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      A case series and review of the literature regarding coronary artery complications associated with coronary sinus catheter ablation

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          Abstract

          Introduction KEY TEACHING POINTS • Variations in coronary artery dominance and the relationship to the coronary sinus can lead to unexpected injury to a coronary artery during coronary sinus ablation. Maintaining alertness during coronary sinus radiofrequency application is critical. • Monitoring the relevant surface electrocardiographic leads during ablation at a sweep speed of 25 mm/s in addition to monitoring of the 12-lead electrocardiogram immediately after ablation are 2 simple measures that can prevent dramatic complications. • Performing a coronary angiogram on every patient undergoing coronary sinus ablation is excessive, tipping the risk–benefit ratio the other direction. Catheter ablation of atrioventricular nodal reentrant tachycardia (AVNRT) and atrioventricular reentrant tachycardia is an established procedure with a high success rate, but procedure-related complications are not rare. 1 One of the feared complications is coronary injury, the frequency of which is estimated to be ≤1%. We have recently shown that the risk of coronary artery injury is especially high when ablating in the coronary sinus (CS) branches, such as the middle cardiac vein (MCV), and the risk correlates inversely with the distance from the ideal ablation site in the CS to the coronary artery. If this distance is <2 mm, the risk of coronary artery injury is as high as 50%. 2 Understanding the relationship between coronary arteries and the CS is essential to avoid this complication. We describe 2 cases in which ablation in a presumed safe area resulted in coronary injury. Case reports Case 1 A 17-year-old white male presented to our institution with severely symptomatic tachycardia refractory to medical therapy. During electrophysiology study, AVNRT was induced and targeted for ablation. A magnetic navigation catheter (Stereotaxis, St. Louis, MO) in an SR-0 sheath was used to create a CARTO map (Biosense Webster; Johnson and Johnson, New Brunswick, NJ) and to perform the ablation. A CS venogram was not performed. In all, 3 separate radiofrequency (RF) applications at 25 W were delivered. The lesions started at the inferior triangle of Koch and continued by gradually pulling the catheter toward the CS ostium, at a level of the middle CS ostium. Junctional beats were seen during the RF applications closer to the CS ostium. During the third RF application, the ablation catheter suddenly moved inferiorly, possibly into the MCV. RF energy was stopped soon after catheter movement was noted. As seen in his echocardiogram (ECG), ST elevation developed in the inferior leads (aVF, III) shortly after this RF application (Figure 1A). Reduction of his clinical arrhythmia was not attempted secondary to the presence of ST elevation. Of note, during ablation, only leads I, II, and V1 were monitored at a paper speed of 200 mm/s and ST elevation was not appreciated during RF application. The patient was immediately transferred to the cardiac catheterization laboratory. Access was obtained via the radial artery. The right coronary artery (RCA) was angiographically dominant, and the RCA and right posterior descending artery were both normal. At the ostium of the right posterior-lateral, there was a complete occlusion, as shown in Figure 1B. Aspiration thrombectomy did not retrieve significant thrombus, and a 2 × 18-mm bare metal stent was deployed. The final angiographic result was excellent, with TIMI-3 flow, as seen in Figure 1C. A transthoracic echocardiogram performed the day after ablation revealed normal systolic function and mild hypokinesis of the inferior myocardium. The patient was discharged on acetylsalicylic acid for life and clopidogrel for 30 days. At 14 months of follow-up, he has had no clinical tachycardia recurrence or chest discomfort. Case 2 A 39-year-old white female with preexcitation presented to our institution after 2 previous unsuccessful ablations. A CS angiogram, performed at the start of our case, did not reveal any abnormalities. Through mapping of the right atrium during ventricular pacing, the accessory pathway (AP) was identified near the roof of the CS, approximately 1.5 cm from the ostium, which is generally thought not to be a high-risk area for coronary artery injury. We monitored antegrade preexcitation during RF application, and ablation at this site eliminated conduction in 1 second. Considering the patient’s history of 2 previous failed ablations and the pathway slant, we elected to perform additional RF applications. 2 additional lesions were site. placed more distal and proximal to the original A fourth application was applied to the ventricular end of the AP, at the level of mid CS ostium. Shortly after the third ablation, ST elevation was noted in the inferior leads (Figure 2A), and a coronary angiogram was performed via the radial artery. Of note, during ablation, only leads I, II, and V1 were monitored at a paper speed of 200 mm/s, and ST elevation was not appreciated. An angiogram showed the RCA, left main coronary artery, and left anterior descending artery to be normal. The left circumflex was dominant. At the ostium of the second obtuse marginal, there was a 100% occlusion, as shown in Figure 2B. Because aspiration thrombectomy was nonproductive, a balloon and a bare metal stent resulted in TIMI-3 flow, as shown in Figure 2C. A transthoracic echocardiogram revealed normal systolic function with hypokinesis of the basal inferolateral and inferior myocardium. The patient was discharged on acetylsalicylic acid for life and ticagrelor for 1 year. At 15 months of follow-up, she has had no tachycardia recurrence or chest pain. Discussion Understanding the relationship of the coronary arteries to the CS is critical during ablation. The left circumflex artery is located on the epicardial surface of the atrioventricular groove, near the CS. The CS is usually situated more atrial to the atrioventricular groove, as shown in Figure 3, with only 16% of cases in the “normal” atrioventricular (AV) groove position. Figure 3, Figure 3 show this relationship with a venogram and arteriogram in the right anterior oblique projection. Figure 3, Figure 3 show this in the left anterior oblique projection. The more atrial CS path varies: 1–3 mm above the AV groove is seen in 12% of patients, a moderate elevation (4–7 mm) in 50%, and an extreme elevation (8–15 mm) in 22%. As the left cardiac chambers and mitral annulus dilate, the CS shifts toward the ventricular part of the mitral valve annulus. 