Author + information
- Alfonso Ielasi1
Patient initials or identifier number
Relevant clinical history and physical exam
A 40 years old, male hypertensive and dyslipidemic. Previous trans-catheter ablation for atrioventricular nodal re-entrant tachycardia. Parossistic Atrial Fibrillation. 09/06/2009: hospital admission for supraventricular parossistic tachycardia (SVPT). An accessory pathway was suspected.
Relevant test results prior to catheterization
10/06/2009: SVPT ablation by the aortic retrograde approach. During the ablation procedure, sudden onset of angina and diffuse ST elevation complicated by cardiogenic shock.
Relevant catheterization findings
Basal angio showed an ostial LCx and LAD occlusion (Fig). After giving nitroglycerin, dopamine and IABP placement a partial resolution of the occlusion was noticed (Fig). Few seconds later an electric storm occurred with angiographic evidence of slow-flow phenomenon associated with severe spasm on LAD-Diag and LCx (Fig). Multiple DC shocks were required to obtain sinus rhythm and the patient underwent OT intubation.
LAD and LCx were wired and then balloon inflation was performed (SC 3.0 x 30 mm). A 3.5 x 23 mm DES was implanted from ostial LM toward prox LAD with transient LCx no-reflow resolved by i.c.nitro. After Lcx re-wiring and kissing balloon inflation, a good angiographic result was obtained (Fig). Three hours later, the patient experienced inferolateral ST-segment elevation associated with low-output state and severe LV dysfunction at echo (EF30%). Emergent angio revealed a flow-limiting dissection from LM roof toward Lcx and severe spasm on a diagonal branch (Fig). LCx and OM1 were wired and balloon inflation (SC 3.0 x 20 mm) was performed resulting in dissection. POBA was also performed on LAD-D1. Despite the suboptimal angiographic result (persistent, no flow-limiting dissection on Lcx and diagonal spasm, Fig.), it was decided to avoid stent implantation because progressive ST-elevation and symptoms resolution. I.v. adrenaline (at vasodilator dose) was given. The patient maintained hemodynamically and electrically stable while the systolic function progressively improved (EF 30% to 45%). At 10 days from the index, procedure angiography revealed a complete sealing of Lcx dissection and spasm resolution.
the coronary occlusion is a rare complication during TCRF ablation. Direct thermal injury or vessel dissection during catheter manipulation are considered the common causes. Although PCI with stent implantation appears the treatment of choice in case of persistent occlusion after vasodilators injection, however, slow/no-reflow may occur. This phenomenon is thought to relate to endothelial dysfunction and both functional and morphological endothelial changes induced by radiofrequency. Low-dose adrenaline infusion with a selective vasodilator effect through the beta-2 adrenoceptor distributed in small arterioles may help in association with clinically driven PCI to solve this dramatic condition.