The novel coronavirus (COVID-19) pandemic has placed a substantial burden on patients undergoing elective cardiac electrophysiologic (EP) procedures. Many institutions that perform EP procedures were forced to place patient cases deemed elective on hold during the COVID-19 pandemic; however, the definition of an elective case can vary from hospital system to hospital system. Percutaneous atrial fibrillation (AF) ablations are usually considered to be elective in nature. Guidelines have been developed during the COVID-19 pandemic to help electrophysiologists triage patient cases in an effort to prioritize our most vulnerable patients during this challenging time. Many of these guideline documents have placed routine AF ablation in a more semi-elective or elective nature.1 At the beginning of the COVID-19 crisis, many patients with highly symptomatic atrial fibrillation had to be rescheduled weeks to months from their original procedure date.
This placed some patients at substantially higher risk of clinical decompensation, leading to lengthy hospital stays and poor outcomes.
It has been our experience that many patients who have symptomatic, drug-refractory persistent atrial fibrillation have gone on to have a higher degree of atrial remodeling and electrical scarring than we would have typically observed in our patient population during a more normal time. This is of significant concern, because many of these patients are at risk of developing deleterious cardiac remodeling that can lead to decompensated heart failure.2 Due to these concerns, we have prioritized our most at-risk AF patients to undergo an ablation in a time-efficient manner based on patient risk tolerance of contracting COVID-19 while in the hospital. We report a case of a patient with long-standing persistent atrial fibrillation (LSPersAF) who underwent percutaneous AF ablation at our institution, and discuss our clinical decision-making pathways during the COVID-19 pandemic.
A 68-year-old male with a long history of symptomatic, drug-refractory LSPersAF and atypical flutter presented for outpatient electrophysiologic evaluation in March 2020. The patient has a history of two previous AF ablations in 2018 and 2019, both at other centers that perform a high volume of catheter-based AF ablation. In March 2018, he underwent a radiofrequency (RF) ablation that included a pulmonary vein isolation (PVI), an anterior roof line, and a right-sided cavotricuspid (CTI) ablation for typical atrial flutter. Post procedurally, he had multiple recurrences of atrial fibrillation and atypical left atrial flutter, requiring several ED visits and inpatient hospitalizations over the ensuing year. He then underwent a second ablation in April 2019; per the outside case report, the patient was in an atypical flutter and underwent a cryoablation. Additional radiofrequency (RF) ablation was required to terminate a left-sided atrial flutter.
During his clinical evaluation in March 2020, he was noted to be in recurrent atypical atrial flutter. He believed he had been out of rhythm since soon after his ablation in April 2019. He initially planned to undergo an AF ablation in late March 2020. However, due to a rise in COVID-19 cases in the region, all elective procedures were placed on hold until a later date. He then re-presented for an office visit in late April 2020. He was feeling poorly with worsening dyspnea, paroxysmal nocturnal dyspnea, and orthopnea. He went from having New York Heart Association (NYHA) class I symptoms to NYHA class III symptoms over the course of a month. Medical treatment for his atrial fibrillation included diltiazem for rate control and apixaban for stroke prophylaxis. He had failed attempts at rhythm control with flecainide and amiodarone. On physical examination, the patient was noted to have a resting tachycardia of 140 bpm, body mass index (BMI) of 27 kg/m2, elevated jugular venous pressure, pulmonary vascular congestion and 2+ lower extremity edema. His electrocardiogram (ECG) demonstrated an atypical atrial flutter with a rapid ventricular response. Blood tests were unremarkable. On echocardiogram, the patient had an ejection fraction (EF) of 35-40%, a moderate to severely dilated left atrium, moderate mitral regurgitation, mild aortic regurgitation, and a right ventricular systolic pressure of 45 mmHg. A previous echocardiogram in late 2019 was consistent with a normal range EF and mildly dilated left atrium.
