Author + information
- Received May 23, 2017
- Revision received June 13, 2017
- Accepted June 20, 2017
- Published online September 13, 2017.
- Umihiko Kaneko, MD∗ (, )
- Yoshifumi Kashima, MD,
- Daitaro Kannno, MD,
- Takayuki Kitai, MD,
- Hiroshi Taniguchi, MD,
- Kikuya Uno, MD and
- Tsutomu Fujita, MD
- Department of Cardiovascular Medicine, Sapporo Cardio Vascular Clinic, Sapporo Heart Center, Sapporo, Japan
- ↵∗Address for correspondence:
Dr. Umihiko Kaneko, Cardiovascular Medicine, Sapporo Cardio Vascular Clinic, Sapporo Heart Center, North 49, East 16, 8-1 Higashi Ward, Sapporo, Hokkaido 007-0849, Japan.
- coronary artery dissection
- coronary spasm
- left main obstruction
- intravascular ultrasound
- optical frequency-domain imaging
- radiofrequency ablation
A 70-year-old woman underwent second radiofrequency ablation at the left coronary cusp for recurrent and drug-refractory premature ventricular contractions arising from the left coronary cusp. Pre-procedural coronary angiography showed no stenosis in either coronary artery. Radiofrequency energy application (30 W/50°C/30 s) with an open-irrigated catheter resulted in premature ventricular contraction suppression (Figure 1A). No catheter insertion into the left main coronary artery (LMCA) was observed during ablation. However, the patient suddenly developed severe hypotension and escaped junctional rhythm. Angiography revealed an acute critical true bifurcation lesion in the LMCA (Figure 1B). Optical frequency-domain imaging (LUNAWAVE, Terumo, Tokyo, Japan) demonstrated significant medial thickening, suggestive of severe coronary spasm (Figures 1A to 1C, Online Video 1). Furthermore, intravascular ultrasound (IVUS) revealed acute dissection into the media in the proximal left anterior descending artery, in addition to medial thickening (Figures 1a’ to 1c’, Online Video 2). After repeated intracoronary injections of nitroglycerin and intra-aortic balloon pump insertion, the patient gained hemodynamic stability. She was managed medically with nifedipine, isosorbide mononitrate, pravastatin, and aspirin. Angiography at 4 days post-operatively showed improvement in the LMCA lesion with Thrombolysis in Myocardial Infarction flow grade 3 (Figure 1C). Although localized acute coronary dissection had been detected on baseline IVUS, substantial improvement of the coronary spasm was confirmed under medical therapy with TIMI flow grade 3 on a repeat angiogram. Therefore, she had been treated medically. However, 3 months later, she developed non–ST-segment elevation myocardial infarction and cardiogenic shock due to total occlusion in the LMCA (Figure 1D). High-definition 60-MHz IVUS (Alta View, Terumo) demonstrated a persistent medial thickening covered with homogeneous intimal hyperplasia and healed dissection (Figure 1b”, Online Video 3). Bifurcation reconstruction with 2 drug-eluting stents was successfully performed (Figure 1E).
This is the first report demonstrating acute coronary dissection into the media, in addition to severe spasm, as the primary mechanism of radiofrequency-induced coronary artery injury, successfully demonstrated by IVUS and optical frequency-domain imaging (1). Acute coronary dissection and spasm led to residual medial thickening with gradual reorganization and intimal hyperplasia, and finally to delayed LMCA obstruction. This case also highlights the importance of bailout stenting in the setting of radiofrequency-induced coronary artery injury.
For supplemental videos and their legends, please see the online version of this article.
Dr. Fujita has served a consultant for Terumo Corporation. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received May 23, 2017.
- Revision received June 13, 2017.
- Accepted June 20, 2017.
- 2017 American College of Cardiology Foundation