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Ann Thorac Surg 2003;76:276-277
© 2003 The Society of Thoracic Surgeons

Case report

Left main coronary arterial lesion after microwave epicardial ablation

Eric Manasse, MD*a, Dante Medici, MDb, Simone Ghiselli, MDa, Diego Ornaghi, MDa, Roberto Gallotti, MDa

a Unità Operativa di Cardiochirurgia, Istituto Clinico Humanitas, Rozzano, Italy
b Divisione di Cardiochirurgia, Ospedale Civico, Alessandria, Italy

Accepted for publication December 6, 2002.

* Address reprint requests to Dr Manasse, Via G de Grassi 17, Milan 20123, Italy, USA
e-mail: e.manasse{at}inwind.it


   Abstract
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 Abstract
Introduction
 Comment
 References
 
We present a case of left main coronary arterial lesion in a 62-year-old man who had undergone mitral valve replacement and microwave epicardial ablation. On postoperative day 90, the patient had an anterior myocardial infarction. The coronary angiography displayed the diagnosis of the left main trunk lesion. A myocardial revascularization was urgently performed, the postoperative course was uneventful, and the patient was in sinus rhythm. The left atrial epicardial ablation represents the ultimate step in the surgical treatment of chronic atrial fibrillation; nevertheless, the left main trunk lesion may occur as an extremely severe complication. The incorrect placement of the microwave probe may be responsible for the development of critical coronary artery stenosis.


   Introduction
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 Abstract
 Introduction
Comment
 References
 
The left main trunk lesion may represent an important complication of the epicardial ablation treatment of chronic atrial fibrillation. The incorrect placement of the ablating probe may provoke coronary artery stenosis.

We present a case of left main trunk lesion in a 62 year-old man who had undergone mitral valve replacement and left atrial microwave epicardial ablation. The patient had severe rheumatic mitral valve stenosis and chronic atrial fibrillation. He was admitted to our hospital to undergo mitral valve replacement and concomitant left atrial ablation.

The patient had a 6-year history of chronic atrial fibrillation with multiple unsuccessful external electrical cardioversions. He presented symptomatic for dyspnea on effort and nocturnal paroxysmal dyspnea (New York Heart Association functional class III). A coronary angiography showed normal coronary arteries.

The patient underwent a mitral valve replacement with a mechanical prosthesis and left atrial epicardial microwave ablation to encircle the four pulmonary veins using the Flex 4 probe (AFx Inc, Freemont, CA) with a setting of 65 Watts for 90 seconds. The ablating procedure was first carried out while the patient was on cardiopulmonary bypass.

Aortic cross-clamp and extracorporeal-circulation time were 65 and 94 minutes, respectively.

The postoperative course was uneventful. The patient was discharged on postoperative day 5 in good general conditions and in sinus rhythm.

On postoperative day 90, the patient had a recurrence of angina (New York Heart Association functional class III) and presented with an anterior myocardial infarction. An angiographic study (Fig 1) displayed a critical left main trunk lesion also involving the proximal part of the left anterior descending and circumflexarteries. The patient underwent an aortic valve replacement, because of an underestimated aortic regurgitation. The patient also underwent a myocardial revascularization by means of a double bypass graft, in which the left internal mammary artery was grafted to the left anterior descending coronary artery and the left radial artery was grafted to the obtuse marginal coronary artery (Y-grafted to the left mammary artery in situ). The postoperative course was uneventful.



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  		Fig 1. Coronary angiography: left main trunk lesion.

 

   Comment
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Different sources of energy are being used to treat chronic atrial fibrillation. During the last year we have been using microwave either by an epicardial or endocardial approach. The epicardial approach may offer some theoretical advantages (ie, reducing cardiac ischemic time, avoiding unnecessary left atriotomy, and being apt for a thoracoscopic approach) [1–2].

The ablative pattern is represented by a single encircling of the four pulmonary veins, the superior and inferior tract being the transverse and oblique sinus, respectively, the medial tract being parallel to the interatrial septum, and the lateral tract being lateral to the left atrial appendage.

A threatening complication may be represented by the lesion of the main trunk or the first tract of its divisions. In fact these epicardial coronaries are at jeopardy if the probe is misplaced while ablating, respectively, in the transverse sinus and in the lateral tract (Fig 2).



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  		Fig 2. Dangerous zone.

 
In the transverse sinus the probe should be directed toward the patient’s back slightly to the feet (Fig 3A), and when closing the lateral tract between the two left pulmonary veins it should be beyond the left atrial appendage (between the left atrial appendage and the pericardial sac). Should the probe be placed at less than 90° to the origin of the left main trunk or between the left atrial appendage and the heart, the left main trunk or the circumflex coronary artery could be seriously damaged (Fig 3B).



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  		Fig 3. Probe placement: (A) Correct. (B) Incorrect; the viewer is looking toward the apex of the heart, and the aorta is being retracted away from the superior vena cava.

 

   References
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 Abstract
 Introduction
 Comment
 References
 
  1. Manasse E, Ghiselli S, Barbone A, Citterio E, Ornaghi D, Gallotti R. A new surgical technique for chronic atrial fibrillation. In: The 8th Annual Current Trends in Thoracic Surgery Meeting, Miami, FL, Jan 23–26, 2002.
  2. Mauane E, Infante M, Ghiselli S, Cariboni U, Alloisio M, Barbone A, Addis A, Gallotti R. A video-assisted thoracoscopic technique to encircle the four pulmonary veins: a new surgical intervention for atrial fibrillation ablation. Heart Surg Forum 2002;5:337–9.



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This Article
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Dante Medici
Roberto Gallotti
Right arrow Permission Requests
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Right arrow Articles by Manasse, E.
Right arrow Articles by Gallotti, R.
Right arrow Search for Related Content
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Right arrow Articles by Manasse, E.
Right arrow Articles by Gallotti, R.
Related Collections
Right arrow Electrophysiology - arrhythmias

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