Due to the rise in COVID-19 cases in many regions of the United States during this time, many elective cardiac procedures had been postponed or cancelled. In late April, our hospital started reviewing elective procedures on a case-by-case basis to triage our most at-risk patient population. Given the patient’s worsening symptoms along with significant atrial and ventricular remodeling, the decision was made to perform an AF ablation.3 Recent Heart Rhythm Society guidelines have suggested that performing AF ablation for the most at-risk patients during the COVID-19 pandemic is reasonable and should be considered after thoughtful clinical assessment.1 Our hospital was in support of proceeding with the patient’s case, and the patient presented for complex AF ablation in early May 2020.
The patient presented to the electrophysiologic laboratory in atypical atrial flutter. Following informed consent, general anesthesia and endotracheal intubation was administered. The patient underwent an initial electrophysiologic study followed by creation of 3D electroanatomic impedance maps of the right and left atria (CARTO, Biosense Webster, Inc., a Johnson & Johnson company) with a focus on zero/minimal fluoroscopy techniques.4 Baseline ECG and intracavitary electrograms were recorded with a decapolar catheter in the coronary sinus demonstrating an eccentric activation (Figure 2A). The baseline recordings were consistent with a ventricular rate of 130 bpm, PR interval of 158 ms, QRS duration of 78 ms, AH interval of 75 ms, and an HV interval of 47 ms. Intracardiac echocardiography (ICE) was used to help create the initial 3D electroanatomic map (CARTOSOUND, Biosense Webster, Inc.).
Upon evaluation of the left atrium, a signal was noted in the left upper pulmonary vein (LUPV) near the anterior coumadin ridge demonstrating recurrent PV conduction (Figure 2). The right-sided PVs were noted to have durable entrance and exit block at baseline. An activation map, along with Ripple mapping (Biosense Webster, Inc.), noted slow conduction along the LA roof (Video 1, scroll to end of article to view the video). Entrainment of the macro-reentrant flutter demonstrated that the LA roof was part of the circuit. Ablation lesion sets were driven by Ablation Index (VISITAG SURPOINT Module, Biosense Webster, Inc.) targets of 500 anteriorly and 380 posteriorly.5 Isolation of the left PVs was performed with RF ablation (Figure 2B) using an irrigated contact force sensing catheter (THERMOCOOL SMARTTOUCH SF, Biosense Webster, Inc.).6 Once durable PV block was achieved, it was decided to perform a posterior wall “box lesion” set. Upon ablating along the posterior roof of the LA, the flutter circuit initially slowed then terminated (Figure 3). Further ablation along the infero-posterior wall allowed for durable posterior wall isolation (Figure 4). Provocative EP testing with use of intravenous isoproterenol did not induce further arrhythmia. Careful mapping of the previous CTI ablation along with provocative pacing maneuvers demonstrated durable bidirectional block. The patient tolerated the procedure well, and we were able to provide same-day discharge.
The COVID-19 pandemic has placed a significant challenge on performing elective electrophysiologic procedures, leading to an accumulation of deferred procedures. There is little doubt that EP centers that routinely perform a high volume of catheter ablation procedures are experiencing a “new normal.” Over the last few months, we all have had to be dynamic with clinical decision-making and procedural scheduling. However, as illustrated in this case, not all AF ablation cases should be considered elective in nature. The risk of deleterious myocardial remodeling from decompensated atrial fibrillation can lead to poor patient outcomes. The recent data from the CABANA and CASTLE-AF trials have shown strong mortality reductions in patients who have undergone AF ablation with pre-existing reduced LV systolic function.2,7 Without AF ablation, this patient was at risk for a prolonged heart failure hospitalization, exposing his risk to a potential hospital-acquired COVID-19 infection.
During these challenging times, careful patient selection along with close coordination between EP physicians, EP lab coordinators, and clinical staff is paramount. Like many health systems, we have had to make hard choices in allocation of hospital resources in order to best serve our entire patient population. For most ablation procedures, we have implemented a same-day discharge protocol as clinically feasible. This has helped to reduce the risk of nosocomial COVID-19 inoculation in our patients as well as allow for increased hospital bed availability, especially during times of increased COVID-19 prevalence in our community. Thankfully, our nursing team in the post-procedure recovery area has been very supportive of this, and we have had good success with this implementation over the short term. Despite these efforts, we have had to be facile with procedural scheduling, especially when hospital resources become limited.
