What is the management approach for a 63-year-old male with reduced left ventricular function (ejection fraction 35%), history of atrial fibrillation, status post ablation, experiencing premature ventricular complex (PVC) breakthrough despite pacing at 90-100 beats per minute with an Assurity (pacemaker) device?

From the Guidelines

For a 63-year-old male with reduced ejection fraction (35%), history of atrial fibrillation, and persistent PVCs despite ablation and an Assurity pacemaker, I recommend optimizing medical therapy with beta-blockers and antiarrhythmics, prioritizing rate control and rhythm control strategies to improve morbidity, mortality, and quality of life. The patient's history of atrial fibrillation and reduced ejection fraction suggests a high risk of cardiovascular events, and therefore, it is crucial to prioritize rate control and rhythm control strategies to reduce symptoms and improve outcomes 1.

• The 2024 ESC guidelines for the management of atrial fibrillation recommend rate control therapy as initial therapy in the acute setting, an adjunct to rhythm control therapies, or as a sole treatment strategy to control heart rate and reduce symptoms 1.
• Beta-blockers, such as metoprolol succinate or carvedilol, are recommended as first-choice drugs to control heart rate and reduce symptoms in patients with AF and LVEF ≤40% 1.
• If PVCs persist, consider adding amiodarone, with regular liver, thyroid, and pulmonary function monitoring, or alternative antiarrhythmics like sotalol, with QT interval monitoring 1.
• Ensure optimal heart failure therapy, including ACE inhibitors/ARBs and mineralocorticoid receptor antagonists, and consider cardiac resynchronization therapy upgrade if the patient has significant ventricular dyssynchrony 1.
• Regular monitoring with Holter studies every 3-6 months will help assess treatment efficacy and guide further management decisions 1. Key considerations in this patient's management include:
• Maintaining potassium >4.0 mEq/L and magnesium >2.0 mg/dL to prevent arrhythmias and ensure optimal pacemaker function.
• Monitoring for signs of heart failure exacerbation, such as increased dyspnea, fatigue, or edema, and adjusting therapy accordingly.
• Considering a biventricular pace-and-ablate strategy or surgical ablation in case of an established indication for conventional cardiac surgery, as recommended by the 2019 European Heart Journal article on atrial fibrillation ablation in heart failure 1.

From the Research

Patient Profile

• 63-year-old male with a history of atrial fibrillation
• Ejection fraction of 35%
• Had ablation but experienced PVC break through despite pacing 90-100 beats per minute
• Has an Assurity pacemaker placed

Relevant Studies

• A study published in 2020 in Current Cardiology Reports 2 suggests that rhythm control via endocardial ablation can improve ejection fraction, oxygen consumption, and reduce mortality in patients with heart failure and reduced ejection fraction.
• Another study published in 2020 in the Journal of Cardiovascular Electrophysiology 3 found that catheter ablation of atrial fibrillation can reduce heart failure rehospitalization in patients with heart failure with preserved ejection fraction.
• A systematic review and meta-analysis published in 2019 in BMC Cardiovascular Disorders 4 found that catheter ablation is superior to medical therapy in patients with atrial fibrillation and heart failure with reduced ejection fraction, with significant reductions in mortality and heart failure-related hospitalizations.
• A scientific statement from the American Heart Association published in 2021 in Circulation: Arrhythmia and Electrophysiology 5 recommends nonpharmacological rhythm control of atrial fibrillation in heart failure with reduced ejection fraction, citing multiple randomized clinical trials that have shown superiority of catheter ablation in improving survival, quality of life, and ventricular function.
• A study published in 2022 in The American Journal of Emergency Medicine 6 compared the incidence of adverse effects in patients with heart failure with reduced ejection fraction who received IV diltiazem or metoprolol for acute management of atrial fibrillation, finding no difference in total adverse events but a higher incidence of worsening heart failure symptoms in the diltiazem group.

Key Findings

• Catheter ablation can be an effective treatment for atrial fibrillation in patients with heart failure and reduced ejection fraction, with improvements in ejection fraction, oxygen consumption, and reductions in mortality and heart failure-related hospitalizations 2, 4, 5.
• The choice of medication for acute management of atrial fibrillation in patients with heart failure with reduced ejection fraction should be carefully considered, with beta blockers potentially being a safer option than non-dihydropyridine calcium channel blockers 6.