Exacerbation of Gastroparesis After Ablation for Atrial Fibrillation

Abstract

A 54 year old woman with a history of paroxysmal atrial fibrillation (afib) and myasthenia gravis (MG) was referred to our clinic for a gastroparesis (GP) exacerbation. Her medications included cellcept, mestinon, prednisone and IV immunoglobulin. She was diagnosed with GP on a prior gastric emptying study, but had been asymptomatic on diet alone. She had failed two prior radiofrequency ablations (RFA) for afib, and therefore underwent a third cardiac cryoablation (CRYO) of all four pulmonary veins. The procedure was done with general anesthesia and was uncomplicated. The day after the ablation, she developed epigastric abdominal pain, nausea, vomiting, and post-prandial fullness lasting 5-6 hours. These symptoms prompted an emergency department visit, during which they ruled out an acute coronary syndrome. She was referred for urgently to our clinic where she reported ongoing symptoms. Upper endoscopy revealed mild gastric antral erythema without other significant findings, similar to her prior endoscopies. Thus her symptoms were thought to be secondary to an exacerbation of her GP. Due to her MG medications and risk for QTc prolongation with antiemetics such as ondansetron, metoclopramide and phenergan, a scopolamine patch was started, which somewhat improved her nausea. Numerous causes of GP are known including diabetes, scleroderma, neuromuscular diseases, hypothyroidism, and post gastrointestinal surgery. GP is a known risk of cardiac ablation secondary to vagus nerve injury, due to its proximity to the cardiac ablation site. While this complication is well established in cardiology literature, this case represents only the second instance of post-ablation GP discussed in gastroenterology literature and the first in which CRYO was utilized. The prevalence of post ablation GP is unknown, but thought to occur in 7-17% of patients. Further study is needed to determine if there is a difference in risk for GP between RFA vs. CRYO. Some have suggested the use of CRYO or microwaves instead of RFA as a potential means of reducing rates of post-ablation GP, but a clinical trial has yet to be performed. Most cases of post-ablation GP occur within the first 96 hours post-ablation and eventually resolve within 12 months. Extra consideration and planning should be considered in patients with a prior diagnosis of GP prior to afib ablation. This case demonstrates a noteworthy risk factor for GP, which is often unrecognized by gastroenterology providers.