2021 AF Symposium:

Challenging Cases in AF Management

Always one of  the most interesting presentations at the AF Symposium is the section “Challenging Cases in AF Management”. Some of the world’s leading EPs talk about their most difficult cases they had to struggle through that year.

They go into great detail and don’t hesitate to discuss any possible mistakes or embarrassing moments. It’s amazing to see such a lack of ego among this group of the best EPs in the world. It’s one of the best learning experiences of the AF Symposium.

The panelists this year were:

▪ Moderator Dr. David Keane of St. Vincent’s Hospital, Dublin, Ireland
▪ Dr. John Day of the Intermountain Heart Institute, Murray, UT
▪ Dr. Moussa Mansour of Massachusetts General Hospital, Boston, MA
▪ Dr. Francis Marchlinski of the Un. of Pennsylvania, Philadelphia, PA
▪ Dr. Andrea Natale of the Texas Cardiac Arrhythmia Institute, Austin TX
▪ Dr. Douglas Packer of the Mayo Clinic, Rochester, MN
▪ Dr. Eric Prystowsky of St. Vincent’s Hospital, Indianapolis, IN
▪ Dr. Jeremy Ruskin of Massachusetts General Hospital, Boston, MA
▪ Dr. Jacqueline Saw of Vancouver General Hospital, Vancouver British Columbia, Canada

Case #1: The “Torrential” Catheter Ablation Case 

Dr. John D Day

Presenter: Dr. John Day of the Intermountain Heart Institute, Murray, UT

The Patient

The patient was a 56-year-old male Jehovah’s Witness with paroxysmal A-Fib.

In 2019 he had been given a stent in his Left Anterior Descending (LAD) artery which had to be re-stented in March 2019 because of thrombosis. He was on dual antiplatelet therapy (Clopidogrel, Prasugrel). (In the discussion after the case, 2 EPs were surprised at this combination. In the patient’s first stent, aspirin was used.)

He also had a Troponin leak (indicating significant cardiac muscular injury). He was hospitalized three times (February, March, and April) in 2020 for A-Fib with a rapid ventricular rate despite being on amiodarone.

His A-Fib Catheter Ablation (But No Blood Transfusions, if Needed)

He was scheduled for an A-Fib catheter ablation after his April hospitalization. During the Consent process he was OK with most procedures.

But he was adamant that he didn’t want to receive any blood products, that he would choose death rather than be given blood. (Jehovah’s Witnesses believe that it’s against God’s will to receive blood.)

Successful Ablation, Then Tamponade!

During the ablation everything went very well. The veins were well isolated. There were no spikes in the grams of force applied by the catheter. They didn’t see any problem with the ablation catheter movement. Until the end of the case “when we were giving him isoproterenol to test, we noted marked hypotension.

When we re-adjusted our ICE catheter, it was pretty obvious he was in significant tamponade (bleeding from the heart into the pericardium sac). Something that as an operator you don’t want to see, that makes our heart sick or stop.”

Draining the Pericardium Sac

After tamponade was diagnosed, they easily performed pericardiocentesis (removing fluid from the pericardium sac). At first this worked, but then there was no sign of the blood leak stopping or slowing down.

Cardiothoracic Surgery was called. “The surgeon was in the room with us as we were pulling it off. We were using a Cell Saver (Blood Salvage)” which collects the blood as it leaks into the pericardium sac and gives it back to the patient through a tube that goes directly into his blood. The Jehovah’s Witness patient had stated he was OK with this autotransfusion.

We brought the family together. We told them he might not make it. We had discussions with his family members to see if we could talk someone into using blood products.”

Cardiac Arrest!

The plan was to transfer him to the operating room (OR). “But just as we got him off of the table and onto the stretcher and were leaving the EP lab, he went into PEA (Pulseless Electrical Activity, cardiac arrest) requiring chest compressions. We quickly put him back on the EP Lab table. We put in a  second pericardial drain. Now we had 2 EPs pulling as fast as we could doing an autotransfusion and re-inducing his leaking blood as fast as we could.”

Repairing a 1cm Perforation in the EP Lab

The decision was made that there was no way they would be able to wheel him to the OR in time. Instead, they opened up his chest in the EP lab. They found a 1 cm perforation at the base of the Left Atrial Appendage. It was repaired in the EP lab.

“Miraculous” Recovery!

“We got him to the Cardiac Surgery ICU in our hospital. There was ongoing bleeding. We thought he was going to pass away. Everything was going in the wrong direction.

And then miraculously he started recovering about 12 hours after arriving in the Cardiac ICU. And no blood was used. Somehow miraculously after 12 hours in the Cardiac ICU, everything started turning around.”

Follow-up: A-Fib Free

After a few days he did well and was discharged home from the hospital. He did have some early A-Fib episodes in the first month. But there after he had no A-Fib and has been A-Fib free.

Topics and Issues Raised by Dr. Day

When thinking back on this patient’s case, many questions arose in Dr. Day’s mind. He posed the following questions for the attendees to contemplate:

Should A-Fib ablation be done at facilities without Cardiac Surgery backup? “Clearly in this case the patient would have died if we didn’t have a Cardiac Surgeon in the room.”

In preparation for possible tamponade, we should have Cell Saver. And being able to use a double pericardium drain with 2 EPs pulling off as fast as we could probably saved this patient’s life.

Should uninterrupted dual antiplatelet therapy be done with A-Fib ablation?

In this patient’s case, he had a re-stenting just a month before his ablation. We did not feel comfortable stopping the dual antiplatelet therapy.

Should his ablation have been delayed till we could safely stop one antiplatelet agent?

Should an ablation be offered if we can’t use blood products?

“This is something I’m still struggling with.” We couldn’t explain the perforation location. There was no ablation anywhere near the base of the appendage.

The moderator Dr. Keane called this a “torrential” case. Few tamponade cases are this severe and difficult to cope with.

If you find any errors on this page, email us. Y Last updated: Monday, February 22, 2021

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