Case Report

A 57-year-old male marathon runner with a history of atrial flutter (AFL), treated twice with radiofrequency (RF) ablation, was admitted to the emergency department with abrupt onset of chest pain, lightheadedness, and diaphoresis which started during a sprint interval workout. Emergency medical personnel found him lying on the floor with a systolic blood pressure 72 mm Hg, heart rate 120. In the emergency room, systolic blood pressure ranged from 70 to 90 mm Hg despite 2 liters of normal saline solution. Electrocardiogram showed sinus tachycardia at 116 beats/min, premature ventricular contractions, and no acute ST-T changes. Computerized tomography scan of the chest showed a large pericardial effusion, suggesting cardiac tamponade.

The patient had his first RF ablation for AFL nearly a year before the atriocaval rupture occurred. He underwent cavotricuspid isthmus RF ablation with an 8-mm tip catheter. The catheter was withdrawn from the tricuspid annulus to the inferior vena cava over a long isthmus, and there was poor catheter stability, considered to be due to a ridge, noted in the midportion. Bidirectional line of block was achieved.

Ten months after his first RF ablation, he underwent a repeat ablation for recurrent typical AFL. Initial mapping showed conduction through the line in the area where the catheter had been unstable because of a presumed ridge. Using an irrigated tip catheter, a drag lesion line was performed from the tricuspid annulus to the inferior vena cava. Conduction persisted despite eliminating all atrial electrograms along the line. An 8-mm catheter was then used to deliver 4 additional point applications, to the center of the line. Bidirectional line of block was achieved. Warfarin was resumed after the procedure.

On present admission, 4 liters of 0.9% sodium chloride were given, vitamin K and 4 units of fresh frozen plasma were administered for an international normalized ratio of 3.1. Dopamine was started, and the patient was intubated. He was taken emergently to the operating room for suspected myocardial rupture and placed on cardiopulmonary bypass. On entering the pericardium, a significant amount of bleeding was noted from a 5 mm tear at the right atrial isthmus. To minimize bleeding, a 30 Fr Foley catheter was placed in the inferior vena cava, the balloon was inflated below the diaphragm and retracted. Blood flow was significantly reduced and multiple pledgeted sutures were used to repair the defect. After hemostasis was obtained, the patient was weaned from bypass, and the pericardium was reapproximated. Postoperatively, he developed paroxysmal atrial fibrillation, which was controlled with sotalol 80 mg and metoprolol 12.5 mg twice daily.