Gastroparesis: An under-recognized complication after atrial fibrillation catheter ablation procedure

Calvo, Naiara; García de Yébenes-Castro, Manuel; Arguedas, Hugo; García-Bolao, Ignacio

doi:10.1016/j.medcle.2016.04.026

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In a recent European study incidence of complications secondary to catheter ablation of atrial fibrillation was 7.7%,<a class="elsevierStyleCrossRef" href="#bib0050">1</a> being cardiovascular complications (mainly pericarditis) the most frequently reported. Among gastrointestinal complications, only one case of esophageal ulcer was reported. However, some cases of gastroparesis have been exceptionally described in the medical literature and its approach has not been established.We report 2 cases of gastroparesis after percutaneous ablation of AF.Both patients had symptomatic AF and refractory to antiarrhythmic therapy. Both of them underwent percutaneous ablation of AF consisting of the circumferential isolation of pulmonary veins using non-fluoroscopic electroanatomic mapping system. Radiofrequency was used in both cases as an energy source, with an irrigated catheter with a temperature up to 40°C and a maximum power of 35W. The procedure was performed without any complications and the patients were discharged after 24h. A few days later the patients came to our center with symptoms of dyspnea, feeling of gastric fullness and epigastric pain. They underwent a CT scan and the presence of gastro-esophageal fistula was ruled out, but the CT showed a significant gastric dilation with food remains. Patients underwent an endoscopic study, which revealed small superficial erosions in the esophagus, and a study of gastric emptying, which showed gastric hypomotility. Treatment was initiated with prokinetic agents, proton-pump inhibitors and NPO. The symptoms were subsiding and oral diet was reintroduced with good tolerance after 3 days. Patients remain asymptomatic more than 12 months after ablation.In this paper we describe a poorly defined extracardiac complication of catheter ablation of atrial fibrillation caused by vagus nerve injury. To date, only a few cases of gastroparesis have been reported after using radiofrequency during percutaneous ablation of AF.<a class="elsevierStyleCrossRef" href="#bib0055">2</a> The vagus nerve runs down and borders both sides of esophagus and trachea. The vagus nerve joins the sympathetic fibers at the back of the left atrium, forming a nerve plexus. In most cases, this plexus is located behind the right inferior pulmonary vein.<a class="elsevierStyleCrossRef" href="#bib0060">3</a> Caudally, the vagus nerve is divided into two branches responsible for the innervation of the upper part of the digestive tract, controlling gastric motility and pylorus.<a class="elsevierStyleCrossRef" href="#bib0065">4</a> Because of the proximity between esophagus and left atrium, radiofrequency might injure the nerve with the subsequent gastric hypomotility and pyloric hypertonia, leading to a delayed gastric emptying. In both cases, the procedures were performed according to the standard protocol, using local anesthesia and mild sedation without chest pain or hypotension observed, manifestations that have been linked to a higher incidence of gastroparesis.<a class="elsevierStyleCrossRef" href="#bib0070">5</a> Symptoms of gastroparesis occur from 48h after procedure and include nausea, vomiting, abdominal pain and abdominal bloating. Its early onset is associated with increased severity of gastroparesis, but it can occur up to 15 days after the procedure. Given the anatomical variability of the vagus nerve, knowing which patients are more likely to have it damaged is unpredictable.<a class="elsevierStyleCrossRef" href="#bib0075">6</a> For diagnosis, a study of gastric motility and an upper endoscopy are required, ensuring esophagus has not been damaged after ablation. A CT scan can rule out the existence of an atrioesophageal fistula and proves the presence of gastroparesis. Other techniques used for diagnosis are real-time MRI<a class="elsevierStyleCrossRef" href="#bib0080">7</a> and gastric-emptying scintigraphy.<a class="elsevierStyleCrossRef" href="#bib0085">8</a> Treatment based on an NPO and the use of proton-pump inhibitors and prokinetic agents has been proven effective and should be established early. More severe cases have required botulinum toxin injections in the pylorus or gastrojejunostomy. Due to its occurrence several days after the procedure, this complication might be underestimated and therefore it might be more frequent than as reported in the medical literature. Among the various measures taken to prevent its occurrence, we should note the decreased radiofrequency energy applied during ablation of the posterior part of the right inferior pulmonary vein, esophageal temperature control<a class="elsevierStyleCrossRef" href="#bib0090">9</a> and diet poor in fiber within 7 days after the procedure. Since the introduction of these measures, no new cases of gastroparesis have been reported in our center." "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Calvo N, García de Yébenes-Castro M, Arguedas H, García-Bolao I. Gastroparesia: una complicación poco reconocida de la ablación percutánea de la fibrilación auricular. Med Clin (Barc). 2015;145:552–553." ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:9 [ 0 => array:3 [ "identificador" => "bib0050" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "ESC-EURObservational research programme: the atrial fibrillation ablation pilot study, conducted by the European heart rhythm association" "autores" => array:1 [ 0 => array:3 [ "colaboracion" => "Atrial Fibrillation Ablation Pilot Study Investigators" "etal" => true "autores" => array:6 [ 0 => "E. Arbelo" 1 => "J. Brugada" 2 => "G. Hindricks" 3 => "A. Maggioni" 4 => "L. Tavazzi" 5 => "P. 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Citescore

CiteScore measures average citations received per document published.

Citescore 2023

3.1

SJR

SRJ is a prestige metric based on the idea that not all citations are the same. SJR uses a similar algorithm as the Google page rank; it provides a quantitative and qualitative measure of the journal's impact.

SJR 2023

0.371

SNIP

SNIP measures contextual citation impact by wighting citations based on the total number of citations in a subject field.

SNIP 2023

0.511

View more metrics

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Vol. 145. Issue 12.

Pages 552-553 (December 2015)

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