So where is the heart?

A 75-year-old gentleman presented to his general practitioner with palpitations and dizziness. A 24-hour Holter monitor confirmed the diagnosis of paroxysmal sustained atrial flutter and episodes of less organised rhythm, that were thought to be atrial fibrillation. His symptoms failed to improve on combination treatment with digoxin and bisoprolol. He was referred for flutter ablation. Our aim was to replace the above pharmacological agents with a class 1C drug. The patient was not taking warfarin. A transoesophageal echocardiogram (TOE) was therefore arranged to exclude left atrial thrombus, prior to performing the ablation.