Near-Fatal Coronary Artery Spasm During Cryoballoon Pulmonary Vein Isolation

Abstract

A 50-year-old nonsmoker with paroxysmal atrial fibrillation was referred to our hospital for pulmonary vein isolation (PVI). He had a known 1-vessel coronary artery disease. Because of stable angina, a drug-eluting stent had been implanted into the midportion of the left anterior descending artery in 2010. Otherwise he was healthy. His medical treatment included warfarin, sotalol, an angiotensin-converting enzyme-inhibitor and a statin. Cryoballoon-PVI (Arctic Front Advance 28 mm; Medtronic) was scheduled under general anesthesia (international normalized ratio, 2-9; minimal activated clotting time, 300 s). After transseptal access, the left PV were targeted first, followed by the right inferior PV and right superior PV, respectively. PVI of all PVs could be visualized in real-time and gained within 40 s. Two freezethaw cycles were used for each PV, except for the left superior PV, which had to be treated 3×, because of an initially ineffective freeze (Table I in the Data Supplement ). The procedure had been uneventful, until a sudden blood pressure drop occurred (70/40 mm Hg), immediately after the second right superior PV-freeze. Cardiac tamponade was excluded. Twelve-lead ECG revealed global ST-depression and progressive ST-elevation in aVR, consistent with coronary main stem occlusion ( Figure 1). Pulseless electric activity developed rapidly, necessitating cardiopulmonary resuscitation. Coronary angiography showed a severe spasm of the left coronary main stem, without evidence for air-or thromboembolism (Figure 2A), which could be completely reverted by balloon dilatation and intracoronary nitroglycerine administration ( Figure 2B). The right coronary artery showed a less severe spasm, which was treated by nitroglycerine alone (Figure 3A and 3B). Immediately after coronary reperfusion, ventricular fibrillation occurred, affording several direct current shocks. Because of severe global myocardial stunning, without effective myocardial contractions, an extracorporeal cardiac life support system (veno-arterial extracorporeal cardiac life support system) had to be implanted. Myocardial stunning reverted completely during the following 5 days, and the patient could be weaned from the extracorporeal cardiac life support system. He survived without any major focal neurologic deficit, but impairment of short-term memory was apparent during follow-up. Predischarge echocardiography showed normal biventricular function without wall motion abnormalities. About the used cryoballoon device, the manufacturer excluded a technical malfunction. DiscussionIn this case report, to date, we describe an unreported serious complication of a near-fatal coronary artery main stem spasm during cryoballoon-PVI. We suspect cryoenergy-induced blood cooling, as the most likely trigger, rather than a direct ablation effect, given the distance between the pulmonary veins and the left main stem ( Figure I in the Data Supplement). Further evidence for this theory is provided in Figure 1, which retrospectively showed progressive development of...

Spastic occlusion of coronary artery during cryoballoon pulmonary vein isolation

“…Some cases with a cryoenergy-induced coronary artery spasm by CB ablation and cryocatheter ablation were reported. 3 , 4 These reports speculated the cause of coronary artery spasm as a cryoenergy-induced blood cooling. However, the coronary spasm site was not necessarily close to the cryoapplication site, and an indirect effect owing to blood cooling was suggested.…”

“… 1 On the other hand, several complications, such as esophageal erosions and phrenic nerve injuries, have been reported with AF ablation using second-generation CB. 2 Lehrmann and colleagues 3 have reported a case of near-fatal coronary artery spasm during PVI using second-generation CB. In this case, the mechanism of coronary artery spasm was speculated as cryoenergy-induced blood cooling, which was attributable to the close proximity between the CB and coronary artery spasm site.…”

Recurrent and late-onset coronary spasms after cryoballoon ablation procedure in a patient with atrial fibrillation

“…Some cases of coronary spasms related to PV isolation by radiofrequency ablation have been reported that suggested direct thermal effects on the coronary artery and also a possible indirect effect that could induce coronary spasms through the autonomic nervous system 1, 2. A case of near-fatal left main coronary spasms following a cryoablation procedure was also reported 3 . That report suggested the possibility of an indirect effect on the coronary artery because an ST-T change was already observed after starting the first cryoenergy application for the LSPV, which is somewhat distant from the left main coronary artery.…”

First case report: Late‐onset coronary artery spasm after radiofrequency catheter ablation for atrial fibrillation in a Caucasian patient

“…Recently, cryoballoon-induced CAS is also reported. 3,12 As more extensive and complicated ablations are performed for drug-refractory AF, the incidence of ablation-induced CAS may increase. Therefore, the postprocedural observation and recognition of this rare but potentially life-threatening complication will improve the conventional practice of catheter ablation for patients with drug-refractory atrial fibrillation.…”