Flash pulmonary edema immediately after cavotricuspid isthmus ablation for typical atrial flutter: a case report

Q: What is the clinical evidence from this study?

Study design: Case Report. Population: Cavotricuspid isthmus-dependent typical atrial flutter (n=1). Intervention: Cavotricuspid isthmus radiofrequency catheter ablation. Primary outcome: Flash pulmonary edema complicated by type II respiratory failure.

Q: What does this research mean for the field?

Flash pulmonary edema can occur as an immediate, life-threatening complication following isolated cavotricuspid isthmus ablation for typical atrial flutter in patients with impaired cardiopulmonary reserve. Novelty: ClaimNovelty.NOVEL_FINDING. Consensus alignment: ConsensusAlignment.NEUTRAL.

Yufei Xu; Meng Wang; Xiaoqing Liu

doi:10.1186/s12872-026-06992-2

November 13, 2026BMC Cardiovascular DisordersOpen Access

Flash pulmonary edema immediately after cavotricuspid isthmus ablation for typical atrial flutter: a case report

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Key result

Cavotricuspid isthmus ablation triggers severe flash pulmonary edema successfully reversed with diuresis, vasodilation, and BiPAP.

n=1

Why the study?

Flash pulmonary edema is a rare, life-threatening complication with an unclear mechanism, and previous reports have mostly involved electrical cardioversion or atrial fibrillation ablation rather than cavotricuspid isthmus ablation for atrial flutter.

Key Points

To describe a rare case of flash pulmonary edema occurring immediately after cavotricuspid isthmus ablation for typical atrial flutter in a patient with underlying cardiopulmonary disease.
Clinical case report of a 78-year-old man (N=1) with chronic heart failure, severe mitral regurgitation, silicosis, and chronic obstructive pulmonary disease undergoing catheter ablation for cavotricuspid isthmus-dependent atrial flutter.
The patient received an intraprocedural fluid input of 1560 mL and was managed with vasodilation, diuresis, and noninvasive ventilation initiated approximately 2 h after symptom onset.
Serial evaluation included arterial blood gas analysis, chest computed tomography, laboratory biomarkers, and transthoracic/transesophageal echocardiography through 1-month follow-up.
Approximately 2 min after termination of atrial flutter, the patient experienced an abrupt ventricular rate drop from 145 beats/min to 80 beats/min, followed by blood pressure rising to 183/108 mmHg, heart rate to 146 beats/min, SpO₂ dropping to a nadir of 50%, and acute type II respiratory failure.
Following afterload reduction, diuresis, and noninvasive ventilation, SpO₂ increased gradually to 90%, and the patient was discharged on postoperative day 7.
At 1-month follow-up, left atrial transverse diameter decreased from 51 mm to 43 mm, mitral regurgitation improved from severe to mild-to-moderate, and E/e′ decreased from 23 to 13.

Study Design

Type

Case Report (n=1)

Multicenter

No

Structured PICO

P

Population

1 male patient aged 78 years with typical atrial flutter, chronic heart failure, severe mitral regurgitation, silicosis, and COPD, followed for 1 month.

I

Intervention

Catheter ablation for cavotricuspid isthmus-dependent counterclockwise atrial flutter (radiofrequency energy at 40 W, temperature limit 55 °C, contact force 5-15 g, ablation index target 380-400, irrigation flow rate 30 mL/min, 60 applications, 1500 s cumulative delivery time over 89 min), followed by emergency management of flash pulmonary edema with intravenous furosemide (60 mg cumulative in three boluses), intravenous sodium nitroprusside infusion (titrated to maintain BP 100-130/60-80 mmHg, total 6.36 mg over 9 h 23 min), intravenous morphine (9 mg cumulative in three divided doses), and noninvasive bilevel positive airway pressure (BiPAP) ventilation.

O

Outcome

Clinical resolution of flash pulmonary edema and type II respiratory failure, with hospital discharge on postoperative day 7 and 1-month follow-up evaluation of cardiac biomarkers, rhythm, and echocardiographic parameters.safety

This case demonstrates that life-threatening flash pulmonary edema and type II respiratory failure can occur immediately after isolated cavotricuspid isthmus ablation for typical atrial flutter in high-risk patients with concomitant severe mitral regurgitation and poor cardiopulmonary reserve.

