Medical and interventional options to treat pulmonary embolism

Pulmonary and Paradoxical Embolism after Slow Pathway Ablation: A Thrombotic Disorder Unmasked by a Rare Complication

Cardiac electrophysiology study (EPS) and catheter ablation procedure are established diagnostic and therapeutic procedures for cardiac arrhythmias. Pulmonary embolism (PE) is a relatively rare but potentially fatal complication of Cardiac electrophysiology study (EPS). The paradoxical embolism (PDE) occurs due to an intracardiac defect with a right to left shunt with patent foramen ovale (PFO) being the most common cause. The simultaneous occurrence of PE and PDE is rare. Here we present a case of PE and PDE after EPS and radiofrequency catheter ablation (RFCA) of the slow pathway in a patient with recurrent supraventricular tachycardia (SVT) due to atrioventricular nodal reentry tachycardia (AVNRT). To our knowledge, such a case of PE and PDE has not been reported after SVT ablation.

Pulmonary embolism as a complication of an electrophysiological study: a case report

BACKGROUND

Electrophysiological studies have become an established practice in the evaluation and treatment of arrhythmias. Symptomatic pulmonary embolism as a result of deep vein thrombosis arising from multiple venous sheath femoral vein catheterization is an uncommon complication associated with it. We report the case of a 33-year-old woman who developed pulmonary embolism after an electrophysiological study, which was successfully treated at a cardiac hospital in Bangladesh.

CASE PRESENTATION

A 33-year-old Bangladeshi woman with hypertension and diabetes had initially presented with recurrent episodes of paroxysmal atrial fibrillation that manifested as palpitations for 2 years. Her atrial fibrillation was drug-refractory and could not be attributed to a treatable etiology. She had undergone an electrophysiological study at a different hospital, where right femoral venous catheterization was performed followed by the insertion of three venous sheaths. However, tachyarrhythmia could not be induced and a procedure to isolate the pulmonary vein was postponed because all the veins could not be isolated. Forty-eight hours later, she presented to our hospital with shortness of breath, chest heaviness, palpitations, and recurrent episodes of syncope. She had normal coronary arteries and no other risk factors for venous thromboembolism. She was hemodynamically stable on examination. There was echocardiographic evidence of pulmonary hypertension and right ventricular dilatation and dysfunction. A computed tomography pulmonary angiogram confirmed pulmonary embolus in the descending branch of her left pulmonary artery, extending up to the segmental arteries. Subsequently, a duplex ultrasound confirmed acute deep vein thrombosis affecting her right ilio-femoral segment. She was successfully managed with subcutaneous enoxaparin and oral warfarin (target international normalized ratio 2.5-3).

CONCLUSIONS

Pulmonary embolism is a rare but serious complication that may occur in patients who undergo electrophysiological studies. Multiple venous sheaths inserted into the femoral vein and catheter-induced endothelial injury, further compounded by prolonged procedural time, may be responsible for the increased thrombogenicity leading to deep vein thrombosis and subsequent pulmonary embolism. An adequate observation time after the procedure and clinical alertness are necessary for rapid diagnosis and treatment.