Quiz

   A 60-year-old male is referred for management of paroxysmal atrial fibrillation. These subjective episodes occur several times a week, lasting 1 to 6 hours and are associated with incapacitating palpitations and dizziness . Multiple episodes of sinus rhythm and atrial fibrillation with ventricular response of 100-130/min have been documented. There is history of an extensive anterior and lateral wall myocardial infarction two years ago. Echocardiography showed a left ventricular ejection fraction of around 25% with expected segmental wall motion abnormalities. The patient is on chronic anticoagulation with warfarin.