Damage to the left descending coronary artery due to radiofrequency ablation in the right ventricular outflow tract: Clinical case series and anatomical considerations

Abstract

The purpose of this paper was to highlight the importance of the anatomy of the right ventricular outflow tract (RVOT) and the proximity of the mid segment of the left anterior descending coronary artery (LAD) to the RVOT in the setting of ablation of ventricular arrhythmias in the RVOT. During the period from 2014 till 2017, five patients with injury to the LAD during ablation within RVOT were identified in three centers, in Belgium, Germany and Israel. The clinical characteristics, procedural data and follow up data, where available, are reported. The literature review over coronary artery damage during radiofrequency ablation procedures is provided and the anatomy of the RVOT and the neighboring vascular structures is discussed. We present five patients who underwent radiofrequency ablation of ventricular arrhythmias mapped to the inferior and anterior part of the RVOT, at the insertion of the right ventricular wall to the septum, whereby ablation resulted in occlusion in four and severe stenosis in one, of the mid segment of the LAD coronary artery. All patients underwent percutaneous coronary intervention and stenting, four of them immediately during the same procedure and one 3 days later because of lack of signs and symptoms of acute coronary occlusion. In conclusion, the mid segment of the LAD at the level of the second septal perforator/second diagonal branch runs in very close proximity to the endocardial aspect of the lower part of the RVOT and care should be taken during ablation of ventricular arrhythmias in this region. Additional imaging such as intracardiac echocardiography and coronary angiography may be helpful in avoiding complications.

Coronary arterial injury during right ventricular outflow tract ablation: Know your neighbors

“…However, the three-dimensional relationship between the coronary arteries and the RVOT, and consequently the risk of potential collateral damage to the coronary arteries when ablating in the RVOT, is often overlooked. 1 The study by Dilling-Boer et al 2 with a relatively slurred QRS onset in these patients. Many of these ECG features are reminiscent of arrhythmias successfully ablated in the anterior interventricular or intraseptal veins.…”

“…The study by Dilling‐Boer et al 2 in this issue of the Journal illustrates a rare and underappreciated hazard associated with ablation in the RVOT. The authors report acute or subacute injury to the left anterior descending (LAD) coronary artery in five patients after ablation in the RVOT.…”

Are antiarrhythmic agents indicated in premature ventricular complex‐induced cardiomyopathy and when?

“…While ablation of PVCs originating from the RVOT is very safe, unusual risks of complications and the safety aspects, as illustrated in Case 2, are noteworthy. Dilling‐Boer et al 15 reported a group of 5 patients with coronary injury during ablation within RVOT. These patients underwent CA at 3 experienced centers in Germany, Israel and Belgium.…”