From Fluttering Hearts to Restless Stomach: Navigating Atrial Fibrillation, Ablation and Gastroparesis.

Background: We present a case of severe gastroparesis with pyloric spasm secondary to radiofrequency catheter ablation (RFCA) with a focus on procedural risk factors, prevention, and treatment modalities.

Case report: A 39-year-old man with paroxysmal atrial fibrillation underwent RFCA after failed pharmaceutical treatment. The procedure involved three-dimensional mapping and controlled RFCA near the oesophagus. Post-procedure, he developed severe abdominal pain, distention, and vomiting. Imaging revealed stomach distention and pyloric spasm. An upper endoscopy confirmed gastroparesis due to ablation. Metoclopramide was administered, improving food tolerance. However, persistent symptoms led to a gastric emptying study showing delayed emptying, consistent with gastroparesis. Despite treatment with metoclopramide, the patient's symptoms persisted, prompting consideration of esophageal botulinum toxin and medication changes for symptom management.

Conclusions: In a patient with no prior history of abdominal symptoms or chronic gastric disorder post ablation presentation of new-onset abdominal distention, pain, and vomiting ablation-induced gastroparesis should be high on the differential and different treatment modalities should be tried if severe symptoms such as postprandial regurgitation persist. Moreover, better oesophageal protection strategies should be implemented, and guidelines be added to procedure performance limiting excessive force, energy, manipulation, and introduction of oesophageal temperature control holding parameters.

Learning points: Gastroparesis can be an under-recognized complication of left atrial ablation.Posterior wall ablation near the oesophagus is high-risk for gastrointestinal complications.Symptoms usually persist for 3-6 months but may last long term.