Sirs: One year ago, a 68-year-old man was treated with pulmonary vein (PV) isolation for paroxysmal AF. Ostial PV isolation was performed by using the High Density Mesh Ablator Catheter (Bard Electrophysiology, Lowell, MA, USA). The deployed Mesh Ablator was positioned at the anatomical PV ostium. Lesions were created with pulsed RF energy from an RF energy generator (Stockert 1000 XP, Biosense Webster Inc., Diamond Bar, CA, USA). Target temperature was set at 58 C with a maximum energy output of 80 W. After each energy delivery time of 300 s, endocardial electrograms from 10 mm distal to the anatomical PV ostium were obtained with the Mesh Ablator Catheter to confirm circumferential PV isolation. With an energy delivery time of 600 s for each PV, isolation of all PVs could be achieved. Due to AF recurrence, re-ablation was performed 12 months after the first procedure. Before re-ablation, electrical reconnection was documented with a decapolar spiral catheter (Reflexion Spiral Variable Radius Catheter, St. Jude Medical, St. Paul, MN, USA). No PV stenosis was found. For re-ablation, we used a threedimensional mapping system (Ensite NavX, Verismo, St. Jude Medical) for navigation based on a fusion with cardiac computer tomography, and an irrigated-tip ablation catheter (Cool Path, St. Jude Medical) for ablation. To achieve better catheter stability, a steerable sheath (Agilis, St. Jude Medical) was used. The ablation setting consisted of a preselected catheter tip temperature of 42 C, a power of 30 W, and a flow rate of 17 mL/min. Adjacent to the oesophagus visualized with contrast medium swallowed immediately before sedation of the patient, the power was reduced to 25 W. The right sided and the left sided PVs were isolated with a single circumferential antral line and additional ablations at the carina between the superior and inferior PVs, respectively (Fig. 1). After completion of the ablation lines, successful PV isolation was confirmed with the spiral catheter for all PVs. The cumulative RF delivery time was 2,860 s, the procedure time was 230 min. The procedure was completed without any complications. The patient was discharged on a betablocker, an ACE-inhibitor, a proton pump inhibitor and phenprocoumon. The patient was readmitted to hospital 14 days after the second AF ablation because of symptoms suggestive of pericarditis. The leading symptoms consisted of fever up to 38.5 C and chest pain, exacerbated by movement and inspiration. The 12-lead ECG showed non-ischemic STelevation in leads I, II, III, aVL, aVF and V2–V6 (Fig. 2) and blood work showed elevated c-reactive protein and erythrocyte sedimentation rate. A CT scan of the chest and echocardiography revealed no abnormalities. Cardiac enzymes remained negative and the patient was therefore treated with anti-inflammatory drugs. On the fourth day of hospitalization, the patient experienced syncope with subsequent severe cardiogenic shock accompanied by dilated jugular veins associated with not detectable blood pressure. Transthoracic echocardiography performed in the ICU showed significant pericardial effusion. At pericardiocentesis, 400 ml of blood could be removed resulting in restoration of normal blood pressure. Laboratory analyses of the removed blood showed a haemoglobin level comparable to peripheral blood with an oxygen saturation of 91% indicating active bleeding from the left atrium. At this point of time, INR was 1.93 and the T. Lambert (&) C. Steinwender F. Leisch R. Hofmann Cardiovascular Division, City Hospital Linz, Krankenhausstrase 9, 4020 Linz, Austria e-mail: Thomas.lambert@akh.linz.at
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Oct 20, 2023
A A Tolstikhina + 2
Open Access