Left anterior descending coronary artery dissection during ventricular tachycardia ablation – case report

Abstract

Fascicular left ventricular tachycardia (VT) is the second most frequent idiopathic left VT in the setting of a structurally normal heart. Catheter ablation is curative in most patients with low complication rates. We report a case of ostial left anterior descending coronary artery (LAD) occlusion during fascicular ventricular tachycardia ablation. Dissection was the most likely cause of LAD obstruction. To the authors' best knowledge, this is the first case reporting selective LAD dissection during electrophysiology study with no left main coronary artery (LMCA) affection.

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 . In this group, retrospective review of the angiograms suggested that it had been induced by a deep insertion of an ablation catheter into a short LMCA, which itself had been left unharmed.…”

“…In three cases, glycoprotein IIB/IIIA receptor antagonist abciximab (potent antiplatelet agent) was administered . In one patient with LMCA dissection, and two others with ostial LAD occlusion caused by deep LMCA penetration, aspirational thrombectomy was attempted, but no thrombus was retrieved …”

“…This may be explained by the aortic valve crossing technique and the fact that an ablation electrode is naturally oriented by the arch of the ascending aorta towards the left sinus of Valsalva. When LMCA is a short and wide vessel, LAD, Cx, ramus intermedius or first‐diagonal branch can be selectively traumatized during catheter unintentional insertion …”

“…In cases of catheter‐related LMCA and LAD dissection, aspirational thrombectomy proved futile, prolonging total ischemic time, and it is not recommended according to the latest recommendations due to the risk of coronary and cerebral embolism . The haziness seen in a dissected artery may often be the result of an intramural hematoma rather than significant intraluminal thrombus burden.…”

ST‐segment elevation during arrhythmia ablations—A review

“…The transient STE was determined to be a Brugada phenocopy during ablation of ventricular tachycardia because of coronary vasospasm of unknown etiology 18 . A case of left anterior descending coronary artery dissection during ablation of fascicular left ventricular tachycardia has been reported a swell 19 . The patient developed STE in leads V1 through V5 and the dissection was hypothesized to be because of catheter manipulation after several attempts at crossing the aortic valve.…”