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Chronic Left Coronary Artery Stenosis After Radiofrequency Ablation of Idiopathic Premature Ventricular Contraction Originating From Left Coronary Sinus Cusp

2016; Lippincott Williams & Wilkins; Volume: 9; Issue: 8 Linguagem: Inglês

10.1161/circep.116.004353

1941-3149

Yuechun Li, Jiafeng Lin, Xueqiang Guan, Chen Peng,

Cardiac pacing and defibrillation studies

HomeCirculation: Arrhythmia and ElectrophysiologyVol. 9, No. 8Chronic Left Coronary Artery Stenosis After Radiofrequency Ablation of Idiopathic Premature Ventricular Contraction Originating From Left Coronary Sinus Cusp Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyRedditDiggEmail Jump toFree AccessResearch ArticlePDF/EPUBChronic Left Coronary Artery Stenosis After Radiofrequency Ablation of Idiopathic Premature Ventricular Contraction Originating From Left Coronary Sinus Cusp Li Yue-Chun, MD Lin Jia-Feng, MD Guan Xue-Qiang, and MD Chen PengMD Li Yue-ChunLi Yue-Chun From the Department of Cardiology, Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, China. , Lin Jia-FengLin Jia-Feng From the Department of Cardiology, Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, China. , Guan Xue-QiangGuan Xue-Qiang From the Department of Cardiology, Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, China. , and Chen PengChen Peng From the Department of Cardiology, Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, China. Originally published20 Jul 2016https://doi.org/10.1161/CIRCEP.116.004353Circulation: Arrhythmia and Electrophysiology. 2016;9IntroductionA 50-year-old man was referred for radiofrequency catheter ablation of idiopathic premature ventricular contraction (PVC) refractory to metoprolol. The ECG characteristics of the PVCs suggested that the PVCs originated from left coronary sinus (LCC). Mapping was performed in the LCC using a 7F irrigated-tip ablation catheter via the right femoral artery. During clinical PVCs, the local ventricular activation was the earliest at the LCC. Radiofrequency (RF) energy application was attempted at the site (Figure [A1] and [B1]). Coronary angiography was performed before RF application, revealing a normal left coronary artery without stenosis. The distance from the catheter tip to the left main coronary artery (LMCA) ostium was ≈10 mm by fluoroscopy (Figure [A2] and [B2]). One application of RF energy at this site (43°C, 30 W, 17 mL/min) terminated spontaneous PVCs within 15 s and was maintained for 180 s. However, the clinical PVCs appeared during isoproterenol infusion. Another 3 applications around this point with a maximal setting of 40 W were 180 s in duration and finally eliminated the PVCs. Mean impedance drop was 12±2 Ω for the lesions. Popping or impedance rises did not occur during RF applications. No catheter dislodgment was observed during ablation, and ablation was performed only within the LCC. The patient experienced some chest discomfort during ablation. Repeat angiography after ablation showed normal left coronary artery without coronary spasm, stenosis, or occlusion. The ECG after the procedure showed normal sinus rhythm and no ST-T changes. The patient was then discharged on aspirin for 1 month. During the 3 months of follow-up, the patient remained clinically free of symptoms. Four months later, the patient was readmitted because of exertional chest pain. The chest pain had developed 3 weeks previously when he was climbing stairs, which was relieved by several minutes of rest. A 12-lead ECG recorded on admission showed sinus tachycardia and remarkable ST-segment depression in leads V1 through V6 and ST-segment elevation in lead aVR. The patient's peak troponin level was 1.7 ng/mL. His creatine kinase-MB was not increased. Coronary angiography showed 60% stenosis in the body and distal segment of LMCA and 90% stenosis in the proximal left anterior descending artery (LAD) with TIMI 3 (thrombolysis in myocardial infarction) flow (Figure [C1] and [D1]). The left circumflex artery and right coronary artery were normal. Balloon predilation with a 2.5×20 mm balloon and a 3.0×10 mm cutting balloon was performed. A 4.0×24 mm sirolimus-eluted stent was then deployed from the LAD to the LMCA with intravascular ultrasound guidance (Figure [C2] and [D2]). A final angiogram after LMCA stenting showed an optimal angiographic result. Intravascular ultrasound revealed positive remodeling characteristics in the LAD lesion,1 whereas the external elastic membrane cross-sectional area of LAD lesion was significantly greater than that of the LMCA lesion (Figure [E] and [F]). The therapy resulted in significant symptom relief. During the 12 months of follow-up after stenting, the patient remained clinically free of symptoms without any ischemic events. Coronary computed tomography showed stent patency at 10 months of follow-up.Download figureDownload PowerPointFigure. The fluoroscopic position of the ablation site, as well as coronary angiography and intravascular ultrasound of the left coronary artery. Left anterior oblique (LAO; A1) and right anterior oblique (RAO; B1) fluoroscopic views showing the radiofrequency ablation site in the left coronary sinus. Coronary angiography performed before ablation in an LAO projection (A2) and an RAO projection (B2), showing a normal left coronary artery without stenosis. The