Journal of Arrhythmia 31 (2015) 238–239

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Case Report

Sudden manifestation of sinus arrest nine months after catheter ablation treatment for persistent atrial fibrillation Masateru Takigawa, MDn, Taishi Kuwahara, MD, Kenji Okubo, MD, Atsushi Takahashi, MD Cardiovascular Center, Yokosuka Kyosai Hospital, 1-16 Yonegahama Street, Yokosuka 238-8558, Japan

art ic l e i nf o

a b s t r a c t

Article history: Received 10 August 2014 Received in revised form 12 November 2014 Accepted 26 November 2014 Available online 18 March 2015

A 39-year-old man with a seemingly non-remodeled, small heart suffered persistent atrial fibrillation (AF). Extensive isolation of the pulmonary vein, superior vena cava, and posterior left atrium, in conjunction with right atrium focal ablation, was performed to ablate multiple AF foci during two catheter ablation sessions. Sinus arrest occurred suddenly during follow-up, despite the absence of recurrent AF, ultimately necessitating pacemaker implantation. This case underscores the necessity of careful follow-up after catheter ablation, highlighting the risk of sudden, severe sinus node dysfunction, even in young AF patients with small hearts. & 2015 Japanese Heart Rhythm Society. Published by Elsevier B.V. All rights reserved.

Keywords: Atrial fibrillation Sinus arrest Catheter ablation

1. Introduction Several studies have described an association between age or atrial size and atrial fibrosis [1,2], which may play a role in sinus node dysfunction. Although catheter ablation (CA) is a standard treatment for patients with atrial fibrillation (AF) [3], some patients, who are difficult to identify pre-procedurally, develop sinus node dysfunction after CA.

2. Case report A 39-year-old man underwent cardioversion for drug-refractory, symptomatic AF that had persisted for six months. The patient was scheduled for CA due to persistent AF burden, despite anti-arrhythmia therapy. Preoperative echocardiography revealed no structural heart disease, but revealed a small left atrium (LA; 33 mm) and a sharp left atrial appendage peak flow velocity (92.8 cm/s), without spontaneous echo contrast. AF was determined during initial CA to originate from multiple foci including the pulmonary veins, superior vena cava (SVC), posterior LA, and right atrium (RA) crista terminalis. Therefore, the SVC was electrically isolated, the other foci were focally ablated, and extensive circumferential pulmonary vein isolation was performed without any obvious complications. Linear ablation was not performed. The patient's clinical course following cardioversion is described in Table 1. n

Corresponding author. Tel.: þ 81 46 822 2710; fax: þ 81 46 825 2103. E-mail address: [email protected] (M. Takigawa).

Although the patient experienced short palpitations, antiarrhythmia therapy was discontinued after a three-month blanking period because objective evidence of arrhythmia was absent. However, AF recurrence was detected three months later during 24-h Holter monitoring. Nine months after the initial CA, sudden presyncope occurred due to sinus arrest. During the second CA performed 15 months later, an electrical reconnection was present between the LA and SVC, rather than between the LA and the four pulmonary veins. Isoproterenol drip infusion induced spontaneous AF initiation from the SVC and multiple foci from the posterior LA and septal RA. Therefore, the SVC was re-isolated, the posterior LA was electrically isolated, and the RA foci were focally ablated. The AF was controlled completely after the second CA, but frequent episodes of sinus arrest with pre-syncope persisted. Six months after the second CA, the patient's condition had not improved, and he underwent pacemaker implantation (PMI). Consequently, his pre-syncope symptoms disappeared completely.

3. Discussion The specific reasons for the patient's sinus arrest are unknown. However, we speculate that the potential sinus node dysfunction might have progressed after the initial CA as a natural course in this patient's morphologically small heart, which is generally considered to be less remodeled. Masuda et al. [4] reported that PMI was required in five (5.0%) of 102 patients (mean age, 68 years) due to sick sinus syndrome following CA for chronic AF; in these patients, AF had persisted for approximately five years. Three of the patients underwent PMI for brady–tachycardia syndrome with recurrent AF, but two

http://dx.doi.org/10.1016/j.joa.2014.11.007 1880-4276/& 2015 Japanese Heart Rhythm Society. Published by Elsevier B.V. All rights reserved.

