Congestive heart failure after atrial fibrillation ablation

A 49-year-old man with persistent atrial fibrillation (AF) underwent catheter ablation of AF [pulmonary vein (PV) isolation, left atrial linear lesions, and ablation of complex fractionated atrial electrograms], with a 3.5 mm open-irrigation ablation catheter. Overall, 4.4 L of crystalloid fluid was administered during the procedure. Seventy-two hours post-discharge, the patient reported symptoms of dyspnoea and a 3.6 kg weight gain. The electrocardiogram was unchanged and demonstrated sinus rhythm. A chest X-ray and computed tomography scan were ordered; the former demonstrated pulmonary oedema and the latter ruled out pulmonary embolism and PV stenosis. Trans-thoracic echocardiography (TTE) demonstrated new right ventricular (RV) dilation ( Figure 1 A and B ) and elevation of the RV systolic pressure (RVSP) to 49 mmHg without change in the right or left ventricular systolic function. The patient was admitted to a hospital with a diagnosis of congestive heart failure (CHF) and treated with intravenous loop diuretics. The following day, a repeat TTE demonstrated normalization of the RV size ( Figure 1 C and D ) and RVSP coincident with resolution of the patient's symptoms and weight gain. Apical four-chamber view obtained 72 h post-atrial fibrillation ablation ( A ) at end-diastole and ( B ) at end-systole and 24 h later following diuresis ( C ) at end-diastole and ( D ) at end-systole. LVIDd, left ventricular internal diameter at end-diastole; RVIDd, right ventricular internal dimension at end-diastole. Congestive heart failure is a new but increasingly recognized complication post-AF ablation. In patients undergoing extensive ablation procedures, this syndrome may be related to a combination of volume overload, increased circulating cytokine levels, or reduction in natriuretic peptides with extensive ablation of atrial tissue. The appearance of symptoms 3–4 days post-ablation procedure has increased speculation that the aetiology of this syndrome is due to a humoral effect rather than direct volume overload. The presence of RV dilation in this case supports fluid overload as a component of post-AF ablation CHF. Conflict of interest: none declared. S.M.S. is a recipient of a Detweiler Traveling Fellowship from the Royal College of Physicians and Surgeons of Canada, Ottawa, Ontario, Canada.