RADIO-FREQUENCY ABLATION: LET'S ADD IT TO THE CAUSES OF DIFFUSE ALVEOLAR HEMORRHAGE

Abstract

SESSION TITLE: Monday Abstract Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Transcatheter ablation of pulmonary veins (PVI) is the mainstay of treatment for refractory atrial fibrillation (AF) [1]. Complications of ablative strategies include access site infection and bleeding, thromboembolism, pericarditis and tamponade. Pulmonary hemorrhage is a rare but life threatening complication of radiofrequency catheter ablation (RFA) with unknown incidence in literature [2]. Herein, we present a case of diffuse alveolar hemorrhage (DAH) post-RFA bringing forth the challenges associated with peri-procedural anti-coagulation among such patients. CASE PRESENTATION: A 69-year-old male was elected for PV isolation (PVI) by RFA due to symptomatic heart failure secondary to worsening burden of AF. The patient was receiving prior anticoagulation with Warfarin and had therapeutic international normalized ratio (INR) at the time of procedure. Per protocol, peri-procedural heparin was administered to maintain optimal anti-coagulation. Immediately post-procedure, bloody secretions were noted in the endotracheal tube warranting an emergent bronchoscopy. The latter showed bright red blood with clots throughout the tracheobronchial tree, most notably in the right lung. No signs of tracheal or bronchial tree injury were present. Subsequent computed tomography (CT) imaging showed extensive consolidation in bilateral lungs with normal pulmonary vasculature. Two subsequent bronchoscopies revealed active bleeding from right upper and lower lobes with serial aliquots suggestive of DAH. After instillation of thrombin to aid hemostasis, the patient was weaned off the ventilator and successfully extubated after 4 days. DISCUSSION: Hemoptysis and pulmonary hemorrhage are rare complications of PVI, typically occurring weeks to months post procedure as a result of PV stenosis. While PV stenosis has a mean incidence of 2% post PVI, up to 1 in 23 patients with PV stenosis post-ablation experience hemoptysis [2]. Acute hemoptysis (<2 weeks post-procedure) has been reported post cryoablation due to direct pulmonary vascular injury, high energy transfer causing bronchial erosion, or cryoinjury to the lung parenchyma. Interestingly, pulmonary hemorrhage after RFA is extremely rare, with only one case reported in literature so far. The overall success rate, procedural time and long-term complications between RFA & cryoablation are similar [3]. However, this raises the question of why hemoptysis and pulmonary hemorrhage are more frequently reported in one technique over the other. CONCLUSIONS: In current practice, regardless of pre-procedural anticoagulation treatment, all patients receive full anticoagulation with intravenous heparin during catheter ablation. This case serves as a reminder of a rare yet potentially lethal complication of RFA and raises the question of revisiting peri-procedural anticoagulation guidelines given the increasing demand of catheter ablation to treat AF. Reference #1: S.M. Hosseini, G. Rozen, A. Saleh, et al. Catheter ablation for cardiac arrhythmias: utilization and in-hospital complications 2000 to 2013. J Am Coll Cardiol EP, 3 (2017), pp. 1240-1248 Reference #2: B.C. Housley et al. Acute Pulmonary Hemorrhage Following Radiofrequency Ablation of Atrial Fibrillation. Journal of Cardiothoracic and Vascular Anesthesia 31 (2017) 1397-1400. Reference #3: Ali H. Hachem, Joseph E. Marine, Housam A. Tahboub, et al., “Radiofrequency Ablation versus Cryoablation in the Treatment of Paroxysmal Atrial Fibrillation: A Meta-Analysis,” Cardiology Research and Practice, vol. 2018 DISCLOSURES: No relevant relationships by Omer Bajwa, source=Web Response No relevant relationships by Garima Dahiya, source=Web Response No relevant relationships by Briana DiSilvio, source=Web Response No relevant relationships by Sheldon Rao, source=Web Response