Acute gastric dilatation and portal venous gas after pulsed field ablation for atrial fibrillation: a cautionary case report

Pulsed field ablation (PFA) is considered to reduce collateral extracardiac injury compared with conventional thermal ablation. However, transient effects on autonomic nerves and adjacent smooth-muscle structures remain incompletely characterized.

An 80-year-old lean man underwent PFA for paroxysmal atrial fibrillation using a variable-loop circular catheter. Because stable tissue proximity was difficult to achieve around the left inferior pulmonary vein, additional ablation sets were delivered in this region. Approximately 24 h after the procedure, the patient developed acute abdominal pain. Computed tomography demonstrated marked gastric dilatation and portal venous gas with elevated lactate levels, without superior mesenteric artery occlusion or findings of irreversible bowel necrosis. Nasogastric decompression, fasting, intravenous fluids, and antibiotics resulted in rapid clinical and biochemical improvement. Portal venous gas resolved on follow-up imaging, oral intake was resumed, and the patient was discharged without surgical intervention.

The temporal relationship raises the possibility of a PFA-associated transient gastrointestinal dysmotility, although causality cannot be established from a single case. Potential mechanisms include transient effects on the periesophageal vagal plexus and/or adjacent smooth muscle. Portal venous gas was likely secondary to marked gastric dilatation rather than a direct effect of PFA.