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From electrophysiology to open heart surgery: A fatal case of atrial fibrillation ablation gone wrong
No full textIntroduction: Atrial fibrillation (AF) is the most common arrhythmia, affecting 0.4–1.0% of the global population [1], with a rising prevalence. AF is associated with a 1.5 to 2-fold increased risk of mortality, a 2.4-fold higher risk of stroke, and an elevated risk of myocardial infarction, heart failure, and chronic kidney disease [2]. Current evidence supports the use of general anesthesia (GA) for most AF ablation procedures, as it enhances patient comfort, improves the accuracy of electrical mapping, allows for more precise catheter manipulation, and increases ablation success rates [2,3]. The most common life-threatening complication of AF ablation is cardiac perforation with resulting pericardial effusion and tamponade, occurring in 0.4–1.3% of cases [2,3]. Case Presentation: We present the case of an 80-year-old female with a PMH of HTN, DM, CAD, mild MS, and atrial fibrillation that remained persistent despite medical management, multiple cardioversions, and a prior PVI ablation. An arterial line was placed, and she was induced and intubated for a repeat ablation. The procedure was complicated by a left atrial (LA) perforation, leading to a pericardial effusion and an acute, refractory drop in blood pressure despite fluid resuscitation and phenylephrine administration. The patient subsequently went into cardiac arrest. Cardiopulmonary resuscitation (CPR) was initiated, and serial pericardiocenteses were performed, but they were complicated by a right ventricular (RV) perforation. Return of spontaneous circulation (ROSC) was achieved; however, the patient’s condition continued to deteriorate, and she was emergently transferred to the main OR for sternotomy and surgical exploration on cardiopulmonary bypass. During surgery, the cardiac surgeon removed the pericardiocentesis pigtail catheter from the pulmonary artery, identified and repaired a bleed in the right superior pulmonary vein, and repaired the RV and LA perforations. The patient was transferred to the SICU in critical but stable condition. Postoperatively, she developed cardiogenic shock, acute respiratory and renal failure, and shock liver. Despite aggressive management, her condition deteriorated, and she suffered another cardiac arrest three days after surgery. Multiple rounds of CPR were performed, but resuscitation efforts were ultimately unsuccessful. Conclusion: Anesthesiologists are increasingly involved in electrophysiology (EP) procedures due to the growing complexity of these cases and the presence of patient comorbidities. EP procedures present unique challenges, including possible unfamiliar equipment, the isolated location of the EP lab, fluoroscopy equipment obstructing access to the patient, and staff unfamiliar with the specific needs of anesthesia care. These factors can lead to delays in patient care during critical moments. Patients undergoing AF ablations are typically on anticoagulation, and anesthesiologists must be prepared to manage bleeding and significant hemodynamic instability during the transseptal puncture and in the case of a perforation. As a result, vigilance and strong communication are key in the EP lab – a rapid, coordinated response can significantly influence patient outcomes. 1. Fujii, S. et al. (2018) Journal of Cardiothoracic and Vascular Anesthesia 32(4):1892-910 2. Kiwakyou, L. et al. (2024) Atrial Fibrillation – Current Management and Practice. IntechOpen 3. Alvarez, C.K. et al. (2023) Journal of Cardiothoracic and Vascular Anesthesia 37(1):96-11
A survey of psychiatric residents\u27 attitudes and clinical practice in neuropsychiatric education
No full textMassive pulmonary embolism in acromegaly: A perfect storm of thrombotic risk
No full textPurpose: To describe a case of massive pulmonary embolism (PE) in a patient with acromegaly and multiple prior venous thromboembolic (VTE) events who was perioperative, emphasizing the hypercoagulable risk and management challenges. Background: Acromegaly, characterized by elevated insulin-like growth factor-1, may predispose patients to thrombotic events via endothelial dysfunction and procoagulant changes. Data linking acromegaly to venous thromboembolism (VTE) are limited, but recurrent events are clinically significant, especially when anticoagulation is interrupted perioperatively. Methods: A 64-year-old male with acromegaly secondary to a pituitary microadenoma (s/p gamma knife) and a history of multiple VTE events presented for elective substernal thyroidectomy and parotidectomy. Anticoagulation with rivaroxaban was held for 48 hours preoperatively. On post operative day one, he suffered a witnessed cardiac arrest while ambulating. Return of spontaneous circulation was achieved after one round of cardiopulmonary resuscitation. Results: Post-arrest evaluation revealed acute bilateral PE with severe right ventricular (RV) dysfunction. Given recent surgery, systemic thrombolysis was deferred. The patient underwent catheter-directed thrombectomy with partial improvement but remained in RV failure requiring vasopressors, inhaled nitric oxide, and milrinone. He was transferred for possible extracorporeal membrane oxygenation support but improved with medical management. He was discharged on warfarin with home health, and hematology recommended indefinite anticoagulation. Inferior vena cava (IVC) filter placement was advised if anticoagulation interruption is ever required again. Conclusion: This case highlights the thrombotic risk in patients with acromegaly and recurrent VTE, especially in perioperative settings. Interruption of anticoagulation, even briefly, may result in life-threatening events. Prophylactic strategies, including bridging or IVC filters, should be considered in select high-risk patients
Comparative cardiovascular outcomes between carvedilol and metoprolol in patients with takotsubo syndrome: A propensity-matched cohort study
No full textStrokes of Bad Luck: A Pediatric Case Series of Acute Onset Lower Extremity Neurological Changes
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GLP-1 receptor agonists in patients with type 2 diabetes mellitus and obstructive sleep apnea: Cardiovascular, pulmonary, and mortality outcomes
No full textHuman Ecology, 1971 Winter, V2 N2
No full textLutheran General Hospital, Park Ridge, IL: Magazine published quarterly by the Lutheran General and Deaconess Hospitals. This publication keeps employees and friends of the hospital informed on current news and hospital updates.https://institutionalrepository.aah.org/alldocuments/2223/thumbnail.jp
