Komeyama Shotaro, Watanabe Takuya, Yamagata Kenichiro, Fukushima Norihide
Department of Transplant Medicine, National Cerebral and Cardiovascular Center, 6-1, Kishibe-shinmachi, Suita, Osaka 564-0018, Japan.
Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka 564-0018, Japan.
Eur Heart J Case Rep. 2022 Jul 22;6(7):ytac277. doi: 10.1093/ehjcr/ytac277. eCollection 2022 Jul.
Catheter ablation (CA) has been reported to be an effective therapeutic option for ventricular arrhythmias, even in patients with a left-ventricular assist device (LVAD). However, the issues of right-to-left shunting due to iatrogenic atrial septal defect (iASD) associated with procedures for CA have not been well documented. We describe a rare case of refractory hypoxia associated with right-to-left shunting via iASD after CA through the transseptal approach in an LVAD patient.
A 52-year-old Asian man with a continuous-flow implantable LVAD and progressive right ventricular (RV) dysfunction was admitted because of refractory ventricular tachycardia (VT) and subsequent right heart failure. Since VT could not be controlled by intravenous administration of multiple antiarrhythmic drugs, VT ablation via the transseptal approach was performed. Ventricular tachycardia was terminated to the sinus rhythm after VT ablation; however, hypoxia associated with significant right-to-left shunting across the iASD was detected. Intensive medical management, such as an adjusted mechanical ventilator to increase pulmonary vascular compliance and adjustment of LVAD pump speed, as well as the use of intravenous inotropes to support impaired RV function successfully stabilized the haemodynamic and improved hypoxia for the disappearance of right-to-left shunting. Echocardiography at 7 months after CA showed that the significant iASD and right-to-left shunting had disappeared.
The evaluation of RV function prior to VT ablation via the transseptal approach is important in the postoperative management of patients with LVAD, because RV dysfunction may cause refractory hypoxia due to iASD.
据报道，导管消融术（CA）是治疗室性心律失常的有效方法，即使对于植入左心室辅助装置（LVAD）的患者也是如此。然而，与CA手术相关的医源性房间隔缺损（iASD）导致的右向左分流问题尚未得到充分记录。我们描述了1例LVAD患者经房间隔途径行CA术后因iASD导致右向左分流而出现难治性低氧血症的罕见病例。
1例52岁亚洲男性，植入持续血流型LVAD且右心室（RV）功能进行性减退，因难治性室性心动过速（VT）及随后出现的右心衰竭入院。由于静脉注射多种抗心律失常药物无法控制VT，遂行经房间隔途径的VT消融术。VT消融术后VT终止转为窦性心律；然而，检测到与iASD处明显右向左分流相关的低氧血症。强化内科治疗，如调整机械通气以增加肺血管顺应性、调整LVAD泵速，以及使用静脉注射正性肌力药物支持受损的RV功能，成功稳定了血流动力学并改善了低氧血症，使右向左分流消失。CA术后7个月的超声心动图显示，明显的iASD及右向左分流已消失。
对于LVAD患者，在经房间隔途径行VT消融术前评估RV功能对术后管理很重要，因为RV功能障碍可能因iASD导致难治性低氧血症。
