© 2003 by European Society of Cardiology
CASE REPORT
Left anterior descending coronary artery occlusion after left lateral free wall accessory pathway ablation
What is the possible mechanism?
lcaslan3
1Department of Cardiology, Medical Faculty of Gaziantep University Gaziantep, Turkey;
2Department of Cardiology, SSK Hospital Bursa Turkey;
3Department of Cardiology, GATA Military Hospital Ankara, Turkey;
4Department of Cardiology, Atatürk State Hospital 
zmir, Turkey;
5Department of Cardiology, SSK Hospital Eski
ehir, Turkey
Manuscript submitted 28 August 2002. Accepted after revision 29 March 2003.
Correspondence: Dr Hakan Dinckal, Gazi Mah. Karacaoglan Cad. No: 26/B-1 Sukru Ercan Apt, Sehitkamil/Gaziantep, Turkey. Tel.: +90-342-335-2998; Fax: +90-342-360-1617; E-mail: mhdinckal{at}gantep.edu.tr
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Abstract |
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We describe a complication after radiofrequency (RF) ablation of a left free wall accessory pathway that resulted in acute occlusion of proximal left anterior descending (LAD) coronary artery in a 32-year-old male non-cocaine abuser. An interesting feature is the site of coronary artery occlusion which is remote from the RF application site. The RF energy applications were performed in the left lateral annulus remote from the LAD. The occlusion was successfully treated with placement of an intracoronary stent.
Key Words: Radiofrequency catheter ablation, coronary occlusion, accessory pathway
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Introduction |
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Radiofrequency (RF) catheter ablation is an established first line therapy for the curative treatment for many of the supraventricular tachycardias. The success rates of catheter ablation of various types of cardiac arrhythmias are impressively high. Procedure-related complications can be attributed to the invasive nature of the technique (e.g., bleeding or other vascular complications, radiation exposure) but may also occur as a specific complication related to the type of intervention performed (e.g., complete AV-block following attempted modification of the AV-node[1]
). Coronary artery occlusion as a complication of an RF catheter ablation is quite rare. |
Case report |
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A 32-year-old man was admitted to the cardiology clinic with frequent episodes of supraventricular tachycardia (SVT), which was resistant to antiarrhythmics. He had no history or documentation of previous atrial fibrillation. Clinical examination was unremarkable and no history of substance abuse including cocaine was evident. During electrophysiological study, orthodromic tachycardia was easily induced by programmed atrial stimulation. During the orthodromic atrioventricular reentrant tachycardia, the site of the earliest atrial activation was determined to be in the left lateral atrial site by endocardial mapping in the coronary sinus. There was no advancement in atrial activation following premature ventricular extrastimuli given from the basal anteroseptal region of the right ventricle during His refractoriness eliminating a bystander anteroseptal accessory pathway. The ablation procedure was performed via the transseptal approach through a patent foramen ovale (PFO). The patient received 10,000 IU intravenous heparin during the procedure. After four applications of RF energy to the earliest atrial activation site in the left lateral annulus, the accessory pathway was ablated and the tachycardia was no longer inducible. There was no procedure-related complication. The ECG was normal after the procedure. The patient was discharged on the next day on aspirin 300 mg per day for 1 month. He remained asymptomatic for 10 days, and then he presented with new onset rest angina and dyspnoea for 5 h. Resting-ECG demonstrated anterolateral ST segment elevation with sinus tachycardia. The cardiac enzymes were high including Troponin T. The patient was admitted to the coronary care unit with the diagnosis of an acute coronary syndrome. Coronary angiography demonstrated total occlusion of the proximal left anterior descending (LAD) artery (Fig. 1). The appearance was of a large thrombus burden lesion. Intravenous nitroglycerin was initiated to attempt to rule out coronary spasm. The circumflex artery and right coronary artery were normal. PTCA and stent implantation were immediately and successfully performed (Fig. 2).
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Discussion |
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Thermal damage from RF energy has been a concern since the inception of RF ablation[2,
3]. Coronary artery occlusion complicating RF ablation may be caused by dissection due to catheter manipulation or direct thermal impact followed by thrombus formation. Although early coronary angiographic studies did not show lesions, later reports have shown coronary artery involvement during or after ablation, sometimes with permanent damage[4]. Solomon et al.[3] analyzed 70 patients who underwent RF ablation of the atrial insertion of an accessory pathway. Quantitative coronary angiography was performed before, immediately after and again at a mean of 42 days after RF ablation. Only one patient demonstrated a reduction in vessel caliber immediately after RF ablation due to acute coronary spasm with distal occlusion, which was reversed with medical therapy. Lesh et al.[5] also reported one patient in a series of 100 patients, who developed transient ST segment elevation suggestive of coronary spasm. Finally, Calkins et al.[6], reporting on 106 patients, described one case of inadvertent RF energy delivery in the circumflex coronary artery resulting in myocardial infarction. Two cases of left main coronary artery (LMCA) thrombosis after RF ablation have been recently reported. Kosinski et al.[7] described a 17-year-old male in whom VT and ST segment elevation occurred after RF ablation for a left sided accessory pathway. Coronary angiography showed complete occlusion of the LMCA. In spite of emergency angioplasty and subsequent bypass surgery, the patient ultimately died. Hope et al.[8] reported a second case of LMCA occlusion 12 h after RF ablation for an accessory pathway in a 40-year-old woman. Ischaemic complications during ablation with normal coronary arteries on angiography are thought to be result of focal spasm provoked by RF energy. Coronary angiography 6 months after the application of RF current in pigs did not show significant abnormalities but pathological specimens of the right coronary artery near ablation sites demonstrated intimal thickening and vessel obstruction[9]. Coronary artery damage is most likely to occur during ablation on the atrial side of the valve annuli and within the coronary sinus. Transmural lesions with involvement of epicardial coronaries are also possible during catheter ablation within the ventricle.
