Complications of cardiac ablation: ED presentations, evaluation, and management

Authors: Caroline Arnold, MD (Emergency Medicine Resident, University of Kentucky) and Joel Hamm, MD, MPH (Assistant Professor, University of Kentucky) // Reviewed by: Tim Montrief, MD (@EMinMiami), Alex Koyfman, MD (@EMHighAK) and Brit Long, MD (@long_brit)

Case:

A 28-year-old male arrives to your emergency department complaining of burning chest pain. He is tearful and states this started suddenly and he hasn’t experienced pain like this before. He says the pain is worse when he swallows and is constant. He recently had cardiac ablation for atrial fibrillation in the past month, but otherwise has no other medical history. He appears uncomfortable and distressed. He is tachycardia with a heart rate of 110, hypotensive with a blood pressure of 90/70 mm Hg, and febrile to 101° F. The resident gives him bolus of lactated ringers and orders labs. Suddenly, the patient has a two minute generalized tonic clonic seizure.

What are the common complications of cardiac ablation? Could this patient’s chest pain and seizure both be related to the recent ablation procedure? What are the next steps in management?

Background

Cardiac ablation has been a common procedure for complicated arrhythmia since the 1990s. For tachyarrhythmias such as supra ventricular tachycardias (SVT), atrial fibrillation, atrial flutter, and Wolff-Parkinson-White, ablation is often the next line treatment after failed medical management.¹ During ablation, multiple catheters are passed through a vein or artery into the heart. The catheters include a mapping catheter to identify abnormal electrical activity and an ablation catheter to heat the abnormal pathway via radio frequency energy. The heated tissue, most often near the pulmonary veins, is then scarred in order to prevent the transmission of abnormal signals.

Ablation procedures have increased 138% over the past ten years (from 1,953 in 2006 to 4,648 in 2015) with the majority being for atrial fibrillation.² Out of 16,309 patients, 12,535 have resolution of symptoms after ablation.³ The overall complication rate of cardiac ablation has been shown to be 6.29%.⁴ Most common complications of procedure were cardiac (2.65%), vascular (1.33%), and neurological (1.05%) as shown in Table 1.⁵ According one study, cardiac tamponade was the most common complication with a rate of 1.31%.³ The independent risk factors for complications included older age, complex procedures, female sex, and lower hospital volumes.⁶  Complication rates increased from 2.79% in the 18-44 year old age group to 6.58% in the > 75 year age group.⁷ Ablation for ventricular tachycardia had the highest complication rate at 9.9%, possibly due to majority of cases being nonelective (62%.)⁷The patient population with ventricular tachycardias also had the highest rate of comorbidities.⁷ White males were the highest population undergoing catheter ablation, however SVT ablation was highest in women.⁸

Table 1. Complications of cardiac ablation by system

Let’s focus on complications that we can’t miss in the Emergency Department…

Atrio-esophageal Fistula

Atrio-esophageal fistula (AEF) is a rare, yet deadly complication of cardiac ablation. In a study of 191,215 performed ablations, an esophageal perforation or fistula was reported in 31 patients.⁹ The average time to presentation is 19 days however can present up to 60 days later.^9,10,45 One study showed an overall 1% risk where a total of four patients developed atrio-esophageal fistula.⁹ Three of the four had air emboli and neurologic deficits and were treated with esophageal resection. The other died from massive air emobolism.¹¹ Among the possible complications following an ablation, atrio-esophageal fistula has the second highest mortality rate after tamponade.⁵

As the esophagus descends into the mediastinum, it runs posteriorly to the left atrium and pulmonary veins. At some points, the esophagus is within millimeters of these structures leading to potential thermal damage.¹²

Although the specific cause of esophageal injury and subsequent fistula formation is unknown, direct thermal injury, ischemic injury through thermal occlusion of end- arterioles, acid reflux, and infection from the lumen are through to be mechanisms.¹³ Esophageal ulcers are a fairly common complication of ablations with one study showing a rate of 17%.¹⁴ Ulcers are thought to be the precipitating event to fistulization. Deneke et al assessed over 800 patients undergoing cardiac ablation with endoscopy four days after the procedure; 82% of patients had no esophageal abnormalities.¹⁵ Of the patients with esophageal findings, two thirds had only erythema and no ulcer. The five documented esophageal perforations occurred in patients with documents ulcerations.¹⁵ The progression to fistula likely initiates from the esophagus to the left atria and forms a one-way valve with the left atria. The isolated opening into the atria allows for spillage from the esophagus. Proximity of left atria and esophagus shown below in Figure 1.

