Management of severe right ventricular perforation following radiofrequency ablation of extrasystoles of the right ventricular outflow tract (RVOT). A case report

Background: The risk of cardiac tamponade after radiofrequency (RF) ablation of the right ventricle (RV) is <1%. In contrast to atrial perforation the management of RV perforation often requires a faster treatment, which can be challenging especially in hospitals without on-site cardiac surgery. This case report shows several aspects, that are helpful for successful bridging to surgical treatment.

Case Presentation: A 51 year old woman agreed to interventional treatment of idiopathic RVOT ventricular extrasystoles (bigeminus, VE burden 38%, Fig.1) after medical treatment with flecainid and betablockers was not effective. After CARTO-guided mapping 3 RF-pulses were delivered with 40 W (irrigated tip, pressure < 15g, Fig.2). During the third pulse “popping” was recognized followed by a rapid fall of blood pressure. Pericardial puncture and insertion of an 8F sheath (30cm Arrows) was performed quickly after the pericardial tamponade was diagnosed echocardiographically. Suprarenin, arterenol, intubation and CPR were performed simultaneously. Because of the massive bleeding autotransfusion of the pericardial blood was performed directly into an 8F sheath, that was placed into the femoral vein. To avoid clotting of the pericardial blood the activated clotting time (ACT) was held between 150 and 200 sec. by fractionated heparin injections. The transfer to the nearest cardiac surgery department was organized simultaneously. Flushing of the sheath had to be performed with NaCl every 10 min. and despite venous anticoagulation a clotting of pericardial blood could be observed echocardiographically followed by rapid fall of blood pressure. After intermittend CPR the aspiration of pericardial blood through the sheath was possible again, assumably as a consequence of pericardial thrombus fractionation due to CPR. Therefore, CPR with the corpuls3-system (Corpuls^c) was continued even in the ambulance during the whole transfer time of 40 min. to the surgical heart centre (35 km distance). During the transfer continuous aspiration and autotransfusion of pericardial blood had to be performed (approximately 2.500 ml). At arrival in the operation room the patient was still under CPR but SaO2 was 92% and pH 7.0. ECMO therapy was initiated immediately followed by surgical relieve of the tamponade and suturing the perforation located in the anterior RVOT (15 mm). After a stay at the ICU for 6 days (ECMO time 10 h.) the patient could be discharged from hospital without any neurological or cardiac disorders. The patient was in very good condition despite this severe complication and holter ECG showed no VES even after a follow-up time of 6 months.

Conclusion: This case highlights important aspects in the management of severe left ventricular tamponade especially when on site cardiac surgery is not available:

1.      1. Placement of an 8F sheath into the pericardium that enables aspiration of massive bleeding

2.      2. Anticoagulation (ACT 150 -200 s) to avoid pericardial blood clotting

3.      3. Autotransfusion of the pericardial blood directly into the venous system

4.      4. Flushig of the pericardial sheath with NaCl in case of blood clotting within the sheath

5.      5. CPR in case of pericardial blood clotting to enable further aspiration after thrombus fractionating

6.      6. Transfer to cardiac surgery unit immediately

Figure 1: Bigeminus (idiopathic RVOT extrasystoles)

 

 

Figure 2: Left side: RVOT Extrasystole, Right side: Pacemap at the target in the anterior RVOT