous episodes of possible unsustained ventricular tachycardia, both during fibrillation and sinus rhythm.

At the time of that specialist visit the patient’s domiciliary therapy included: Cardioaspirin, Almarytm, Enapren and Totalip.

The cardiologist diagnosed “paroxysmal atrial fibrillation as a result of post-infarction cardiopathy. Ventricular arrhythmias, possibly of an iatrogenic nature.” Therefore, transcatheter ablation with RF (radiofrequency) of pulmonary veins was prescribed to be carried out. At that point the patient’s domiciliary therapy was amended to: Coumadin, Enapren and Totalip.

The patient was hospitalized for transcatheter ablation, the details of which are as follows:

1) CONCLUSIONS:

“Procedure duration: 240 mins. Fluoroscopy duration: 31 mins. The procedure was successful. Ablation of the pulmonary veins was carried out, achieving the circumferential isolation of the right veins and the left common ostium. During the procedure there was a repeated conversion of atrial fibrillation to isthmus-dependent atrial flutter (common typical flutter). The procedure was completed with the creation of a cavotricuspid isthmus block line (AD inferolateral–DP 130 msec). During the procedure, the patient was subjected to electric cardioversion (150-J effective biphasic shock) to optimize mapping in sinus rhythm.”

2) SUMMARY OF RESULTS:

“Patient with a history of paroxysmal atrial fibrillation as a result of post-infarction ischemic cardiopathy. Class III bradycardia medication was badly tolerated by the patient.

Ablation with circumferential isolation of right pulmonary veins and common left ostium. Carlo Merge electroanatomical mapping was used, with cardiac angio MRI image.

During the procedure there was a repeated conversion of atrial fibrillation to common typical atrial flutter (isthmus-dependent). Therefore, we completed the procedure by creating linear lesions in the cavotricuspid isthmus region. We recommend continuing with anticoagulant therapy for at least six months.”

The patient was discharged with a normalized heart rhythm. After 3 months, the patient had a relapse with a similar clinical picture as that preceding the transcatheter ablation.

Online Doctor Consultation – Medical Questions:

1) What is the best therapeutic strategy to adopt?

2) Specifically, can another ablation be carried out?

3) If so, which center worldwide has the best success rates?

4) What is the prognosis?

Expert Report and Opinion:

The patient is a 68 year old gentleman with a history of coronary artery disease, Paroxysmal Atrial Fibrillation and possible episodes of Non Sustained Ventricular Tachycardia. The patient did not tolerate amiodarone treatment because of symptomatic bradycardia and class IC medication was not effective. He had a successful atrial fibrillation ablation, using CARTO merge, including right inferior isthmus ablation. The final result of the ablation is not clear as the patient (with paroxysmal atrial fibrillation) required cardioversion.

According to the most recent guidelines of the American Heart Association/ American College of Cardiology/ Heart Rhythm Society/ European Society of Cardiology, CO ablation of atrial fibrillation is indicated in patients not tolerating amiodorone (or other anti-arrhythmics). As ablation may require more than one procedure, it may still be indicated for this patient.

So, in response to your online medical questions:

1. Ablation is the best treatment if medical treatment is not effective or not tolerated.

2. Ablation may be required more than once, even, occasionally more than twice.

3. The most experienced centre in the world is in Milano, Dr Carlo Poppone at the S. Raffaele Hospital.

4. The prognosis is good in Paroxysmal Atrial Fibrillation (however, as mentioned, often after more than one procedure).