Iatrogenic Pan–Right Atrial Denervation

BACKGROUND: Right atrial (RA) ablation is routine; however, the RA harbors critical hubs of the intrinsic cardiac nervous system. Extensive ablation can cause autonomic dysfunction. CASE SUMMARY: 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. DISCUSSION: 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. TAKE-HOME MESSAGE: Extensive RA ablation can cause severe autonomic failure requiring norepinephrine rather than dopamine.