Example AF Case

The patient is a 29-year-old female student who was first diagnosed with atrial fibrillation (AF) in 2005. Her first episode was persistent, requiring cardioversion. She is physically active and runs on a regular basis. She continued to have paroxysmal AF with dizziness after running. In 2009, the frequency of her arrhythmias dramatically increased, to the point that she was having daily episodes. Ambulatory ECG monitoring showed both a rapid, regular SVT approaching 200 bpm and AF. She was treated with flecainide and metoprolol, but again returned in persistent atypical atrial flutter requiring cardioversion. She was then admitted for further antiarrhythmic drug trials and spent 10 days as an inpatient. Propafenone was initiated, but she developed symptomatic post-AF termination pauses of up to 7 seconds.

A pacemaker was recommended so that she could safely take another antiarrhythmic such as dofetilide. At that point she sought a second opinion with our group — expressing both a strong desire to become pregnant and to avoid long-term medications and/or a pacemaker. We felt she would be a reasonable candidate for pulmonary vein (PV) isolation.

She was taken to Sequoia Hospital’s electrophysiology (EP) lab in December 2009. A complete diagnostic electrophysiology study revealed no evidence of any reentry supraventricular tachycardia, bypass tracts, or atrial tachycardia at baseline, on isoproterenol or during washout. All 4 pulmonary veins were isolated (Figure 1), and a right atrial cavotricuspid isthmus line was ablated with documented bidirectional block. Total AF procedure time was 75 minutes.

Post-ablation, she has had no further arrhythmias, completed a successful pregnancy, and recently ran in the Boston Marathon. Ultimately, the solution to her problem was a curative procedure that took only 75 minutes with an overnight observation, compared with her 10-day hospital stay for drug loading that failed to maintain sinus rhythm. The case sounds simple, but as many electrophysiologists know, the evolution of electrophysiological advances leading to her successful ablation was long and complex.

Discussion

In this article we will discuss the evolution of our AF ablation program at Sequoia Hospital in Redwood City, California. We have performed over 2,000 AF ablation procedures since 2003. Our case mix includes many patients referred by outside electrophysiologists after a failed ablation or Maze procedure; only 30% of our patients have paroxysmal AF. Our current AF ablation procedure is the result of refinements of our techniques through the assimilation of technology, experience, and continued reflection upon our previous results. We will discuss several aspects of our current technique that we consider to be innovative and that have given us excellent results despite being a bit different than other centers.