Delayed presentation of left main coronary artery dissection due to catheter ablation in a patient with bicuspid aortic valve. Coincidence or manifestation of inherent vulnerability?

Abstract

Left main coronary artery (LMCA) injury is an uncommon complication of catheter ablation. Due to the large myocardial area at risk, its presentation is usually acute with a dramatic course and life-threatening sequelae. Increased susceptibility to spontaneous coronary artery dissection has recently been implied in patients with bicuspid aortic valve (BAV). We present the first case of iatrogenic coronary dissection in a BAV patient, with an atypically delayed manifestation. The patient sustained ablation catheter-induced mechanical damage of LMCA due to its inadvertent penetration during the attempts to cross the aortic valve. After three days of recurring chest pain, he was readmitted with anterior myocardial infarction and imminent cardiogenic shock, and underwent emergent coronary stenting.Literature review suggests that in BAV inherent susceptibility to both spontaneous and iatrogenic coronary dissection may exist. Therefore, we advocate that in BAV extreme caution should be exercised during electrophysiological procedures involving the coronary artery cannulation for tagging or pace mapping, or when the left ventricle is to be entered retrogradely, and likewise in percutaneous coronary interventions. Such patients may be doubly predisposed to iatrogenic injury; firstly, by more difficult catheter manipulation in the malformed aortic cusps, and secondly, by the underlying vulnerability of coronary ostia.<Learning objective: Arteriopathy in bicuspid aortic valve (BAV) is not limited to the aorta. It is considered a connective tissue disease predisposing to spontaneous coronary artery dissection. This predisposition may also render the patients more vulnerable to iatrogenic dissection.Ablation in the aortic cusps or with the aortic valve crossing, and percutaneous coronary interventions may require special precautions in the BAV population.Physicians attending post-ablation patients should be aware of a delayed coronary artery occlusion risk.>