Figure 1. Computed Tomography image representing proximity of esophagus to left atria. Right Ventricle (RV), Right Atrium (RA), Left Ventricle (LV), Left Atrium (LA), Esopaghus (E), Aorta (A)

With contamination of the left atria, the clinical presentation may resemble endocarditis with septic emboli.³⁸  Patients may present with a sepsis-like picture or with neurologic sequelae. Presentation may be less obvious at the beginning stages of formation and include chest discomfort, nausea, vomiting, dysphagia, hematemesis, and melena. In a review of 53 cases of atrio-esophageal fistula after ablation, the most common presenting symptoms were fever (n=44), neurological deficits (n=27), and hematemesis (n= 19.)¹⁶ The bacteria allowed in through the one-way valve leads to bacteremia and air allowed in leads to stroke.

If atrio-esophageal fistula is on your differential, prompt diagnosis is needed as patient’s can quickly decompensate. White blood cell count should be obtained as it is an early and sensitive marker of fistula being present in all patients at presentation.¹⁷ Order blood cultures, lactic acid, as well as complete blood count, complete metabolic panel, and lactic acid. Blood cultures from  CT chest with IV contrast has shown to be most diagnostic with up to 98% (n = 95 of 98) of scans being abnormal.⁴⁵ The most common findings are pneumomediastinum and pneumopericardium.¹⁸  In a study of five patients with fistula, CT detected free air in all five: in mediastinum in 3, the pericardium in 1, and left atrium in 1.³⁹  Avoid EGD, as insufflation of balloon could lead to air emboli and thus stroke and death. Contrast will aid in observing the fistula tract. Out of 53 documented cases in a review, 27 of the fistulas were found using CT of the chest.¹⁶ When looking at the scan, keep an eye out for air or contrast extravasation from the esophagus as seen in image below (Figure 2).

Figure 2. Example of pneumomediastinum found on CT scan (white arrows). Case courtesy of Dr Maciej Mazgaj, radiopaedia.org, rID: 30376.

Without emergent surgical treatment, mortality is 100%.¹⁹ Patients will need two large bore IVs and will be best served in a critical room. AEF often show Gram positive organisms; broad spectrum antibiotics including vancomycinshould be promptly started in these patients. Avoid esophageal manipulation including Nasogastric tube. Once diagnosis is made or suspected, emergent cardiothoracic surgery consult is needed. The surgical management options include esophageal stents and primary esophageal repair. In a retrospective cohort analysis of 29 patients, 100% of esophageal stent patients died versus 41% of primary repair patients.²⁰

Figure 3. Flow diagram showing clinical emergency medicine management of AEF

Delayed Cardiac Tamponade

Delayed cardiac tamponade is a rare, yet deadly complication. Cardiac tamponade is a known complication of cardiac ablation, however emergency medicine physicians must keep delayed presentation on the differential for post ablation patients. In one meta-analysis, 45 out of 27,921 ablation cases resulted in delayed cardiac tamponade.²² The average number of days to presentation post procedure was 12, however one case study discussed a patient presenting 61 days later.²²

During ablation procedures, tamponade is caused by mechanical trauma to the myocardium via heat, most often during linear atrial ablation and higher frequency power.²³ Most common presenting symptoms were chest pain, edema, shortness of breath, feelings of doom.²⁴  Surprisingly, in the study mentioned above, only 13% of the forty-five presented with hypotension and shock. 85% presented to Emergency Department for initial care.²²  Patients may also present with the classic “Beck Triad” of hypotension, jugular venous distension, and distant heart sounds, however lack of these findings does not rule out tamponade. The hallmark of cardiac tamponade is pulsus paradoxus where systolic arterial pressure drops greater than 10 mmHg during inspiration.⁴⁰  EKG may show decreased QRS voltage and electrical alternans.⁴²

Cardiac tamponade can be quickly assessed at bedside with point of care ultrasonography. Refer to chart for most common findings.

