Complications
Eight patients (6.3%) experienced procedural complications (Figure 2B, Table 2). These were noteworthy for five cases of cardiac tamponade. One was intraprocedural in a patient undergoing a fourth procedure for repeated and refractory atypical flutters requiring emergency room presentations. PVI was noted on initial mapping but no non-PV foci or inducible arrhythmias were seen on high dose isoproterenol. VOM ethanol, CS isolation, lateral MI ablation, and SVC isolation were performed prior to the notice of an accumulating effusion thought secondary to right atrial perforation. Pericardiocentesis was performed and ablation of the CTI was deferred. It is noteworthy that he has had good arrhythmia control over 24 months of follow-up except for a single presentation of typical atrial flutter to the emergency room. An additional four patients (3.1%) had a delayed presentation of tamponade (Figure 4), presenting at 12 to 33 days post procedure. One of these four patients had a dissection of the VOM during initial venography and another one of the patients had a possible VOM perforation. Interestingly, two of these patients had unrevealing transthoracic echocardiograms (at three and twelve days post procedure) done for other clinical reasons in the weeks before presenting with tamponade (Figure 4). On a third patient, the hematocrit on the pericardial fluid was assessed due to a dark red appearance and was found to be less than 1%.
The only other notable complication was sinus injury, occurring in three patients. In one, sinus arrest was noted immediately upon the initial VOM ethanol infusion. VOM venography in that case revealed a typical branching pattern without discernable collaterals to the right atrium/SVC or left atrial roof. Some low voltage regions were seen in the right atrium in the sinoatrial region. The other two sinus injury complications were from direct radiofrequency, both in patients undergoing third AF procedures, one from empiric SVC isolation and the other from ablation of a high cristae AF trigger. All three patients recovered some sinus function but due to pauses or chronotropic incompetence underwent pacemaker implantation in the days to weeks that followed. No additional complications including PV stenosis, stroke, esophageal injury, AV block, left atrial appendage isolation, or anaphylaxis from ethanol infusion were noted. Two deaths occurred which were each judged to be unrelated to the procedure. One patient died 40 days post procedure due to intractable bleeding around rupture of an aortic graft remote from the sites of ablation or trans-septal puncture. The other experienced persistent AF recurrence eleven months post procedure and died the following month of intractable mixed cardiogenic and distributive shock.