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 No more ablation was performed after that point, and the mapping catheter was subsequently withdrawn from the short sheath.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.