Saif Younas

Background: Catheter ablation for atrial arrhythmias is a common procedure with the possibility of causing complications, typically involving vascular access sites or cardiac tamponade. However, hepatic haemorrhage as a complication of cardiac catheter ablation is extremely rare. We present a case of life-threatening intra-abdominal bleeding originating from a hepatic vein following a catheter ablation for atrial tachycardia. Case summary: A 67-year-old man with a history of mitral valve repair and multiple ablation procedures for atrial fibrillation, atrial flutter, and macro-reentrant atrial tachycardia (MRAT) underwent a redo catheter ablation for MRAT. After the procedure, he developed right flank pain, hypotension, and a drop in haemoglobin. Imaging revealed extensive hemoperitoneum, originating near the right hepatic vein. Angiography of the visceral arteries was performed on which no major source of bleeding was identified. Because of persisting haemodynamic instability, the patient underwent emergency laparoscopy during which a capsular venous bleeding on the caudal liver surface was identified, likely caused by transient guidewire passage and injury in the hepatic veins. The bleeding was cauterized, and abdominal lavage was performed to clear the hemoperitoneum. He was transferred to the ICU for vasopressor support. Anticoagulation was restarted 1 week later, and the patient was discharged in stable condition. Conclusion: This case highlights a rare but serious complication of catheter ablation. Prompt recognition of intra-abdominal haemorrhage and a multidisciplinary approach involving cardiology, radiology, and surgery were crucial for a successful outcome. Operators should remain vigilant for atypical bleeding complications in ablation procedures and be prepared to initiate rapid intervention.

Background: VEXAS syndrome is a newly described autoinflammatory condition; cardiac involvement is exceedingly rare. This case illustrates a reversible complete heart block due to myocarditis in VEXAS, successfully treated with targeted therapy. Case summary: A 69-year-old man with known VEXAS syndrome presented with dizziness and syncope. Workup revealed third-degree atrioventricular (AV) block and imaging consistent with myocarditis. Standard therapy (atropine, isoprenaline infusion) stabilized the patient, and ruxolitinib (a JAK inhibitor) was initiated alongside corticosteroids to treat the underlying inflammatory syndrome. Within days, the patient’s AV conduction was restored without the need for pacemaker insertion. He was discharged with improved cardiac function and ongoing immunomodulatory therapy. Discussion: Targeted immunomodulation can reverse cardiac conduction block caused by inflammation in VEXAS syndrome. This case underscores the importance of recognizing autoinflammatory syndromes as a cause of heart block and suggests a potential role for JAK inhibitors in treating inflammatory myocarditis.