Catheter ablation combined with left bundle optimized cardiac resynchronization therapy for persistent atrial...

Atrial fibrillation (AF) is characterized by rapid and disordered atrial electrical activity. Rhythm and rate control are the primary strategies applied in AF management. In clinical practice, the patient's symptoms, comorbidities, drug tolerance, cardioversion effectiveness, and risk of disease must be comprehensively evaluated to reasonably recommend strategies for rhythm and rate control.

A 65-year-old Asian man experienced persistent AF complicated by malignant arrhythmia. He was poorly treated with medications, which led to heart failure and repeated wide QRS complex tachycardia episodes.

Based on the patient's overall presentation and electrocardiographic monitoring findings, a diagnosis of persistent AF complicated with malignant arrhythmia and heart failure was made.

To restore sinus rhythm, improve myocardial synchronization, and prevent malignant arrhythmia induced by AF, a one-stop treatment strategy of AF catheter ablation combined with atrioventricular nodal ablation and left bundle optimized cardiac resynchronization therapy was adopted for the patient.

At follow-up after 1 year, his N-terminal pro-brain natriuretic peptide level decreased, cardiac shadow reduced, and left ventricular ejection fraction increased. Atrial high-rate episodes were detected without the occurrence of any malignant arrhythmia. Since then, the patient has not developed cardiac insufficiency or syncope.

When drug therapy alone is not satisfactorily effective, AF catheter ablation can optimally maintain sinus rhythm. However, considering that sinus rhythm may be difficult to maintain and secondary malignant arrhythmia may be fatal, atrioventricular nodal ablation may be performed to eliminate the effects of AF and rapid ventricular rate, whereas physiological pacing, including left bundle optimized cardiac resynchronization therapy, can be performed to restore the sequence of optimal cardiac contractions. The one-stop comprehensive treatment strategy described herein would be a good option under certain conditions.