Los casos de Dr. Pepe – Caso de Diploma 13 (Resuelto)
Hola amigos, hoy os presento a un paciente tratado mediante ablación por fibrilación auricular. La radiografía se tomó en la revisión de los seis meses tras la ablación.
¿Cuál sería vuestro diagnóstico?
1. Cambios normales post-ablación
2. Neumonía LII
3. Infarto pulmonar
4. Nada de lo expuesto
Podéis dar vuestra opinión hasta el viernes, día en el que se publicará la solución.
Haz click aquí para ver la respuesta
Hallazgos: En la radiografía de tórax se observan opacidades en el lóbulo inferior izquierdo (flecha). En un paciente asintomático con estos hallazgos debe pensarse en un infarto pulmonar y realizar un TC de tórax con sincronización cardíaca para valorar las venas pulmonares.
El angioTC demuestra una estenosis-oclusión de la vena del lóbulo inferior izquierdo (A, flecha) que no se rellena de contraste en la adquisición tardía (B, flecha). Se observa realce de las estructuras perivenosas probablemente por circulación colateral. El angioTC sobreestima las estenosis de las venas pulmonares que pueden no estar completamente ocluidas a pesar de parecerlo.
La ventana de pulmón muestra un aumento de densidad con patrón alveolar en la periferia de LII, vidrio deslustrado y engrosamiento septal asociados (C, flecha) que no varían con el paciente en decúbito prono (D, flecha). Estos signos sugieren un infarto pulmonar venoso.
La angiografía demostró que no había oclusión completa y se decidió colocar un stent que permeabilizó la vena del lóbulo inferior izquierdo (E, flecha):
Diagnóstico final: Infarto pulmonar con estenosis de vena pulmonar tras ablación.
Es importante diagnosticar la estenosis de las venas pulmonares después de la ablación porque puede ser tratada mediante un stent.
Este caso sirve para comentar las complicaciones del tratamiento de la fibrilación auricular (FA) mediante ablación. La fibrilación auricular es la arritmia más frecuente con una prevalencia de 0,4-1% que aumenta con la edad llegando hasta el 8% en los mayores de 80 años. Aumenta el riesgo de muerte, de insuficiencia cardíaca y de accidentes cerebrovasculares, de los cuales, uno de cada seis ocurre en un paciente con FA.
La FA se trata con antiarrítmicos y cardioversión eléctrica. Cuando ésta no tiene éxito o cuando la FA tiene una duración mayor de 2 años o se ha producido una dilatación de la aurícula izquierda de hasta 55-60 mm está indicada la ablación para su tratamiento. La ablación consiste en quemar los focos ectópicos localizados alrededor de las venas pulmonares mediante catéteres desde el interior de la aurícula derecha. Por eso, una de las complicaciones son las estenosis venosas.
El seguimiento de los pacientes después del procedimiento se realiza en la mayoría de los centros habitualmente mediante ecocardiografía y radiografías de tórax.
La TC es útil cuando se sospechan algunas complicaciones como estenosis de las venas pulmonares (figura 1) o la fístula atrio esofágica infrecuente pero muy grave (figura 2).
La incidencia de estenosis venosas después de la ablación es del 1 al 10%. Pueden tardar meses en producir síntomas (figura 1). Si son muy severas pueden producir oclusión de las venas pulmonares como en el caso inicial.
Figura 1. Estenosis de vena pulmonar. El estudio pre-ablación muestra una vena pulmonar inferior izquierda normal (A, flecha). Seis meses tras la ablación, la vena muestra una disminución de calibre superior al 50% (B, flecha). No se observan defectos de repleción que sugieran trombosis. Se trató mediante dilatación y colocación de stent (C, flecha).
Figura 2. Cortes axial y coronal en paciente con fístula atrioesofágica tras ablación de venas pulmonares que asocia signos de derrame pericárdico y derrame pleural bilateral.
El dato más importante ante la sospecha de una fístula atrio-esofágica es la presencia de gas a nivel de la aurícula izquierda que aparece a menudo unas 2 o 3 semanas después de la intervención. (A-B, flechas). Su incidencia es de 0,07% y presenta una alta mortalidad. La TC es la técnica de elección para el diagnóstico. (Imágenes cortesía del Dr Girish Shroff et al., UT-MHH Houston,TX, USA).
La radiografía de tórax permite sospechar otras complicaciones tales como el infarto venoso, neumonía (figura 3), hemorragia pulmonar o lesiones del nervio frénico (figura 4) y del nervio vago (figura 5).
La neumonía es un de las complicaciones de la ablación y en algunos casos tiene un curso fatal. Es importante diferenciar una neumonía de otras complicaciones severas como el infarto venoso pulmonar identificando las venas pulmonares de aspecto normal. Por eso, cuando el curso de la neumonía no es el habitual está indicado hacer un TC (figura 3):
Figura 3. Consolidación en el lóbulo inferior izquierdo y derrame pleural (A, B flechas) en un paciente con fiebre, tos, dolor torácico, astenia y cefalea que había sido tratado de FA mediante ablación 25 días antes.
