2022 AF Symposium: Challenging Cases: The Patient has the Last Say
My new report from the 2022 AF Symposium is about one of the “Challenging Cases” presentations. This is when some of the world’s leading Electrophysiologists (EPs) describe the most difficult Atrial Fibrillation cases they had to cope with through the year. Frankness prevails.
Dr. Erik Prystowsky of St. Vincent’s Hospital, Indianapolis, IN, described a 65-year-old man with Atrial Fibrillation, shortness of breath, and a critically low Ejection Fraction (10%). And a severely enlarged left atrium (5.4 cm).
The patient was offered a catheter ablation procedure but would not accept even after the most persuasive attempts to convince him—it would likely fix his A-Fib, improve his Ejection Fraction, and reduce the size of his left atrium. To learn how this patient’s health evolved over the next 5-6 years, read my full report: Challenging Cases—The Patient has the Last Say.
2022 AF Symposium Challenging Cases in AF Management: The Patient has the Last Say
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.
If you find any errors on this page, email us. Y Last updated: Tuesday, February 22, 2022
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My Top 5 Picks: Advanced-Level Atrial Fibrillation Videos
The A-Fib.com Video Library is for those readers who learn visually through motion graphics, audio, personal interviews and animations.
These are my top 5 picks of advanced-level videos. For the reader wanting a more in-depth look inside the EP lab and surgery, and at advanced topics relating to atrial fibrillation.
1. Step-by-Step: Cardioversion Demonstration by ER Staff
The goal of electrocardioversion is to convert the patient’s rhythm from atrial fibrillation back to normal sinus rhythm.
In this video, emergency room medical personnel demonstrate the equipment, pads placement and procedures of cardioversion. The video describes where pads are properly placed on the patient; how medication is chosen to produce deep sedation; and how after the shock is delivered, a successful cardioversion is confirmed by viewing a normal sinus rhythm on the cardiac monitor.
Close-up of the equipment is shown along with the monitor display. (2:10 min.) Uploaded by Alfred Sacchetti. Go to video->
2. Your Heart’s Ejection Fraction (EF): What You Need to Know
In the following three short videos, cardiac electrophysiologist, Dr. Robert Fishel, discusses the ejection fraction (EF) a measurement of the pumping efficiency of the heart and why cardiac patients should know their EF percentage.
Video 1: What is the ejection fraction? (:54 sec.) Cardiac Ejection Fraction (EF) is the percentage of blood pumped from the heart’s main chamber during each heartbeat, and why it’s important.
Video 2: Who should know their ejection fraction (EF)? (:34 sec.) Measurement of your Ejection Fraction (EF) is an important test and why A-Fib patients need to know their EF number.
Video 3: How is an ejection fraction measured? (:56 sec.) Ejection Fraction (EF) can be measured by various techniques including an echocardiogram.
Videos hosted by Share.com. Go to videos->
3. Mini-Maze Surgery In-Depth: Inside the O.R. with Dr. William Harris, Cardiovascular Surgeon
Cardiovascular Surgeon, Dr. William Harris describes the Mini-Maze surgery for Atrial Fibrillation. In the Mini-Maze the heart is accessed through small incisions in the chest.
Of interest to A-Fib patients who can not tolerate blood thinners and thus do not qualify for a Catheter Ablation. The Mini-maze surgery is a highly effective with an 85%–95% success rate. (4:49 min.) Dr. Harris is with Baptist Medical Center, Jackson, Miss. Go to video->
4. Pulmonary Vein Isolation In-Depth: Step-by-Step Inside the EP Lab Using Mapping & CT Scan
Cardiac Electrophysiologist Dr. James Ong begins with a brief tour of the EP lab and control room; Dr. Ong explains how pulmonary vein isolation is done with radiofrequency ablation to cure atrial fibrillation.
Included are: Mapping technology; the Virtual Geometrical shell of the heart displayed next to the CT scan; Placement of the catheter, real time tracking; the Complex Fractionated Electrogram (CFE) Map used to identify and eliminate the extra drivers (aside from the pulmonary veins). (6:01 min.) From a series of videos by Dr. Ong, Heart Rhythm Specialists of Southern California. Go to video->
5. Long-Standing Persistent A-Fib: A Live Case of Catheter Ablation Through 3D Mapping & ECG Images
Presented entirely through 3D mapping and ECG images, a live demo of ablation for long-standing, persistent A-Fib is followed from start to finish. Titles identify each step (no narration).
3D mapping and ECG images show the technique of transseptal access, 3D mapping, PV isolation, and ablating additional drivers of A-Fib. (8:03 min.) With Dr. James Ong, Heart Rhythm Specialist of Southern California. Go to video->
Note: These videos may require basic understanding of cardiac anatomy and A-Fib physiology.
Visit our A-Fib.com Video Library
for more Advanced-Level Videos
STEVE RYAN VIDEOS:
We’ve edited Steve’s most interesting radio and TV interviews to create several short (3-5 min.) videos. Check out Videos Featuring Steve S. Ryan, PhD, publisher of A-Fib.com.
VIDEO: Step-by-Step: Cardioversion Demonstration of by ER Staff
The goal of electrocardioversion is to convert the patient’s rhythm from atrial fibrillation back to normal sinus rhythm.
In this video, emergency room medical personnel demonstrate the equipment, pads placement and procedures of cardioversion. The video describes where pads are properly placed on the patient; how medication is chosen to produce deep sedation; and how after the shock is delivered, a successful cardioversion is confirmed by viewing a normal sinus rhythm on the cardiac monitor. Close-up of the equipment is shown along with the monitor display.
Uploaded on Jan 5, 2012 (2:10 min.) by Alfred Sacchetti.
YouTube video playback controls: When watching this video, you have several playback options. The following controls are located in the lower right portion of the frame: Turn on closed captions, Settings (speed/quality), Watch on YouTube website, and Enlarge video to full frame. Click an icon to select.
If you find any errors on this page, email us. Y Last updated: Monday, January 15, 2018
New Video Posted: Dr. Bruce Janiak’s Cardioversion from Atrial Fibrillation
Dr. Bruce Janiak, a 74 year old full-time emergency medicine physician, videotaped his cardioversion from atrial fibrillation in order to demonstrate both the ease and safety of this procedure.
In a very low-key, conversational manner, Dr. Janiak and the hospital staff conduct his cardioversion. Dr Janiak discusses his previous experiences with chemical conversions. He shares before and at the conclusion of the procedure. 15:08 min. Published by Augusta University, Medical College of Georgia. Go to video->