Atrial Fibrillation after Inhalational Lung Injury: A Troubling Complication of a Rare Problem

Ragesh Panikkath,Alejandro Perez-Verdia,Kenneth Nugent

doi:10.1155/2012/302057

Ragesh Panikkath, Alejandro Perez-Verdia + Show 1 more

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https://doi.org/10.1155/2012/302057

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Abstract

Atrial fibrillation (AF) has been associated with lung diseases like pneumonia and chronic obstructive pulmonary disease but has only infrequently been associated with inhalational lung injury. We report two cases of resistant AF, which developed in young healthy manual laborers shortly after inhalational lung injury due to massive quantity of pesticides and anhydrous ammonia, respectively. They had no evidence of valvular or structural heart disease and did not have any previous medical problems. The AF was resistant to antiarrhythmic drugs and required pulmonary vein isolation in first patient and possibly the second patient who is currently being evaluated for this procedure. These arrhythmias may reflect direct myocardial injury during and after exposure. Alternatively, multiple mechanisms can cause atrial fibrillation in lung diseases, including hypoxemia, acidemia, inflammatory mediators, and structural changes in the atria and ventricle, and these could lead to AF in inhalational lung injury cases. AF needs to be excluded when patients present with palpitations after inhalational lung injury, especially since, if unrecognized, AF may lead to complications, like thromboembolic phenomenon and tachycardiomyopathy.

Highlights

Age adjusted multivariate analyses have shown that the major risk factors for atrial fibrillation (AF) are hypertension, heart failure, diabetes, and valvular heart diseases [1]
He presented with shortness of breath and hemoptysis to the emergency department immediately after the event. He subsequently developed diffuse interstitial lung disease, identified as desquamative interstitial pneumonia on lung biopsy (Figure 1). His pulmonary function tests (PFT) revealed a forced expiratory volume in first second (FEV1) 2.5 L (57% predicted), forced vital capacity (FVC) 3.3 L (61% predicted), and FEV1/FVC of 94% predicted consistent with a restrictive defect
The time course suggests that their AF developed as a consequence of inhalational lung injury, possibly secondary entry of high concentrations of chemicals and inflammatory mediators into the pulmonary veins with direct delivery into the left atrium

Summary

Introduction

Age adjusted multivariate analyses have shown that the major risk factors for atrial fibrillation (AF) are hypertension, heart failure, diabetes, and valvular heart diseases [1]. A repeat study three months later at another facility reported a normal left ventricular systolic and diastolic function with an ejection fraction of 60–65% He underwent bilateral antral pulmonary vein isolation due to an inadequate drug response. The second patient is a 36-year-old man who was accidentally exposed to anhydrous ammonia when the tube transferring ammonia broke He sustained lung injury and was brought to the emergency department. He recently underwent chemical cardioversion with dofetilide but had recurrence within one week of cardioversion His echocardiogram revealed a left ventricular ejection fraction of 65–69%, normal diastolic function and chamber dimensions, and left atrial dimension of 2.7 cm. This patient initially had respiratory failure after the exposure and required intubation, his lung function recovered His PFTs later revealed a FVC of 6.2 L (110% predicted), FEV1 of 3.6 L (80% predicted), and a FEV1/FVC 72% of predicted.

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