- The patient is a 40-year-old female with diabetes, hypertension, and persistent atrial fibrillation who was referred for further management. - She was experiencing shortness of breath and fatigue from her atrial fibrillation. Her risk of stroke was assessed to be high based on her CHA2DS2VASC score of 3. - After attempting rate control medication, she continued having symptoms. Radiofrequency catheter ablation was performed to isolate the pulmonary veins and eliminate the triggers for atrial fibrillation, with the goal of improving her symptoms long term.

1. Stepwise Management of
Persistant Atrial Fibrillation
“Case Presentation”
Salah Atta, MD
Consultant Cardiac Electrophysiology
Saud Albabtain Crdiac Center, Al-Dammam, KSA
Ass.Prof. Cardiology, Assiut Univ. Egypt
ESC & SHA Congress, Al-Dammam, 9/11/ 2013.

2. :Learning Objectives
• Outline major principles of AF management
• Ensure the appropriate selection of rhythm
versus rate control strategy
• Define the position of ablation therapy in the
management of AF.
• Clarify
confusions
anticoagulation.
about
post
ablation

3. -A 40 years old female patient, diabetic,
hypertensive, referred after 1ry management in
another hospital with symptomatic atrial
fibrillation of one week duration.
Symptoms: SOB, fatiguability
discomfort with daily activity.
causing
her
B.W.: 70 kg, Height 160 cm
BP: 135/75, HR 80/min, irregular, compensated.

5. Normal echocardiographic findings, LA:
3.8 cm.
Normal Renal and hepatic functions,
normal thyroid functions.
-Patient came with these medications for a
week:, Atenolol 50 mg od, Co_renitic
20/12.5 mg, Amlodipine 5 mg, Digoxin
tab: 0.25 mg, Dabigatran 150 mg twice
daily mg in addition to oral
hypoglycaemic medication.

6. Is there any thing more
?to be done
• The patient is young, DM, HTN, with
normal heart, presenting with persistent
AF, already controlled AF rate,
haemodynamically stable, non disabling
symptoms, not in heart failure, already
anticoagulated for one week.

7. Objectives of Clinical Management of
: patients with AF
1- Prevention of thromboembolism.
3-Symptom relief .
2-Optimal management of concomitant
cardiovascular disease.
4. Rate Control.
5.Correction
of
the
rhythm
disturbance.

8. ?!To anticoagulate or not
What is this patient annual risk of
thromboembolism?

9. Balancing the Risk of Stroke
and the risk of bleeding
HASBLED score = 0, CHA2DS2VASC2 = 3
OAC confer greater benefits than risks for this patient

10. Focused Update of ESC 2012
Guidelines

12. Objectives of Clinical Management of
: patients with AF
1- Prevention of thromboembolism.
3-Symptom relief .
2-Optimal management of concomitant
cardiovascular disease.
4. Rate Control.
5.Correction
of
the
rhythm
disturbance.

13. How to assess patient‘s AF?!related symptoms
•

14. Rate control or rhythm control
1. Age of the patient.
2. Symptoms and quality of life.
3. AF type (paroxysmal, persistent,
long-lasting persistent).
4. Underlying cardiovascular disease
and comorbidities.
5. Atrial remodeling and risk of
progression of AF.

16. Rhythm control was decided
-DC cardioversion to sinus rhythm
by
synchronized biphasic 120 J after TEE
excluded LA thrombi and the patient was
maitained on AC plus medical treatment with
Beta blockers and propaphenone to maintain
sinus rhythm.

17. Follow Up
• During follow up, the patient was still
symptomatic with recurrent palpitations
shortness of breath on exertion and
fatigue (EHRA III) despite medical
treatment (Propaphenone, Sotalol).
• Myocardial perfusion imaging ruled out
reversible or non reversible ischaemia.
• 24 hours Holter proved frequent
recurrences of the AF throughout the
day.

18. When to consider ablation
?therapy for AF

19. Older 2010 ESC Recommendations

20. Older 2010 ESC Recommendations

22. Focused Update of ESC 2012
Guidelines

24. The procedure:
The left atrium was catheterized via a
trans-septal puncture.
Selective pulmonary venography.
The image of each vein was continuously
displayed on a server screen throughout
the procedure.

25. Precautions to reduce risk of
:complications
• TEE performed (2-5 days before ablation).
• Bridging with heparin to maintain
anticoagulation in the periablation period.
• Intracardiac Echo to guide
puncture and RF lesions.
transseptal
• 3D mapping guided RF ablation and using
oesophageal temp. probe.

26. Transeptal Puncture

27. LASSO

28. Monitoring RF application

32. Catheter Based Pulmonary
Vein Isolation – The Goal
L superior
PV
R superior
PV
L inferior
PV
R inferior
PV
Complete Isolation of Each
Pulmonary Vein Orifice

33. Follow-Up
Patient was discharged home the day after
ablation.
Follow-up was scheduled after ablation with
repeated Holter monitoring.
She was free of recurrence of AF for two
years.
Now, can we stop her anticoagulation,
otherwise what is the benefit of ablation?!

34. Long Term Outcome
• AF is a chronic progressive disease
specially in patients at risk for
stroke and ablation is aimed at
improving patient’s symptoms.
• One year freedom of AF: around 80%
• At 5 years: it is around 52%.

35. Post Ablation Anticoagulation