Management of Ablation-Refractory Atrial Fibrillation During Pregnancy

Development of new atrial fibrillation (AF) is uncommon in pregnancy with an incidence of 0.03%. The occurrence of drug-refractory AF during pregnancy in individuals with structurally normal hearts is even rarer, and there are no reports of ablation-refractory AF during pregnancy in the literature. Early recognition and treatment of AF are crucial, as it causes hemodynamic changes that can adversely impact both the mother and fetus, potentially resulting in poor outcomes. We report a case of a 35-year-old woman at 19 weeks of gestation who presented with recurrent paroxysmal AF. Two years earlier, during her previous pregnancy, she was hospitalized for AF, where she experienced labetalol-related hypotension and failed therapy with verapamil and digoxin. She was then managed with flecainide pill-in-pocket therapy until delivery. Eighteen months before this pregnancy, she underwent catheter ablation and remained stable until this current pregnancy, when she experienced 2 episodes of AF. These episodes were unresponsive to her scheduled regimen, prompting an increase in her beta-blocker dose. However, the patient developed syncope and persistent palpitations prompting her presentation to the emergency department (ED).