A 73-year-old woman presented with a history of persistent atrial fibrillation, which had lasted more than five years. She also had a remote history of transient ischemic attack and had received warfarin therapy. The international normalized ratio had been carefully maintained at slightly subtherapeutic levels because of recurrent gastrointestinal bleeding, which was severe enough to require frequent blood transfusions. With colonoscopy, the source of bleeding was localized to multiple arterial-venous malformations. The patient underwent catheter ablation of the atrioventricular junction and received a single chamber pacemaker. Two years later, she received a dual chamber pacemaker followed by cardioversion to restore a sinus rhythm. Following brief cardioversion, her symptoms of atrial fibrillation returned after two days.Investigations
Transesophageal echocardiography, pacemaker interrogation.Diagnosis
Persistent atrial fibrillation, gastrointestinal bleeding requiring transfusion.Management
Percutaneous left atrial appendage occlusion, antiplatelet therapy.