Anatomical variations of the right coronary artery may be a source of difficult block and conduction recurrence in catheter ablation of common-type atrial flutter

Klemm, Hanno; Weber, Tim Frederik; Johnsen, Christin; Begemann, Philipp G. C.; Meinertz, Thomas; Ventura, Rodolfo

doi:10.1093/europace/euq320

Cited by 9 publications

(7 citation statements)

References 16 publications

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“…The minimum distance to the isthmus was 4.5 ± 2.6 mm. In their study, at the septal side of the CTI, the distance to the RCA increased with a mean of 7.3 ± 3.3 mm . In another study, Al Aloul et al conducted a similar analysis studying the proximity of the RCA to the CTI using contrast enhanced computed tomography images.…”

Section: Discussionmentioning

confidence: 94%

Coronary artery injury related to catheter ablation of cardiac arrhythmias: A systematic review

Pothineni

Kancharla

Katoor

et al. 2018

Cardiovasc electrophysiol

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Introduction: Catheter ablation (CA) has emerged as the preferred modality of treatment for many cardiac arrhythmias. Anatomical sites of ablation are often located in close proximity to coronary arteries. However, the incidence of CA-related coronary injury has not been well studied. We sought to systematically evaluate all cases of CA-related coronary injuries.Methods and Results: A PubMed search was conducted from inception until May 1, 2017 using the keywords "coronary artery" and "ablation." We identified 2817 published articles of which 43 articles met our inclusion criteria representing 61 cases of coronary artery injury attributed to CA procedures from 1992 to 2017.Posteroseptal accessory pathway ablation was associated with the highest incidence of coronary injury (35.6% of cases), followed by cavotricuspid isthmus-dependent flutter (19.3%). The right coronary artery was the site of injury in over two-thirds of all reported cases. Coronary injury was detected intraprocedurally in about half of the cases (43.1%), whereas it was a delayed presentation in the other half. Coronary intervention was performed in a third of all cases (32.7%). There were a total of three deaths attributed to coronary artery injury. Conclusions: Most (91.8%) coronary injuries are a result of anatomic proximity to the site of ablation. Awareness of the relation between coronary artery course and anatomical site of ablation could prevent myocardial damage and improve procedural safety. K E Y W O R D S atrial flutter, catheter ablation, complications, coronary artery injury, myocardial infarction, ventricular tachycardia

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Section: Discussionmentioning

confidence: 94%

Coronary artery injury related to catheter ablation of cardiac arrhythmias: A systematic review

Pothineni

Kancharla

Katoor

et al. 2018

Cardiovasc electrophysiol

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“…In adults undergoing catheter ablation for accessory pathways, a study located a coronary artery within 2 mm of the coronary sinus or its tributaries in over 60% of the population. In addition to the above, unanticipated variation in the anatomy of the coronary arteries may place the arteries in direct line for damage during the ablation procedure [7].…”

Section: Discussionmentioning

confidence: 99%

Coronary artery occlusion following low-power catheter ablation

Isa

Khan

Changezi

et al. 2020

Journal of Community Hospital Internal Medicine Perspectives

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Myocardial infarction (MI) is an unusual but potentially serious complication of catheter ablation procedures. This case describes the occurrence of acute myocardial infarction following lowpower ablation in a young patient and highlights the importance of maintaining high index of suspicion following catheter ablation irrespective of the ablation power used. A 22-year-old patient had low-power ablation of the right posteroseptal accessory pathway in the ostium of the coronary sinus on account of persistently symptomatic WPW syndrome with orthodromic re-entrant tachycardia. Two hours after the procedure, she developed moderately severe chest pain. Electrocardiogram showed ST elevation in the inferior leads. Coronary angiography showed 100% stenosis of the right coronary artery just beyond the posterior descending artery. She failed balloon angioplasty and a drug eluting stent was placed in the posterolateral branch of the right coronary artery. The symptoms resolved and follow up echocardiogram showed normal left ventricular systolic and diastolic functions with no regional wall motion abnormality. This case demonstrates the occurrence of MI following low-power catheter ablation. Patients should be monitored for this complication irrespective of the ablation power used.

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“…Figure 6 shows the anatomy of tricuspid isthmus and how the right coronary artery runs closely behind the tricuspid annulus [7]. In certain individuals, the thickness of right ventricular myocardium can be less than 5 mm.…”

Section: Discussionmentioning

confidence: 99%

“…In addition, the deviation of the RCA from the tricuspid valve plane towards the atrial aspect was calculated. SVC: superior vena cava; CT: crista terminalis; ER: Eustachian ridge; CS: coronary sinus; AV: atrioventricular nodal branch; PDA: posterior descending artery; PLA: posterolateral artery; IVC: inferior vena cava [7]. …”

Section: Discussionmentioning

confidence: 99%

Cardiogenic Shock, Acute Severe Mitral Regurgitation and Complete Heart Block After Cavo-Tricuspid Isthmus Atrial Flutter Ablation

2017

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Radiofrequency (RF) ablation is the first-line management of cavo-tricuspid isthmus dependent atrial flutter. It has been performed with 95% success rate. Adverse events are very rare. We report the first case of acute severe mitral regurgitation (MR) and complete heart block developed after successful atrial flutter ablation. A 62-year-old female with mild MR presented with palpitations. Surface electrocardiogram was suggestive of isthmus dependent atrial flutter. A duodecapolar mapping catheter showed an atrial flutter with cycle length of 280 ms. An 8 mm tipped Thermistor RF ablation catheter was placed at the cavo-tricuspid isthmus. RF energy was delivered as the catheter was dragged to the inferior vena cava. Temperature limit was 60 °C; the power output limit was 60 W. The patient converted to sinus rhythm with the first ablation line. Bi-directional block was recorded. Two additional ablation lines lasting 60 - 120 s were delivered. The patient started having chest pain and developed complete heart block with no escape rhythm. She became hypotensive and was immediately paced from the right ventricle. There were no signs of pericardial tamponade. Emergent bedside echo demonstrated severe MR with a retracted posteromedial mitral valve leaflet. She was 100% paced and EKG changes could not be assessed. Based on the sudden onset chest pain, hypotension, complete heart block and acute severe MR after ablation, the right coronary artery occlusion was suspected. She was immediately transferred to the catheterization laboratory. Coronary angiography revealed a total occlusion of the posterolateral branch from the right coronary artery. Balloon angioplasty and coronary artery stenting was performed. Complete heart block subsequently resolved. Subsequent bedside echocardiogram showed marked improvement of the MR. Patients with smaller body size have smaller hearts and more likely to have injury from RF current. Higher energy penetrates deeper and causes more tissue damage. The use of lower temperature limits (55 °C) and lower energy (60 W) for small, elderly, and female patients is encouraged.

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Anatomical variations of the right coronary artery may be a source of difficult block and conduction recurrence in catheter ablation of common-type atrial flutter

Abstract: The RCA affects CTI ablation as higher power settings are required at closer distances to the ablation site. Late conduction recurrences were observed in patients with a variation of the RCA, leaving the atrioventricular groove towards the atrial aspect.

Cited by 9 publications

References 16 publications

Coronary artery injury related to catheter ablation of cardiac arrhythmias: A systematic review

Coronary artery injury related to catheter ablation of cardiac arrhythmias: A systematic review

Coronary artery occlusion following low-power catheter ablation

Cardiogenic Shock, Acute Severe Mitral Regurgitation and Complete Heart Block After Cavo-Tricuspid Isthmus Atrial Flutter Ablation

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