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Regional pericarditis status post cardiac ablation: a case report.

Orme J, Eddin M, Loli A - N Am J Med Sci (2015)

View Article: PubMed Central - PubMed

Affiliation: Department of Internal Medicine, Banner Good Samaritan Medical Center, Phoenix, Arizona, USA. E-mail: Geoffrey.orme@bannerhealth.com.

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Dear Editor, We sincerely appreciate the response to our recently published article regarding regional pericarditis as it is a very difficult diagnosis and requires the exclusion of the more common etiologies of chest pain and ST-segment elevation... For this reason, our case is of great interest, as in our case regional pericarditis is due to post-atrial fibrillation ablation resulting in transmural myocardial cell death... At time of presentation, the patient had an elevated troponin of 17.2 ng/ml, which may be consistent with a post-cardiac ablation... The ECG at time of presentation to the emergency department revealed normal sinus rhythm with a heart rate of 78 beats per minute with anterolateral ST-segment elevations in leads I and aVL and V2-V4, reciprocal inferior ST-segment depressions in leads III and aVF and subtle PR-segment depressions [Figure 2]... However, after coronary-artery angiography revealed no significant obstructive coronary artery disease, the ECG revealed resolving ST-segment depressions in the inferior leads and increased ST-segment elevation in leads V5-V6 [Figure 3] consistent with regional pericarditis... Furthermore, a 2D echocardiogram was performed prior to discharge, and after further review from the previous article, revealed a left ventricular ejection fraction of 55-60%, no wall motion abnormalities and a new trace regional pericardial effusion around the posterolateral wall compared to the echocardiogram two days prior during the pre-procedural ischemic work-up [Figure 4]... Two-week follow-up ECG revealed normal sinus rhythm with heart rate of 81 beats per minute with a left-posterior fascicular block and no ST-segment abnormalities other than T-wave inversions isolated in leads I and aVL [Figure 5]... Oliva et al., explained the T-wave evolution and morphology following a transmural myocardial infarction related regional pericarditis... It is known that T-wave inversions are seen during an ischemic event and accompany myocardial infarction... However, in post-infarction regional pericarditis, the T-waves either remain positive for 48 hours despite infarction or they undergo pre-mature gradual reversal of inversion... Our patient did not have T-wave inversions at time of presentation or at time of discharge... This strongly suggests that myocardial ischemia was not the culprit for this case of regional pericarditis... Coronary vasospasm was ruled out as seen on coronary angiography [Figure 7]... In conclusion, all evidence as mentioned within is suggestive of a regional myo-pericarditis secondary to transmural myocardial cellular death due to an aggressive atrial-fibrillation ablation, which resolved with conservative therapy for traditional pericarditis.

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ECG at time of presentation to the emergency department revealing normal sinus rhythm with heart rate 78 beats per minute with anterolateral ST-segment elevations in leads I and aVL and V2- V4, reciprocal inferior ST-segment depressions in leads III and aVF and subtle PR-segment depressions
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Figure 2: ECG at time of presentation to the emergency department revealing normal sinus rhythm with heart rate 78 beats per minute with anterolateral ST-segment elevations in leads I and aVL and V2- V4, reciprocal inferior ST-segment depressions in leads III and aVF and subtle PR-segment depressions

Mentions: The electrocardiogram (ECG) prior to cardiac ablation was relatively unremarkable [Figure 1]. Patient underwent elective atrial fibrillation ablation. During the ablation, aggressive radiofrequency, and cryoablation of the pulmonary veins, left atrial posterior wall, and the left and right isthmus was required for adequate treatment of the arrhythmia. The patient was then discharged home 24 hours after the ablation. Shortly after returning home, patient developed chest pain and presented to the emergency department 36 hours after the procedure. At time of presentation, the patient had an elevated troponin of 17.2 ng/ml, which may be consistent with a post-cardiac ablation.[8] The ECG at time of presentation to the emergency department revealed normal sinus rhythm with a heart rate of 78 beats per minute with anterolateral ST-segment elevations in leads I and aVL and V2-V4, reciprocal inferior ST-segment depressions in leads III and aVF and subtle PR-segment depressions [Figure 2]. However, after coronary-artery angiography revealed no significant obstructive coronary artery disease, the ECG revealed resolving ST-segment depressions in the inferior leads and increased ST-segment elevation in leads V5-V6 [Figure 3] consistent with regional pericarditis. Furthermore, a 2D echocardiogram was performed prior to discharge, and after further review from the previous article,[1] revealed a left ventricular ejection fraction of 55-60%, no wall motion abnormalities and a new trace regional pericardial effusion around the posterolateral wall compared to the echocardiogram two days prior during the pre-procedural ischemic work-up [Figure 4]. Two-week follow-up ECG revealed normal sinus rhythm with heart rate of 81 beats per minute with a left-posterior fascicular block and no ST-segment abnormalities other than T-wave inversions isolated in leads I and aVL [Figure 5]. This is consistent with a pericarditis as T-waves may become inverted around the third week and resolve within several weeks thereafter.[6] A 3-month follow-up ECG revealed a normal sinus rhythm with heart rate of 82 beats per minute with a left posterior fascicular block and resolution of non-specific T-wave abnormalities [Figure 6].


Regional pericarditis status post cardiac ablation: a case report.