3 Two previous studies searched for coronary artery injury and found the incidence of ablation-related coronary injury to be 1%.4, 5 Retrospective and prospective registries have reported coronary artery injury from ablation as low as 0.06%–0.1% in adults and 0.03% in children.6, 7, 8 The underlying mechanism for injury is not completely understood. Transient thermal irritability resulting in coronary spasm appears to be the primary mechanism, and this stenosis can be relieved with intracoronary glycerine trinitrate in 100% of patients, as described in a recent study. 9 However, an additional inflammatory component may exist. As noted in reports of animal experiments, the inflammatory component may result in delayed medial necrosis and intimal hyperplasia causing late stenosis. 10 Unfortunately, the risk factors that predispose patients to coronary artery injury are not completely defined. One proposed hypothesis is that vessels <3 mm in diameter do not have the protection of the heat-sink effect, making them more vulnerable to RF heat and therefore injury. Certain procedural situations, by virtue of the targeted site for ablation, may also increase this risk. These scenarios include linear ablation within the CS, epicardial posteroseptal APs, and ablation of AVNRT. Linear ablation within the CS to create an LA isthmus line may lead to circumflex artery injury. Longstanding persistent atrial fibrillation with perimitral flutter is a common form of LA macroreentry. Procedural success usually requires additional ablation within the CS to either terminate the tachycardia or create an LA isthmus block, often necessitating extension ablation. Wong et al 9 found that 28% of their patients had circumflex artery angiographic changes post ablation, when compared with preprocedure coronary angiograms. Of note, 33% of these patients had a significant response to intracoronary glycerine trinitrate. Makimoto et al 11 reported a case of delayed incessant ventricular tachycardia >40 hours after the creation of an LA isthmus line in the coronary venous system. Coronary injury may result from ablation of epicardial posteroseptal APs that used part of the CS muscle for conduction. The ablation target, where the ventricular end of the epicardial AP is located, is often within a tributary of the CS, the MCV, or the neck of a CS diverticulum. Stavrakis et al 2 reviewed results of 240 patients with such pathways and their preablation coronary angiograms. They found an inverse correlation between the risk of coronary artery injury and the distance from the ablation site, with a 50% risk if the target was within 2 mm of the artery. Ablation of AVNRT can also lead to coronary artery injury. The atrioventricular node (AVN) artery is the primary blood supply to the AVN as well as the His bundle. The posterior descending and posterolateral left ventricular branches also supply the inferior aspect of the interventricular septum. Arterial supply varies with dominance of the coronary circulation. In approximately 85% of patients in whom the circulation is right dominant, the AVN artery is supplied by a branch of the RCA. In patients who have left-dominant circulation, the AVN artery originates from the left circumflex artery. 12 The AVN artery usually ends as single vessel, with the remainder being shaped like a fork or as a double-stranded vessel. Lin et al 13 studied the risk of AV block during slow pathway ablation for AVNRT using coronary angiography either before or after ablation. Irrespective of other common electrophysiology signals, they found that an ablation distance of <2 mm to the distal end of the AV nodal artery almost always caused suprahisian block. This case series exposes the inherent dangers to the coronary circulation when RF energy is delivered within or near the CS, especially when the targeted area is thought to be safe. Multiple ablation procedures may increase the risk of damage to coronary arteries, but this relationship has not been studied specifically. In our institute, coronary angiography is performed in patients when the ablation target may be near the coronary artery, especially if it is located in the MCV or at the floor of the proximal CS. However, coronary angiograms are not performed on every patient when the ablation target is located at the CS ostium, such as with AVNRT. Performing preablation angiograms on every patient in such cases seems excessive. Diagnostic cardiac catheterization is safe, with a complication rate from death, myocardial infarction, or major embolization that is well below 1%. 14 In centers that perform high-volume radial access, vascular complications are reduced even further. 15 Although there are no data specifically addressing preablation angiograms, or even cardiac computed tomography scans, when ablation within the CS is contemplated, specific pros (noninvasive, well-defined anatomy) and cons (contrast load, increased radiation exposure) of each approach will need to be evaluated by the physician for each patient. Regardless, an understanding of coronary artery variances in relation to the CS is essential, especially when ablation within the coronary sinus may be required. Conclusion Keeping a high degree of suspicion for coronary artery injury with CS RF application is highly recommended. Checking relevant ECG leads for ST changes at a sweep speed of 25–100 mm/s during an ablation may not be feasible in all patients, such as when AV conduction is being monitored. However, checking a 12-lead ECG immediately after ablation is a critical step that can diagnose ST changes and possibly prevent dramatic complications. Performing imaging of the coronary circulation on every patient undergoing CS ablation, whether with a cardiac computed tomography scan or with a diagnostic catheterization, may be unnecessary and should be individualized for each case.

