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Ann Thorac Surg 2003;76:1291-1293
© 2003 The Society of Thoracic Surgeons

Case report

Circumflex artery stenosis induced by intraoperative radiofrequency ablation

Georges Fayad, MDa*, Thomas Modine, MDa, Thierry Le Tourneau, MD, PhDa, Christophe Decoene, MDa, Richard Azzaoui, MDa, Sharif Al-Ruzzeh, FRCSb, Jean Marc Lablanche, MDa, Henri Warembourg, MDa

a Service de Chirurgie Cardiovasculaire, Hôpital Cardiologique, CHRU de Lille, France
b National Heart and Lung Institute, Imperial College of Science, Technology and Medicine, Harefield Hospital, Middlesex, United Kingdom

Accepted for publication February 20, 2003.

* Address reprint requests to Dr Fayad, Service de Chirurgie Cardiovasculaire, CCVB, Hôpital Cardiologique, CHRU, 59037 Lille Cedex, France
e-mail: g-fayad{at}chru-lille.fr


   Abstract
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 Abstract
Introduction
 Comment
 References
 
We report a case of circumflex artery stenosis after intraoperative radiofrequency ablation for permanent atrial fibrillation in a patient who had a previous mitral valve replacement. The patient presented with acute pulmonary edema and severe angina 1 year after an uneventful recovery. The patient underwent a diagnostic angiography that showed the presence of stenosis of a long segment of the circumflex artery, adjacent to the radiofrequency ablation site, which was reopened successfully by angioplasty. Intraoperative radiofrequency ablation caused circumflex artery stenosis. We believe that this complication could have been avoided by applying the radiofrequency ablation more distally between the left pulmonary veins and the mitral valve.


   Introduction
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 Abstract
 Introduction
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In spite of the substantial morbidity and the relatively long operating time, the Maze III procedure has become the gold standard in the treatment of atrial fibrillation (AF), and is performed when surgery is indicated for other reasons [1]. Radiofrequency ablation (RFA) has recently been used as an alternative for the Maze III procedure. However, some specific complications related to this procedure are not yet known.

We report the case of a symptomatic stenosis of the circumflex artery after intraoperative RFA procedure on the left atrium. This stenosis was confirmed by diagnostic angiography and was subsequently treated successfully by percutaneous transluminal coronary angioplasty.

A 63-year-old woman presented with an acute pulmonary edema and severe angina. She previously underwent a mitral valve replacement for mitral stenosis using a mechanical prosthesis (Bicarbon27), associated with intraoperative RFA isolation [2] of the left atrium for permanent atrial fibrillation that had been resistant to medical therapy (antiarrhythmic drugs and cardioversion). Preoperative angiogram showed normal coronary arteries. The procedure was performed using moderate hypothermic (28°C) cardiopulmonary bypass and hemodilution with repeated anterograde cold blood cardioplegia every 30 minutes. The RFA procedure consisted of six applications (Fig 1) of 120 seconds each (target temperature 75°C, power output 150 W) using a Thermaline probe (Boston Scientific, San Jose, CA).



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  		Fig 1. Initial (left) and modified (right) radiofrequency ablation techniques (with the authorization of Medtronic Ltd, Paris, France). (Cx = circumflex artery; MV = mitral valve; RIPV = right inferior pulmonary vein; RSPV = right superior pulmonary vein.)

 
Postoperative recovery was uneventful, and a postoperative transthoracic echocardiogram showed a satisfactory result. The patient was discharged after 14 days with a normal electrocardiogram displaying sinus rhythm. One year later, she was readmitted to the hospital with severe angina and acute pulmonary edema. The electrocardiogram showed sinus rhythm with ST depression in the lateral leads, and troponin measurements remained within normal range. The transthoracic and transesophageal echocardiograms showed satisfactory function of the mitral valve with marked lateral and apical hypokinesia. Therefore, the patient underwent a diagnostic angiography that showed stenosis of a long segment of the proximal part of the circumflex artery, including the first marginal branch, with thrombosis of the distal circumflex (Fig 2). The patient did not have any other stenotic or atherosclerotic lesions elsewhere in her coronary arterial system, and this observation suggested the possibility of the cryoablation injury. The circumflex stenosis was adjacent to the mitral valve on the line of the RFA applications. This lesion was successfully treated by percutaneous transluminal coronary angioplasty (Fig 3). After percutaneous transluminal coronary angioplasty, the patient recovered from her pulmonary edema and had complete relief from angina.



