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2023 AF Symposium

Challenging Case―An EP’s Nightmare

Dr. Karl-Heinz Kuck, Lubeck, Germany

Dr. Karl-Heinz Kuck of the University of Lubeck, Lubeck, Germany described the tragic case of a 77-year-old male who was a retired Cardiologist and a personal friend of his for over 40 years. This case resonated emotionally with both the panelists and the audience who seemed to have experienced similar experiences with their patients.

Persistent A-Fib―Successful Ablation

Dr. Kuck’s patient was suffering from persistent A-Fib since 2014. He had had a successful PVI (Pulmonary Vein Isolation/ablation) and roof line ablation in 2015.

A couple of weeks later, the patent had a repeat ablation including an isthmus line and was doing well for 6 years. But then he came back in with Tachycardia (high heart rate).

Dr. Kuck did another ablation in 2021. He found using voltage mapping that the patient had slow conduction around the scarring on the roof of the anterior wall. Among other techniques, Dr. Kuck made a roof line from the scar area to the annulus. He was able to terminate the tachycardia.

The patient was scheduled for a Left Atrial Appendage (LAA) closure procedure in 6 weeks. He was OK with that but didn’t want to come back for another ablation. He was told to continue taking anticoagulation.

Stops Taking Anticoagulation―Dies in 3 Days!

The patient stopped taking the anticoagulant apixaban (Eliquis) within a week of his ablation for fear of bleeding. He thought or was told by others or by his reading that he could substitute high dose aspirin for taking Eliquis. He was admitted at another hospital. A CT scan showed ischemia (an inadequate blood supply to the heart) and severe edema (swelling). He died 3 days later.

How to Prevent Patients Stopping Their Anticoagulation?

The audience was stunned.

An intense discussion among the panelists and the audience talked about why patients go off of anticoagulants when they shouldn’t.

People suffer a fall, develop cancer, have to have surgery, etc. and for various reasons are taken off of anticoagulants. Then they often develop a stroke.

During the discussion, some suggested closing off the LAA as soon as possible, even during an initial PVI ablation. The session’s last thought: “Should closing off the LAA be a first line procedure?”

Editor's CommentsEditor’s Comments

Nightmare of Patients Not Taking their Anticoagulant: Dr. Kuck’s case struck an emotional chord that resonated with attendees. A major nightmare EPs face is their patients not taking their anticoagulants, then having a  stroke. This happens all too often and has probably occurred or will occur to every EP.
But, except for insisting that patients take their anticoagulants and other meds, there isn’t much an EP can do.

Closing Off the LAA May Be the Solution: Closing off the LAA does work and prevents stroke. It’s an effective substitute for a lifetime on anticoagulants. Then patients (and their doctors) don’t need to be preoccupied about a patient going off of anticoagulants. Instead of being a last resort procedure, many attendees seemed to think that LAA closure should be a first-line treatment for many patients.

If you find any errors on this page, email us. Y Last updated: Thursday, May 11, 2023

Return to 2023 AF Symposium Reports

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