Iatrogenic Pan-Right Atrial Denervation: Biphasic Autonomic Crash After Complex Scar-Related Flutter Ablation

Right atrial (RA) ablation is routine; however, the RA harbors critical hubs of the intrinsic cardiac nervous system. Extensive ablation can cause autonomic dysfunction.

A 78-year-old woman with prior mitral valve repair underwent ablation for scar-related atrial flutter. Ablation involving the cavotricuspid isthmus, posterior wall, and superior vena cava caused a biphasic autonomic crash. Initially, hypotension was refractory to dopamine infusion for 3 days. Stabilization was achieved after switching to norepinephrine, consistent with profound vasoplegia. Norepinephrine was required for 10 days, followed by oral midodrine bridging.

This case illustrates how extensive RA ablation can inadvertently target the anterior, posterior, and inferior right ganglionated plexi, resulting in "pan-right atrial denervation." Unlike targeted cardioneuroablation, this diffuse damage necessitates a shift from inotropes to pure vasoconstrictors.

Extensive RA ablation can cause severe autonomic failure requiring norepinephrine rather than dopamine.