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Left Anterior Descending Artery Spasm After Radiofrequency Catheter Ablation for Ventricular Premature Contractions Originating from the Left Ventricular Outflow Tract

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Left Anterior Descending Artery Spasm After Radiofrequency Catheter Ablation for Ventricular Premature Contractions Originating from the Left Ventricular Outflow Tract Left anterior descending artery spasm after radiofrequency catheter ablation for ventricular premature contractions originating from the left ventricular outflow tract Akira Kimata, MD,*† Miyako Igarashi, MD,† Kentaro Yoshida, MD,*† Noriyuki Takeyasu, MD,*† Akihiko Nogami, MD,† Kazutaka Aonuma, MD† From the *Division of Cardiovascular Medicine, Ibaraki Prefectural Central Hospital, Kasama, Japan, and †Cardiovascular Division, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan. Introduction Japan) revealed a good pace-map, and the local electrogram – Coronary artery injury or vasospasm can occur as a direct preceded QRS onset by 25 ms (Figures 1A 1C). RF energy thermal effect of radiofrequency (RF) catheter ablation.1–7 The was not delivered to this site because of the high impedance 9 right coronary artery (RCA) and left circumflex artery (LCx) and limited accessibility of the ablation catheter but was are adjacent to the valvular annuli and are likely to suffer from delivered alternatively to the basal anterior portion of the LV ablation-related injury when RF energy is delivered to acces- endocardium where a good pace-map was also obtained. RF sory pathways1–6 or the mitral isthmus.7 The right ventricular energy was delivered using an irrigated-tip catheter (Ther- outflow tract also lies in close proximity to the major coronary moCool, Biosense Webster, Diamond Bar, CA) at a power 8 1 arteries. However, to the best of our knowledge, injury to the setting of 35 W and maximum temperature of 43 C. VPCs left anterior descending artery (LAD) associated with left transiently disappeared during RF applications but recurred ventricular (LV) endocardial ablation has not been reported. immediately after applications were stopped. RF energy delivered at the LCC at the same settings also failed to eliminate the VPCs. Coronary angiography performed Case report before and after ablation at the LCC did not reveal any A 22-year-old man was admitted to our hospital because of coronary artery injury. Again, we moved to the left ventricle palpitations and dyspnea on effort. Twelve-lead electro- and RF energy was increased to 50 W, which resulted in cardiography showed frequent ventricular premature con- complete elimination of the VPCs (Figure 1C). The sites of tractions (VPCs) that were predicted to originate from the LV ablation are also shown in the CARTO map (Biosense outflow tract based on QRS morphology (Figure 1A). Webster; Figure 1D). Although the patient did not complain Echocardiography revealed reduced LV function with an of any symptoms and the 12-lead electrocardiogram did not ejection fraction of 35%. A decrease in the number of VPCs show any ST-T changes, angiography performed just after and improvement of ejection fraction were observed with the endocardial RF application showed significant stenosis in oral administration of amiodarone. Hence, VPC-induced the proximal portion of the large first diagonal branch of the cardiomyopathy was assumed, and RF catheter ablation LAD (Figure 2). This branch also looked like a so-called dual was indicated for treatment of the VPCs. LAD. The distance between the site of successful RF Mapping of the VPCs was performed at the LV endo- ablation and this branch of the LAD was angiographically cardial surface, coronary sinus, great cardiac vein (GCV), measured to be 9 mm. Isosorbide dinitrate (5 mg) was and aortic left coronary cusp (LCC). Mapping at the GCV injected immediately, but the coronary stenosis did not with a 2Fr catheter (EPstar Fix, Japan Lifeline, Tokyo, improve completely. Several additional vasodilators (nicor- andil 2 mg and nitroglycerin 300 μg) were injected, and the KEYWORDS Ventricular premature contraction; Radiofrequency catheter coronary stenosis was gradually relieved. Oral administra- ablation; Coronary artery; Vasospasm tion of aspirin was continued for 1 month. The patient has ABBREVIATIONS GCV ¼ great cardiac vein; LAD ¼ left anterior descending artery; LCC ¼ left coronary cusp; LCx ¼ left circumflex been free from any arrhythmic and coronary events during a artery; LMCA ¼ left main coronary artery; LV ¼ left ventricular; RCA ¼ 9-month follow-up period. right coronary artery; RF ¼ radiofrequency; VPC ¼ ventricular – premature contraction (Heart Rhythm Case Reports 2015;1:103 106) Discussion Drs. Kimata and Igarashi contributed equally to this work. Address reprint requests and correspondence: Coronary arteries can be damaged by RF energy, and the Dr. Kentaro Yoshida, Division of 1 2 Cardiovascular Medicine, Ibaraki Prefectural Central Hospital. 