Abstract | April 18, 2023

Troponinemia post AF ablation, expected side effect or perfect ACS storm?

Melissa Hidalgo, MD

Tayeeba Tariq, MD, Internal Medicine, PGY2, Broward Health North, Deerfield Beach, FL; Hootan Vakilidastjerd, MD, Internal Medicine PGY2, Broward Health North, Deerfield Beach, FL, Ayman Albittar, MD, Internal Medicine, PGY1, Broward Health North, Deerfield Beach, FL, Yordanka Reyna, MD, Medical Director, Department of Cardiology and Advanced Heart Failure, Broward Health Medical Center, Fort Lauderdale, FL; and Nemer Dabage-Forzoli, MD, Program Director, Internal Medicine, Broward Health North, Deerfield Beach, FL

Learning Objectives

  1. Upon completion of this lecture, learners should be better prepared to identify and discuss pro-thrombotic markers after cardiac ablation.
  2. Upon completion of this lecture, learners should be better prepared to implement the differential diagnosis of acute coronary syndromes in the setting of expected troponinemia post cardiac ablation.

Introduction

Radiofrequency ablation for atrial arrhythmias can result in increased markers of inflammation and myocardial injury (1, 2, 5). Inflammation is a significant contributing factor to the higher pro-thrombotic state early after cardiac ablation (2). Patients undergoing catheter ablation for atrial fibrillation (AF) have increased risk of thromboembolic events 1.1%, especially in the first two weeks after the procedure (2, 3, 4). Here, we present a case of non-ST elevation myocardial infarction (NSTEMI) requiring cardiac stenting post ablation for AF.

Case Presentation

71-year-old male with medical history of hypertension, hyperlipidemia, tobacco use, aortic stenosis (AS), obesity, AF on Xarelto, status post cardiac ablation one day prior to admission, presented with the complain of orthopnea and non-radiating mid-epigastric tightness that started several hours after ablation, at night. Associated symptoms were nausea and lightheadedness. No prior similar episodes. Patient had a negative pharmacological stress test in 2021. Patient also had transthoracic echocardiogram, one month prior, which showed mild concentric left ventricular hypertrophy, moderate-severe AS, moderate left and right atrium dilation, ejection fraction (EF) >55% with no wall motion abnormalities. On admission, blood pressure 173/96 mmHg, other vital signs were unrevealing. Electrocardiogram showed sinus rhythm, rate 88, with premature atrial complexes, no acute ST-T wave changes. On physical examination, S1 and S2 present, regular rate and rhythm, upper left sternal border systolic murmur, bilateral lower lobe expiratory wheezing, no peripheral edema. Labs were significant for troponin level 5.78 nanog/mL, B-type natriuretic peptide 191 pg/mL, WBC 12.85, C-reactive protein 11.15 mg/dL. On imaging, CT angiography showed cardiomegaly, trace pleural effusions and bilateral interstitial infiltrates. Repeat echocardiogram was unchanged from prior. Final/Working Diagnosis

Newly diagnosed acute decompensated heart failure with preserved ejection fraction post cardiac ablation, and NSTEMI.

Management and Outcome

Patient received IV diuretics. Interventional cardiology was consulted and decision was made for cardiac catheterization on day 2 of hospitalization for further evaluation. On left cardiac catheterization, the right coronary artery had a focal high-grade 90% distal stenosis that was stented with a 2.25 x 15 mm drug-eluting stent. Troponin levels trended down. Patient clinically improved and was discharge on Xarelto and Plavix.

 

(1) Haegeli, L.M., Kotschet, E., Byrne, J. et al. (2008). Cardiac injury after percutaneous catheter ablation for atrial fibrillation. EP Europace. 10(3), 273–275.

(2) Lim, H.S., Schultz, C., Dang, J. et al. (2014). Time course of inflammation, myocardial injury, and prothrombotic response after radiofrequency catheter ablation for atrial fibrillation. Circ Arrhythm Electrophysiol. 7:83–89.

(3) Oral, H., Chugh, A., Ozaydin, M., et al. (2006). Risk of Thromboembolic Events After Percutaneous Left Atrial Radiofrequency Ablation of Atrial Fibrillation. Circulation. 114:759–765.

(4) Themistoclakis, S., Corrado, A., Marchlinski, F.E., et al (2010). The risk of thromboembolism and need for oral anticoagulation after successful atrial fibrillation ablation. J Am Coll Cardiol. 55:735–43.

(5) Yune, S., Lee, W.J., Hwang, J.W., et al (2014). Acute myocardial infarction after radiofrequency catheter ablation of typical atrial flutter. J Korean Med Sci. 29(2):292-5.




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