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  		Fig 2. Stenosis of a long segment of the proximal part of the circumflex artery associated with a stenosis of the first marginal branch.

 


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  		Fig 3. Successful percutaneous transluminal coronary angioplasty of the circumflex artery stenosis.

 

   Comment
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 Abstract
 Introduction
 Comment
References
 
Coronary artery stenosis and occlusions after RFA have been previously described in the literature [3, 4]. However, we herein report such a lesion occurring after an intraoperative RFA procedure.

The endocardial RFA lesions develop progressively and were reported in animals 12 months after RFA [3]. The histopathologic mechanism of these lesions seems to be related to intimal hyperplasia of the endothelium of the exposed coronary artery with increased fibrous tissue formation in adventitia and media, caused by direct physical thermic effects of the RFA applications [3].

Development of coronary artery stenosis is considered to be a late complication of RFA [3]. The facts that the postoperative electrocardiogram was normal and that other coronary arteries remained normal in the second angiogram do reinforce this hypothesis. The electrical changes recorded perioperatively in some cases are likely to be related to transient thermic-induced irritability of the coronary artery leading to its spasm [3, 5]. Although risk factors that contribute to coronary artery involvement after RFA have yet to be defined, clinical and experimental data are needed to explain the mechanism of late coronary artery lesions. The proximity between the tip of the ablation probe and the coronary artery, as well as the cumulative energy exposure, might be considered risk factors [3].

Because of the fact that intraoperative RFA could be associated with serious complications, such as the one mentioned in this report, we believe the procedure should only be performed by trained and experienced surgeons. We have also modified our initial technique so that the RFA applications avoid causing a direct injury to the circumflex artery (Fig 1). We now perform one RFA application between the left pulmonary veins and the mitral annulus more distally over the atrioventricular groove after the terminal circumflex vessel has left the groove, thus avoiding the proximal part of the circumflex artery. In addition, using cold cardioplegia just before the RFA application, to minimize the thermic effect, seems to be a good tip for avoiding coronary artery injury. We have also changed the position of the second RFA application joining the isolation of the pulmonary veins to the anterior wall of the left atria to avoid any esophageal injury and reduced its power output to 100 W. We do not routinely perform angiography after intraoperative RFA, but it becomes a necessity in any patient presenting with angina after the procedure.

In conclusion, complications related to intraoperative RFA seem to be underreported and must be thought of. We believe that our modified technique of intraoperative RFA could help avoid serious complications such as coronary artery lesions and esophageal perforation.


   References
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 Abstract
 Introduction
 Comment
 References
 

  1. Cox J.L., Ad N., Palazzo T., et al. Current status of the Maze procedure for the treatment of atrial fibrillation. Sem Thorac Cardiovasc Surg 2000;12:15-19.[Medline]
  2. Melo J., Adragão P., Neves J., et al. Surgery for atrial fibrillation using radiofrequency catheter ablation: assessment of results at one year. Eur J Cardiothorac Surg 1999;15:851-855.
  3. Bertram H., Bökenkamp R., Peuster M., Hausdorf G., Paul T. Coronary artery stenosis after radiofrequency catheter ablation of accessory atrioventricular pathways in children with Ebstein’s malformation. Circulation 2001;103:538-543.[Abstract/Free Full Text]
  4. Hope E.J., Haigney M.C., Calkins H., Resar J.R. Left main coronary thrombosis after radio-frequency ablation: successful treatment with percutaneous transluminal angioplasty. Am Heart J 1995;129:1217-1219.[Medline]
  5. Morady F. Radio-frequency ablation as treatment for cardiac arrhythmias. N Engl J Med 1999;340:534-544.[Free Full Text]



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