EP News: Case Reports

  • T. Jared Bunch
    Address reprint requests and correspondence: Dr T. Jared Bunch, Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah School of Medicine, 30 N 1900 E, Room 4A100, Salt Lake City, UT 84132.
    Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah
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      A “steam pop” is a feared complication of ablation that is the audible sign of excessive tissue heating and is associated with perforation with tamponade, endocardial surface disruption, char and thrombus formation, and excessive injury. Held et al (DOI: provided insight into the anatomy of a steam pop by defining the histologic changes that develop. A 65-year-old man presented for ablation with severe nonischemic cardiomyopathy (ejection fraction 15%) and scar-dependent ventricular tachycardia (VT). Using 40 W with an irrigated tip catheter, a steam pop was heard after 49 seconds of the initiation of energy delivery in the anteroseptal region of the left ventricle. The patient remained stable without the development of an effusion. Despite the ablation procedure, the patient had refractory VT and progressive heart failure and 3 days later underwent orthotopic heart transplantation. The heart was examined from a gross and histologic anatomy perspective. The region of the steam pop showed visible acute necrosis and hemorrhage that was 2 cm in diameter and 5–12 mm in depth. The area of the steam pop showed “complete tissue destruction, with dissolution of all cells, seemingly replaced by open spaces representing non-tissue fluid or gas.” This case provides an illustration of the destructive energy delivered in the setting of a steam pop and the associated genesis of gas bubbles. The extent of surface and deep myocardial injury, even without perforation, can augment the risk of thromboembolism and mechanical function that can lead to peri- and postprocedural complications.
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