Transient sinus arrest caused by coronary spasm of the sinus node artery after pulsed field ablation for superior vena cava isolation: a case report

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  Figure 1. Activation mapping and ablation site at the right atrium–superior vena cava junction. (A) Activation map during sinus rhythm showing the location of the sinus node (SN) and a spontaneous conduction block line (dotted line) just superior to the SN. (B) Posterior view demonstrating preserved conduction between the right atrium (RA) and superior vena cava (SVC) through the posterior pathway (red arrows), bypassing the spontaneous conduction block line. (C) Fluoroscopic and electroanatomical mapping view showing the circular pulsed field ablation (PFA) catheter positioned along the posterior RA–SVC junction targeting the remaining conduction pathway.

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  Figure 2. Timeline of sinus arrest and coronary angiographic findings after pulsed field ablation. A structured timeline of events is shown. After four pulsed field ablation applications, sinus arrest occurred ∼1 min later, and high right atrial pacing was initiated. Coronary angiography (CAG ①) revealed complete interruption of blood flow in the sinus node artery (arrowheads) arising from the right coronary artery. Following CAG ① intracoronary, isosorbide dinitrate was administered into the right coronary artery. Sinus rhythm resumed 26 min after onset. Repeat angiography (CAG ②) demonstrated restoration of blood flow in the sinus node artery. Stable sinus rhythm was subsequently maintained.