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          Most cited references 12

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          The 1998 NASPE prospective catheter ablation registry.

          The results of the NASPE Prospective Voluntary Registry are reported. A total of 3,357 patients were entered. For those undergoing atrioventricular (AV) junctional ablation (646 patients), the success rate was 97.4% and significant complications occurred in 5 patients. A total of 1,197 patients underwent AV nodal modification for AV nodal reentrant tachycardia, which was successful in 96.1% and the only significant complication was development of AV block (1%). Accessory pathway ablation was performed in 654 patients and was successful in 94%. Major complications included cardiac tamponade (7 patients), acute myocardial infarction (1 patient), femoral artery pseudoaneurysm (1 patient), AV block (1 patient), pneumothorax (1 patient), and pericarditis (2 patients). A total of 447 patients underwent atrial flutter ablation and acute success was achieved in 86% of patients. Significant complications included inadvertent AV block (3 patients), significant tricuspid regurgitation (1 patient), cardiac tamponade (1 patient), and pneumothorax (1 patient). Atrial tachycardia was attempted for 216 patients and the success rate was higher for those with right atrial (80%) or left atrial (72%) compared to those with septal foci (52%). A total of 201 patients underwent ablation for ventricular tachycardia. The success rate was higher for those with idiopathic ventricular tachycardia compared to those with ventricular tachycardia due to ischemic heart disease or cardiomyopathy. While the number of AV junction ablation were higher for those > 60 years of age, there was no significant difference in the success rate or incidence of complication comparing patients > or = 60 to those 100 ablation/year) with lower volume centers or between teaching and non-teaching hospitals.
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            Coronary arteriography 1984-1987: a report of the Registry of the Society for Cardiac Angiography and Interventions. I. Results and complications.

