Pulmonary Hypertension due to Radiofrequency Catheter Ablation (RFCA) for Atrial Fibrillation: The Lungs, the Atrium or the Ventricle?

Abstract

Atrial fibrillation is the most common heart rhythm disorder in United States, characterised by rapid and irregular beating of both the atria resulting in the similar ventricular response. While rate and rhythm control using pharmacological regimens remain the primary management strategies in these patients, radiofrequency catheter ablation (RFCA) is rapidly rising as an alternative modality of treatment. Increase in the incidence of RFCA has shed light on complications associated with this procedure. Pulmonary hypertension (PH) is one of the long-term complications that has been observed postcatheter ablation. There have been multiple mechanisms which have been proposed to explain these elevated pulmonary pressures. These include the involvement of the lungs due to pulmonary vein stenosis, pulmonary vein occlusion and, rarely, pulmonary embolism. Radiofrequency catheter ablation can also lead to scarring of the atrium which can cause left atrial diastolic dysfunction leading to elevated pulmonary pressures. Recently, it was also proposed that elevated pulmonary pressure was related to the unmasking of left ventricular diastolic dysfunction occurring after this procedure. In this article, we review all the mechanisms that are associated with the development of pulmonary hypertension in patients undergoing RCFA for atrial fibrillation and the approach to diagnosis and management of such patients.

Safety and complications of catheter ablation for atrial fibrillation: Predictors of complications from an updated analysis the National Inpatient Database

“…Our analysis however, identified CKD and PAH as the only major predictors of complications after accounting for potential confounders. With regard to PAH, we could only postulate potential mechanisms such as elevation in pulmonary pressures with a deleterious impact on pulmonary hemodynamics that may pose risks of complications 19,20 …”

Late onset cardiac cirrhosis and portal hypertensive ascites after atrial fibrillation ablation

“…Low wedged‐free hepatic vein gradient (<5 mmHg) was compatible with post‐hepatic portal hypertension 1 . We propose that this patient developed severe pulmonary hypertension (PH) because of PVS after catheter ablation resulting in elevated right‐sided heart pressures, congestive hepatopathy, and ascites 2 . These events occurred insidiously without the patient experiencing respiratory symptoms which are the more common manifestation of serious complications associated with PVS following ablation for AF 3 – 5 .…”

When Hindsight Is 20/20

“…Post-ablation pulmonary hypertension occurs in ∼8% of cases and may be due to pulmonary vein stenosis, SLAS, and/or LV diastolic dysfunction unmasked by the procedure ( 4 ). Because our patient had both LA appendage and ASD closure devices, it is feasible that these devices may also have reduced atrial compliance.…”