Dyspnea Following Electrophysiology Ablation
A 57-year-old male patient presents to the outpatient clinic complaining of chest pain and shortness of breath after an atrial flutter ablation 10 days prior to his visit. His past medical history is significant for atrial flutter, non-ischemic cardiomyopathy (most recent left ventricular ejection fraction measured at 35%), hypertension, human immunodeficiency virus on highly active antiretroviral therapy (HAART), mild intermittent asthma and mild cognitive impairment. Medications include atorvastatin, aspirin, losartan, hydrochlorothiazide, metoprolol, dabigatran and HAART. Physical exam revealed jugular venous distension but was otherwise normal. Electrocardiogram showed normal sinus rhythm with occasional premature ventricular contractions (Figure 1). Chest X-ray performed in the office was significant for enlarged cardiac silhouette and loss of the normal cardiac contour (Figure 2). A transthoracic echocardiogram (TTE) was performed showing a large, circumferential pericardial effusion, an inferior vena cava (IVC) diameter of 3.4cm which collapsed <50% with inspiration, and significant variation of inflow velocities across the tricuspid and mitral valves during the respiratory cycle (Figure 3A-F). Given his symptoms and TTE findings, the patient was taken for pericardiocentesis where 500 mL of bloody pericardial fluid were removed. After the pericardiocentesis, the patient had only minimal improvement in his shortness of breath. A repeat TTE was performed (Figure 4A-F) showing significant septal bounce, continued inflow velocity variation across the tricuspid and mitral valve, and IVC plethora. Labs at the time of repeat TTE showed an elevated C-reactive protein.
Figure 1: ECG at presentation in the outpatient clinic
Figure 2: Chest X-ray 2 months prior to outpatient visit (left) and on the day of his clinic presentation (right)
Figure 3: Transthoracic echocardiogram on the day of admission. Apical 4 chamber (Panel A) and parasternal short axis (Panel B) views help with sizing of the effusion. Inflow velocities across the mitral (Panel C) and tricuspid (Panel D) valves showed significant variation (33% and -74% respectively) throughout the respiratory cycle and the IVC was plethoric and non-collapsible (Panel E and F).
Figure 4: Transthoracic echocardiogram after pericardiocentesis. Apical 4 chamber (Panel A), and parasternal short axis (Panel B) show only a small residual effusion. Inflow velocities across the mitral (Panel C) and tricuspid (Panel D) valves still show significant variation (52% and -78% respectively) throughout the respiratory cycle and the IVC was plethoric and non-collapsible (Panel E and F).
Which of the following is the most appropriate next step in the management of this patient?