Title : Cardiac tamponade following vein of marshall ethanol ablation for atrial fibrillation (AF): Rare but can be life-threatening
Abstract:
Introduction: Atrial Fibrillation (AF) is the most common sustained arrhythmia, and its incidence and prevalence are growing in the United States and worldwide. Catheter ablation was successful in decreasing recurrence of AF by 48% and symptomatic AF by 51% compared with drug therapy over 5 years of follow-up. (1) Vein of Marshall ethanol infusion (VOM-ABL) can lead to a notably higher rate of long-term freedom from AF (risk ratio [RR], 1.28; 95% confidence interval [CI], 1.12-1.47; p= 0.00) and effective mitral isthmus (MI) block (RR, 1.52; 95% CI, 1.16-1.99; p= 0.00). (2).
Case Presentation: A 60-year-old female with a history of paroxysmal atrial fibrillation (AF) and atrial flutter presented for a fourth catheter ablation. She had undergone three previous ablations, the latest was in 2022. Previous procedures included Radiofrequency Catheter Ablation (RCFA) for pulmonary vein isolation (PVI), left atrial posterior wall isolation, and the creation of a mitral annular line. She was on anticoagulation with apixaban and flecainide for rhythm control. Her CHA2DS2-VASc score was 2, indicating a low stroke risk. Prior to the present procedure, she was hospitalized for AF with rapid ventricular response (RVR), which required transesophageal echocardiogram (TEE)-guided direct current cardioversion (DCCV). A month later, she described episodes of atypical fluttering and symptomatic paroxysmal AF, leading to the decision for repeat ablation. Following the ablation, she experienced presyncope and post-procedural hypotension (69/50 mmHg), pallor, and diaphoresis. The jugular venous pressure was elevated, and her heart sounds were distant. A transthoracic echocardiogram (TTE) indicated a large pericardial effusion, raising suspicion for cardiac tamponade. An emergency pericardiocentesis was attempted but was unsuccessful, allowing only 105 mL of fluid removal. Given her hemodynamic instability, she underwent a pericardial window surgery where 400 mL of dark blood was evacuated. There was no re-accumulation of fluid on the follow-up echocardiogram, and she remained hemodynamically stable.
Discussion: Ethanol infusion into the vein of Marshall is a very effective and safe modality of AF treatment. Of note, only nine cardiac tamponades were observed among 644 patients (PR 0.8%, 95% CI 0.1-1.5%) who underwent ethanol VOM-ABL combined with RFCA. (3) Cardiac tamponade is a rare but significant side effect of this treatment that can be fatal and demands immediate medical attention. This case underscores the need for close post-procedural monitoring and timely intervention for managing this complication successfully.
