A rare case of cardiac perforation at the right ventricular outflow tract following ablation therapy effectively addressed through surgical intervention: a case report

Introduction

Cardiac perforation, particularly at the right ventricular outflow tract (RVOT), is a rare but serious complication following catheter ablation therapy, a procedure commonly used to treat arrhythmias such as premature ventricular contractions (PVCs), atrial fibrillation, and other tachyarrhythmias (1). Although catheter ablation is generally considered a safe and effective treatment, it carries inherent risks, including perforation of the heart wall, vascular injury, and damage to surrounding structures. RVOT perforation, while uncommon, can lead to significant hemodynamic instability and life-threatening consequences if not managed promptly and effectively. The RVOT is a critical anatomical structure, serving as the passage for blood from the right ventricle to the pulmonary artery. Injury to this region can lead to cardiac tamponade, arrhythmias, or severe hypotension. The perforation may occur due to excessive catheter manipulation, the application of excessive radiofrequency energy, or inadvertent contact with myocardial tissue during ablation (1). In cases of perforation, immediate recognition and intervention are paramount to prevent further damage and to stabilize the patient. Surgical intervention is often required to repair the perforation, especially when the condition is complicated by pericardial effusion or tamponade (2). The management of RVOT perforation typically involves the removal of the catheter, closure of the perforation through direct suturing or patching, and, in some cases, stabilization of the heart with supportive measures, such as inotropic support (2). Importantly, timely surgical intervention can lead to successful outcomes, as demonstrated by improved hemodynamics following the repair. While the risk of RVOT perforation following ablation remains low, this complication underscores the need for careful monitoring and preparedness in patients undergoing catheter ablation therapy. Despite this, choosing the most suitable treatment for each case remains a complex task (1). Here we report a rare and unfortunate case of cardiac perforation at the RVOT, following catheter ablation therapy. This case warrants a discussion as there are no available recent literature pertaining cardiac perforation following catheter ablation therapy. The clinical presentation and treatment strategy are discussed in order to improve disease awareness and encourage prompt diagnosis. We present this case in accordance with the CARE reporting checklist (available at https://jxym.amegroups.com/article/view/10.21037/jxym-24-59/rc).

Case presentation

All procedures performed in studies were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration and its subsequent amendments. Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal. A 61-year-old male, without any significant medical history, was scheduled for elective catheter ablation therapy for his PVCs. His symptoms first appeared a year ago, when he experienced dizziness, palpitations, and occasional shortness of breath. After undergoing several diagnostic tests, including an electrocardiogram, echocardiogram, and Holter monitoring, he was diagnosed with PVCs. Throughout the following year, he was admitted to the hospital twice for his condition and was offered the option of ablation therapy, but he was initially hesitant to proceed. During a follow-up visit a year later, he consented to undergo the elective ablation procedure. Physical examination prior to the procedure was normal, and the patient had no complaints symptomatically. The area of RVOT was mapped with tacticath. Clinically, there were two PVCs, both at the inferior axis. First PVCs was ablated with tacticath 30W 120 seconds in total. Area of second PVCs ablated and managed to achieve suppression of PVCs by extending the ablation more septal and anterior of RVOT. Halfway through the course of the ablation procedure, the patient became hemodynamically unstable, with a significant drop in blood pressure to 55/35 mmHg and a heart rate between 100 and 110 bpm. Shortly thereafter, the patient experienced cardiac arrest, necessitating immediate cardiopulmonary resuscitation (CPR). Post return of spontaneous circulation, we performed an echocardiogram, which revealed a significant pericardial effusion. An emergency pericardiocentesis was done and 500 mL of blood was drained out (Figure 1). The patient continued to be hemodynamically unstable, necessitating emergency surgery. A median sternotomy was carried out, revealing minimal blood clots on the left side of the heart. After removing the clots and thoroughly inspecting the area, a 1 cm linear perforation was identified at the RVOT (Figure 2). No active bleeding was observed from the perforation site. Factoring in the overall condition of the patient and size of the injury, we chose not to place the patient on cardiopulmonary bypass, as the injury was considered easy to approach and the potential risks outweighed the benefits. Primary repair was done by pledget sutures to secure the perforated area (Figure 3). There was also evidence of thermal stain over the left-hand side of the pericardium. Postoperatively, the patient had a smooth recovery without any complications and was discharged on the seventh day following surgery. He remained well throughout his follow up which was at the first and third months.

