Severe Left Atrial Edema and Heart Failure After Atrial Fibrillation Ablation
A 66-year-old woman with drug-refractory symptomatic paroxysmal atrial fibrillation presented for atrial fibrillation ablation. Before the procedure, she underwent a transthoracic echocardiogram and contrast-enhanced chest computed tomography (CT) scan (Figure, a) to define both her left atrial and pulmonary vein anatomy. Both structures were normal. The following day, a left atrial circumferential radiofrequency ablation throughout the atria was performed. The procedure was well tolerated, and she was discharged the following day. Two months later, the patient presented with progressive dyspnea, orthopnea, and dry cough. The ECG revealed sinus rhythm but was otherwise normal. She had an elevated pro-brain natriuretic peptide (pro-BNP) level of 562 pg/mL. A bedside transthoracic echocardiogram demonstrated a normal ejection fraction and lack of atrial mechanical systole, as shown by the absence of an A-wave on the Doppler mitral inflow pattern (Figure, b). A contrast-enhanced chest CT showed significant circumferential edema of the left atrium, large bilateral pleural effusions, and the absence of pulmonary vein stenosis (Figure, b). There were no pulmonary emboli visualized. The patient improved with aggressive diuresis and was discharged 7 days later. She has remained free of atrial fibrillation and heart failure. Six months after ablation, transthoracic echocardiography and chest CT documented a small A-wave and resolution of the left atrial edema (Figure, c). Her pro-BNP level was improved, at 95 pg/mL. Left atrial edema is a known complication of atrial fibrillation ablative procedures; however, documentation by CT scan has not been described. In this case, mechanical stunning from left atrial edema contributed to the patient’s presenting symptoms and elevated pro-BNP level. Congestive heart failure associated with left atrial edema can be managed conservatively and should be considered in patients who present with congestive heart failure soon after an atrial fibrillation ablative procedure.