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Abstract: The patient in this case is a 71-year-old mother-in-law. The patient was transferred to our department from the emergency department. The patient reported that she was resting at home at around 9:00 p.m. that night and suddenly felt her heart beating erratically, and she had uncomfortable panic attacks, so she was seen in our emergency department. The electrocardiogram showed: fast ventricular rate atrial fibrillation with a heart rate of 160 beats/min. Based on the symptoms and electrocardiogram, the diagnosis of paroxysmal atrial fibrillation was clear. Surgery + medication was given. The surgery went well, and the condition has been controlled with good treatment effect.
Basic information】Female, 71 years old
Type of disease】Paroxysmal atrial fibrillation
Hospital】Wuhan University People’s Hospital
Date of Consultation】May 2021
Treatment plan】Surgical treatment (transcatheter cardiac radiofrequency ablation) + medication (amiodarone hydrochloride injection, rivaroxaban tablets, amiodarone hydrochloride tablets, sakubatril valsartan sodium tablets)
Treatment period】6 days of inpatient treatment, 3 months of outpatient follow-up
Treatment effect】The operation went well, the disease was controlled, and the treatment effect was good
I. Initial consultation
The patient was transferred from the emergency department to our ward. The patient reported that he was resting at home around 9:00 p.m. that night and suddenly felt his heart beating randomly, like it was about to jump out, and it was beating irregularly, and he had severe panic attacks, so he called 120 to our emergency department for consultation. The patient had never had such an uncomfortable feeling before, and was usually in good health, but had a history of hypertension for more than ten years, without discomfort or medication control. The electrocardiogram showed: fast ventricular rate atrial fibrillation with a heart rate of 160 beats/min. The emergency department doctor gave her an intravenous injection of amiodarone hydrochloride, and by the time she came to the ward, her heart rhythm had changed to a normal sinus rhythm. The ECG monitor showed that the heart rate was neat and 70 beats/minute, and the symptoms of panic were basically improved.
II. Treatment history
After admission, the patient had no episodes of atrial fibrillation for the time being, but based on the symptoms and ECG, the diagnosis of paroxysmal atrial fibrillation was clear. If not further treated, the patient would still have intermittent episodes in the future, and each episode would bring certain risks, such as panic, chest tightness, decreased cardiac function, and left atrial thrombosis, which would increase the risk of stroke or embolism in other parts of the body.
After admission, a 24-hour ambulatory electrocardiogram was arranged to assess the frequency of atrial fibrillation episodes; a transesophageal cardiac ultrasound was performed to check and observe the presence of structural and functional abnormalities of the heart and thrombus; and blood pressure testing and routine examinations were performed. The cardiac ultrasound results showed an enlarged left atrium, thickened ventricular wall, fair cardiac function, no thrombus was found, and blood pressure was above the normal range, basically 140/80 mmHg-160/90 mmHg.
The patient was informed of the dangers and risks of paroxysmal atrial fibrillation, and the causes of the onset of atrial fibrillation were analyzed, on the one hand, in relation to increasing age; on the other hand, in relation to uncontrolled hypertension, leading to left atrial enlargement. First, blood pressure was controlled and cardiac remodeling was improved with sakubatril valsartan sodium tablets, while rivaroxaban tablets were given for anticoagulation and thrombosis prevention, and the patient was advised to undergo early treatment by minimally invasive radiofrequency ablation, which has a chance to eradicate atrial fibrillation, and the patient, after discussing with his family, wished to get a better treatment by surgery. The procedure was performed by puncture at the thigh vessel, and the ablation catheter was sent through the vessel into the heart for pulmonary vein-left atrial electrical isolation, which was completed and the procedure was successfully concluded. Postoperative administration of sacubitril valsartan sodium tablets, rivaroxaban tablets, and amiodarone hydrochloride tablets were continued to prevent atrial fibrillation episodes.
(Twelve-lead electrocardiogram results)
III. Treatment results
The procedure was smooth and the ablation goal was achieved. After the operation, the patient routinely rested flat on his back and performed postoperative care such as compression of the surgical puncture site to stop bleeding and braking. On the 2nd postoperative day, the patient was able to get out of bed normally and take care of himself without any discomfort, and the patient recovered well. After 3 days of observation, the patient was discharged from the hospital and hospitalized for a total of 6 days, and the patient’s blood pressure was controlled in the normal range. 3 months later after the outpatient follow-up, the postoperative condition was stable and there had been no cardiac tamponade, and cardiac auscultation revealed a neat heart rhythm and the ECG showed a normal sinus rhythm. She showed me her blood pressure record at home, which was also very stable and under control. In conclusion, the patient’s surgery went well, her condition was controlled, and the treatment was effective, and the patient as well as her family expressed great satisfaction.
IV. Notes
I am very pleased that the patient was treated surgically and achieved the ablation goal, followed by further episodes of heartburn and other discomfort. After the patient underwent radiofrequency ablation, a small puncture wound existed. Although the effect was not significant, proper care should be taken to avoid complications such as wound infection and bleeding. Although radiofrequency ablation is smooth, there is also a certain risk of thrombosis and atrial fibrillation recurrence in the short term after the procedure, so the patient should be treated with anticoagulation and antiarrhythmic drugs for 3 months as prescribed by the doctor. Patients with previously uncontrolled high blood pressure, which is likely to be one of the important reasons for the occurrence of atrial fibrillation, should pay particular attention to taking antihypertensive drugs regularly, monitoring blood pressure and maintaining it within the normal range. In addition, it is important to pay attention to a low-salt and low-fat diet in life, and also to supplement nutrition such as high-quality protein, fresh vegetables and fruits, and avoid foods that are too stimulating.
V. Personal insight
Atrial fibrillation is a relatively common arrhythmia, especially in the elderly population. Hypertension is one of the important causes of atrial fibrillation. If hypertension is not controlled for a long time, excessive pressure load can cause left atrial remodeling and promote the occurrence of atrial fibrillation. Atrial fibrillation is divided into paroxysmal and persistent. Although the patient’s atrial fibrillation is paroxysmal, the attack makes her very uncomfortable and there is a potential risk of blood clot formation. If an elderly person with hypertension, inexplicably, has a racing heart, it is important to consider whether an arrhythmia such as atrial fibrillation is present. For paroxysmal atrial fibrillation, radiofrequency ablation surgery is more effective in the early stage of disease detection, and most patients can be cured with a low recurrence rate. For patients with hypertension, it is important to actively control blood pressure, which is very important to reduce the recurrence rate of atrial fibrillation.