Orme J, Eddin M, Loli A - N Am J Med Sci (2015)

ECG at time of presentation to the emergency department revealing normal sinus rhythm with heart rate 78 beats per minute with anterolateral ST-segment elevations in leads I and aVL and V2- V4, reciprocal inferior ST-segment depressions in leads III and aVF and subtle PR-segment depressions
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4325397&req=5

Figure 2: ECG at time of presentation to the emergency department revealing normal sinus rhythm with heart rate 78 beats per minute with anterolateral ST-segment elevations in leads I and aVL and V2- V4, reciprocal inferior ST-segment depressions in leads III and aVF and subtle PR-segment depressions
Mentions: The electrocardiogram (ECG) prior to cardiac ablation was relatively unremarkable [Figure 1]. Patient underwent elective atrial fibrillation ablation. During the ablation, aggressive radiofrequency, and cryoablation of the pulmonary veins, left atrial posterior wall, and the left and right isthmus was required for adequate treatment of the arrhythmia. The patient was then discharged home 24 hours after the ablation. Shortly after returning home, patient developed chest pain and presented to the emergency department 36 hours after the procedure. At time of presentation, the patient had an elevated troponin of 17.2 ng/ml, which may be consistent with a post-cardiac ablation.[8] The ECG at time of presentation to the emergency department revealed normal sinus rhythm with a heart rate of 78 beats per minute with anterolateral ST-segment elevations in leads I and aVL and V2-V4, reciprocal inferior ST-segment depressions in leads III and aVF and subtle PR-segment depressions [Figure 2]. However, after coronary-artery angiography revealed no significant obstructive coronary artery disease, the ECG revealed resolving ST-segment depressions in the inferior leads and increased ST-segment elevation in leads V5-V6 [Figure 3] consistent with regional pericarditis. Furthermore, a 2D echocardiogram was performed prior to discharge, and after further review from the previous article,[1] revealed a left ventricular ejection fraction of 55-60%, no wall motion abnormalities and a new trace regional pericardial effusion around the posterolateral wall compared to the echocardiogram two days prior during the pre-procedural ischemic work-up [Figure 4]. Two-week follow-up ECG revealed normal sinus rhythm with heart rate of 81 beats per minute with a left-posterior fascicular block and no ST-segment abnormalities other than T-wave inversions isolated in leads I and aVL [Figure 5]. This is consistent with a pericarditis as T-waves may become inverted around the third week and resolve within several weeks thereafter.[6] A 3-month follow-up ECG revealed a normal sinus rhythm with heart rate of 82 beats per minute with a left posterior fascicular block and resolution of non-specific T-wave abnormalities [Figure 6].

View Article: PubMed Central - PubMed

Affiliation: Department of Internal Medicine, Banner Good Samaritan Medical Center, Phoenix, Arizona, USA. E-mail: Geoffrey.orme@bannerhealth.com.

AUTOMATICALLY GENERATED EXCERPT
Please rate it.

Dear Editor, We sincerely appreciate the response to our recently published article regarding regional pericarditis as it is a very difficult diagnosis and requires the exclusion of the more common etiologies of chest pain and ST-segment elevation... For this reason, our case is of great interest, as in our case regional pericarditis is due to post-atrial fibrillation ablation resulting in transmural myocardial cell death... At time of presentation, the patient had an elevated troponin of 17.2 ng/ml, which may be consistent with a post-cardiac ablation... The ECG at time of presentation to the emergency department revealed normal sinus rhythm with a heart rate of 78 beats per minute with anterolateral ST-segment elevations in leads I and aVL and V2-V4, reciprocal inferior ST-segment depressions in leads III and aVF and subtle PR-segment depressions [Figure 2]... However, after coronary-artery angiography revealed no significant obstructive coronary artery disease, the ECG revealed resolving ST-segment depressions in the inferior leads and increased ST-segment elevation in leads V5-V6 [Figure 3] consistent with regional pericarditis... Furthermore, a 2D echocardiogram was performed prior to discharge, and after further review from the previous article, revealed a left ventricular ejection fraction of 55-60%, no wall motion abnormalities and a new trace regional pericardial effusion around the posterolateral wall compared to the echocardiogram two days prior during the pre-procedural ischemic work-up [Figure 4]... Two-week follow-up ECG revealed normal sinus rhythm with heart rate of 81 beats per minute with a left-posterior fascicular block and no ST-segment abnormalities other than T-wave inversions isolated in leads I and aVL [Figure 5]... Oliva et al., explained the T-wave evolution and morphology following a transmural myocardial infarction related regional pericarditis... It is known that T-wave inversions are seen during an ischemic event and accompany myocardial infarction... However, in post-infarction regional pericarditis, the T-waves either remain positive for 48 hours despite infarction or they undergo pre-mature gradual reversal of inversion... Our patient did not have T-wave inversions at time of presentation or at time of discharge... This strongly suggests that myocardial ischemia was not the culprit for this case of regional pericarditis... Coronary vasospasm was ruled out as seen on coronary angiography [Figure 7]... In conclusion, all evidence as mentioned within is suggestive of a regional myo-pericarditis secondary to transmural myocardial cellular death due to an aggressive atrial-fibrillation ablation, which resolved with conservative therapy for traditional pericarditis.

No MeSH data available.


Related in: MedlinePlus