For more, please see this emDocs ultrasound post on pericardial tamponade.

Figure 4. Chart of common findings in cardiac tamponade

(IVC indicated inferior vena cava) Ultrasound images from: (27) Perez-Casares, Alejandro. Echocardiographic Evaluation of Pericardial Effusion and Cardiac Tamponade. Frontiers in Pediatrics. 2017; 5: 79. April 24, 2017. With permission through Creative Commons Attribution Copyright.

Isotonic fluids should be started in order to increase cardiac output.⁴¹ If needed, dobutamine is ionotrope of choice for hypotension.⁴³ Pericardiocentesis must be performed emergently in setting of cardiac tamponade. Cardiology should be consulted as patients may need further intervention such as pericardial window in the cath lab.

Stroke

Thrombo-embolic event leading to cerebral ischemia is a common side effect of ablation for atrial fibrillation. The overall risk of cerebrovascular event ranges from 0.2% and 0.94%.²⁸ Post cardiac ablation patients are at risk for cerebrovascular event up to two weeks post procedure. ²⁹

Thrombi can form secondary to direct trauma, increased turbulence from sheath introduction, or heat from the catheter tip.¹³  Conversely, the introduction of air from the catheter tip is the most common cause of air embolism.³⁰ A left atrial size >4.5 cm is also associated with higher risk of thrombus formation.²⁸

According to the 2017 Consensus Statement on Atrial Fibrillation Ablation, anticoagulation with warfarin or other NOAC should continue for at least two months after procedure.³¹

Patients with cerebral thrombo-embolic events will present with neurological deficits. Recent cardiac ablation is not a definitive contraindication to TPA.²⁸  Air embolism can present as altered mental status, seizure, or focal neurological deficits. As previously discussed, air atrio-esophageal fistula can present with air embolism and will need to be ruled out. Treatment is supportive with supplemental oxygen, fluids, and placing patient in head down position.³² Treatment with hyperbaric oxygen therapy may also prevent further endothelial damage in initiated within a few hours.³³

Atypical Migraines

For unknown reasons, transseptal catheterization during ablation may lead to new onset migraines.  In one study, out of 2,069 patients undergoing ablation, 1.1% had new onset migraines.³⁴ Interestingly, patients that had therapeutic levels of warfarin anticoagulation during peri-procedure period had less migraines.³⁵ There is also an association with isolated visual aura described as a scintillating scotoma.  These symptoms usually resolve after one month post procedure.³⁶

The most important task in these patients for emergency medicine physicians is to rule out stroke. Once CVA has been ruled out, the patient will need outpatient referral to neuro ophthalmologist.

Case Conclusion:

You give the patient 2 mg of ativan which stops the seizure. Due to concern for sepsis, patient was started on broad spectrum antibiotics including vancomycin and cefepime. Patient’s blood pressure stabilizes after another liter of lactated ringers and he is taken for a CT chest with IV contrast. When looking at the scan, the resident notices free air in the right atria and pneumomediastinum. She immediately calls cardiothoracic fellow on call due to concern for atrioesophageal fistula.  Patient is then taken emergently to the operating room where he had primary repair of esophagus.

Take Home Points:

• The overall complication rate for cardiac ablation is 6.29%.
• Atrio-esophageal fistula has up to a 100% mortality without surgery. If considered, emergently consult cardiothoracic surgery.
• EGD may cause fatal massive air embolism in the setting of atrio-esophageal fistula. Avoid even in the case of gross hematemesis.
• Delayed cardiac tamponade may occur even up to several weeks out from the ablation.
• Atypical migraine is a rare post ablation complication and should be considered a diagnosis of exclusion.

FOAMed Resources:

• EM@3AM – Cardiac Tamponade
• EM@3AM – Atrial Fibrillation
• Pneumomediastinum

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