PVCS AND PES: A CASE OF MASSIVE PULMONARY EMBOLISM AFTER ELECTIVE RADIOFREQUENCY ABLATION

Abstract

SESSION TITLE: Medical Student/Resident Pulmonary Vascular Disease Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Thromboembolic events are a known but rare complication of radiofrequency ablation despite the frequent use of intra-procedural anticoagulation. CASE PRESENTATION: A 46-year-old male with history of hypertension and dilated cardiomyopathy underwent elective, repeat ablation for refractory premature ventricular contractions (PVCs) localized to the right ventricular outflow tract (RVOT). The procedure was complicated by bleeding at the groin access sites requiring pressure bandages and bed rest. Prior to discharge at 24 hours, the patient suddenly developed tachypnea, tachycardia, diaphoresis, and worsening hypoxemia. He required intubation with inotropic support; bedside echocardiogram showed a dilated right ventricle (RV). CT angiogram demonstrated extensive bilateral pulmonary emboli (PE). Intravenous heparin was started; however, refractory obstructive shock developed. Despite high minute ventilation, the patient’s hypercarbia and acidemia worsened. The decision was made to initiate veno-arterial extracorporeal membrane oxygenation (VA-ECMO) for impending cardiovascular collapse. Transesophageal echocardiogram during cannulation revealed a hypokinetic RV with clot in transit. The patient demonstrated improved hemodynamics and RV function while on ECMO with heparin anticoagulation, and was subsequently decannulated on day 7. He required tracheostomy and prolonged mechanical ventilation secondary to ventilator associated pneumonia and critical illness myopathy, but is now fully recovered and doing well at home. DISCUSSION: Incidence of deep vein thrombosis after non-atrial fibrillation (AF) ablations is as high as 2.38%(1). Periprocedural anticoagulation is recommended in AF and left sided ablations, but expert consensus recommends its use in RV procedures only when risk of thrombosis is considered high. The duration of the procedure and number of venous catheters used may increase the risk of venous thrombosis(2). RVOT ablations can be long and technically challenging, increasing both bleeding risk and endothelial disruption. Patients with bleeding complications may require bed rest and compression leading to stasis, tipping the coagulation balance towards thrombosis. To date, use of ECMO for massive PE is limited to single center case series with promising outcomes. ECMO should be considered in cases of refractory shock or inability to ventilate due to severe V/Q mismatch, especially when further thrombolysis may exacerbate pre-existing bleeding. PE with right heart thrombi in transit are at particularly high risk for deterioration(3). Fortunately, the diagnosis was made early in our patient’s course which allowed for timely initiation of VA-ECMO. CONCLUSIONS: Providers should maintain a high index of suspicion for PE even in patients with brief hospitalizations for elective procedures. Furthermore, VA-ECMO may be especially useful in patients with both massive PE and ongoing bleeding. Reference #1: Burstein B, Barbosa RS, Kalfon E, Joza J, Bernier M, Essebag V. Venous Thrombosis After Electrophysiology Procedures: A Systematic Review. Chest [Internet]. 2017;152(3):574–86. Reference #2: Cronin EM, Bogun FM, Maury P, Peichl P, Chen M, Namboodiri N, et al. 2019 HRS/EHRA/APHRS/LAHRS expert consensus statement on catheter ablation of ventricular arrhythmias. Hear Rhythm [Internet]. 2020;17(1):e2–154. Reference #3: Kronik G. The european cooperative study on the clinical significance of right heart thrombi. Eur Heart J. 1989;10(12):1046–59. DISCLOSURES: No relevant relationships by Timothy Fernandes, source=Web Response No relevant relationships by Abdurrahman Husain, source=Web Response No relevant relationships by Janna Raphelson, source=Web Response No relevant relationships by Alexandra Rose, source=Web Response