distance from the catheter tip to the left main coronary artery (LMCA) ostium was ≈10 mm. Left coronary angiography was performed once again after the ablation procedure, and ruled out coronary spasms, stenoses, and occlusions. Coronary angiography performed 4 mo after ablation in an RAO+cranial (CRA) projection (C1) and an LAO+caudal (CAU) projection (D1), showing 60% stenosis in the body and distal segment of LMCA and 90% stenosis in the proximal left anterior descending artery (LAD) with TIMI 3 (thrombolysis in myocardial infarction) flow. Repeat left coronary angiography after successful stenting without residual stenosis in an RAO+CRA projection (C2) and an LAO+CAU projection (D2). Intravascular ultrasound performed after stenting, showing positive remodeling characteristics in the LAD lesion (remodeling index=1.48). The external elastic membrane cross-sectional area (EEM CSA=23.49 mm2) of the LAD lesion (E) was significantly greater than that of the LMCA lesion (EEM CSA=15.89 mm2) (F). RI indicates remodeling index.Although most coronary damage in relation to RF ablation presents acutely,2 delayed presentations may also occur. To our knowledge, this is the first report of chronic LMCA and LAD stenoses without occlusion secondary to previous RF ablation. This study also detected the coronary plaques associated with the application of RF energy in a human subject, via intravascular ultrasound. Only 3 cases of acute LMCA occlusion caused by RF-induced thermal injury have been reported.3 Only 1 case report described chronic LMCA occlusion caused by vessel trauma presenting 2 years after ablation of left ventricular tachycardia.3 Only 1 case report described chronic ostial LMCA stenosis of after LCC atrial tachycardia ablation.4 Evidence of chronic injury associated with the application of RF ablation near the coronary arteries has been observed in animal models. In a porcine model, RF ablation proximal to the coronary arteries led to chronic histopathologic changes, characterized by tunica intima and media thickening with replacement of the smooth muscle cells with extracellular matrix; however, no significant stenosis was observed up to 70 days after ablation.5 In the present study, significant LMCA and LAD stenoses developed 4 months after RF ablation. Intravascular ultrasound showed positive remodeling characteristics in the LAD lesion.1 Positive remodeling is strongly associated with plaque rupture.1 This is the first report documenting the progression of LMCA and LAD plaques associated with thermal injury in humans by angiography and intravascular ultrasound. Although the exact time of positive remodeling was not clear, the present study clearly suggests that RF ablation proximal to the coronary arteries may facilitate the development of intracoronary atherosclerotic plaque and rupture of spontaneous plaque. As proposed by most authors, a distance of >1.0 cm from the ablation catheter tip to the left coronary ostium seems to be safe. However, repetitive RF application at high power and for a long duration in the LCC may lead to coronary injury although the distance of >1.0 cm was suggested to be adequate.DisclosuresNoneFootnotesCorrespondence to Li Yue-Chun, MD, and Chen Peng, MD, Department of Cardiology, Second Affiliated Hospital of Wenzhou Medical University, 109 Xueyuan Rd, Wenzhou Zhejiang, China. E-mail [email protected] or [email protected]References1. Inaba S, Mintz GS, Farhat NZ, Fajadet J, Dudek D, Marzocchi A, Templin B, Weisz G, Xu K, de Bruyne B, Serruys PW, Stone GW, Maehara A. Impact of positive and negative lesion site remodeling on clinical outcomes: insights from PROSPECT.JACC Cardiovasc Imaging. 2014; 7:70–78. doi: 10.1016/j.jcmg.2013.10.007.CrossrefMedlineGoogle Scholar2. Roberts-Thomson KC, Steven D, Seiler J, Inada K, Koplan BA, Tedrow UB, Epstein LM, Stevenson WG. Coronary artery injury due to catheter ablation in adults: presentations and outcomes.Circulation. 2009; 120:1465–1473. doi: 10.1161/CIRCULATIONAHA.109.870790.LinkGoogle Scholar3. Walsh KA, Fahy GJ. Anatomy of the left main coronary artery of particular relevance to ablation of left atrial and outflow tract arrhythmias.Heart Rhythm. 2014; 11:2231–2238. doi: 10.1016/j.hrthm.2014.08.006.CrossrefMedlineGoogle Scholar4. De Maria GL, Pedersen M, Leo M, Bashir Y, Banning AP. Iatrogenic constrictive remodeling of left main stem after left coronary cusp atrial tachycardia ablation.Int J Cardiol. 2015; 184:507–509. doi: 10.1016/j.ijcard.2015.02.099.CrossrefMedlineGoogle Scholar5. Viles-Gonzalez JF, de Castro Miranda R, Scanavacca M, Sosa E, d'Avila A. Acute and chronic effects of epicardial radiofrequency applications delivered on epicardial coronary arteries.Circ Arrhythm Electrophysiol. 2011; 4:526–531. doi: 10.1161/CIRCEP.110.961508.LinkGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetails August 2016Vol 9, Issue 8Article InformationMetrics Download: 139 © 2016 American Heart Association, Inc.https://doi.org/10.1161/CIRCEP.116.004353PMID: 27439652 Manuscript receivedMay 17, 2016Manuscript acceptedJune 22, 2016Originally publishedJuly 20, 2016 Keywordscatheter ablation, radiofrequencycoronary stenosiscatheter ablationcoronary artery diseaseventricular premature complexesPDF download SubjectsArrhythmiasCatheter Ablation and Implantable Cardioverter-DefibrillatorChronic Ischemic Heart Disease