The patient is a 69 year-old man diagnosed with persistent recurrent atrial fibrillation.

 

The onset of symptoms included acidity, burping, difficulty digesting, feeling of fullness in stomach, reflux, palpitations and feeling of difficulty breathing. The patient sought medical treatment and was admitted to hospital for diagnostic tests. Based on test results he had eradicating therapy with antibiotics and esopral 40.

 

With this therapy, the patient achieved a significant improvement of symptoms for a time but then reported sudden palpitations. This required him to have a basal ECG on the same day, which showed atrial fibrillation at 140 beats/minute. He was therefore prescribed Lopresor 100, Coumadin 5 mg and Esopral 40. Thyroid tests were also carried out, the results of which were within normal limits.

 

A later ECG carried showed signs of atrial fibrillation with a reduced pulse of 90/minute.

 

A subsequent transthoracic echocardiography was done and showed the following: Left ventricle slightly hypertrophic (see septum IV) and normokinetic; Doppler mitral curve with E-wave deceleration time within normal limits; minimal color signal from mitral reflux; slight dilation left atrial dilation; normokinetic right ventricle; inferior vena cava mobile with breathing, compatible with normal right atrial pressure.

 

Due to persistence of atrial fibrillation with palpitations, an initial attempt was made at electric cardioversion, the current drug therapy remaining unchanged. Further ECG measurements were carried out (ECG with sinus rhythm and ECG with atrial fibrillation), based on which the above drug therapy was confirmed.

 

At a later date a second attempt at electric cardioversion was carried out due to a relapse of atrial fibrillation, with drug therapy including Lopresor 100 mg, Almarytm 100 mg and Coumadin 5 mg (based on INR to be kept between 2 and 3).

 

A follow-up ECG showed a sinusal rhythm, as did the subsequent ECG. A further periodic ECG showed a resumption of atrial fibrillation for which the following new drug therapy was prescribed: Lopresor 200 retard, Lanoxin 0.250 mg and Coumadin 5 mg.

 

A subsequent ECG showed atrial fibrillation with a heart beat of 50/65 minute. A specialist follow-up visit has been scheduled to decide whether to proceed with transcatheter ablation.

 

Online Doctor Consultation – Medical Questions:

1) Do you agree with the option of performing transcatheter ablation?

2) Are there any alternative therapies?

3) Any possible complications and prognosis?      

The patient´s clinical problem is typical of persistent recurrent atrial fibrillation which is in fact a very common arrhythmia affecting people of different ages, with or without heart problems or otherwise healthy.

 

In recent years different modalities of treatment have become available allowing better treatment for this affected population, while at the same time has created confusion regarding the best treatment options for them.

 

The confusion stems from the fact that all these options are considered effective and are accepted by the medical profession (guideline), therefore making it difficult for the treating physician and the patient himself to choose the right treatment.

 

In other words, the patient has the right and possibility to choose one of the treatment options for this medical diagnosis according to his needs or preferences.

 

In the particular case of this patient there are 3 alternative choices of therapy:

1) He can continue with his present regimen of drug treatment which is intented for controlling the heart rate (RATE CONTROL); this mode of therapy has become very popular following the publication of several research medical publications demonstrating the effectiveness of this line of therapy. This modality of therapy implies remaining in atrial fibrillation for life and usually is chosen for patients who feel well on this treatment and are generally satisfied with their quality of life.

 

2) He can be converted again to sinus rhythm using medical and/or electrical cardioversion using different drugs than the one which failed (Almarytm). Sotalol could be used but Amiodarone is considered the most effective drug against atrial fibrillation (although we must consider that Amiodarone has a higher incidence of side effects compared to the previously mentioned drugs).

 

3) Catheter ablation of atrial fibrillation is also an option, but in this case we have to take into account several facts; first of all it is an invasive and not a simple procedure and secondly and most importantly the success rate of the procedure is in debate. The success rate depends signifigantly on the type of atrial fibrillation and also on the experience of the physician performing the procedure. Succes rates may vary from below 50% and up to 90% depending on which institution or physician is performing the procedure. If you decide to go ahead with the procedure I strongly suggest that you investigate the results of the group performing the ablation. You also have to consider that there are some potentially serious side effects when performing the oblation which can also be life threatening; the incidence of these complications are low but still present.

 

4) The possibility of ablating the AV node and implanting a pace maker is there but this option is not indicated or logical in the case of this patient.

 

5) Regarding the continous use of coumadin, I strongly recommend it.

 

In summary, the patient may choose among the different modalities of therapy depending on his needs and preferences.

 

In my opinion, if he is satisfied with his quality of life, I would continue his present medical therapy without further intervention. If his quality of life is not sufficient or for any other reason, and he prefers to be in sinus rhythm I would consider Amiodarone and cardioversion. I would leave the possibility of ablation as the final resort and I would make sure the procedure is performed in a medical center with vast experience in ablating atrial fibrillation.