25 year old female with diagnosed history of inappropriate sinus tachycardia at the age of 17. Also, does have a significant history of psychological issues including bulimia/eating disorder, PTSD, chronic GI issues. Per the limit of records we have, she underwent EPS in Aug 2018 that was unable to trigger SVT, therefore an ablation was not performed at that time. Was placed on multiple rate control medications, however was intolerant secondary to low blood pressure. Additionally, had another mapping and an ablation in September of 2022. She was once again diagnosed with the inappropriate sinus tachycardia, however unknown etiology behind the possible SVT episodes. Attempted beta blockers, calcium channel blockers, and sodium channel inhibitors without improvement.
There was continued concern due to the fact that she was supposedly always “very symptomatic”. Her symptoms included palpitations, fatigue, inability to perform tasks or work, chest pain and shortness of breath. They occurred with and without activity. There nis mention of psychological etiology.
As a last resort, in December of 2022, underwent right thoracoscopic epicardial ablation of the sinus node region and right atrial wall.
The operative note for that procedure and office notes are attached in screenshots.
Should be noted that prior to the procedure, she was explaining the risks of the operation including possible postoperative pacemaker implantation.
Post-operatively PC continued to have symptoms and requested a second opinion due to worsening and frequent syncopal episodes and her holter monitor reported profound bradycardia with long pauses (apparently new onset).
In June of 2023, approximately 6 months after the epicardial ablation, she required an emergent pacemaker which was an Abbott single-chamber atrial. At this point, the second cardiologist suggested that the ablation was inappropriate and potentially not performed correctly. Was diagnosed with SSS and now has a programmed AAIR. This particular cardiologist removed her from the Propranolol she was given, as she was instructed to take a PRN (he deemed inappropriate), regular pacemaker interrogations. However, informed the PC that there's not much they could do at this point since it seems her sinus note is completely destroyed.
Based on this second opinion, we do have concern that there was an issue with the epicardial ablation. PC never had documented SVT, and all EKG’s available to us show sinus rhythms, except for after the procedure in question. This yielded junctional bradycardia and long pauses, as mentioned above.
We do have very scattered and limited documentation, which explains lack of specific details.
We appreciate your opinions in advance and will answer any questions you have.
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Do you believe there might have been medical error?
That is the reason why ablations are performed, to suppress sinus or nodal activity. The fact that she was bradycardic postop certifies the fact that the ablation was successful
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Same as above. One of the “complications” of ablations is excessive suppression of the electrical activity thus necessitating a PPM
What makes you a good expert for this case?
I perform surgical ablations and I’ve been involved in transcatheter ablations as well
How often do you encounter cases similar to this one in your practice?
When I do an ablation, I always tell my patients there is a risk of requiring a PPM
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