Limitations

Bedside ultrasound during the acute event was limited to the pericardium, so ventricular function and acute worsening of mitral regurgitation were not directly assessed.
No invasive hemodynamic assessment was performed during the acute event.
Computed tomographic pulmonary angiography and lower-limb examination were not performed during the acute event, so pulmonary embolism could not be formally excluded.
Neither a bubble study nor a Valsalva maneuver was performed to evaluate a right-to-left shunt across the patent foramen ovale.
Prompt coronary angiography was not performed at symptom onset to definitively exclude an acute coronary event.
Mitral regurgitation was graded semi-quantitatively by color Doppler without quantitative parameters (vena contracta width, effective regurgitant orifice area, and regurgitant volume were not measured).
Focused bedside ultrasound during the acute event was limited to pericardial assessment and did not assess ventricular function, regional wall motion, or mitral regurgitation.
Noninvasive ventilator was not immediately available in the electrophysiology laboratory, delaying initiation of BiPAP by approximately 2 hours.
FiO2 was not measured directly but estimated from the oxygen delivery device and flow rate, making PaO2/FiO2 ratios approximate.

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Implication

May warrant vigilance for flash pulmonary edema after CTI ablation in high-risk patients; leaves open its incidence and mechanisms.

Abstract

With the accelerating aging of the population, the incidence of atrial flutter has continued to rise, and catheter ablation has been recommended by guidelines as an effective treatment strategy for atrial flutter. Flash pulmonary edema is a rare but life-threatening complication whose exact mechanism remains unclear, and previous reports have mostly involved electrical cardioversion or atrial fibrillation ablation. Here, we report a rare case of flash pulmonary edema occurring immediately after cavotricuspid isthmus ablation in a patient with atrial flutter, with the aim of providing a reference for clinical diagnosis and treatment. A 78-year-old man with chronic heart failure, severe mitral regurgitation, silicosis, and chronic obstructive pulmonary disease underwent catheter ablation for cavotricuspid isthmus-dependent atrial flutter. Upon completion of ablation, he suddenly developed flash pulmonary edema complicated by type II respiratory failure. His dyspnea improved rapidly after afterload reduction and diuresis, but hypoxemia persisted; noninvasive ventilation was started on his return to the ward approximately 2 h after onset, after which SpO₂ increased gradually to 90%, and he was discharged on postoperative day 7. At 1-month follow-up, high-sensitivity cardiac troponin I (hs-cTnI) and the electrocardiogram had returned to normal, and N-terminal pro-B-type natriuretic peptide (NT-proBNP) had decreased markedly; echocardiography showed that mitral regurgitation had decreased from severe to mild-to-moderate. Flash pulmonary edema can also occur immediately after isolated cavotricuspid isthmus ablation in patients with typical atrial flutter. In high-risk patients with poor cardiopulmonary reserve and concomitant mitral regurgitation, early recognition, rapid reduction of cardiac preload and afterload, and early respiratory support, including noninvasive ventilation as soon as respiratory failure is recognized, may be key to improving prognosis.

Discussion

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Cite This Study

Xu et al. (2026) conducted a case report in Cavotricuspid isthmus-dependent typical atrial flutter (n=1). Cavotricuspid isthmus radiofrequency catheter ablation was evaluated on Flash pulmonary edema complicated by type II respiratory failure. Cavotricuspid isthmus ablation in a 78-year-old man was immediately complicated by flash pulmonary edema that resolved with vasodilation, diuresis, and BiPAP.

synapsesocial.com/papers/6af88c530e4d8f4b089c1b71 https://doi.org/10.1186/s12872-026-06992-2

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Flash pulmonary edema immediately after cavotricuspid isthmus ablation for typical atrial flutter: a case report

Key Points

Study Design

Structured PICO

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Flash pulmonary edema immediately after cavotricuspid isthmus ablation for typical atrial flutter: a case report

Key Points

Study Design

Structured PICO

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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