1852 Acute Gastroparesis Syndrome After Percutaneous Atrial Fibrillation Ablation

Abstract

INTRODUCTION: Percutaneous radiofrequency ablation (RFA) is now a common minimally invasive procedure for the maintenance of sinus rhythm in drug-resistant atrial fibrillation. We present a rare case of acute delayed gastric emptying after an RFA procedure. CASE DESCRIPTION/METHODS: 57-year-old male with a history significant only for paroxysmal atrial fibrillation, who presented for a planned RFA procedure. He has no other medical or surgical history. The patient tolerated the procedure well and was discharged the same day. That evening, 1-2 hours after he ate dinner, he experienced severe nausea, vomiting, and abdominal pain. He was hemodynamically stable on presentation to the emergency department with labs significant only for a mild leukocytosis. Computed tomography showed a severely dilated stomach and proximal duodenum, with a transition point identified at the third portion of the duodenum. The patient was managed conservatively as a case of proximal small bowel obstruction. As he had mild improvement in symptoms after five days, the decision was made for an exploratory laparotomy. An intra-operative push enteroscopy demonstrated large amounts of retained food in the stomach, but no gastroduodenal outlet obstruction. A diagnosis of acute gastroparesis syndrome was made, and surgical exploration was not done. The patient was discharged, managed conservatively, and on follow-up 4 weeks later his symptoms had significantly improved. DISCUSSION: Acute gastroparesis syndrome is a rare complication of RFA for atrial fibrillation, that occurs due to thermal injury to the peri-esophageal vagal nerves during ablation. Symptoms of nausea, bloating, vomiting, gastric pain occur within 72 hours after the procedure. Most patients fully recover within 1-2 months after the procedure with conservative management. However, a few reported cases with persistent symptoms required eventual esophagojejunal anastomosis or intra-pyloric botulinum injection. Due to wide variation in vagal plexus anatomy around the lower esophagus, and lack of visualization of the nervous system, nerve injury is hard to avoid. Higher BMI was noted to be a protective. Minimizing RF ablative power around the esophagus and/or esophageal temperature monitoring may be a strategy to lower the risk. As RFA ablation for atrial fibrillation becomes more common, gastroenterologists should be aware of this complication.