Ishimura Masayuki, Yamamoto Kayo, Yamamoto Masashi, Himi Toshiharu, Kobayashi Yoshio
Department of Cardiology, Kimitsu Central Hospital, Kisarazu, Japan.
Department of Cardiology, Chiba University Hospital, Chiba, Japan.
J Cardiol Cases. 2023 Feb 22;27(5):207-211. doi: 10.1016/j.jccase.2023.02.006. eCollection 2023 May.
Coronary artery spasm (CAS) associated with catheter ablation is an important perioperative complication. Here we describe a case of late-onset CAS with cardiogenic shock that occurred five hours after ablation.A 55-year-old man diagnosed with CAS previously underwent implantable cardioverter-defibrillator (ICD) implantation due to ventricular fibrillation. Inappropriate defibrillation was repeatedly conducted for frequent episodes of paroxysmal atrial fibrillation. Therefore, pulmonary vein isolation and linear ablation, including cava-tricuspid isthmus line, were performed. Five hours after the procedure, the patient experienced chest discomfort and lost his consciousness. Electrocardiogram monitoring of lead II revealed atrioventricular sequential pacing and ST-elevation. Cardiopulmonary resuscitation and inotropic support were immediately started. Meanwhile, coronary angiography revealed diffuse narrowing in the right coronary artery. Intracoronary infusion of nitroglycerin immediately dilated the narrowed lesion; however, the patient required intensive care with percutaneous cardiac pulmonary support and a left ventricular assist device. Pacing thresholds obtained immediately after cardiogenic shock were stable and almost similar to previous results. This showed that the myocardium was electrically responsive to ICD pacing but was unable to contract effectively due to ischemia.
Coronary artery spasm (CAS) associated with catheter ablation commonly occurs during ablation, but rarely as a late-onset complication. CAS may cause cardiogenic shock despite proper pacing of the dual chamber. Continuous monitoring of the electrocardiogram and arterial blood pressure is crucial for the early detection of late-onset CAS. Continuous infusion of nitroglycerin and admission into the intensive care unit after ablation may prevent fatal outcomes.
与导管消融相关的冠状动脉痉挛（CAS）是一种重要的围手术期并发症。在此，我们描述一例消融术后5小时发生的迟发性CAS并伴有心源性休克的病例。一名先前被诊断为CAS的55岁男性因室颤接受了植入式心脏复律除颤器（ICD）植入术。因频繁发作阵发性房颤，ICD多次不适当放电。因此，进行了肺静脉隔离和线性消融，包括腔静脉 - 三尖瓣峡部线消融。术后5小时，患者出现胸部不适并失去意识。II导联心电图监测显示房室顺序起搏和ST段抬高。立即开始心肺复苏和使用正性肌力药物支持。同时，冠状动脉造影显示右冠状动脉弥漫性狭窄。冠状动脉内注入硝酸甘油立即扩张了狭窄病变；然而，患者需要在重症监护下接受经皮心肺支持和左心室辅助装置治疗。心源性休克发生后立即测得的起搏阈值稳定，且与之前的结果几乎相似。这表明心肌对ICD起搏有电反应，但由于缺血无法有效收缩。
与导管消融相关的冠状动脉痉挛（CAS）通常在消融过程中发生，但很少作为迟发性并发症出现。尽管双腔起搏器起搏正常，CAS仍可能导致心源性休克。持续监测心电图和动脉血压对于早期发现迟发性CAS至关重要。消融后持续输注硝酸甘油并收入重症监护病房可预防致命后果。
