Introduction Left main coronary artery (LMCA) injury is a rare but potentially fatal complication of catheter ablation. Due to LMCA large perfusion area, its occlusion is usually a dramatic event. Methods and Results Reports of LMCA injury complicating catheter ablations from 1987 to 2018 were searched in electronic databases. Twenty‐two cases of serious LMCA damage have been identified. Additionally, four reports of direct mechanical trauma involving major LMCA branches induced by inadvertent catheter insertion have been studied. Typically 86% LMCA injury presented as an acute/subacute complication of retrograde ablation in left ventricle/left ventricular outflow tract or aortic cusps. In at least 86% of patients with an in‐hospital presentation, the LMCA trauma manifested dramatically as a life‐threatening arrhythmia, cardiogenic shock, or severe hypotension requiring vasopressors. In‐hospital mortality rate was 32%. Direct stenting has been found to be the most successful strategy. Conclusion LMCA injury, even if initially asymptomatic with normal angiographic appearance, may cause delayed flow deterioration, requiring prolonged monitoring and extended follow‐up. Special caution should be given to the prevention whereas survival depends on prompt detection and treatment.

Left main coronary artery (LMCA) injury is an uncommon complication of catheter ablation. Due to the large myocardial area at risk, its presentation is usually acute with a dramatic course and life-threatening sequelae. Increased susceptibility to spontaneous coronary artery dissection has recently been implied in patients with bicuspid aortic valve (BAV). We present the first case of iatrogenic coronary dissection in a BAV patient, with an atypically delayed manifestation. The patient sustained ablation catheter-induced mechanical damage of LMCA due to its inadvertent penetration during the attempts to cross the aortic valve. After three days of recurring chest pain, he was readmitted with anterior myocardial infarction and imminent cardiogenic shock, and underwent emergent coronary stenting. Literature review suggests that in BAV inherent susceptibility to both spontaneous and iatrogenic coronary dissection may exist. Therefore, we advocate that in BAV extreme caution should be exercised during electrophysiological procedures involving the coronary artery cannulation for tagging or pace mapping, or when the left ventricle is to be entered retrogradely, and likewise in percutaneous coronary interventions. Such patients may be doubly predisposed to iatrogenic injury; firstly, by more difficult catheter manipulation in the malformed aortic cusps, and secondly, by the underlying vulnerability of coronary ostia.

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