            This prospective series of results and complications of coronary arteriography from the Registry of the Society for Cardiac Angiography and Interventions is the largest ever reported. Since the initial report published in 1982, the results of coronary artery surgery and angioplasty have improved and therefore older and more symptomatic patients are referred for coronary arteriography. More patients are now studied by the femoral approach, and the major complications of the techniques are similar. Despite studying older and higher-risk patients, the complications are remarkably similar to those reported in the older series. Because of the sicker patients being studied, it is probably unlikely that the complication rate will decrease further in the future. The Society for Cardiac Angiography and Interventions will continue its Registry to follow complication rates of both established and new procedure.
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              Radiofrequency catheter ablation of accessory atrioventricular connections in 250 patients. Abbreviated therapeutic approach to Wolff-Parkinson-White syndrome.

              The purpose of this study was to report the results and complications of radiofrequency catheter ablation of accessory atrioventricular (AV) connections by using an abbreviated approach aimed at minimizing the duration of the procedure. Two hundred fifty consecutive patients with the Wolff-Parkinson-White syndrome or paroxysmal supraventricular tachycardia involving a concealed accessory AV connection underwent catheter ablation with the use of radiofrequency current. In 179 of the 250 patients, catheter ablation was performed at the time of an initial electrophysiology test. Two hundred thirty-five patients had one accessory AV connection and 15 patients had two or more. One hundred eighty-three accessory AV connections were manifest and 84 were concealed. One hundred sixty-one were were located in the free wall of the left ventricle, 47 were in the right free wall, 44 were posteroseptal, 10 were anteroseptal, and five were intermediate test, and the ablation procedure was recorded for each patient, as was the total duration of fluoroscopy. A follow-up electrophysiology test was performed 2-3 months after the ablation procedure. Ninety-four percent of patients had all accessory AV connections successfully ablated and remained free of symptomatic tachycardia during a mean follow-up of 10 +/- 4 months. Two hundred nineteen patients (88%) had all accessory AV connections ablated during the initial attempt at catheter ablation. Mean duration of the entire procedure was 134 +/- 75 minutes. Procedure duration was longest in patients with multiple accessory AV connections, shortest in patients with intermediate septal accessory AV connections, and similar in all other locations. A nonfatal complication occurred in nine patients (4%). The results of this study indicate that catheter ablation of accessory AV connections with radiofrequency current can be performed safely and expeditiously in a majority of patients and confirm in a large series the feasibility of catheter ablation at the time of an initial diagnostic electrophysiology test. This abbreviated therapeutic approach avoids the need for electropharmacological testing, long-term antiarrhythmic drug therapy, and surgical therapy in the majority of patients with the Wolff-Parkinson-White syndrome or with symptomatic tachycardias involving accessory AV connections.
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                Author and article information

                Contributors
                Journal
                HeartRhythm Case Rep
                HeartRhythm Case Rep
                HeartRhythm Case Reports
                Elsevier
                2214-0271
                26 May 2015
                September 2015
                26 May 2015
                : 1
                : 5
                : 315-319
                Affiliations
                University of Oklahoma Health Sciences Center, Heart Rhythm Institute, Oklahoma City, Oklahoma
                Author notes
                [* ] Address reprint requests and correspondence: Dr Paul Garabelli, University of Oklahoma Health Sciences Center, Heart Rhythm Institute, 1200 Everett Drive, Room 6E103, Oklahoma City, OK 73104. paul-garabelli@ 123456ouhsc.edu
                Article
                S2214-0271(15)00091-3
                10.1016/j.hrcr.2015.04.008
                5419666
                © 2015 Heart Rhythm Society. Published by Elsevier Inc.

                This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

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                Case Report

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