Analysis of reported cases of left main coronary artery injury during catheter ablation: In search of a pattern

Abstract

Introduction Left main coronary artery (LMCA) injury is a rare but potentially fatal complication of catheter ablation. Due to LMCA large perfusion area, its occlusion is usually a dramatic event. Methods and Results Reports of LMCA injury complicating catheter ablations from 1987 to 2018 were searched in electronic databases. Twenty‐two cases of serious LMCA damage have been identified. Additionally, four reports of direct mechanical trauma involving major LMCA branches induced by inadvertent catheter insertion have been studied. Typically 86% LMCA injury presented as an acute/subacute complication of retrograde ablation in left ventricle/left ventricular outflow tract or aortic cusps. In at least 86% of patients with an in‐hospital presentation, the LMCA trauma manifested dramatically as a life‐threatening arrhythmia, cardiogenic shock, or severe hypotension requiring vasopressors. In‐hospital mortality rate was 32%. Direct stenting has been found to be the most successful strategy. Conclusion LMCA injury, even if initially asymptomatic with normal angiographic appearance, may cause delayed flow deterioration, requiring prolonged monitoring and extended follow‐up. Special caution should be given to the prevention whereas survival depends on prompt detection and treatment.

EP Laboratory Nightmare

“…Each of the aortic sinuses of Valsalva, positioned at the base of the aortic root, is in contact with the ventricular myocardium at their bases, and this structure enables mapping and ablation of arrhythmias with an outflow tract origin ( 1 ). A retrospective analysis of all described cases of severe LMCA injury during catheter ablation identified 22 cases between 1987 and 2018 ( 2 ): 86% of cases manifested dramatically as a life-threatening arrhythmia, cardiogenic shock, or severe hypotension. The in-hospital mortality rate was 32%, and direct stenting was found to be the most successful treatment strategy.…”

Delayed presentation of left main coronary artery dissection due to catheter ablation in a patient with bicuspid aortic valve. Coincidence or manifestation of inherent vulnerability?

“…Along with cardiac tamponade and atrioesophageal fistula, coronary artery injury is among the most dire and potentially lethal complications of catheter ablation. In cases of LMCA trauma with acute/subacute presentation, in-hospital mortality has been assessed as 32% [1]. Due to the large area of myocardium at risk, LMCA and LAD injury causing flow deterioration typically manifests during an ablation procedure or shortly after its termination.…”

“…As observed during complicated by dissection coronary interventions and retrograde ablation procedures, the cranial surface of LMCA is the place of catheter tip impact, as catheters are naturally pointed in this direction by their curves and the aortic cusp backup [1]. In a retrospective analysis of 26 cases of LMCA injury during ablation, unintended catheter insertion was inferred in 73%, with 95% of the latter having involved the aortic valve crossing (only in 18% LMCA penetration had been realized before symptoms/ECG changes developed) [1]. Moreover, spontaneous coronary artery dissections (SCAD) predominantly affect mid-to-distal segments [2].…”

“…When the left main coronary artery (LMCA) and the left anterior descending coronary artery (LAD) are injured, the presentation is typically acute/subacute due to the vast myocardial territory supplied by the vessels. It usually manifests as chest pain with life-threatening ventricular arrhythmias, cardio-genic shock, or sudden cardiac arrest [1]. Prompt diagnosis and urgent treatment are required to save the patient.…”