Signs of hemodynamically significant myocardial ischemia as a complication of transseptal puncture in catheter ablation of atrial fibrillation

IntroductionTransseptal puncture is a commonly used method which we can see being applied nowadays predominantly in electrophysiological studies. This interventional method has been very successful at experienced electrophysiological laboratories and has a low risk of potential complications. One of the described complications is emergence of hypotension or bradycardia or transient ST segment elevation on the basis of parasympathetic activation or air embolism into the coronary artery.Patient, methodsIn the case history we present a substantial response in the context of transseptal puncture during electrophysiological examination with pulmonary vein isolation in a patient with persistent atrial fibrillation. This patient subsequently developed bradycardia and there was no response to atropine so he needed temporary cardiac pacing. Furthermore, a stenocardia was observed, as well as ECG elevations of ST segment in II, III and aVF leads and even in the chest leads, and also a severe hypotension with the need for catecholamine support. Echocardiography examination excluded pericardial effusion, and urgent coronary angiography showed normal findings on coronary arteries. Problems gradually subsided and further course did not require pacing and catecholamine support, and subsequently the performance was completed without any other problems.Discussion and conclusionLiterature describes individual cases with signs of ischemia in the inferior wall after the transseptal puncture. It has always been a temporary complication, and often with a decline of problems after intravenous administration of calcium channel blockers or nitrate. It was therefore suspected that this is a transient coronary artery spasm due to irritation of the autonomic nervous system with vagus nerve activation. Prompt administration of atropine, and if the problems persist also administration of norepinephrine, leads to a decline of problems. It becomes apparent that the need for timely treatment of this complication is necessary. After remission of symptoms and at the exclusion of other possible complications it is possible to finish the electrophysiological study.