Case 161

Abstract

A 60-year-old Caucasian male with a background of hypertension, rheumatic mitral insufficiency, and occasional paroxysmal atrial fibrillation (PAF) develops angina and congestive symptoms in 1996 and undergoes triple vessel coronary artery bypass grafting and mitral valve replacement. MAZE surgery was not performed at that time at his hospital. His angina and congestive symptoms resolve, but his PAF continues. Between 1997 and 2003 he suffers symptomatic AF 6-20 times/year despite trials of metoprolol, verapamil, and sotalol, given by his cardiologist. In addition, a new RBBB is noted on his ECG. Figure 161.1 shows his ECG with sinus rhythm in 2001 prior to RBBB; Fig. 161.2 shows his ECG in 2003 in AF with RBBB. In June 2003 amiodarone (Pacerone) 200 mg/day was begun in addition to the beta blocker being used for his hypertension and over the next 5 months he has 15 more episodes - all with good rate control and less awareness of palpitations. An amiodarone serum level was 0.6. In November 2003, his amiodarone is changed to another amiodarone product, Cordarone, 200 mg/day. The serum concentration rises to 1.0. The dose is increased to 300 mg/day. Between 11/03 and 3/04, only two episodes are detected; however, from 3/04 to 11/06, 31 additional episodes of PAF are noted by the patient - each of which leaves him feeling a little fatigued. He seeks consultation with an electrophysiologist and is offered ablation, but he refuses as a neighbor of his had a stroke during an ablative procedure. Purified omega-3 fish oil is added following reports that it may reduce AF. © Springer-Verlag London Limited 2011.