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Table of Contents
CASE REPORT
Year : 2021  |  Volume : 3  |  Issue : 1  |  Page : 23

Visual symptoms after a cardiac ablation procedure: A report of three cases


Department of Ophthalmology, Hospital Professor Doutor Fernando da Fonseca, Amadora, Portugal

Date of Submission16-Apr-2021
Date of Decision11-Jun-2021
Date of Acceptance21-Jun-2021
Date of Web Publication13-Jul-2021

Correspondence Address:
Dr. Catarina M Monteiro
Hospital Professor Doutor Fernando da Fonseca, IC19, 2720-276 Amadora
Portugal
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/pajo.pajo_88_21

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  Abstract 


The current study reports three cases of both adult and pediatric patients with a history of self-limited episodes of visual symptoms following ablative procedures for cardiac dysrhythmias. Neurological and ophthalmological evaluations were always unremarkable even when performed during the episodes. The visual disturbances subsided spontaneously, and none of the patients developed any kind of permanent visual damage.

Keywords: Cardiac ablation, transseptal catheterization, visual symptoms


How to cite this article:
Monteiro CM, B. Mota MS, R. Ramalho MR, C. Prieto IM. Visual symptoms after a cardiac ablation procedure: A report of three cases. Pan Am J Ophthalmol 2021;3:23

How to cite this URL:
Monteiro CM, B. Mota MS, R. Ramalho MR, C. Prieto IM. Visual symptoms after a cardiac ablation procedure: A report of three cases. Pan Am J Ophthalmol [serial online] 2021 [cited 2021 Nov 27];3:23. Available from: https://www.thepajo.org/text.asp?2021/3/1/23/321299




  Introduction Top


Visual symptoms after catheter ablation are a reported complication of the procedure, mainly after transseptal catheterization. The exact physiopathological mechanism is yet to be discovered. The patient should be made aware that it is usually a self-limited situation and that it has no long-term consequences on vision. Full clinical and neurological examination might be necessary to exclude stroke or other life-threatening conditions, and thus, neuroimaging remains crucial in the evaluation of these symptoms.


  Cases Reports Top


Case 1

A 27-year-old woman with a history of drug-resistant ventricular tachycardia was submitted to a cardiac ablation procedure of a concealed left lateral accessory pathway through a transseptal approach.

Six hours after the procedure, the patient developed an acute onset of a sharp headache in the frontal region, accompanied by a subjective feeling of ocular pressure in both eyes that lasted for 5 min. Later on that day, she developed bilateral visual teichopsia on the right visual fields accompanied by photophobia that subsided after 30 min. She also complained of nausea and vomiting. The symptoms ended as abruptly as they had started and were not associated with headache.

On postoperative day 1, she suffered a new episode of the same visual disturbance bilaterally, that lasted for approximately 20 min, and was followed by left hemicranial pain referred to the retro-orbital region and accompanied by nausea and photophobia.

On postoperative day 2, the patient developed a right parietal headache and the same bilateral visual symptoms that she kept describing as scintillating dots and lines in her right visual field. The episode lasted approximately 15 min. The patient went to the emergency department. Thorough clinical examination and neurological evaluation were normal. Magnetic resonance imaging (MRI) was not available in the emergency setting, but computerized tomography (CT) scan [Figure 1] showed no hemorrhage or other abnormalities.
Figure 1: Computerized tomography scan from the patient of case 1 obtained 2 days after the ablation procedure

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After being evaluated by the neurology department, she was diagnosed with migraine with aura and discharged home with symptomatic medication (ibuprofen and acetaminophen in case of new onset of symptoms).

She had a follow-up ophthalmology appointment 5 days postoperatively. Her visual symptoms had subsided the day before, but she still complained of slight headache and bilateral retro-orbital pressure. Ophthalmological examination was normal. There have been no other episodes.

Case 2

A 12-year-old male child with no relevant medical or ophthalmological priors was submitted to a transseptal ablation procedure for cardiac dysrhythmia.

On postoperative day 4, he complained of two biparietal headache episodes that lasted about 15 min each and were associated with blurry vision and a white haze in the temporal visual fields of both eyes. He also mentioned mild paresthesias in his parietal regions.

On postoperative day 6, the boy developed a new episode with the same characteristics as mentioned above; this motivated a visit to the emergency room. He was hemodynamically stable and apyretic. His neurological examination was unremarkable. He was discharged with pain-relieving medications.

On postoperative day 10, he went to a follow-up ophthalmology appointment. The episodes of headache and visual field disturbances had subsided 2 days before. Ophthalmological evaluation was as innocent as the one from case 1. The optical coherence tomography (OCT) performed [Figure 2] revealed no abnormalities, and there have since been no more episodes.
Figure 2: Optical coherence tomography scan from the patient of case 2, performed 2 days after the end of symptoms

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Case 3

A 33-year-old man with no previous history of migraines or visual symptoms was submitted to a cryoablation procedure in arrhythmogenic foci originating within the pulmonary veins.

On postoperative day 2, the patient complained of a feeling of a bilateral “C”-shaped area with heat waves that were fixed in his left visual fields that lasted for about 40 min and resolved spontaneously. Ophthalmological observation hours after the episode were unremarkable. An OCT was performed that revealed no abnormalities.

On postoperative day 4, a new episode of the same visual disturbances occurred. It lasted for about 90 min and resolved spontaneously. None of the episodes was associated with headaches. No other symptoms were reported, and there were no other episodes.


