Introduction:

when choosing treatment for atrial fibrillation, it is necessary to understand the patient beyond risk scores, to understand the need to drive to sinus rhythm or treatment goals and the speed to be employed given the risk conferred by their chronic diseases and the challenges these diseases pose to conventional strategies.

Case report:

69-year-old male with a history of chronic non-specific ulcerative colitis (CUCI), operated on with subtotal colectomy, since then with abundant, intermittent rectorrhagia. Preoperative assessment of para-stomal hernia revealed AF with an increase in bleeding after the start of anticoagulation, with a high number of episodes, even requiring hospitalization. Due to the hypercoagulable state and immuno-thromboinflammation associated with UC, it was considered a priority to revert to sinus rhythm. Pharmacological cardioversion with amiodarone was attempted without success. He was considered a candidate for cryotherapy ablation after unsuccessful electrical cardioversion, in addition to closure of the left atrial appendage, as he was not considered a candidate for long-term anticoagulation. Cryoablation of the four pulmonary veins was performed without achieving a return to sinus rhythm, so ablation was extended to the posterior wall and left atrial appendage, successfully jugulating the arrhythmia. Finally, a left atrial appendage closure device was placed. After three months of optimal medical management, the patient remained in sinus rhythm, and anticoagulation was discontinued. More than one year after the procedure, the patient is free of thrombotic and bleeding events.

Conclusions:

this case demonstrates the importance of individualizing the approach in atrial fibrillation. Furthermore, extended ablation in atrial fibrillation without origin in the pulmonary veins, and atrial appendage closure, is important as a treatment strategy for patients in complex scenarios who are not candidates for anticoagulation.

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