2022 AF Symposium

Challenging Cases: The Patient has the Last Say

In the “Challenging Cases” presentations, some of the world’s leading Electrophysiologists (EPs) describe the most difficult Atrial Fibrillation cases they had to cope with through the year. I find it one of the best learning experiences of the AF Symposium. (But for reasons I frankly don’t understand, it’s always the least attended. This year was no exception.)

Frankness prevails. The presenters don’t hesitate to discuss challenging situations, possible mistakes, or embarrassing moments. I’m always surprised to see such a lack of ego among this group of the best Electrophysiologists in the world.

The panelists this year were:

▪ Dr. David Keane of St. Vincent’s Hospital, Dublin, Ireland, Moderator
▪ Dr. John Camm of St. George’s Medical Center, London, UK
▪ Dr. John Day of the Intermountain Heart Institute, Murray, UT
▪ Dr. Young-Hoon Kim of Korea University Medical Center, Seoul, South Korea
▪ Dr. Gregory Michaud of Vanderbilt University Medical Center, Memphis, TN
▪ Dr. Eric Prystowsky of St. Vincent’s Hospital, Indianapolis, IN

Dr. Erik Prystowsky: The Patient Has the Final Say

One of the most challenging type of case EPs have to deal with was recalled by Dr. Erik Prystowsky of St. Vincent’s Hospital, Indianapolis, IN.

A 65-year-old man had Atrial Fibrillation and shortness of breath. His Ejection Fraction was an astonishingly 10% (critically low). He was on a beta-blocker and was cardioverted successfully.

Dr Eric Prystowsky

He was sent to Dr. Eric Prystowsky and became his patient. The patient was put on amiodarone and for several months was asymptomatic. His Ejection Fraction actually improved to 50%. He was found to have a severely enlarged left atrium (5.4 cm).

Questions Posed To the Panel: Dr. Prystowsky posed the following questions concerning this patient and asked panelists’ opinion about the best strategy for treating him:

1. Catheter ablation?
2. Switch from amiodarone to dofetilide (Multaq)? (Dr. Prystowsky said he does this frequently, probably because of the long-term toxicity of amiodarone.)
3. Continue on amiodarone?

The general consensus seemed to be to offer the patient a catheter ablation. (This would likely fix his A-Fib, improve his Ejection Fraction, and reduce the size of his left atrium.)

Offered a Catheter Ablation

The patient was offered a catheter ablation procedure. But the patient would not accept an ablation even after the most persuasive attempts to convince him otherwise. (Dr. Prystowsky practices in Indiana, where perhaps people are more conservative in medical choices.)

Dr. Prystowsky continued the patient on amiodarone but had him return to the office every six months.

Two Years Later…

Two years pass. The patient is now symptomatic and had sinus bradycardia (slow heart rate). He still refused a catheter ablation but did get a dual chamber pacemaker for his slow heart rate.

…Three Years After That

Three more years pass and his pacemaker now showed his Atrial Fibrillation had progressed to Persistent A-Fib. His Ejection Fraction was in the 25%-30% range (low). His heart rate was 150 bpm (high). He was again cardioverted back to sinus, but this only lasted a week. So he was once again cardioverted and put on lisinopril (an ACE inhibitor used primarily for high blood pressure and heart failure).

Another Year Later…

The cardioversion lasted about a year with a slightly improved Ejection Fraction, and he was asymptomatic. He complained of lightheadedness. He seemed to improve with an adjustment to his pacemaker taking him off of bi-ventricular pacing. After all this, he still refused to have a catheter ablation.

Bottom Line: The Patient has the Final Say

Dr. Prystowsky talked to the panel and attendees about the dangers of Tachymyopathy (impairment of left ventricular function) which many people never recover from. He stressed how important it was to try to keep patients in normal sinus rhythm, even in difficult cases like this.

In spite of all his problems, this patient feels relatively well and is still adamant about not having a catheter ablation.

As Dr. Prystowsky stated, “The patient has the final say!”

Editor’s Comments

Dr. Prystowsky is one of smartest, most persuasive EPs around. But as frustrating as it must have been for him, he had to let this patient make the final decision.

This is a life-lesson all too many EPs have to come to grips with during their careers. No matter how much education and experience an EP has, even though they know how to fix problems like this patient has, there is only so much an EP can do.

After all, the patient does have the final say.

See all my reports at: 2022 AF Symposium.

If you find any errors on this page, email us. Y Last updated: Tuesday, February 22, 2022

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