Do you have any experience in dealing with permanent (most likely focal right) atrial tachycardia 150-160 bpm which is refractory to medical therapy in a subject with a few thrombi in LAA (on long-term therapeutic INR)?
Would you consider EPS and go for ablation of tachycardia focus if in the right atrium and LV ejection fraction starts to deteriorate? Any protection from thromboembolic events beyond the anticoagulation?
Adrian, what do you mean by "refractory to medical therapy"? Do you target sinus rhythm or just ventricular rate control? I would try first to achieve drug rate conrol. If this is not possible I would certainly try to ablate the tachycardia (but only if right atrial). Restoration of sinus rhythm will change only the heart rate - in atrial tachycardia (as in sinus rhythm) I expect organized contraction, not chaotic as in atrial fibrillation. So the embolic risk after a successful ablation theorically would not be much higher than that of a patient without LAA thrombi. For right atrial tachycardia you can do the procedure on uninterrupted warfarin treatment. Bridging with heparin could be more dangerous.
Dear colleagues,
An interesting question. We should consider the comorbidites of our patient.
Perhaps in an elderly patient with chronic pulmonary disease, we should wait after acute lung decompesation. In other type of patients we should look for a palliative solution: in an elderly patient with high heart rate and impossible to control, perhaps AV ablation, and pacemaker implantation could be a possibility.
She is 50 y/o, active, and no significant co-morbidities, incl. lung disease. By 'refractory" I ment both, no sinus rhythm and no heart rate control, low blood pressure on drugs.
If you are sure that there is thrombus, then I would not fix the rhythm yet.
What rate control did you use?
In any case I would move the INR to 3-4, and go for sinus rhythm when the clot has gone.
Pace and ablate the AV node is not a good treatment for a 50 year old.
Adrian, as Tchavdar pointet out I would not expect LAA Thrombus in an ectopic atrial tachycardia. So probably you deal with multiple arrhythmias which is found quite often.
What about a 7 day holter ecg if possible to determine heart rate on a longer term.
INR 3-4 seems like a good idea --> but if you are sure you deal with a tachycardia induced cardiomyopathy due to atrial tachycardia you have to fix the rhythm soon.
AV Node ablation could make symptoms worse in ectopic atrial tachycardia due to nearly unsolvable pacemaker syndrome.
When you mention "refractory to medical therapy" I assume that on reasonable attempts at treatment with usual medications such as BB and CCB you could not suppress the tachycardia due to inefficacy or patient could not tolerate the medication.
If the patient has been on chronic anticoagulation (with therapeutic INR over 4 weeks) and the thrombus is organized (not mobile,) I would go for RF ablation of the focal atrial tachycardia (only in right atrium) guided by 3-D electro-anatomic mapping while fully anti coagulated.
The right atrial tachycardias are usually located in the region of crista terminals with high cure rate. ( Pwave is negative or isoelectric in aVR and positive in II, III and aVF.) Sometimes what appears like right atrial tachycardia on surface ECG may originate close to right superior pulmonary vein, the morphology maybe difficult to
discern. Generally P wave is negative or isoelectric in aVL and positive in V1 (left atrial origin) and P is >80 msec in V1 and P wave in lead I is >50microvolt and >100 microvolt in lead II, suggesting a Right Superior Pulmonary Vein (Elllenbogen et al)
https://www.inkling.com/read/das-electrocardiography-arrhythmias-1st/chapter-7/atrial-tachycardia
I would wait 4 weeks in anticoagulation therapy and optimizing rate control, if after 4 weeks the thrombus is unchanged I can consider it as organized. I would proceed with catheter ablation guided by 3-D electro-anatomic mapping.
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