6528 Koibu- incidence is reported to range from 0.1% to 1.4%. The chi, Kasama, Ibaraki 309-1793, Japan. E-mail address: [email protected]. majority of reported cases involved RCA injury associated 2214-0271 B 2015 Heart Rhythm Society. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). http://dx.doi.org/10.1016/j.hrcr.2014.12.007 104 Heart Rhythm Case Reports, Vol 1, No 3, May 2015 reasonable mechanism of coronary artery spasm is direct KEY TEACHING POINTS thermal trauma from RF energy. A previous study in pigs Coronary artery injury or vasospasm can occur as a showed that inflammation progresses to the layer of the direct thermal effect of radiofrequency catheter coronary artery within 48 hours after RF energy delivery to ablation. the tricuspid annulus, and such pathophysiologic changes are considered to cause acute coronary spasm.6 Therefore, Although right or left circumflex coronary artery coronary artery damage is most likely to occur during RF injury is prevalent when ablating near the ablation on the atrial side of the valvular annuli and within atrioventricular groove, left ventricular endocardial the coronary sinus because these sites are very close to ablation using an irrigated-tip catheter also has a coronary arteries. Recently, LCx injury associated with risk of injury to epicardial coronary arteries. mitral isthmus ablation has been widely noted because macroreentrant perimitral atrial flutter is common after with ablation for right-sided accessory pathways.3,4 Some ablation of atrial fibrillation. Wong et al7 reported that 15 cases involving LCx injury by ablation for left-sided of 54 patients (28%) undergoing mitral isthmus ablation had accessory pathways also have been reported.5 One acute subclinical LCx injury. Clinical CS distal 100 ms I I II II III V1 III V2 aVR V5 His aVL Uni aVF V1 ABLd RAO 35 V2 ABLp V3 10 CS 1 V4 8 CSd V5 1 RV V6 LAO 45 Sites of success Sites of ablaon Figure 1 A: Twelve-lead electrocardiogram showing ventricular premature contractions (left) and the pace-map at the distal CS (right). B: Local electrograms of the distal CS and ablation catheter precede QRS onset by 25 ms. C: Fluoroscopic images showing the CS catheter and the site of successful radiofrequency applications. D: Three-dimensional map depicted by CARTO SOUND showing the anatomic relationship between the coronary sinus cusps and sites of ablation. ABL ¼ ablation catheter; CS ¼ coronary sinus; CSd ¼ distal CS; LAO ¼ left anterior oblique; LCC ¼ left coronary sinus cusp; LV ¼ left ventricle; NCC ¼ noncoronary sinus cusp; RAO ¼ right anterior oblique; RCC ¼ right coronary sinus cusp; RV ¼ right ventricle; Uni ¼ unipolar electrogram. Kimata et al LAD Spasm After VPC Ablation 105 RAO 35 RAO 35 RAO 30 RAO 30 Cran 30 Cran 30 Figure 2 Coronary angiographic images repeated throughout the procedure. A: After ablation at the left coronary sinus cusp, no coronary artery injury was observed. B: Just after radiofrequency ablation at the basal anterior portion of the left ventricular endocardium, severe stenosis of the first branch of the left anterior descending artery was observed. C: Coronary stenosis did not improve completely after immediate intracoronary injection of isosorbide dinitrate.D: Coronary stenosis was gradually relieved after injections of additional vasodilators. Cran ¼ cranial; RAO ¼ right anterior oblique. There is only 1 report of LAD occlusion after RF ablation. 1. Direct mechanical trauma by an ablation catheter Dinckal et al10 described a 32-year-old man with proximal There are a number of reports of left main coronary LAD occlusion 10 days after RF ablation for a left lateral artery (LMCA) injury.11–13 For example, Yalin accessory pathway. Intravenous nitroglycerin was not effec- et al13 described a 56-year-old man with LMCA tive, and a stent was immediately implanted. Their case is occlusion during RF ablation for a left anterolateral consistent with ours in terms of injury to the LAD but accessory pathway, which was treated by immediate different in that the site of obstruction was far from the percutaneous coronary angioplasty with a bare- ablation site (proximal LAD occlusion after ablation of a left metal stent. All of the cases of LMCA injury were lateral accessory pathway), and the time from catheter associated with a retrograde transaortic approach. ablation to LAD injury was much longer. The most probable cause was direct mechanical In our case, the morphology of the bipolar electrogram at trauma to the LMCA when the ablation catheter the successful ablation site was dull compared with electro- crossed the aortic valve. Although the retrograde grams recorded at the distal coronary sinus, and the unipolar transaortic approach was used in our patient, the site electrogram had a small r wave in its initial portion of damage was far from the ostium of the LMCA, so (Figure 1B), suggesting an intramural or epicardial
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