Complete Heart Block After Pulmonary Artery Thrombectomy for Provoked Massive Pulmonary embolus

Document Type

Article

Abstract

INTRODUCTION: The CDC estimates incidence of venous thromboembolism in 900,000 people annually. Twenty-five percent with a pulmonary embolism (PE) present with sudden death. Updated 2021 American College of Chest Physicians (CHEST) guidelines recommend systemically administered thrombolytic therapy in patients with acute PE and systolic blood pressure < 90 mmHg. Systemic thrombolysis is recommended over localized thrombolysis. However, catheter-directed thrombectomy (CDT) is recommended by CHEST and American College of Cardiology (ACC) in patients with acute PE with hypotension or intermediate-high risk PE and a high bleeding risk or failed systemic thrombolysis despite limited evidence. We present a case of an elderly woman presenting with an acute intermediate-high risk PE who developed a third-degree AV block at the conclusion of CDT.

CASE PRESENTATION: 82-year-old woman with history of hypertension presented to the emergency department (ED) after a syncopal episode 12 days after a proximal right comminuted humeral fracture. She was working with physical therapy when she felt "woozy” and lost consciousness. In the ED, her vitals were temperature 100.1 F, heart rate 135 bpm, blood pressure 90/52 mmHg, and saturation 95% on 3 L nasal cannula. ECG showed sinus tachycardia with LBBB and right axis deviation. CTA chest showed acute bilateral saddle emboli with evidence of right heart strain. TPA was considered but deferred due to subacute humeral fracture. Heparin infusion was started, and she underwent CAT by interventional radiology. During thrombectomy of the left PA, she acutely developed bradycardia to heart rate of 30s and worsening hypotension. ECG showed complete heart block, so the case was discussed with an interventional cardiologist. She was given atropine, started on norepinephrine and dopamine infusions. Trans-venous pacing was discussed, but she reverted to normal sinus rhythm with improved blood pressure. This occurred again the next afternoon. At this point, the patient was recommended a dual-chamber pacemaker which was placed on day 4 of admission and transitioned to apixaban. Her shock resolved, and norepinephrine and dopamine were discontinued. She was discharged to a short-term rehabilitation center day 9 of admission.

DISCUSSION: Prior literature describes transient right bundle branch block (RBBB) on catheterization of the right ventricle or pulmonary artery (PA) during right heart catheterization (RHC) and central venous catheter (CVC) placement. Development of third-degree atrioventricular (AV) block due to a new RBBB in a patient with a preexisting left bundle branch block (LBBB) during the above procedures has also been described. CDT traverses the same structures as those during CVC placement and RHC. However, third-degree AV block in the setting of CDT has not been previously described in literature.

CONCLUSIONS: Cardiac arrhythmias, particularly AV blocks, have been described with CVC placement and RHC. In the perfect storm of a pre-existing LBBB, and irritation of the right ventricle and PA which causes a transient RBBB, a third-degree block can be triggered. We present a case of an elderly patient with a pre-existing LBBB who, after CAT, developed a third-degree AV block and shock ultimately requiring a pacemaker. This presents a new risk associated with catheter-based pulmonary artery thrombectomy.

First Page

A5800

Last Page

A5801

DOI

10.1016/j.chest.2024.06.3440

Publication Date

10-1-2024

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