Chronic Left Coronary Artery Stenosis After Radiofrequency Ablation of Idiopathic Premature Ventricular Contraction Originating From Left Coronary Sinus Cusp

Abstract

A 50-year-old man was referred for radiofrequency catheter ablation of idiopathic premature ventricular contraction (PVC) refractory to metoprolol. The ECG characteristics of the PVCs suggested that the PVCs originated from left coronary sinus (LCC). Mapping was performed in the LCC using a 7F irrigated-tip ablation catheter via the right femoral artery. During clinical PVCs, the local ventricular activation was the earliest at the LCC. Radiofrequency (RF) energy application was attempted at the site ( Figure One application of RF energy at this site (43°C, 30 W, 17 mL/ min) terminated spontaneous PVCs within 15 s and was maintained for 180 s. However, the clinical PVCs appeared during isoproterenol infusion. Another 3 applications around this point with a maximal setting of 40 W were 180 s in duration and finally eliminated the PVCs. Mean impedance drop was 12±2 Ω for the lesions. Popping or impedance rises did not occur during RF applications. No catheter dislodgment was observed during ablation, and ablation was performed only within the LCC. The patient experienced some chest discomfort during ablation. Repeat angiography after ablation showed normal left coronary artery without coronary spasm, stenosis, or occlusion. The ECG after the procedure showed normal sinus rhythm and no ST-T changes. The patient was then discharged on aspirin for 1 month. During the 3 months of follow-up, the patient remained clinically free of symptoms. Four months later, the patient was readmitted because of exertional chest pain. The chest pain had developed 3 weeks previously when he was climbing stairs, which was relieved by several minutes of rest. A 12-lead ECG recorded on admission showed sinus tachycardia and remarkable ST-segment depression in leads V 1 through V 6 and ST-segment elevation in lead aVR. The patient's peak troponin level was 1.7 ng/mL. His creatine kinase-MB was not increased. Coronary angiography showed 60% stenosis in the body and distal segment of LMCA and 90% stenosis in the proximal left anterior descending artery (LAD) with TIMI 3 (thrombolysis in myocardial infarction) flow ( whereas the external elastic membrane cross-sectional area of LAD lesion was significantly greater than that of the LMCA lesion ( Figure [E] and [F]). The therapy resulted in significant symptom relief. During the 12 months of follow-up after stenting, the patient remained clinically free of symptoms without any ischemic events. Coronary computed tomography showed stent patency at 10 months of follow-up.Although most coronary damage in relation to RF ablation presents acutely, 2 delayed presentations may also occur. To our knowledge, this is the first report of chronic LMCA and LAD stenoses without occlusion secondary to previous RF ablation. This study also detected the coronary plaques associated with the application of RF energy in a human subject, via intravascular ultrasound. Only 3 cases of acute LMCA occlusion caused by RF-induced thermal injury have been reported. 3 Only 1 case report described chronic LMCA occlusion cau...

Analysis of reported cases of left main coronary artery injury during catheter ablation: In search of a pattern

“…In total, 22 reports of severe LMCA injury related to catheter ablation have been found, ranging from 1993 to 2018 . Additionally, four reports of serious ostial or proximal LAD and Cx damage have also been identified .…”

“…Of all studied cases, 18 (82%) involved ablation in LV/LVOT (13 AVRT and five VT), three procedures were performed in the aortic cusps (two PVCs and one focal atrial tachycardia), and one patient underwent atrial fibrillation ablation. All 22 procedures were performed with fluoroscopy control, and in the three ablations targeting the left sinus of Valsalva, preprocedural angiography was obtained and intracardiac echocardiography was not utilized …”

“…In small case series and literature reviews, the reported incidence of CAI is 0% . However, several reports of CAI associated with the aortic root ablation have been published . Not all cases of CAI are apparent with symptoms and electrocardiographic changes; therefore, its actual incidence is likely to be underestimated and underreported.…”

“…Late presentations of CAI have also been described. In such patients, energy application or direct mechanical trauma gradually leads to progressive coronary artery stenosis or chronic total occlusion, which may become symptomatic only with time or be incidentally detected months or years postindex procedure …”

Left Main Coronary Trunk Spasm Due to Ablation Catheter Dislocation in Its Ostium During Ectopic Focus Ablation in Aortic Left Coronary Sinus

“…Повреждения КА представлены и в виде остро развившейся окклюзии ветвей правой КА и ствола ЛКА, что требовало проведения незамедлительного стентирования соответствующих артерий, или же была принята консервативная тактика ввиду незначимого стеноза мелкой артерии [1,5]. Описаны также случаи отсрочено развившихся стенозов КА при «нормальном» состоянии артерии сразу после РЧА, что потребовало стентирования [6]. При этом анатомические данные демонстрируют близкое расположение коронарных артерий и, в частности, ствола ЛКА к месту нанесения РЧ-аппликаций [3].…”