EXERTIONAL DYSPNEA AFTER ATRIAL FIBRILLATION ABLATION

Case presented by:

BRIAN D. POWELL, MD AND DOUGLAS L. PACKER, MD

A 63-year-old male with a 10-year history of paroxysmal atrial fibrillation (AF) had frequent episodes with palpitations and fatigue in spite of antiarrhythmic drug therapy. He underwent a pulmonary vein isolation (PVI) ablation procedure without any immediate complications. His palpitations resolved, however, he returned 3 months later with dyspnea on exertion. Evaluation included a Holter monitor, which revealed normal sinus rhythm with a heart rate range of 66 to 110 bpm. Complete blood count and electrolytes were normal.

Question No. 1: What is the most likely cause of His-dyspnea on exertion?

A.Pericardial effusion.

B.Pulmonary vein stenosis.

C.Pleural effusion.

D.Mitral regurgitation.

Discussion

Patients can present with exertional dyspnea for several different reasons after PVI ablation for treatment of AF. When dyspnea occurs within the first week after an ablation, common causes include the following:

1. Fluid overload from an irrigated-tip ablation catheter.
   
2. Pericardial effusion with tamponade.
   
3. Recurrent atrial arrhythmias.

Patients who initially do well after a PVI, then develop dyspnea on exertion in the following weeks to months have the following differential diagnosis:

1. Pulmonary vein (PV) stenosis.
   
2. Delayed pericardial effusion.
   
3. Recurrent atrial arrhythmias.
   
4. Pneumonia, including aspiration pneumonia.
   
5. Exacerbation of previous comorbidities, such as congestive heart failure (CHF), coronary artery disease, or chronic obstructive pulmonary disease.

Symptoms can provide clues to the most likely etiology of the dyspnea that occurs in weeks to months following a PVI. Dyspnea secondary to PV stenosis may present with hemoptysis, cough, or chest pain. PV stenosis occurs in 1 to 2% of patients undergoing AF ablation.¹ Patients with a delayed pericardial effusion may develop edema and physical examination findings of tamponade (elevated jugular venous pressure, edema, and decreased heart sounds). Recurrent atrial arrhythmias may present with symptoms of palpitations and physical exam findings of an increased heart rate with an irregular rhythm. Pneumonia can occur in the setting of aspiration during conscious sedation or general anesthesia during an ablation. A productive cough or fever can be clues to this diagnosis.

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