Difficulties in the management of a patient with heart failure and atrial arrhythmia

Maria Micu ^{1 *}, Maria Muresan ¹, Gabriel Cismaru ², Dana Pop ²

¹ Cardiology Department, Rehabilitation Hospital, Cluj-Napoca, Romania
² 4^th Department of Internal Medicine, Cardiology Rehabilitation, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
* Correspondence to: Maria Micu, Cardiology Department, Rehabilitation Hospital, Cluj-Napoca, Romania.
E-mail: micumaria2017@yahoo.com; Phone: +40751463183

Abstract

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia in elderly patients and is frequently associated with heart failure. The management of drug-refractory AF with inadequate ventricular rate control remains challenging. We report the case of a 75-year-old woman with heart failure and highly symptomatic atrial fibrillation, initially paroxysmal and later persistent, refractory to multiple rhythm- and rate-control strategies. Amiodarone was initially required to control arrhythmic burden, while guideline-directed medical therapy was initiated for concomitant AF-related cardiac decompensation. Due to persistent symptoms and inadequate rate control, an ablate-and-pace strategy was pursued. The patient underwent atrioventricular node ablation followed by implantation of a dual-chamber pacemaker with conduction system pacing. After the procedure, ventricular rate stabilized at approximately 80 bpm, symptoms resolved completely, and sustained clinical improvement was observed. In this context, amiodarone and heart failure–specific therapy were discontinued, as both therapies were no longer clinically indicated. Ablate-and-pace therapy represents an effective and durable treatment option in selected patients with refractory atrial fibrillation and drug intolerance. Early consideration of this strategy may prevent prolonged exposure to antiarrhythmic drug toxicity and improve patient outcomes.