Pleuropericardial Fistula Formation After Prior Epicardial Catheter Ablation for Ventricular Tachycardia

Abstract

HomeCirculation: Arrhythmia and ElectrophysiologyVol. 5, No. 1Pleuropericardial Fistula Formation After Prior Epicardial Catheter Ablation for Ventricular Tachycardia Free AccessCase ReportPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessCase ReportPDF/EPUBPleuropericardial Fistula Formation After Prior Epicardial Catheter Ablation for Ventricular Tachycardia Nilesh Mathuria, MD, Eric Buch, MD, MS and Kalyanam Shivkumar, MD, PhD Nilesh MathuriaNilesh Mathuria From St Luke's Episcopal Hospital/Texas Heart Institute, Houston, TX (N.M.); and UCLA Cardiac Arrhythmia Center, David Geffen School of Medicine at UCLA, Los Angeles, CA (E.B., K.S.). Search for more papers by this author , Eric BuchEric Buch From St Luke's Episcopal Hospital/Texas Heart Institute, Houston, TX (N.M.); and UCLA Cardiac Arrhythmia Center, David Geffen School of Medicine at UCLA, Los Angeles, CA (E.B., K.S.). Search for more papers by this author and Kalyanam ShivkumarKalyanam Shivkumar From St Luke's Episcopal Hospital/Texas Heart Institute, Houston, TX (N.M.); and UCLA Cardiac Arrhythmia Center, David Geffen School of Medicine at UCLA, Los Angeles, CA (E.B., K.S.). Search for more papers by this author Originally published1 Feb 2012https://doi.org/10.1161/CIRCEP.111.968420Circulation: Arrhythmia and Electrophysiology. 2012;5:e18–e19A 61-year-old man with nonischemic cardiomyopathy (left ventricular ejection fraction, 20%) underwent ventricular tachycardia (VT) ablation for recurrent implantable cardioverter-defibrillator shocks despite antiarrhythmic drugs. The patient had undergone a combined endocardial/epicardial VT ablation 3 years prior. During this index procedure, percutaneous epicardial access was obtained as previously described1 without complications and the pericardiogram was normal. Epicardial mapping revealed a large, dense scar covering the lateral wall of the left ventricle. Extensive ablation with an externally irrigated ablation catheter was performed on the epicardial surface, targeting late potentials and pace maps of induced VTs. Steroids were not administered in the pericardial space.The patient was free from VT for 3 years but then had recurrent VT. Given the known epicardial substrate from the prior procedure, a repeat endocardial/epicardial VT ablation was planned. During percutaneous epicardial access, the pericardial space was entered without difficulty and a guide wire easily passed within the pericardial space. Before placement of an epicardial sheath, a pericardiogram was performed, which revealed a large region of contrast extravasation outside the pericardial border, near the posterolateral left ventricle (Figure 1), consistent with a pleuropericardial fistula. This contrast dissipated during the procedure, probably as the result of dilution from the irrigated catheter or diffusion into the pleural cavity. During the procedure, the ablation catheter occasionally entered this fistula, demonstrating “electric silence” and exiting the pericardial space fluoroscopically.Download figureDownload PowerPointFigure 1. Pericardiograms demonstrating pleuropericardial fistula. After epicardial access was obtained and a guide wire was placed within the pericardial space (thin arrow), a pericardiogram demonstrated contrast extravasating outside the pericardial space (block arrow).After the procedure, the patient was noted to have a left pleural effusion, which required 2 days of diuretics (Figure 2). The patient otherwise tolerated the procedure without complications and is currently free of VT at 3-month follow-up.Download figureDownload PowerPointFigure 2. Chest radiographs before (A) and after (B) ablation reveal moderate left-sided pleural effusion.DiscussionTo our knowledge, this is the first report of a pleuropericardial fistula developing after prior epicardial catheter ablation. During the second procedure, only a soft J-tipped guide wire and 5F dilator had entered the pericardial space when the pericardiogram revealed a marked abnormality, before placement of any sheath or catheter. Although congenital pleuropericardial fistulas have been described, the most likely explanation for this finding is a fistula that developed between the pericardial and pleural space as a consequence of prior epicardial ablation.The fibrous pericardial lining is roughly 2 mm in thickness throughout the pericardium.2 The pleural layer abuts the pericardial lining along the anterior and lateral left ventricle. Given that these thin structures are in close proximity and the proinflammatory state caused by ablation on the epicardial surface, the formation of a fistula between the 2 spaces is possible. Additionally, fistulas between the pericardium and the esophagus, stomach, and peritoneal cavity have been described in the setting of malignancies, surgery, or ablation. This abnormality is likely to be underrecognized if a pericardiogram is not performed or if the fistula is small. The possibility of a pleuropericardial fistula should be considered if there is extravasation of contrast outside the pericardial space during a pericardiogram, limited fluid aspiration from the pericardial space during irrigated ablation, or a new left pleural effusion after the procedure.ConclusionsA pleuropericardial fistula can develop after percutaneous epicardial access and ablation. This abnormality can be diagnosed with a pericardiogram and should be considered in cases of new left pleural effusion or difficulty aspirating fluid from the pericardial space.DisclosuresNone.FootnotesCorrespondence to Nilesh Mathuria, MD, St Luke's Episcopal Hospital/Texas Heart Institute, 6770 Bertner St, MC 2–255, Houston, TX 77030. E-mail [email protected]com