Focal Atrial Tachycardia During Central Gemcitabine Administration

Abstract

Background: Gemcitabine is not usually regarded as a cardiotoxic or significantly arrhythmogenic chemotherapeutic agent.

Case summary: A 66-year-old woman developed narrow complex tachycardia immediately after gemcitabine administration via peripherally inserted central cannula. Electrophysiological study diagnosed a focal atrial tachycardia arising from the right atrium adjacent to the tip of the central cannula line abutting the atrial wall. The arrhythmia was successfully ablated with no symptom recurrence.

Discussion: This case suggests that gemcitabine can be arrhythmogenic in combination with improper central line sites. The patient had received gemcitabine previously via a different line without sequalae.

Take-home messages: Gemcitabine has the capability to be directly arrhythmogenic. Centrally placed lines can abut the endocardium or vascular endothelial surface, which may counteract the intention to dilute therapeutic agents in large volumes of blood. A clear temporal relationship between symptom and medication should prompt consideration of the therapeutic as the causative agent.

Keywords: arrhythmogenesis; cardio-oncology; focal atrial tachycardia; gemcitabine; malignancy.

Graphical abstract

Figure 1

Initial 12-Lead Electrocardiograms ECGs demonstrating (Top) normal sinus rhythm without evidence of overt accessory pathway and (Bottom) narrow complex tachycardia at a rate of 155 beats/min. P waves are seen in leads I, II, and aVF. There is limb lead reversal in the ECG taken during tachycardia. ECG = electrocardiogram.

Figure 2

Intracardiac Electrograms Showing Ventricular Overdrive Pacing During Tachycardia of Cycle Length 380 ms The atrial rate is accelerated to the paced cycle length of 360 ms, and on cessation of right ventricular pacing, a VAAHV response is observed along with resumption of the tachycardia (cycle length: 380 ms). Observation of first ventricular signal, then atrial signals on the high right atrial and the His catheters, followed by His signal and further ventricular signal, is the VAAHV response seen here that is indicative of atrial tachycardia. During tachycardia (on the right of the image), high right atrial signals are leading, followed by His-proximal and CS-proximal signals. CS activation is concentric, with proximal (CS 9-10)–to–distal (CS 1-2) activation. CS = coronary sinus.

Figure 3

Three-Dimensional Electroanatomical Images Showing Activation Timing Map and Voltage Map on Right Atrial Geometry (Top) Right lateral view with activation timing with a pin at the point of earliest activation, with the corresponding electrograms shown to the right. (Bottom Left) Modified right lateral view with activation timing color overlay showing the location of ablation lesions colored as per ablation index. (Bottom Right) Bipolar voltage map (0.05-0.5 mV) with a focus of low voltage (<0.05 mV; in red) in the right lateral atrium that corresponded to the tip of the PICC line on fluoroscopy (blue arrow). PICC = peripherally inserted central cannula.

Figure 4

Fluoroscopic and Electroanatomical Images Showing the Ablation Catheter Relative to the Tip of the PICC Line (Top) Fluoroscopic RAO and AP projections with quadripolar high right atrial, decapolar coronary sinus, multipolar mapping catheter in the mid cavity, and ablation catheter at the tip of the PICC catheter, where the first ablation lesion was delivered. The blue arrows indicate the PICC line, which appears to be abutting the atrial wall. (Bottom) Electroanatomical RAO and AP views in “glass mode” showing the ablation lesion locations mirroring the position of the catheters in the fluoroscopic images above. AP = anteroposterior; PICC = peripherally inserted central cannula; RAO = right anterior oblique.

Figure 5

Transthoracic Echocardiography With Artifact Transthoracic echocardiography 4-chamber view with artifact in the lateral right atrium (arrows), which may represent the PICC line against the lateral right atrial wall. The artifact is more easily appreciated in Video 1.

Figure 6

Timeline Demonstrating the Events in the Case Described The timeline highlighted in red indicates when the patient experienced paroxysmal episodes of palpitations (after gemcitabine was administered in this cycle until successful ablation of the tachycardia). PICC = peripherally inserted central cannula; SVT = supraventricular tachycardia.