Recurrent paroxysmal AF despite flecainide — case discussion

Presentation

Practice case (not a real patient). A 61-year-old man in Australia has symptomatic paroxysmal AF that keeps recurring despite flecainide. His only other condition is treated hypertension, and he has taken apixaban for 4 months.^[1][5] He wants to stay in sinus rhythm and asks whether an ablation would help.^[2]

Step 1 — Is he a candidate?

Discussion:

• Yes. ESC 2024 recommends catheter ablation in paroxysmal or persistent AF resistant or intolerant to antiarrhythmic drug therapy, to reduce symptoms, recurrence and progression of AF (Class I, Level A).^[1]
• ACC/AHA 2023 finds ablation useful to improve symptoms in symptomatic AF when antiarrhythmic drugs have been ineffective and continued rhythm control is desired (COR 1, LOE A).^[2]
• The 2018 NHFA/CSANZ guideline summary, which predates both, says failure of rate or rhythm control should prompt consideration of percutaneous or surgical ablation.^[5]
• ESC 2024 recommends shared decision-making that takes account of procedural risks, likely benefits and risk factors for recurrence (Class I, Level C), so his blood pressure control, weight, alcohol intake and sleep are reviewed with him.^[1][3]

Step 2 — Before the procedure

• His CHA2DS2-VA score is 1 (hypertension); ESC 2024 says a score of 1 should be considered an indicator of elevated thromboembolic risk for decisions on initiating OAC (Class IIa, Level C).^[1]
• ESC 2024 recommends OAC for at least 3 weeks before ablation in patients at elevated thromboembolic risk (Class I, Level C) and uninterrupted OAC through the procedure (Class I, Level A); he has taken apixaban for 4 months, and it is continued.^[1]
• He is not in any of the high-risk groups ESC 2024 names (which include cardiac amyloidosis, rheumatic heart disease and hypertrophic cardiomyopathy), in which it says cardiac imaging before ablation should be considered regardless of preceding effective OAC. Separately, ESC 2024 notes observational studies suggesting patients with a low thromboembolic risk profile may be managed without LAA visualisation, but no RCTs have been performed.^[1]

Step 3 — The procedure

• He has cryoballoon pulmonary vein isolation; entrance block is confirmed in all veins, which the consensus regards as an adequate procedural endpoint with contemporary technology.^[3]
• Heparin is given before transseptal puncture and the ACT is kept at 300 s or more, in line with the consensus.^[3]
• The effects of right phrenic nerve pacing are monitored, which the consensus considers a standard part of cryoballoon ablation.^[3]

Step 4 — Palpitations at day 10

• An ECG shows AF. The consensus says some early recurrences may resolve with time, recurrence during the blanking period is not counted as treatment failure, and its writing group recommends an 8-week blanking period.^[3]
• ACC/AHA 2023 finds short-term AAD therapy after ablation can be useful in some patients to reduce early recurrences of atrial arrhythmia and hospitalisation (COR 2a, LOE A).^[2]
• Apixaban continues: ESC 2024 recommends OAC for at least 2 months after ablation in all patients, irrespective of rhythm outcome or CHA2DS2-VA score (Class I, Level C).^[1]

Step 5 — Twelve months later

• He has had no symptoms, and ambulatory monitoring has shown no AF. He asks to stop apixaban.^[3]
• ESC 2024 recommends continuing OAC after ablation according to the CHA2DS2-VA score and not the perceived success of the ablation (Class I, Level C); his score is 1.^[1]
• The consensus places men with CHA2DS2-VASc 1 in its intermediate-risk group, in whom stopping anticoagulation may be considered 12 months after ablation in the absence of clinical symptoms or ECG-documented AF recurrence, with a proposed prerequisite of commitment to long-term rhythm monitoring.^[3]
• ALONE-AF, a randomised clinical trial of 840 adults at 18 hospitals in South Korea, which enrolled patients with at least 1 non-sex-related stroke risk factor and no documented atrial arrhythmia recurrence for at least 1 year after ablation, found a lower 2-year rate of the composite of stroke, systemic embolism and major bleeding with discontinuation than with continued DOAC (0.3% vs 2.2%).^[9]
• After a shared discussion, he chooses to stop apixaban and agrees to long-term rhythm monitoring to screen for AF recurrence and guide restarting anticoagulation.^[3]

Learning points

• Ablation after antiarrhythmic drug failure: ESC 2024 Class I, Level A (paroxysmal or persistent AF resistant or intolerant to AAD therapy); ACC/AHA 2023 COR 1, LOE A (symptomatic AF, AADs ineffective, contraindicated, not tolerated or not preferred, continued rhythm control desired).^[1][2]
• Anticoagulation (ESC 2024): uninterrupted OAC is recommended through the procedure (Class I, Level A) and for at least 2 months afterwards in all patients, irrespective of rhythm outcome or CHA2DS2-VA score (Class I, Level C), and continuing it after ablation is recommended according to the CHA2DS2-VA score, not the perceived success of the ablation (Class I, Level C).^[1]
• A recurrence within the blanking period is not counted as treatment failure; the consensus recommends an 8-week blanking period.^[3]
• Longer-term OAC after ablation follows stroke risk: ACC/AHA 2023 says it should be dictated by stroke risk, such as a CHA2DS2-VASc score of 2 or more (COR 1, LOE B-NR), and the consensus gives stroke-risk tiers for stopping it, with no class.^[2][3]