Electrophysiology Case Conference
Case #5 Discussion

I believe that a) is the most correct answer. Coumadin is probably the most important therapy for decreasing his risk of stroke, especially since he has multiple risk factors including, age, diabetes, and hypertension. Interestingly, he also had some wide complex rhythms, which were likely due to aberrant conduction of atrial fibrillation. Since he had both wide and narrow complex tachycardia, and the palpitations bothered him enough, we also recommended an electrophysiology study.

Premature atrial contractures were observed on low dose of isoproterenol. These PACs were mapped to the posterolateral wall of the right atria. Ablation during atrial fibrillation, returned the patient back to sinus rhythm.

A potential pitfall in this case, would be to perform pulmonary vein isolation or left atrial substrate modification procedure, while the PACs initiating the atrial fibrillation is originating from the right atria. This stresses the importance of performing an electrophysiology study prior to performing a pulmonary vein isolation or left atrial substrate modification procedure.