Left Atrial Hypertension After Repeated Catheter Ablations for Atrial Fibrillation

Abstract

fibrillation (AF). The original procedure targeted focal triggers of AF arising from within the pulmonary veins (PVs). This technique generated minimal left atrial (LA) scar but was complicated by the development of PV stenosis (1). Pulmonary vein antral isolation (PVAI) creates circular ablation lines within the left atrium, minimizing the risk for PV stenosis, and has become the preferred procedure for paroxysmal AF ablation. However, when PVAI is combined with adjunctive ablation, as much as 40% of the LA myocardium may be replaced by scar during a single catheter ablation (2), raising a concern that the procedure may adversely affect the ability of the left atrium to act as a contractile chamber (transport function) and/or compliance chamber (reservoir function). Although prior studies have examined the effect of AF ablation (3) and scar (4) on LA contractility, the effect on LA compliance has received less attention. We report 3 patients with histories of multiple LA ablations who presented with unexplained dyspnea on exertion and demonstrated hemodynamic findings consistent with LA hypertension.All 3 patients had histories of multiple catheter ablations for AF and presented with unexplained dyspnea up to 6 years later. Right-heart catheterization with volume challenge was performed. Large V waves were defined as 7 mm Hg greater than mean pulmonary wedge pressure (PWP) (5) and LA hypertension as a mean PWP Ͼ12 mm Hg. Patient #1 was a 68-year-old woman who underwent focal atrial tachycardia and crista terminalis ablation in 2001; LA tachycardia ablation, PV isolation, and lateral and septal mitral annular ablation in 2002; and PVAI and superior vena cava isolation in 2004. Patient #2 was a 69-year-old man who underwent PVAI in 2003 and 2004, with a third PVAI, cavotricuspid isthmus ablation, and LA posterior and septal wall debulking in 2007. Patient #3 was a 74-year-old man who underwent PVAI with left linear ablation and superior vena cava isolation in 2008, followed by repeat PVAI later in 2008. On presentation, each patient had echocardiographic evidence of elevated right ventricular systolic pressure (65, 48, and 48 mm Hg, respectively). Records were available for each patient documenting no significant elevation of right ventricular systolic pressure before his or her final ablation (37, 24, and 30 mm Hg, respectively). No evidence of PV stenosis, left ventricular (LV) systolic dysfunction, or significant mitral valve (MV) disease was found as the cause of elevated right ventricular systolic pressure.Right-heart catheterization demonstrated large V waves on PWP tracings. Mean PWP increased with volume challenge (from 17 to 33 mm Hg, from 6 to 13 mm Hg, and from 11 to 19 mm Hg in each patient, respectively). V waves increased from 31 to 56 mm Hg, from 13 to 26 mm Hg, and from 19 to 36 mm Hg, respectively (Fig. 1). LV end-diastolic pressure was normal in all 3 patients.Thus, all 3 patients shared the distinctive feature of large unexplained V waves on PWP tracings that were further accentuated with volume...

2012 HRS/EHRA/ECAS Expert Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation: Recommendations for Patient Selection, Procedural Techniques, Patient Management and Follow-up, Definitions, Endpoints, and Research Trial Design

“…1110,1111,1270,1271,1272,1273 One early report described a series of three patients with unexplained exertional dyspnea, LA hypertension, and large V waves on LA pressure or pulmonary capillary wedge pressure (PCWP) tracings after multiple surgical LA ablation procedures. 1271 A subsequent study prospectively collected 1380 consecutive patients undergoing ablation, obtaining echocardiograms before and after ablation to assess for pulmonary hypertension.…”

Role of obstructive sleep apnea in cardiovascular disease

“…As the volume of AF ablation procedures has increased, a post-ablation syndrome of diastolic dysfunction, secondary pulmonary hypertension, and unexplained dyspnea has been recognized and is thought to be related to extensive atrial scarring from the ablation procedure causing decreased left atrial compliance [55]. OSA is associated with a 6-fold increase in risk of this ‘stiff left atrial syndrome’ [56*] and may act to decrease pulmonary vascular compliance pre-ablation, thus leaving the pulmonary vasculature more vulnerable to the effects of increased post-capillary pressure following the procedure.…”

Recurrent dyspnea following multiple ablations for atrial fibrillation explained by the “stiff left atrial syndrome”

“…Accordingly, there have been very few reports in the literature describing the way in which these patients present [5,8]. Therefore, it is likely still unclear to most clinicians what presentation would lead one to suspect stiff LA syndrome.…”