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.

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