Case Report: Diaphragmatic Hernia after Epicardial Catheter Ablation

Figures

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  Figure 1. Twelve-lead electrocardiogram during moderate bicycle exercise test (145 W, 7.4 METs) showing sinus tachycardia followed by ventricular tachycardia at a heart rate of 185.

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  Figure 2. (A) Right anterior oblique view of the heart with implantable cardioverter defibrillator electrodes in the right ventricle (1) and right atrium (2), a penta-polar pacing catheter in the right ventricle (3), and steerable sheath in the coronary sinus ostium (4). A JR4 guiding catheter (5) with percutaneous coronary intervention (PCI)-wire and a microcatheter (6) was used to cannulate a coronary sinus side branch and intentionally perforate to the epicardial space, verified by contrast injection (arrow). CO2 gas was injected through the microcatheter. The gas is visible by fluoroscopy and creates space for transcutaneous puncture from the subxiphoid position with diminished risk of touching the cardiac surface with the needle. (B) Left anterior oblique view of the heart with ablation catheter (1) through the Agilis epi steerable sheath (2) into the epicardial space along the posterolateral wall of the left ventricle, with tip electrode in ablated area (3). The dome of the left diaphragm (4) is visible beneath the heart shadow. An additional guidewire (5) in the epicardial space secures access in case of dislocation and outlines the epicardial space.

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  Figure 3. (A) Activation map of the epicardial surface of the left ventricle (posterior view) with blue colour (red arrow) indicating the region with the most delayed potentials. This is also illustrated with distinct, sharp signals from the distal and proximal bipolar electrodes of the ablation catheter (Map 1–2 and Map 3–4, yellow arrows) occurring after the surface QRS signal. (B) Synchronous activation map (left) and voltage map (right) in a left posterior oblique view, including the left ventricle (1) and atrium (2) merged with a computed tomography angiography showing the epicardial surface and the left coronary artery (3). The voltage map displays normal voltage in violet tint, low-voltage scar/fibrous tissue in red, and the border zone in blue, green, and yellow. The red and pink dots (yellow arrows) represent tags at the locations where we delivered radiofrequency energy to eliminate the ventricular tachycardia.

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  Figure 4. (A) Anteroposterior computed tomography scout view with the herniation of abdominal organs into the left thoracic cavity (yellow arrow), displacing the heart (1) towards right and the left lung (2) superiorly. (B) Sagittal computed tomography view with blue arrows marking the hernial opening, and abdominal organs extending into the left thoracic cavity.