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Images and Case Reports in Arrhythmia
and Electrophysiology
Pleuropericardial Fistula Formation After Prior Epicardial
Catheter Ablation for Ventricular Tachycardia
Nilesh Mathuria, MD; Eric Buch, MD, MS; Kalyanam Shivkumar, MD, PhD
A
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tion outside the pericardial border, near the posterolateral left
ventricle (Figure 1), consistent with a pleuropericardial
fistula. This contrast dissipated during the procedure,
probably as the result of dilution from the irrigated catheter
or diffusion into the pleural cavity. During the procedure,
the ablation catheter occasionally entered this fistula,
demonstrating “electric silence” and exiting the pericardial
space fluoroscopically.
After the procedure, the patient was noted to have a left
pleural effusion, which required 2 days of diuretics (Figure 2). The patient otherwise tolerated the procedure
without complications and is currently free of VT at
3-month follow-up.
61-year-old man with nonischemic cardiomyopathy
(left ventricular ejection fraction, 20%) underwent ventricular tachycardia (VT) ablation for recurrent implantable
cardioverter-defibrillator shocks despite antiarrhythmic
drugs. The patient had undergone a combined endocardial/
epicardial VT ablation 3 years prior. During this index
procedure, percutaneous epicardial access was obtained as
previously described1 without complications and the pericardiogram was normal. Epicardial mapping revealed a large,
dense scar covering the lateral wall of the left ventricle.
Extensive ablation with an externally irrigated ablation catheter was performed on the epicardial surface, targeting late
potentials and pace maps of induced VTs. Steroids were not
administered in the pericardial space.
The patient was free from VT for 3 years but then had
recurrent VT. Given the known epicardial substrate from the
prior procedure, a repeat endocardial/epicardial VT ablation
was planned. During percutaneous epicardial access, the
pericardial space was entered without difficulty and a guide
wire easily passed within the pericardial space. Before placement of an epicardial sheath, a pericardiogram was performed, which revealed a large region of contrast extravasa-
Discussion
To our knowledge, this is the first report of a pleuropericardial fistula developing after prior epicardial catheter ablation.
During the second procedure, only a soft J-tipped guide wire
and 5F dilator had entered the pericardial space when the
pericardiogram revealed a marked abnormality, before placement of any sheath or catheter. Although congenital pleuropericardial fistulas have been described, the most likely
Figure 1. Pericardiograms demonstrating
pleuropericardial fistula. After epicardial
access was obtained and a guide wire
was placed within the pericardial space
(thin arrow), a pericardiogram demonstrated contrast extravasating outside the
pericardial space (block arrow).
Received October 16, 2011; accepted December 13, 2011.
From St Luke’s Episcopal Hospital/Texas Heart Institute, Houston, TX (N.M.); and UCLA Cardiac Arrhythmia Center, David Geffen School of
Medicine at UCLA, Los Angeles, CA (E.B., K.S.).
Correspondence to Nilesh Mathuria, MD, St Luke’s Episcopal Hospital/Texas Heart Institute, 6770 Bertner St, MC 2–255, Houston, TX 77030. E-mail
[email protected]
(Circ Arrhythm Electrophysiol. 2012;5:e18-e19.)
© 2012 American Heart Association, Inc.
Circ Arrhythm Electrophysiol is available at http://circep.ahajournals.org
e18
DOI: 10.1161/CIRCEP.111.968420
Mathuria et al
Pleuropericardial Fistula From Epicardial Ablation
e19
Figure 2. Chest radiographs before (A)
and after (B) ablation reveal moderate
left-sided pleural effusion.
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explanation for this finding is a fistula that developed
between the pericardial and pleural space as a consequence of
prior epicardial ablation.
The fibrous pericardial lining is roughly 2 mm in thickness
throughout the pericardium.2 The pleural layer abuts the
pericardial lining along the anterior and lateral left ventricle.
Given that these thin structures are in close proximity and the
proinflammatory state caused by ablation on the epicardial
surface, the formation of a fistula between the 2 spaces is
possible. Additionally, fistulas between the pericardium and
the esophagus, stomach, and peritoneal cavity have been
described in the setting of malignancies, surgery, or ablation.
This abnormality is likely to be underrecognized if a pericardiogram is not performed or if the fistula is small. The
possibility of a pleuropericardial fistula should be considered
if there is extravasation of contrast outside the pericardial
space during a pericardiogram, limited fluid aspiration from
the pericardial space during irrigated ablation, or a new left
pleural effusion after the procedure.
Conclusions
A pleuropericardial fistula can develop after percutaneous
epicardial access and ablation. This abnormality can be
diagnosed with a pericardiogram and should be considered in
cases of new left pleural effusion or difficulty aspirating fluid
from the pericardial space.
Disclosures
None.
References
1. Sosa E, Scanavacca M, d’Avila A, Pilleggi F. A new technique to perform
epicardial mapping in the electrophysiology laboratory. J Cardiovasc Electrophysiol. 1996;7:531–536.
2. Shabetai F. Pericardial anatomy. In: Shabetai F, ed. The Pericardium.
Norwell, MA: Kluwer Academic Publishers; 2003;2–5.
KEY WORDS: epicardial
䡲 ventricular tachycardia 䡲 fistula 䡲 catheter ablation
Pleuropericardial Fistula Formation After Prior Epicardial Catheter Ablation for
Ventricular Tachycardia
Nilesh Mathuria, Eric Buch and Kalyanam Shivkumar
Downloaded from http://circep.ahajournals.org/ by guest on May 11, 2017
Circ Arrhythm Electrophysiol. 2012;5:e18-e19
doi: 10.1161/CIRCEP.111.968420
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