Sinus Conversion of Atrial Fibrillation by Restoration of Atrial Perfusion in a Patient with Chronic Total Occlusion

A 72-year-old woman with hypertension and diabetes mellitus visited the outpatient clinic complaining of chest discomfort. Her electrocardiogram (ECG) revealed AF with rapid ventricular response and 1 mm ST-segment elevation in I, aVL, aVR, V4-V6 leads (Figure 1). Blood tests revealed normal cardiac enzyme levels. A 2D-echocardiogram demonstrated normal regional wall motion, good systolic function, and mild left atrial (LA) enlargement (size Aron Jeong, MD; Sung Soo Kim, MD; Semi Kim, MD; Dong Goo Kang; MD; Seung Wook Lee, MD; Sang Ki Cho, MD


Sinus Conversion of Atrial
Fibrillation by Restoration of Atrial Perfusion in a Patient with Chronic Total Occlusion 42 mm). As she had a CHA₂DS₂-VASc (congestive heart failure, hypertension, age≥75 years, diabetes mellitus, stroke/transient ischemic attack, vascular disease, age 65-74 years, sex category) score of 5 points, she was commenced on oral anticoagulation and a β-blocker.
Despite the administration of appropriate treatment for her AF, after 3 months, she continued to complain of intermittent substernal chest discomfort relieved by sublingual nitroglycerin therapy. She was referred for cardiac catheterization, which revealed total occlusion of the proximal RCA with grade III collateral filling of the distal RCA from the septal branches of the left anterior descending (LAD) artery ( Figure 2). A discrete mid 80% stenosis of the LAD was also present. Coronary intervention targeting the RCA via an antegrade approach with a hydrophilic floppy wire (Fielder FC™, Asahi Intec, Japan) and a microcatheter (Corsair™, Asahi Intec. Japan) was performed. After several attempts, the guide wire was passed through the occluded lesion, and the lesion was dilated using a 1.0 mm, 2.5×15 mm balloon.
The coronary angiogram then showed a thrombolysis in myocardial infarction (TIMI) grade III blood flow through the RCA, the sinoatrial nodal branch, the acute marginal branches and the atrioventricular nodal branch. The patient's cardiac rhythm reverted from AF to sinus rhythm immediately ( Figure 3). The patient remained in sinus rhythm throughout the duration of her hospitalization. She was subsequently discharged on a regimen of aspirin, clopidogrel, dabigatran, a β-blocker, statin, and an angiotensin-converting enzyme inhibitor. ECG, and 24-hour Holter monitoring were performed 1 month later, and no evidence of recurrent AF was found. As such, anticoagulation was carefully discontinued in favor of dual antiplatelet therapy. The patient was followed up at the outpatient department over the next 12 months. There was no evidence of AF recurrence throughout this period.

Discussion
To the best of our knowledge, this is the first report on immediate cardioversion from AF after the restoration of atrial perfusion in a patient with chronic total occlusion of the RCA.
AF is a common arrhythmia, and restoration of sinus rhythm is These findings support the hypothesis that atrial ischemia can cause AF, and that the mechanical reperfusion of occluded atrial branches can terminate this potentially dangerous arrhythmia.
The recurrence and duration of paroxysmal AF can result in its chronicity. 7 Structural and electrical remodeling are among the mechanisms implicated in this process. Thus, prompt revascularization in myocardial ischemia may improve the longterm prognosis of any associated AF.
Comorbid AF and coronary artery disease complicates anticoagulation and antiplatelet therapy, and is associated with higher mortality rates. 8,9 There is insufficient data to guide clinical practice optimally in such cases. Current guidelines recommend dual antiplatelet agent and anticoagulation for patients with AF after coronary artery stenting. 2,10 However, some cases of AF detected after myocardial ischemia may be short self-terminating phenomena, and thus strict adherence to the guidelines may    Sinus Conversion of Atrial Fibrillation by Restoration of Atrial Perfusion