Figure 1 Emergency pericardiocentesis. (A) Amount of blood drained from pericardiocentesis; (B) pericardiocentesis catheter.

Figure 2 Intraoperative findings. Arrowhead shows linear perforation at the right ventricular outflow tract.

Figure 3 Intraoperative approach. Arrowhead shows primary repair with pledged sutures.

Discussion

Cardiac perforation of the RVOT is an uncommon yet potentially fatal complication following catheter ablation, a procedure used to treat arrhythmias. This therapy involves the use of radiofrequency energy to eliminate abnormal tissue responsible for arrhythmic events, often within the RVOT. Despite its overall safety, the procedure carries the risk of perforation, especially if the catheter inadvertently damages the heart wall (1). The RVOT, being a thin and sensitive area, is particularly prone to injury. Catheter ablation is widely employed to treat a variety of arrhythmic conditions, but it is not without its risks. Large studies have reported that severe complications occur in 2.9% to 6.0% of cases, including death, significant bleeding, arteriovenous fistulas requiring surgery, thromboembolic events, and permanent atrioventricular block. Among these, cardiac perforation is one of the most dangerous, with an incidence of 1.2% to 1.7% in ablation procedures (1). Symptoms of cardiac perforation following ablation therapy can be classified as sudden or delayed. Sudden occurrence of cardiac perforation following catheter ablation typically results in immediate hemodynamic instability. However, in cases of delayed onset of cardiac perforation, symptoms can present differently, such as sepsis or neurological impairments caused by a left atrial oesophageal fistula or left atrial bronchial fistula (3,4), often manifesting as sudden collapse. Therefore, patients who undergo catheter ablation for arrhythmias should be monitored closely, as delayed cardiac perforation can still occur, even several months post-procedure. While delayed perforation usually presents more subtly, it remains a potential concern, with signs such as hypotension emerging gradually (5). The occurrence of delayed cardiac tamponade post-catheter ablation was reported as 0.16% in a global survey (6). In this case, our patient experienced hemodynamic instability, classifying him under the category of an acute onset.

Upon suspicion of cardiac perforation and tamponade, echocardiography is considered the most reliable method for confirming the diagnosis. The cardiac silhouette is assessed using left anterior oblique and right anterior oblique projections for signs of motion, or intracardiac echography (ICE) images were reviewed for evidence of pericardial effusion (2). In the treatment of cardiac perforation following catheter ablation, four main strategies are outlined in the literature: conservative care, pericardiocentesis, intervention with a closure device, and surgical treatment (1). Each method offers its own set of advantages and limitations, taking into account that the main goal of the treatment is to restore hemodynamic stability. As mentioned in the above case, the patient had hemodynamical instability leading to asystole, which required CPR, and the echocardiography revealed that there was cardiac tamponade present. In this situation, the priority is to rapidly restore hemodynamic balance, making pericardiocentesis the preferred initial intervention to relieve tamponade. In cases where surgical repair is required after pericardiocentesis, the situation can become extremely urgent and critical if there is persistent bleeding from the perforation site or if the tamponade cannot be effectively managed. Several surgical techniques are employed to manage cardiac perforation, such as removing clots, performing suture repairs, applying adhesive glue, or using a combination of sutures and glue (1). The majority of patients with cardiac perforation were initially treated with pericardiocentesis to relieve cardiac tamponade, rather than undergoing open surgical repair. Pericardiocentesis, along with appropriate medical management, successfully stabilized most patients with cardiac perforation following catheter ablation (7). This suggests that the perforation caused by the catheter may have sealed spontaneously, with stabilization achieved through drainage of blood from the pericardial space to alleviate cardiac tamponade. As a result, surgical repair is not typically considered the first-line treatment for catheter-related cardiac perforation (7), with only occasional reports or small case series documenting its use in the literature. To the best of our knowledge, there are currently no large-scale studies or comprehensive reviews addressing the management of this issue through surgery. As a result, due to limited surgical experience, it remains difficult for surgeons to determine the appropriate surgical approach for this complication. However, if surgical intervention is required for cardiac perforation after initial pericardiocentesis, it is likely to be an urgent and critical situation, especially if there is ongoing bleeding from the perforation site or if cardiac tamponade cannot be effectively relieved. Furthermore, given the limited experience with surgical repair for cardiac perforation following catheter ablation in such emergency scenarios, surgeons may face challenges in selecting the most suitable surgical procedure for each individual patient. In this case, we opted for clot removal and the application of pledget sutures to address the perforation near the RVOT. This decision was driven by the available experiences and also concerns that adhesive glue alone might not provide a sufficient repair. The decision to place the patient on cardiopulmonary bypass hinges on the surgeon’s expertise and the patient’s hemodynamic status at that particular moment. Cardiopulmonary bypass is typically not needed if the perforation site is readily accessible, as was the case in our situation. Approach and management are customized based on the specific case scenario, with the goal of achieving the best outcome for the patient while considering the available expertise at that moment.