Los síntomas persistían después del tratamiento antibiótico y se realizó un TC sin sincronización cardíaca con adquisición tardía que demostró que la vena del lóbulo inferior izquierdo era permeable (flecha en D). Se aisló Stenotrophomona Maltophilia.
Figura 4. Elevación del hemidiafragma derecho (A, flecha) en un paciente con FA por lesión del nervio frénico en una radiografía realizada un mes después de la ablación. El 90% de estos pacientes presenta una recuperación completa o parcial al cabo de varios meses como ocurrió en este caso (B, flecha).
Figura 5. Gastroparesia por lesión del nervio vago. Paciente con vómitos, dolor abdominal, plenitud postprandial, estreñimiento e hinchazón en las primeras 36 horas después de la ablación. La radiografía de tórax muestra distensión gástrica (A, flechas). El TC muestra abundante contenido alimenticio que no se vacía con el paso del tiempo (B, flecha).
En un TC previo a la ablación el estómago no estaba distendido. Esta lesión se previene monitorizando la temperatura esofágica durante el procedimiento. El tratamiento con eritromicina intravenosa mejora el vaciado gástrico.
Consejos
- Las complicaciones de la ablación para el tratamiento de la fibrilación auricular pueden implicar a radiólogos generales.
- Algunas complicaciones son tardías y graves como la fístula atrio esofágica que se diagnostica mediante TC al ver gas en la aurícula derecha.
- Ante una neumonía con curso anormal o consolidación sin clínica infecciosa hay que sospechar un infarto pulmonar y realizar un TC.
- Mira la cámara gástrica en estos pacientes especialmente si presentan vómitos. Sugerir tratamiento con eritromicina si se sospecha gastroparesia.
- Si ves un diafragma muy elevado tranquiliza al médico que pide la radiografía de tórax.
- Si ves en un TC una estenosis venosa severa o una obstrucción después de una ablación sugiere la colocación de un stent. La TC sobreestima las estenosis de las venas pulmonares.
Caso preparado por los Drs. Alberto Villanueva y Paula García Barquin.
1. pulmonary infarction (lingula)
2. lingular pneumonia
see bio
The patient has no fever.
Siempre es bueno estar al tanto de las posibles complicaciones post-ablación. La imagenología es clave para un buen diagnóstico.
Se observa un incremento de la densidad en el lóbulo inferior izquierdo. Asociado a presencia de líneas B de kerley e incremento de índice cardiotoracico de predominio cavidades izquierdas sugiere la probabilidad de falla ventricular izquierda no dejando de lado las estenosis de las venas pulmonares posterior a la ablación.saludos
Considerando que la afectación es focal, yo pondría la estenosis de vena como primera posiblidad.
gracias por la retroalimentacion.dr. pepe
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After ablation for atrial fibrillation, it is common to see changes on the chest x-ray due to the healing and remodeling process of the heart tissue.
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En algunos casos, los cambios post-ablación pueden ser sutiles y no generar complicaciones graves como neumonía o infarto pulmonar. Sería interesante ver la solución el viernes.
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Given the timeframe, some post-procedural inflammation or minor scarring wouldn’t be surprising. While LII pneumonia is possible, the timing seems less likely. However, I’m no radiologist!
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¡Hola! Interesante caso, Dr. Pepe. Basándome en la radiografía, me inclino por la opción 2, Neumonía en el LII. ¿Podría ser un factor predisponente la alteración post-ablación? Mientras tanto, ¡me relajo un poco jugando Block Blast!
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Interesting case—looking forward to seeing the final diagnosis on Friday. Always great to learn from these clinical discussions.
Interesting case! Always helpful to review these images after an ablation. Curious to see the final answer on Friday
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El objetivo es analizar los hallazgos radiológicos y debatir el posible diagnóstico entre varias opciones: cambios normales post-ablación, neumonía del lóbulo inferior izquierdo, infarto pulmonar o ninguna de las anteriores. Este tipo de ejercicios fomenta el razonamiento clínico y el intercambio de opiniones antes de conocer la solución final, que se publicará el viernes.
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Interesante caso Tras una ablación por fibrilación auricular, pueden aparecer cambios pulmonares secundarios, pero si la radiografía es a los seis meses, me plantearía algo más que cambios post-procedimiento. La neumonía en LII podría ser posible, aunque también consideraría la opción 3 si hubiera datos clínicos compatibles. Mi voto provisional:
Gracias por compartir el caso, Dr. Pepe. En pacientes tratados por fibrilación auricular, especialmente tras ablación, siempre hay que pensar en complicaciones pulmonares tardías. Sin conocer la clínica, me inclino por
Si la imagen muestra consolidación en el lóbulo inferior izquierdo, la primera impresión podría ser 2. Neumonía LII, pero el contexto post-ablación obliga a ampliar el diagnóstico diferencial. A los seis meses, los cambios normales deberían estar resueltos. Mi apuesta: 2, aunque con reservas.
Muy buen caso para debatir. Considerando el tiempo transcurrido tras la ablación, me cuesta pensar que sean solo cambios normales. Sin más datos clínicos, me quedo con 4. Nada de lo expuesto. ¡Deseando conocer la respuesta final!
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