Ventricular fibrillation associated with multi-vessel coronary spasms following radiofrequency ablation of atrial fibrillation and atrial flutter

Cardiac arrest due to late-onset coronary artery spasm after radiofrequency catheter ablation in a patient with an implantable cardioverter-defibrillator

Coronary artery spasm (CAS) associated with catheter ablation is an important perioperative complication. Here we describe a case of late-onset CAS with cardiogenic shock that occurred five hours after ablation.A 55-year-old man diagnosed with CAS previously underwent implantable cardioverter-defibrillator (ICD) implantation due to ventricular fibrillation. Inappropriate defibrillation was repeatedly conducted for frequent episodes of paroxysmal atrial fibrillation. Therefore, pulmonary vein isolation and linear ablation, including cava-tricuspid isthmus line, were performed. Five hours after the procedure, the patient experienced chest discomfort and lost his consciousness. Electrocardiogram monitoring of lead II revealed atrioventricular sequential pacing and ST-elevation. Cardiopulmonary resuscitation and inotropic support were immediately started. Meanwhile, coronary angiography revealed diffuse narrowing in the right coronary artery. Intracoronary infusion of nitroglycerin immediately dilated the narrowed lesion; however, the patient required intensive care with percutaneous cardiac pulmonary support and a left ventricular assist device. Pacing thresholds obtained immediately after cardiogenic shock were stable and almost similar to previous results. This showed that the myocardium was electrically responsive to ICD pacing but was unable to contract effectively due to ischemia.

Learning objective

Coronary artery spasm (CAS) associated with catheter ablation commonly occurs during ablation, but rarely as a late-onset complication. CAS may cause cardiogenic shock despite proper pacing of the dual chamber. Continuous monitoring of the electrocardiogram and arterial blood pressure is crucial for the early detection of late-onset CAS. Continuous infusion of nitroglycerin and admission into the intensive care unit after ablation may prevent fatal outcomes.

Incidence and Characteristics of Coronary Artery Spasms Related to Atrial Fibrillation Ablation Procedures - Large-Scale Multicenter Analysis

BACKGROUND

Coronary artery spasms (CASs), which can cause angina attacks and sudden death, have been recently reported during catheter ablation. The aim of the present study was to report the incidence, characteristics, and prognosis of CASs related to atrial fibrillation (AF) ablation procedures.Methods and Results:The AF ablation records of 22,232 patients treated in 15 Japanese hospitals were reviewed. CASs associated with AF ablation occurred in 42 of 22,232 patients (0.19%). CASs occurred during ablation energy applications in 21 patients (50%). CASs also occurred before ablation in 9 patients (21%) and after ablation in 12 patients (29%). The initial change in the electrocardiogram was ST-segment elevation in the inferior leads in 33 patients (79%). Emergency coronary angiography revealed coronary artery stenosis and occlusions, which were relieved by nitrate administration. No air bubbles were observed. A comparison of the incidence of CASs during pulmonary vein isolation between the different ablation energy sources revealed a significantly higher incidence with cryoballoon ablation (11/3,288; 0.34%) than with radiofrequency catheter, hot balloon, or laser balloon ablation (8/18,596 [0.04%], 0/237 [0%], and 0/111 [0%], respectively; P<0.001). CASs most often occurred during ablation of the left superior pulmonary vein. All patients recovered without sequelae.

CONCLUSIONS

CASs related to AF ablation are rare, but should be considered as a dangerous complication that can occur anytime during the periprocedural period.

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

Most of the coronary vasospasms were found intraprocedurally, and it is very rare to see late-onset vasospasms that happened a few hours after uncomplicated ablations. The recognition of this rare but potentially life-threatening complication is important to improve the conventional practice of catheter ablation for patients with drug-refractory atrial fibrillation.

Coronary vasospasm complicating atrial fibrillation ablation: a case report and review of the literature

Radiofrequency ablation is one of the alternative treatment strategies in patients with atrial fibrillation. With the increasing number of such ablation procedures being performed it is important for the physicians to be aware of the associated complications. We present a very rare case of severe triple coronary vessel spasm during radiofrequency catheter ablation. The procedure was complicated by cardiac arrest secondary to ventricular fibrillation and cardiogenic shock requiring subsequent management with a temporary mechanical circulatory support device. Multi-vessel spasm is a rare and life-threatening complication leading to ventricular fibrillation and cardiac arrest. One should be extra vigilant in monitoring patients during extensive ablations and the procedure should be terminated at the earliest signs of ischemia in order to prevent this rare but fatal complication.

Coronary Artery Spasm during Cryoballoon Ablation in a Patient with Atrial Fibrillation

The patient was a 63-year-old man with drug-resistant atrial fibrillation who developed coronary spasm during cryoballoon ablation (CBA). CBA was started from the left inferior pulmonary vein. ST elevations in II, III, and aVf, with reciprocal ST depressions in V2-5, occurred in association with chest pain just after balloon rewarming and deflation, and the patient's blood pressure fell to 50 mmHg. Coronary angiography revealed 90% diffuse stenosis from the orifice of segment 1 to segment 4 in the right coronary artery. The stenosis and ST elevations improved after the intracoronary injection of nitroglycerine. Using continuous peripheral intravenous coronary vasodilation, we electrically isolated the other pulmonary veins with CBA without incident.