S4503 Gastroparesis Following Ablation for Atrial Fibrillation

Introduction: Gastroparesis is a gastric motility disorder characterized by the delayed emptying of stomach contents in the absence of mechanical obstruction. The present case highlights a unique instance in which gastroparesis was noted to occur post radiofrequency ablation for paroxysmal atrial fibrillation. Case Description: A 64-year-old White woman with a history of persistent paroxysmal atrial fibrillation with failure to achieve control on pharmacotherapy underwent radiofrequency ablation. Prior medical history was significant for heart failure with reduced ejection fraction, hypertension, diabetes mellitus, and hyperlipidemia. Three weeks after her procedure, the patient presented to the emergency department with generalized malaise, epigastric pain, nausea, and poor oral intake that began days after radiofrequency ablation. She did not have vomiting, or unintended weight loss. Heart rate was noted to have improved post-ablation, and abdominal symptoms were noted to be more persistent after the procedure. Patient did not have any prior endoscopies. Scintigraphic gastric emptying of a standardized meal demonstrated 91%, 82%, 70%, and 59% retention of the meal at 1, 2, 3, and 4 hours, respectively. Retention of the meal at >10% after 4 hours demonstrated findings consistent with severe gastroparesis. The patient was trialed on metoclopramide 10 mg daily, pantoprazole 40 mg daily and famotidine 20 mg daily to alleviate her symptoms. Her abdominal symptoms improved, although the paroxysmal atrial fibrillation persisted requiring eventual left atrial appendage ligation. Discussion: Large-scale national studies have estimated prevalence of gastroparesis to be from 0.02%-0.27% within the United States. However, the pathophysiology and mechanism of this condition remains nebulous. It is speculated that during ablation, especially when radiofrequency energy is delivered to the posterior left atrial wall, the close anatomical proximity of the esophagus and its associated vagal nerve branches makes them susceptible to collateral thermal damage. This injury disrupts the vagal innervation of the stomach, particularly the gastric antrum and pylorus leading to impaired gastric motility and delayed gastric emptying. Treatment modalities for gastroparesis include dietary modification and initiation of prokinetic agents. This case underscores the importance to acknowledge gastroparesis as a possible adverse clinical sequela to radiofrequency ablation in the setting of atrial fibrillation.