Precipitation of de novo atrial fibrillation during Shockwave Intravascular Lithotripsy® after pacing capture during the treatment of proximal right coronary artery disease: a case report

Abstract

Background Shockwave Intravascular Lithotripsy® has been recently translated to the treatment of coronary artery disease with a long history of use for ureteric stones where it has been observed to have caused cardiac arrhythmias. The risk of arrhythmia with the use of this method in coronary artery disease is currently unknown. Case summary A 72-year-old man undergoing planned percutaneous intervention to a heavily calcified proximal right coronary artery (RCA) lesion using S-IVL developed pacing capture from the device and subsequently new atrial fibrillation (AF) during the procedure. The technique resulted in successful treatment of the coronary lesion and he spontaneously reverted within an hour of the procedure before discharge. Discussion We postulate the pulsed energy delivered to break apart the calcium has the capacity to cause depolarization, and therefore, affect cardiac rhythm as seen in treatment of renal stones in the past before the introduction of routine electrocardiogram (ECG) gating. In this case, the proximity of the RCA to the right atrium caused short circuiting and development of AF in a susceptible patient. Both the pacing implications and the risk of arrhythmia needs to be investigated further and the potential for ECG gating of the pulsed energy to mitigate this effect needs to be explored to enhance the safety of this technique.

Acoustic energy and cardiac electrophysiology: Ultrasonic cardiac pacing and novel shockwave ablation catheters

“…There are three reported atrial and ventricular tachyarrhythmias cases during S‐IVL (Table 1). 11–13 Curtis et al. reported a case of de novo atrial fibrillation in a 72‐year‐old man undergoing S‐IVL to a calcific lesion in the proximal right coronary artery (RCA) 11 .…”

“… 11–13 Curtis et al. reported a case of de novo atrial fibrillation in a 72‐year‐old man undergoing S‐IVL to a calcific lesion in the proximal right coronary artery (RCA) 11 . McGarvey et al.…”

“…[3][4][5][6][7][8][9][10][11][12][13] This clinical observation dates to the era of first-generation urologic lithotripters and has decreased significantly with the improvement of the accuracy of these machines but reappeared at the end of the last decade with the cumulative use of S-IVL and the reporting of multiple observations of cardiac pacing by SSW since the introduction of S-IVL into clinical practice. 4,7,11,12 Inspired by these observations, investigators are conducting experimental studies on pacemakers that stimulate the heart with SSW or use ultrasound and ablation catheters that deliver SSW to use in interventional electrophysiology. This comprehensive review will discuss SSW effect on cardiac rhythm and its potential use in electrophysiology.…”

“…However, cardiac pacing can occur with SSW 3–13 . This clinical observation dates to the era of first‐generation urologic lithotripters and has decreased significantly with the improvement of the accuracy of these machines but reappeared at the end of the last decade with the cumulative use of S‐IVL and the reporting of multiple observations of cardiac pacing by SSW since the introduction of S‐IVL into clinical practice 4,7,11,12 .…”

New Modalities of Treatment for Coronary Calcific Lesions

“…37,38 IVL can trigger supraventricular arrhythmias or paroxysmal atrial fibrillation in susceptible patients undergoing right coronary artery intervention. 39 There are anecdotal reports of coronary perforation with the use of IVL. 40,41 IVL is to be used with caution in critical lesions and in very tortuous vessels.…”