Ventricular Fibrillation After Robotic Off-Pump Left Atrial Appendage Clipping: A Coronary Spasm Event

EP Lab Digest. 2023;23(2):19.

In this article, we discuss the important role of differential diagnosis in the medical management of a patient undergoing robotic-assisted left atrial appendage (LAA) closure and then presenting with ventricular fibrillation (VF). We present a brief case in which VF required multiple attempts of electrical defibrillation after minimally invasive, off-pump, robotic-assisted LAA clipping.

Case Presentation

A 55-year-old severely obese male with a history of persistent atrial fibrillation (AF) since 2016 presented with persistent AF, fatigue, and repeated episodes of gastrointestinal (GI) bleeding. He underwent investigation for the management of LAA clipping.

His past medical history was remarkable for persistent AF on apixaban and rate control therapy with metoprolol 25 mg bid, severe obesity (body mass index 40.1 kg/m²), primary hypertension, obstructive sleep apnea on continuous positive airway pressure, gout, knee surgery, anxiety, and end-stage renal disease on hemodialysis. In August 2002, the patient also had a spontaneous episode of GI bleeding that required multiple blood transfusions as well as other minor bleeding episodes that led to a halt of anticoagulation therapy.    

The preoperative electrocardiogram (ECG) showed AF (Video). A transthoracic echocardiogram (TTE) showed an ejection fraction of 55% and no regional left ventricular wall abnormalities. Chest computed tomography (CT) without contrast was normal. Coronary angiography demonstrated a left dominant anatomy and no coronary artery lesions.

Based on the outcomes of the LAAOS III clinical trial,¹ the high Society of Thoracic Surgeons (STS) risk score (8%), and the presence of other associated comorbidities, the heart team opted for off-pump robotic-assisted LAA clipping. The procedure was successfully completed using a left mini-thoracotomy approach. The LAA was clipped, the apex of the appendage was removed and inspected for clots, and the remaining appendage was sutured (Video). At the wound closure, there was an episode of VF requiring 6 attempts of electrical defibrillation.

The differential diagnosis was stenosis of the circumflex coronary artery due to LAA clipping, a clot occluding the coronary arteries, or electrical R-on-T ventricular extrasystole of distinct cause (including myocardial infarction [MI]) capable of triggering VF. The patient was quickly brought to the catheterization laboratory and underwent coronary angiography to exclude occlusion of the circumflex coronary artery or the presence of a clot occluding the coronary arteries. Coronary angiography demonstrated a spasm of the left anterior descending artery that readily resolved after intravenous nitroglycerin administration. The postoperative course was unremarkable, laboratory analysis was normal (including potassium level), and the patient was discharged on postoperative day 1. Postoperative TTE was normal; ECG showed AF, similar to the preoperative ECG (Video).

Video. Preoperative and postoperative ECG, chest CT scan, preoperative and postoperative TTE, and preoperative and postoperative coronary angiography and intraoperative LAA clipping.

Discussion

Coronary artery spasm in an extremely sensitive heart may lead to MI. However, circumflex artery stenosis due to clipping occlusion can be one of the reasons leading to MI.² Therefore, urgent coronary angiography can lead to a definitive diagnosis.

Off-pump robotic-assisted LAA clipping reduces the chances of stroke¹ and is a valid alternative to conventional sternotomy. The procedure helps to avoid sternotomy complications (diastasis and infection, among others) while presenting a lower rate of postoperative pain, shorter intubation time, and decreased hospital length of stay.^3,4

As fast postoperative recovery is important in this population of patients, the minimally invasive approach with off-pump robotic-assisted LAA clipping is helpful for early extubation and prompt recovery of the patient.   

The combined advantages of sternal sparing, off-pump surgery, reduced ventilation time, and AF incidence are key factors for good outcomes in this subset of patients.

Conclusion

In patients presenting with VF after LAA clipping, coronary spasm should be included in the differential diagnosis using coronary angiography, and treated accordingly. 

Disclosures: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. They have no conflicts of interest to report regarding the content herein.

References

1. Whitlock RP, Belley-Cote EP, Paparella D, et al; LAAOS III Investigators. Left atrial appendage occlusion during cardiac surgery to prevent stroke. N Engl J Med. 2021;384(22):2081-2091. doi:10.1056/NEJMoa2101897

2. Kuzmin B, Staack T, Wippermann J, Wacker M. Left atrial appendage occlusion device causing coronary obstruction: a word of caution. J Card Surg. 2021;36(2):723-725. doi:10.1111/jocs.15222

3. Torregrossa G, Sá MP, Van den Eynde J, et al. Robotic-assisted versus conventional off-pump coronary surgery in women: a propensity-matched study. J Card Surg. 2022;37(11):3525-3535. doi:10.1111/jocs.16878

4. Torregrossa G, Sá MP, Van den Eynde J, et al. Hybrid robotic off-pump versus conventional on-pump and off-pump coronary artery bypass graft surgery in women. J Card Surg. 2022;37(4):895-905. doi:10.1111/jocs.16247