Temporary Rhythm Control with Flecainide in Atrial Fibrillation-Related Conversion Pauses Prior to Catheter Ablation: A Case of Successful Pharmacological Bridging.

The management of paroxysmal atrial fibrillation with conversion pauses remains challenging, with catheter ablation and permanent pacemaker implantation representing the main therapeutic strategies. Catheter ablation may eliminate atrial fibrillation paroxysms and prevent conversion pauses, whereas pacemaker implantation combined with antiarrhythmic therapy for rhythm control is another accepted option. We report a case of successful management of paroxysmal atrial fibrillation with conversion pauses using antiarrhythmic agents for rhythm control prior to catheter ablation. A 61-year-old woman had episodes of palpitations, dizziness, and presyncope. Ambulatory 12-lead 24-hour ECG monitoring showed 51 episodes of atrial fibrillation and atrial flutter with conversion pauses after each of them; the longest pause was 7460 ms. Atrial fibrillation lasted for 46.9% of the total monitoring time. When ambulatory 24-hour monitoring was performed, the patient was highly symptomatic (complaints of palpitations and fear of death were predominant, but dizziness episodes were also noted). Catheter ablation was unavailable in the short-term period and permanent pacemaker implantation was not accepted by the patient. Thus, flecainide at a dose of 100 mg BID under close supervision for rhythm control was administered. Also, anticoagulation with edoxaban was provided. The patient remained asymptomatic until ablation was performed. Pulmonary vein isolation with pulsed field ablation and cavotricuspid isthmus ablation was performed 10 days after ambulatory ECG monitoring. There were no paroxysms of atrial fibrillation after ablation. Antiarrhythmic agents in patients with conversion pauses may worsen sinus node function but may also eliminate atrial fibrillation paroxysms preventing conversion pauses. Thus, catheter ablation may be an option for a patient presenting with atrial fibrillation and conversion pauses to avoid unnecessary permanent pacemaker implantation. Short-term pharmacological bridging with flecainide under close supervision may be used in patients with atrial fibrillation and conversion pauses without other signs of sinus node dysfunction, providing effective rhythm control.