  Discussion Top


Although uncommon, there have been some reports regarding the occurrence of headache and visual symptoms in patients submitted to cardiac ablation procedures, mainly transseptal catheterization. This procedure creates an iatrogenic atrial septal defect, leading to a transient right-to-left shunt that, in most cases, closes by 12 months.[1] Both in patients born with patent foramen ovale and in patients with artificially right-to-left shunts, there have been several reports of an increased prevalence of migraine-like episodes.[2]

A variety of physiopathological explanations have been proposed, but the exact mechanism is yet to be found. The most consensual theories include cerebral microembolism due to migration of platelets, thrombin, and other substances, exposure of the cerebral circulation to certain venous factors such as 5-hydroxytryptamine due to loss of pulmonary clearance, and other changes in hemostasis.[3],[4]

One study made a connection between new or worsening migraine symptoms and subtherapeutic international normalized ratio during the cardiac ablation procedure and new silent cerebral infarcts on brain MRI.[4] This may suggest the relevance of hypercoagulability regarding the symptoms developed and may lead to changes of the periprocedural anticoagulation regimen.

Another study postulated that microemboli and/or particulate material from the equipment used during the cardiac ablation procedure might trigger cortical spreading depression without infarct and be associated with migraine-like headache and the associated visual symptoms, similar to what was demonstrated in a mouse model.[5],[6]

However, visual symptoms after cardiac ablation procedures are still an uncommon situation. Chilukuri et al., evaluated 571 patients submitted to procedures involving tuberous sclerosis complex over 3 years.[7] Of these, three patients (0.5%) experienced transient reversible visual symptoms of scintillating scotoma not associated with headache. Noheria and Roshan followed 2069 patients who had an atrial septal puncture for left atrial access and registered 22 patients with new-onset definite migraine following the procedure (1.1%), and a majority of these patients had visual symptoms (68%).[8] Jordaens et al., analyzed 87 consecutive patients submitted to transseptal puncture and concluded that a total of 15 patients reported new visual symptoms or exacerbations of migraine or headache with ocular phenomena.[9]

In our reported cases, the first one reported her symptoms as a fortification phenomenon, describing scintillating scotomas in her right visual field. The patient from case 2, a 12-year-old child, reported blurry vision and a white haze in the temporal visual fields. In case 3, the patient describes a “C”-shaped area with heat waves that were fixed in his left visual fields. As we can see, visual symptoms can be diverse and it is not always simple to differentiate between a benign aura and a stroke.

Most common visual symptoms associated with stroke patients include hemianopsia but also neglect reduced visual acuity and visual field defects.[10] Diagnostic features of a visual aura include propagation of a scintillating scotoma, zigzag lines, fortification spectra, or photopsia.[11] However, these positive visual symptoms can also sometimes be attributable to a focal seizure or occipital lobe ischemia.[12]

Therefore, neuroimaging continues to be the gold standard for stroke exclusion in these patients, but both doctor and patient should be aware that it is most likely a benign and self-limited situation associated with their cardiac ablation procedure.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Rillig A, Meyerfeldt U, Kunze M, Birkemeyer R, Miljak T, Jäckle S, et al. Persistent iatrogenic atrial septal defect after a single-puncture, double-transseptal approach for pulmonary vein isolation using a remote robotic navigation system: Results from a prospective study. Europace 2010;12:331-6.  Back to cited text no. 1
    
2.
Kato Y, Hayashi T, Kobayashi T, Tanahashi N. Migraine prevalence in patients with atrial septal defect. J Headache Pain 2013;14:63.  Back to cited text no. 2
    
3.
Wilmshurst P, Nightingale S. The role of cardiac and pulmonary pathology in migraine: A hypothesis. Headache 2006;46:429-34.  Back to cited text no. 3
    
4.
Mohanty S, Mohanty P, Rutledge JN, Di Biase L, Yan RX, Trivedi C, et al. Effect of catheter ablation and periprocedural anticoagulation regimen on the clinical course of migraine in atrial fibrillation patients with or without pre-existent migraine: Results from a prospective study. Circ Arrhythm Electrophysiol 2015;8:279-87.  Back to cited text no. 4
    
5.
Kato Y, Hayashi T, Kato R, Takao M. Migraine-like headache after transseptal puncture for catheter ablation: A case report and review of the literature. Intern Med 2019;58:2393-5.  Back to cited text no. 5
    
6.
Nozari A, Dilekoz E, Sukhotinsky I, Stein T, Eikermann-Haerter K, Liu C, et al. Microemboli may link spreading depression, migraine aura, and patent foramen ovale. Ann Neurol 2010;67:221-9.  Back to cited text no. 6
    
7.
Chilukuri K, Sinha S, Berger R, Marine JE, Cheng A, Nazarian S, et al. Association of transseptal punctures with isolated migraine aura in patients undergoing catheter ablation of cardiac arrhythmias. J Cardiovasc Electrophysiol 2009;20:1227-30.  Back to cited text no. 7
    
8.
Noheria A, Roshan J, Kapa S, Srivathsan K, Packer DL, Asirvatham SJ. Migraine headaches following catheter ablation for atrial fibrillation. J Interv Card Electrophysiol 2011;30:227-32.  Back to cited text no. 8
    
9.
Jordaens L, Janse P, Szili-Torok T, Belle Y. Migraine accompagnée after transseptal puncture. Neth Heart J 2010;18:374-5.  Back to cited text no. 9
    
10.
Sand KM, Midelfart A, Thomassen L, Melms A, Wilhelm H, Hoff JM. Visual impairment in stroke patients–A review. Acta Neurol Scand Suppl 2013:52-6.  Back to cited text no. 10
    
11.
Micieli A, Kingston W. An approach to identifying headache patients that require neuroimaging. Front Public Health 2019;7:52.  Back to cited text no. 11
    
12.
Olesen J, Friberg L, Olsen TS, Andersen AR, Lassen NA, Hansen PE. Ischaemia induced (symptomatic) migraine attacks may be more frequent than migraine-induce ischaemic insults. Brain 1993;116:187-202.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2]



 

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