3 DIFFERENTIAL DIAGNOSIS, INVESTIGATIONS, AND TREATMENT
After written informed consent was obtained, the electrophysiology
procedure was performed under the guidance of a three-dimensional
electroanatomic mapping system (CARTO3). A 3.5-mm-tip saline irrigating
catheter (NaviStar ThermoCool SmartTouch) was introduced into the aorta
via an 8F short sheath inserted in the right femoral artery. A 3D image
of the aorta was first reconstructed by the mapping catheter on the
electroanatomic mapping system. The mapping catheter was then introduced
into the left ventricle, using the retrograde transaortic manipulation
approach, to find the ablation target of PVC. The earliest activation
site of the PVC was located at the anterior papillary muscle of the left
ventricle (31ms ahead the surface QRS wave, Figure 1B). Several
radiofrequency applications (40w, 43°C) were performed around the target
and eliminated the PVCs. During the 30-minute observation period, some
provocative PVC was observed after the infusion of isoproterenol.
Therefore, reinforcement ablation was attempted. After several attempts
of retrograde transaortic manipulation, the mapping catheter had finally
been introduced into the left ventricle (Figure 2). However, about 40
seconds after the last retrograde transaortic manipulation (Figure 2),
she presented a sudden large body movement from the bed (supplementary
video). After returning to the normal supine position, she reported that
a severe sense of weightlessness had led to her uncontrolled body
movement. Moreover, she had also reportedly encountered the symptoms of
vertigo, nausea, vomiting, and limb ataxia, coupled with an increased
blood pressure (from the baseline of 120/76mmHg to the highest of
198/110mmHg). No more ablation was performed after that point, and the
mapping catheter was subsequently withdrawn from the short sheath. No
charring was observed at the tip of the ablation catheter. Urgent
consultation with a neurologist was conducted. An emergency brain
computed tomography scan was performed and excluded the occurrence of a
hemorrhagic stroke. An AIS of the posterior circulation was suspected.
Emergency cerebral arteriography and interventions was suggested but was
refused by the patient, who had reported of a relief of symptoms at that
point. Conservative treatments (low molecular weight heparin,
atorvastatin, edaravone, betahistine, etc.) were administered to relieve
her symptoms.
4 OUTCOME AND FOLLOW-UP
A cervical computed tomography angiography, performed on the second day
after the ablation, revealed left common carotid artery atherosclerosis
and an anomaly of the left vertebral artery, which directly originated
from the aortic arch (Figure 3). Cranial magnetic resonance imaging,
performed on the third day after the ablation, showed acute left
cerebellar infarction and bilateral periventricular ischemic lesions
(Figure 4). By the third day, her symptoms were significantly improved.
On the 16th day after the ablation, she was discharged without obvious
neurological sequelae after the conservative treatments. At the 6-month
follow-up, she reported a relief of palpitation with a reduced PVC
burden of 2.8%, without neurological sequelae.