M. Takigawa et al. / Journal of Arrhythmia 31 (2015) 238–239

239

Table 1 Patient history. Date

Events

Memo

2011/11/21 2012/2/6 2012/2/7 2012/5/11 2012/8/10 2012/11/9 2013/4/5 2013/5/16 2013/5/17 2013/5/22 2013/6/28 2013/9/6 2013/9/27 2014/1/10 2014/4/4

Cardioversion Holter ECG First CA Holter ECG Holter ECG Holter ECG Holter ECG Second CA Holter ECG Holter ECG Holter ECG Holter ECG PMI Holter ECG Holter ECG

Recover to normal sinus rhythm (200J) AADs (bisoprolol and flecainide) PVI, SVCI, and focal ablation (posterior LA and RA crista) AADs (bisoprolol and flecainide) AADs (bisoprolol) AADs (bisoprolol) No AADs Re-SVCI, posterior LAI, posteroseptal RA focal ablation No AADs No AADs No AADs No AADs VVI mode No AADs No AADs

Mean HR (range), bpm

Type of AF

Maximum R–R intervals

Type of SSS

74 (50–186)

PAF

1.8



85 (64–125) 87 (52–123) 90 (30–127) 107 (32–226)

Short PAF PAF PAF PAF

1.1 1.6 6 6.3

– – II II

89 85 85 86

(57–113) (55–136) (52–127) (28–150)

– – – –

4.8 5.7 6.4 7.6

II II II II

93 (60–155) 92 (64–141)

– –

1.3 1.3

– –

AADs, antiarrhythmic drugs; AF, atrial fibrillation; CA, catheter ablation; ECG, electrocardiogram; HR, heart rate; LA, left atrium; LAI, left atrial isolation; PAF, paroxysmal atrial fibrillation; PMI, pacemaker implantation; PVI, pulmonary vein isolation; RA, right atrium; SSS, sick sinus syndrome; SVCI, superior vena cava isolation.

required PMI for sinus bradycardia following sinus rhythm restoration and CA [4]. Sinus node injury due to SVC isolation has been reported in 4.5% of cases, usually immediately after the procedure [5]. This unique case details sudden-onset sinus arrest nine months after CA treatment in a young patient with a small heart whose AF had persisted for only six months. It may be inappropriate to discuss the extent of atrial remodeling at the initial CA without objective pre-procedural magnetic resonance imaging or intraoperative voltage mapping findings. However, it was found during the initial CA that the AF originated from multiple foci in the LA and RA. This suggests that the patient had relatively advanced atrial electrical remodeling, despite his small heart size. Additionally, a putative injury to the sinus node region, during aggressive ablation (including SVC isolation), might have caused sinus node dysfunction, without being immediately evident. The late sequela of sinus arrest may indicate the progression of non-critical sinus node dysfunction following the initial CA, leading to a critical result as a natural course thereafter. Regardless of the reason, the PMI risk should be explained to AF patients before performing CA, even to young patients with small hearts without apparent remodeling. Additionally, careful follow-up should be conducted to avoid the risk of sudden progression of severe sinus node dysfunction. Conflict of interest None.

Disclosures None.

Acknowledgments None.

References [1] Knackstedt C, Gramley F, Schimpf T, et al. Association of echocardiographic atrial size and atrial fibrosis in a sequential model of congestive heart failure and atrial fibrillation. Cardiovasc Pathol 2008;17:318–24. [2] Burstein B, Nattel S. Atrial fibrosis: mechanisms and clinical relevance in atrial fibrillation. J Am Coll Cardiol 2008;51:802–9. [3] Bhargava M, Di Biase L, Mohanty P, et al. Impact of type of atrial fibrillation and repeat catheter ablation on long-term freedom from atrial fibrillation: results from a multicenter study. Heart Rhythm 2009;6:1403–12. [4] Masuda M, Inoue K, Iwakura K, et al. Preprocedural ventricular rate predicts subsequent sick sinus syndrome after ablation for long-standing persistent atrial fibrillation. Pacing Clin Electrophysiol 2012;35:1074–80. [5] Chen G, Dong JZ, Liu XP, et al. Sinus node injury as a result of superior vena cava isolation during catheter ablation for atrial fibrillation and atrial flutter. Pacing Clin Electrophysiol 2011;34:163–70.

Sudden manifestation of sinus arrest nine months after catheter ablation treatment for persistent atrial fibrillation.

A 39-year-old man with a seemingly non-remodeled, small heart suffered persistent atrial fibrillation (AF). Extensive isolation of the pulmonary vein,...
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