Cardiac perforation at the RVOT following ablation therapy is a rare but significant complication. The strength in this particular case lies in the ability to rapidly identify the complication and patients’ hemodynamic instability, allowing for prompt surgical intervention. This approach helps prevent additional heart damage and enhances patient recovery outcomes. Surgical repair allows for direct correction, including patch closure or suturing, reducing the risk of haemorrhage or arrhythmias. However, limitations of this case lie in the fact that there are not many previous similar cases being reported, and there is no proposed standard treatment. Surgeons’ experience in dealing with such cases is crucial in decision making.

Conclusions

Cardiac perforation that occurs after catheter ablation is infrequently reported. It is a severe condition that typically requires immediate rescue or surgical intervention. Although most patients initially receive treatment with pericardiocentesis, persistent bleeding or unresolved cardiac tamponade may necessitate surgical intervention. There are multiple surgical options available, each suited to different scenarios where surgical repair becomes critical for saving the patient’s life. Surgeons’ experience in dealing with such cases plays a crucial role in the choice of surgical repair and whether the patient requires cardiopulmonary bypass. Management should be personalized according to the particular situation, since a one-size-fits-all solution is not applicable.

Patient’s perspective

The patient expressed profound appreciation for surviving the incident and recognized the commitment and expertise of the medical team.

Acknowledgments

The authors thank all the efforts provided by the cardiothoracic surgical team from Hospital Sultan Idris Shah, Serdang, Malaysia.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://jxym.amegroups.com/article/view/10.21037/jxym-24-59/rc

Peer Review File: Available at https://jxym.amegroups.com/article/view/10.21037/jxym-24-59/prf

Funding: None.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://jxym.amegroups.com/article/view/10.21037/jxym-24-59/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in studies were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration and its subsequent amendments. Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Wu SJ, Fan YF, Chien CY. Surgical Strategies for Cardiac Perforation After Catheter Ablation or Electrophysiology Study. Int Heart J 2021;62:1257-64. [Crossref] [PubMed]
2. Tokuda M, Kojodjojo P, Epstein LM, et al. Outcomes of cardiac perforation complicating catheter ablation of ventricular arrhythmias. Circ Arrhythm Electrophysiol 2011;4:660-6. [Crossref] [PubMed]
3. Velghe D, Apers T, Devriendt S, et al. Atriobronchial Fistula Complicated by Septic Cerebral Air Emboli After Pulmonary Vein Ablation. Crit Care Med 2017;45:e867-71. [Crossref] [PubMed]
4. Schuring CA, Mountjoy LJ, Priaulx AB, et al. Atrio-Esophageal Fistula: A Case Series and Literature Review. Am J Case Rep 2017;18:847-54. [Crossref] [PubMed]
5. Wolf DA, Burke AP, Patterson KV, et al. Sudden death following rupture of a right ventricular aneurysm 9 months after ablation therapy of the right ventricular outflow tract. Pacing Clin Electrophysiol 2002;25:1135-7. [Crossref] [PubMed]
6. Cappato R, Calkins H, Chen SA, et al. Delayed cardiac tamponade after radiofrequency catheter ablation of atrial fibrillation: a worldwide report. J Am Coll Cardiol 2011;58:2696-7. [Crossref] [PubMed]
7. Hamaya R, Miyazaki S, Taniguchi H, et al. Management of cardiac tamponade in catheter ablation of atrial fibrillation: single-centre 15 year experience on 5222 procedures. Europace 2018;20:1776-82. [Crossref] [PubMed]