Our collective perception of what constitutes as “elective” has been challenged during the COVID-19 pandemic. As the number of COVID-19 cases sharply rose in New York City and other major metropolitan cities in the U.S. in March and April, concerns of viral spread led to a reduction in the amount of elective EP procedures nationwide. We must remember that AF prevalence in the U.S. is estimated to be around 6-7 million and accounts for close to 500,000 hospitalizations per year.8 There are likely many sick AF patients who have suffered at home over the last several months because they are fearful of COVID-19 exposure in the hospital environment. Recent data collected by the CDC since February 1st has demonstrated that there are roughly 25,000 to 50,000 deaths, in excess, than would be anticipated over this time in a typical year.9 Although these are not all attributed to cardiac deaths, it can be reasonably deduced that there are likely more patients staying at home with decompensated cardiac conditions, including atrial fibrillation. This further supports that catheter ablation, despite an ongoing pandemic, can go a long way in reducing risk of hospitalization and poor patient outcomes from symptomatic, drug-refractory atrial fibrillation.
This case demonstrates that catheter ablation of atrial fibrillation should not always be considered elective in nature depending on the severity of patient symptoms and presentation. It sometimes takes only weeks or months for destructive cardiac remodeling to occur from drug-refractory persistent atrial fibrillation, leading to poor patient outcomes. The COVID-19 pandemic has placed a serious strain on healthcare systems worldwide. With thoughtful patient case assessment and careful pre-procedural planning, AF catheter ablation remains a very important treatment strategy for our most at-risk patients.
Contact the author on Twitter at @JJSenMD.
Acknowledgement. A special thanks to Ari Collymore, RN, Katie Leventis, CAS, and Carson Jackson, CAS in procuring the figures and video for this case presentation.
Disclosures: Dr. Senfield has no conflicts of interest to report regarding the content herein. Outside the submitted work, he reports personal fees as a speaker for ZOLL Medical and Bristol-Myers Squibb.
Featured Video Commentary From Dr. Senfield:
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- Packer DL, Mark DB, Robb RA, et al. Effect of catheter ablation vs antiarrhythmic drug therapy on mortality, stroke, bleeding, and cardiac arrest among patients with atrial fibrillation: the CABANA Randomized Clinical Trial. JAMA. 2019;321(13):1261-1274.
- Chung MK, Refaat M, Shen WK, et al. Atrial fibrillation: JACC Council perspectives. J Am Coll Cardiol. 2020;75(14):1689-1713.
- Osorio J, Bubien RS, Ruff JD, et al. Single day observational experience at high volume ablation programs: what is the impact to practicing electrophysiologists? J Atr Fibrillation. 2018;11(4):2059.
- Hussein A, Das M, Chaturvedi V, et al. Prospective use of Ablation Index targets improve clinical outcomes following ablation for atrial fibrillation. J Cardiovasc Electrophysiol. 2017;28(9):1037-1047.
- Natale A, Reddy VY, Monir G, et al. Paroxysmal AF catheter ablation with a contact force sensing catheter: results of the prospective, multicenter SMART-AF trial. J Am Coll Cardiol. 2014;64(7):647-656.
- Marrouche NF, Brachmann J, Andresen D, et al. Catheter ablation for atrial fibrillation with heart failure (CASTLE-AF). N Engl J Med. 2018;378:417-427.
- Benjamin EJ, Muntner P, Alonso A, et al. Heart disease and stroke statistics — 2019 update: a report from the American Heart Association. Circulation. 2019;139(10):e56-528.
- Woolf SH, Chapman DA, Sabo RT, Weinberger DM, Hill L. Excess deaths from COVID-19 and other causes, March-April 2020. JAMA. 2020 Jul 1;e2011787. Online ahead of print.