Different mechanisms can be proposed to explain coronary injury subsequent to RF ablation. Spasm is postulated to be the most common cause especially if the RF energy is delivered within the coronary sinus because of its proximity to the epicardial surface of the heart[6,7]. Inadvertent delivery of intracoronary RF current can result in serious coronary complications with acute or subacute occlusion. Alternatively, a coronary artery could be directly traumatized by the ablation catheter during attempts to cross the aortic valve with subsequent intimal dissection and thrombus formation. This hypothesis is considered to be the most logical explanation for the three previously published cases with LMCA occlusion[7,8,10].
In our patient, since we used the transseptal approach via PFO, direct trauma to the LAD was not possible. Due to the RF application site (left lateral atrioventricular groove) indirect thermal trauma would be expected to affect the circumflex artery, but the vessel occlusion was detected in the proximal LAD. The explanation for the LAD occlusion is still controversial. One of our suggestions was that the obstruction was due to oedema and intimal injury within the vessel wall due to thermal trauma, but the obstruction site is far from the target site. Another explanation is coronary spasm, but spasms occur mostly during or immediately after the procedure. Our patient's symptoms began on 10th day after discharge and we initiated intravenous nitroglycerin to attempt to rule out spasm. We assumed that thrombus formation at the site of RF ablation with embolization into the coronary circulation might be another possible mechanism.
Coronary artery occlusion illustrates a rare complication of RF ablation that can occur despite appropriate anticoagulation during the procedure and antiplatelet therapy following it. The tip of the catheter was free of any coagulum after the procedure. Whether the presence of PFO adds an additional risk for thromboembolism remains uncertain. Coronary injury and subsequent myocardial ischaemia could be responsible for ventricular arrhythmias or unexplained sudden death in subacute or chronic phase after RF ablation. Although the overall risk of coronary artery complications with RF ablation is low, this case reinforces the importance of RF application to be performed carefully and particularly when the target site is on the left atrial site. Although this case report does not support prolonged anticoagulation following left sided RF ablation procedures, further prospective studies designed to assess which anticoagulation or antiplatelet therapy should be used. Therefore, we recommend full anticoagulation during the left sided cardiac procedures, careful manipulation of catheters and proper monitoring and titration of RF energy.
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References |
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[1] Hindricks G. for the MERFS investigators. The Multicentre European Radiofrequency Survey (MERFS): complications of radiofrequency ablation of arrhythmias. Eur Heart J 1993; 14: 1944–1953.
[2] Strickberger SA, Okishige K, Meyerovitz S, Shea J, Friedman PL, Shea J, Friedman PL. Evaluation of possible long-term adverse consequences of radiofrequency catheter ablation of accessory pathways. Am J Cardiol 1993; 71: 473–475.[Medline]
[3] Soloman AJ, Tracy CM, Swartz JF, et al. Effect on coronary artery anatomy of radiofrequency catheter ablation of atrial insertion sites of accessory pathways. J Am Coll Cardiol 1993; 21: 1440–1444.[Abstract]
[4] Pons M, Beck L, Leclercq F, Ferriere M, Albat B, Davy JM. Chronic left main artery occlusion: a complication of radiofrequency ablation of idiopathic left ventricular tachycardia. Pacing Clin Electrophysiol 1997; 20: 1874–1876.[CrossRef][Medline]
[5] Lesh MD, Van Hare GF, Schamp DJ, et al. Curative percutaneous catheter ablation using radiofrequency energy for accessory pathways in all locations: results in 100 consecutive patients. J Am Coll Cardiol 1992; 19: 1303–1309.[Abstract]
[6] Calkins H, Sousa J, El-Atassi R, et al. Diagnosis and cure of Wolff–Parkinson–White Syndrome or paroxysmal supraventricular tachycardia during a single electrophysiologic test. N Engl J Med 1991; 324: 1612–1618.[Abstract]
[7] Kosinski DJ, Burket MW, Durzinsky D. Occlusion of the left main coronary artery during radiofrequency ablation for the Wolff–Parkinson–White syndrome. Eur J Card Pacing Electrophysiol 1993; 3: 63–66.
[8] Hope EJ, Haigney MC, Calkins H, Resar JR. Left main coronary thrombosis after radiofrequency ablation: successful treatment with percutaneous transluminal angioplasty. Am Heart J 1995; 129: 1217–1219.[CrossRef][Web of Science][Medline]
[9] Paul T, Bokenkamp R, Mahnert B, Trappe HJ. Coronary artery involvement early and late after radiofrequency current application in young pigs. Am Heart J 1997; 133: 436–440.[CrossRef][Medline]
[10] Strobel GG, Trehan S, Compton S, Judd VE, Day RW, Etheridge SP. Successful pediatric stenting of a nonthrombotic coronary occlusion as a complication of radiofrequency catheter ablation. Pacing Clin Electrophysiol 2001; 24: 1026–1028.[Medline]
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