Abstract
Pulmonary veins electrical isolation as an invasive treatment of atrial fibrillation has been widely used in electrophysiology laboratories. This case report presents a rare and transient complication, during transseptal puncture for atrial fibrillation ablation. ST-segment elevation, hypotension and bradyarrhythmia related to catheterization were observed despite cineangiocoronariography without obstructive lesions. Clinical stability was achieved after administration of intravenous atropine and saline solution. It is speculated that the phenomenon is attributed to an increased vagal tone after the mechanical effect of transseptal puncture in the interatrial vagal network. The procedure was completed despite the phenomenon.
Highlights
Access to the left atrium by transseptal puncture is a common practice in electrophysiology laboratories in the treatment by radiofrequency of cardiac arrhythmias
The ST segment elevation during transseptal puncture is mostly described as a sudden and transient alteration on the electrocardiogram, accompanied or not by symptoms with vagal action characteristics.The main pathophysiological mechanisms are vasospasm, due to the imbalance in autonomic innervation; coronary hypoperfusion secondary to reflex action; or air embolism.The incidence of this phenomenon is not well defined, and its description comes from case reports or retrospective records
A 67-year-old man with paroxysmal atrial fibrillation refractory to the use of antiarrhythmics, a candidate for radiofrequency ablation, received oral anticoagulation for three weeks before the procedure, maintaining the international normalized ratio (INR) between 2 and 3, and underwent transesophageal echocardiography, who demonstrated a left atrium with an indexed volume of 39 mL/m2, a left ventricular ejection fraction of 62%, without an intracavitary thrombus
Summary
Access to the left atrium by transseptal puncture is a common practice in electrophysiology laboratories in the treatment by radiofrequency of cardiac arrhythmias. A 67-year-old man with paroxysmal atrial fibrillation refractory to the use of antiarrhythmics, a candidate for radiofrequency ablation, received oral anticoagulation for three weeks before the procedure, maintaining the international normalized ratio (INR) between 2 and 3, and underwent transesophageal echocardiography, who demonstrated a left atrium with an indexed volume of 39 mL/m2, a left ventricular ejection fraction of 62%, without an intracavitary thrombus In LAO, it was between the final two thirds between the curvature of the right atrium and the coronary sinus catheter (Fig. 2) In this position, the septum was punctured, and, right after the transseptal puncture with a drop-off signal observed in fluoroscopy, it was recorded on the electrophysiology polygraph (EP-TRACER V 1.0®) elevation of the ST segment of 4 mm in DIII, in addition to junctional bradycardia with a heart rate of 35 bpm, blood pressure 93 × 37 mmHg and sweating. After the normalization of the ST segment with hemodynamic stability and the absence of coronary changes, the procedure was successfully concluded
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