Patients with hemophilia: Unique challenges for atrial fibrillation management

Case report A 54-year-old man with mild to moderate hemophilia A, obstructive sleep apnea on continuous positive airway pressure, and paroxysmal AF was referred for AF catheter ablation. Four years prior, he was evaluated for palpitations and dyspnea. AF was confirmed on ambulatory monitoring. His CHA2DS2-VASc score was 0. He was trialed on a series of antiarrhythmic medications including flecainide, propafenone, dronedarone, dofetilide, and sotalol. In spite of these medications, he continued to remain highly symptomatic with paroxysms of AF initially lasting 6–9 hours at a time, 3–5 times a month but later increasing in frequency and duration. He never required cardioversion. Because of the unique comorbidity of hemophilia A, options for management of his AF were carefully considered. This included treatment with amiodarone, surgical ablation with left atrial appendage ligation, and AF catheter ablation. In conjunction with his hematologist, the decision was made to pursue an AF catheter ablation using the Arctic Front Advance Cryoballoon catheter (Medtronic Inc, Minneapolis, MN) with a standard infusion protocol of a third-generation recombinant factor VIII. He was well established with a primary hematologist for his hemophilia with a baseline 5% factor activity level (mildmoderate disease severity). With the use of standard factor VIII replacement protocols, he had previously undergone other procedures including an appendectomy. He had a