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Difficult Cases in Atrial Fibrillation Management

by Steve S. Ryan, PhD

One of the most hotly discussed cases at this years Symposium was that of a 14-year-old boy who developed A-Fib. This case was presented by Dr. Claudio Tondo from the Centro Cardiologico Monzino of Milan, Italy. (This is the youngest person the author has ever heard of who developed A-Fib.) The boy regularly exercised intensely (the type of exercise was’t specified). He developed frequent palpitations throughout the day not necessarily related to the times he was exercising. He felt very weak. ECGs and Holter monitoring revealed frequent, repetitive atrial ectopic beats and sustained episodes of A-Fib. They gave him atenolol to slow his heart rate, but it had seemingly no effect. His family didn’t have a history of A-Fib.

As in previous Symposiums, audience members had remotes where they could select 1-10 choices. Dr. Tondo gave the audience the following choices:

  1. Stop sport activity and increase beta-blocker dose.(No one selected this. Beta-blockers don’t normally stop A-Fib.)
  2. Add an AAD (antiarrhythmic drug) and see how it goes. (12% selected this. An AAD might restore him to sinus rhythm. But no one has much experience prescribing antiarrhythmic drugs to young children.)
  3. Discontinue beta-blocker therapy, impose no physical activity for at least three months and prescribe OAT (oral anticoagulant). (No one selected this. It’s very doubtful that someone this young and athletic would be at a real risk of an A-Fib stroke.)
  4. No beta-blocker, no sport and just add aspirin. (2% did select this. I have no idea why. Many studies have shown that aspirin has very limited effectiveness in preventing A-Fib stroke. Aspirin has been removed from the current guidelines.)
  5. Give him Class 1C AAD + ILR to monitor the frequency of arrhythmias.(11% selected this. It seems a better choice than #2 above. But one wonders how well an active 14-year-old boy would tolerate a monitor.)
  6. Counseling patient and parents about the nature of the arrhythmia(s), highlighting the clinical risk of sustained and frequent A-Fib episodes. Making them aware of the different therapeutic choices. (48% selected this.I personally think this is a horrible and cruel choice. You are basically leaving this 14-year-old in A-Fib with his heart jumping around in his chest. He has got to be terrified, not to mention the frustration of no longer being able to play the sport he obviously loves.)
  7. Mapping of atrial arrhythmias, define the sites or origin and ablate. (27% selected this choice including me. A 14-year-old can’t possibly have developed an extensive type of A-Fib. An ablation for him would be relatively simple. There is probably no need to ablate (isolate)) all four of his Pulmonary Vein openings. In fact, it would probably be a mistake to burn all four of his veins unnecessarily. Doctors take an oath to do no harm. [Back in 1998 when I had my Pulmonary Vein Ablation (Isolation) (PVI), only one of my veins was isolated. I’ve been A-Fib free for 14 years.] Once this young boy is cured and matures, he may never have A-Fib again.)

Dr. Tondo decided on option #6 to treat this young boy. He succeeded in convincing him to not play his sport for three months (this kid must have been really terrified of his A-Fib to agree to this.) But he was still highly symptomatic and had long periods of A-Fib. In addition, he had frequent nose bleeds from taking low molecular weight heparin (an anticoagulant).

Dr. Tondo then performed an ablation and only had to isolate one vein to stop the young boy’s A-Fib (it probably would have been considered overkill to ablate all four PVs on this young boy. Why perform any damage to his other veins when he may never have A-Fib again?) He was released on low molecular weight heparin. He had further complications but is now doing well.

Some doctors asserted that you don’t take a 14-year-old into the lab without a lot of soul searching. Others countered that patients like this often have a rapid-firing focus on a particular vein. When it is ablated, they do very well.


Last updated: Tuesday, December 2, 2014

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