Delayed manifestation of severe coronary artery injury/stenosis associated with cavo-tricuspid isthmus ablation: a case report

Background: Radiofrequency ablation (RFA) procedures including cavo-tricuspid isthmus (CTI) ablation have proven to be safe and effective therapies for the treatment of many cardiac tachyarrhythmias. The incidence of coronary arterial injury (CAI) associated with RFA including CTI ablation is estimated to occur in <0.1% of patients. Most instances of CAI occur during ablation procedures or within a few weeks after RFA. Case summary: We report a case of delayed manifestation of CAI of the right coronary artery 1 year after RFA, likely associated with a CTI ablation. The coronary angiography and intravascular ultrasound images revealed significant stenotic lesions primarily consisted of heterogeneous fibrous plaques including few echolucent lesions that consisted of a relatively smaller lipid or necrotic core without echo-attenuated plaques consisting of a fibroatheroma with a necrotic core or pathological intimal thickening with a lipid pool, and corresponded to the site of the CTI ablation. The patient remained stable without any symptoms 6 months post-percutaneous coronary intervention at that site. Discussion: Physicians should consider the possibility of CAI associated with RFA procedures involving ablation near the coronary arteries (CAs) in patients presenting with chest discomfort after RFA, even when the presentation is remote from the index procedure. Unanticipated anatomic variations can predispose to CAIs. Therefore, awareness of the relationship between CA course and anatomical ablation site before RFA may be important to prevent CAIs and improve procedural safety.