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

Abstract

BackgroundElectrophysiological 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 presentationA 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).ConclusionsPulmonary 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.

Thromboembolic Events Following Atrial Fibrillation Cardioversion and Ablation: What’s the Culprit?

“…Large emboli migrated from leg veins can lodge in the right ventricle [36], whereas smaller emboli are likely to pass unimpeded to the pulmonary arteries. The occurrence of pulmonary embolism following EP procedures has previously been reported, especially in patients with a thrombophilic state [37]. Moreover, two cases of floating atrial thrombi following EP studies were successfully treated with thrombolysis in asymptomatic patients [38].…”

Prevention and Treatment of Lower Limb Deep Vein Thrombosis after Radiofrequency Catheter Ablation: Results of a Prospective active controlled Study

“…The advent of RFCA has significantly changed the therapeutic landscape of supraventricular tachyarrhythmia (SVTA) and has become the first choice of treatment 14 . Most of the definite supraventricular and malignant ventricular arrhythmia may be cured successfully with RFCA procedures 2 15 .…”

“…Although femoral vein remains a crucial emergency venous access route, it is associated with lower extremity DVT after catherization 13 . During RFCA, Multiple venous sheaths are inserted into the femoral vein, which remain in contact with the endothelium for the entire procedural time causing endothelial injury and consequent thrombogenecity leading to fatal DVT and PE 14 . Hence, Patients receiving RFCA therapy should be immediately recommended initial ambulation to prevent the formation of DVT and PE 15 .…”

Pulmonary Thromboembolism after Catheter Ablation of Cardiac Arrhythmias

“…There are several presumed sources of procedure-related PE, such as DVT (usually at femoral vein puncture site), preexisting thrombus in the inferior caval vein or at the right atrial/ventricular wall and thrombus formed at the catheter tip or within the (long) sheaths (3,(6)(7)(8)(9). Importantly, duplex ultrasonography assessment before and after CA demonstrated occurrence of new non-occlusive (asymptomatic) DVT on the day following the procedure in 17.6% of the femoral veins that were used for the catheter access (7).…”

“…Insertion of "foreign materials", such as sheaths and mapping catheters, into the blood flow strongly activate the coagulation cascade. Obstruction of venous lumen by multiple sheath/catheters inserted via single femoral vein, the use of inguinal compressive bandages or sandbag for hemostasis and bedrest lead to venous stasis (5)(6)(7)(8)(9). Endocardial ablation of arrhythmic substrate by thermally-mediated myocardial necrosis and surrounding tissue inflammation favors cardiac thrombosis (15).…”