Controlling rate and rhythm increases feasibility of CT angiography in atrial fibrillation

Area of Science:

• Cardiology
• Medical Imaging
• Interventional Cardiology

Background:

• Severe rheumatic mitral stenosis and uncontrolled permanent atrial fibrillation (AF) pose challenges for preoperative cardiac assessment.
• Standard invasive coronary angiography was not feasible due to patient-specific vascular complications.
• Transesophageal echocardiogram revealed a large left atrial appendage clot, contraindicating cardioversion.

Observation:

• Significant motion artifacts from atrial fibrillation (AF) hindered cardiac CT angiography (64 slices).
• A temporary pacemaker was inserted via the right femoral vein to control rhythm and rate.
• Intravenous metoprolol (25 mg) and verapamil (5 mg) were administered to achieve a heart rate below 65 bpm.

Findings:

• The combined approach of temporary pacing and pharmacological rate control successfully mitigated motion artifacts.
• High-quality cardiac CT angiography images of coronary arteries and the left atrial appendage clot were obtained.
• The patient subsequently underwent successful mitral valve replacement and maze procedure.

Implications:

• This strategy offers a viable solution for obtaining diagnostic cardiac imaging in complex AF patients when conventional methods fail.
• Effective management of motion artifacts is crucial for accurate preoperative assessment in patients with arrhythmias.
• Successful intervention demonstrates the importance of tailored imaging protocols for high-risk cardiac surgery patients.