Coronary Artery Injury Related to Catheter Ablation for Cardiac Arrhythmias　― A Systematic Review ―

Abstract

Catheter ablation is a widely used treatment modality for various cardiac tachyarrhythmias, including atrial and ventricular arrhythmias. Although it is generally considered safe, the procedure carries potential complications, with coronary artery injury being one of the most significant. The aim of this systematic review was to assess the incidence, mechanisms, contributing factors, diagnostic strategies, and preventive measures related to coronary artery injury in patients undergoing catheter ablation, including radiofrequency catheter ablation, cryoablation, and pulsed-field ablation.

Catheter ablation is a widely used treatment for various types of cardiac arrhythmias, including atrioventricular re-entrant tachycardia (AVNRT), atrioventricular reciprocating tachycardia, atrial fibrillation (AF), atrial flutter, and ventricular arrhythmias.^1–3 Although the procedure has high success rates, it is not without complications; coronary artery injury is a potentially severe yet underreported consequence. Although rare, coronary artery injury can result in significant morbidity and mortality due to ischemic events or myocardial infarction.

The coronary arteries are situated in close proximity to various ablation targets.^4–6 Therefore, the coronary vasculature may be susceptible to damage from the energy delivered during radiofrequency catheter ablation (RFCA), cryoablation, or pulsed-field ablation (PFA). Moreover, even when the ablation targets are not adjacent to the coronary arteries, indirect damage, such as coronary artery spasm, may occur due to an imbalance in autonomic nerve activity via the ganglionated plexi. As the use of catheter-based ablation techniques increases, recognizing and mitigating this risk has become crucial.

Thus, the aim of this systematic review was to evaluate the incidence, mechanisms, and clinical consequences of coronary artery injuries related to catheter ablation for arrhythmias. In addition, we discuss the role of imaging modalities in diagnosing this complication and outline strategies for prevention and management.

Clinical Data

Complications associated with RFCA and cryoablation procedures include pericardial effusion or cardiac tamponade, stroke or transient ischemic attack, pulmonary vein stenosis, atrioesophageal fistula, phrenic nerve paralysis, and peripheral vascular complications such as deep vein thrombosis, pseudoaneurysm, and hematoma at the catheter insertion site, which may require transfusion or invasive intervention.^1,7–17 Despite being rare, coronary artery injury is a potential complication of catheter ablation.

The first large-scale survey, conducted from 1989 to 1993 using data from a multicenter ablation registry of all types of arrhythmias, reported that coronary artery injury was mostly limited to endocardial ablation of accessory pathways (0.06% [3/5,427]).¹⁸ This was likely due to the fact that the arrhythmias targeted by RFCA were predominantly Wolff–Parkinson–White syndrome and that the ablation site was near the atrioventricular groove. By the 1990s, catheter ablation had been applied to complex arrhythmias, and, with the development of standard anticoagulation protocols during the procedure, retrograde ablation of the left ventricle or aortic cusp was also performed.

A second large retrospective study focusing on detailed cases of coronary artery injury reported an incidence of approximately 0.1%.¹⁹ In a cohort of 4,655 procedures performed between 1998 and 2008, only 4 (0.09%) patients experienced coronary artery injury due to ablation.¹⁹ Coronary artery injury occurred during epicardial ventricular tachycardia ablation in 2 patients: 1 who underwent irrigated RFCA and the other who had cryoablation. The remaining cases were associated with RFCA within the middle cardiac vein. All ablation sites involved the coronary arteries. Two cases were identified where acute occlusion, characterized by ST-segment elevation, occurred shortly after ablation during the procedure. In both cases, the occlusion did not respond to nitroglycerin or balloon dilation, necessitating the use of stenting. One patient experienced an acute myocardial infarction 2 weeks after undergoing epicardial ablation, resulting in the occlusion of a coronary artery branch. Angiography revealed moderate asymptomatic stenosis after epicardial cryoablation in 1 patient. Although the time of symptom onset varied, all injuries were related to the ablation site.¹⁹

The findings of studies subsequent to these early reports are summarized in the following sections.

Atrial Fibrillation

The significant role of the pulmonary veins in initiating AF was first demonstrated in 1998 and 1999.^20,21 RFCA of AF has since evolved rapidly and become a key treatment for curing AF.^22–27 Coronary artery spasm as a complication related to RFCA for AF was first reported in 2005,²⁸ followed by additional reports.^29–32

In a large cohort of patients who underwent RFCA for AF or postablation atrial tachycardia, coronary artery injury was reported in only 8 (0.14%) patients²⁹ (Table 1). Three patients developed ventricular fibrillation due to occlusion of the distal or proximal circumflex artery from RFCA in the distal coronary sinus or at the base of the left atrial appendage. The timing of these events ranged from 20 min to 6 h after the procedures.²⁹ One patient experienced an acute myocardial infarction, and 2 required stenting. Five patients developed acute sinus node dysfunction related to RFCA near the sinus node artery, which courses over the anterior left atrium or septal right atrium. Two of these patients required permanent pacemaker placement.²⁹ The target sites of RFCA appeared to be in the distal coronary sinus and anterior left atrium, correlating with the course of the coronary artery.²⁹ Subsequently, in a prospective study following RFCA of the mitral isthmus, 28% (15/54) of patients exhibited focal narrowing or occlusion in the circumflex artery or obtuse marginal artery, which resolved with intracoronary nitroglycerin boluses.³³ No changes were detected on electrocardiograms during the procedures. The distance between the circumflex artery and the catheter positioned in the coronary sinus at 4 o’clock was significantly shorter in patients with than without circumflex artery injury (mean [±SD] 3.2±1.9 vs. 5.6±3.2 mm; P=0.04).³³

Table 1.

Key Studies on Coronary Artery Injury in Patients Undergoing Catheter Ablation for Atrial Fibrillation

Study	Publication year	Sample size	Energy type	Timing of symptom onset	Clinical presentation	Incidence (%)	Angiographic finding	Suspected mechanism of injury	Treatment
Chugh et al.29	2013	5,709	RFCA	During procedure to 6 h after procedure	VF: 38%; acute MI: 13%; SN dysfunction: 63%	0.14	Stenosis to occlusion with/without thrombus	Thermal injury to the LCx or sinus node artery	Stenting: 25%
Miyazaki et al.30	2021	4,173	Cryoballoon	During procedure	Spasm with transient ST-segment elevation: 100%; acute MI: 0%	0.17	No data	Spasm, no data	All recovered spontaneously or after nitroglycerin administration
Nakamura et al.31	2021	3,288 18,596	Cryoballoon RFCA	During procedure	ST-segment elevation: 72%; VF or CPA: 16%; acute MI: 0%	0.34 0.04	Spastic to total occlusion	Spasm due to change in autonomic tone	All recovered after nitroglycerin administration
Ekanem et al.32	2024	17,642	PFA	During procedure to postprocedure recovery	ST-segment elevation: 92%; hypotension: 20%; VF: 8%; acute MI: 0%	0.14	No data	Proximity- related spasm (88%), remote spasm (12%)	All recovered spontaneously or after nitroglycerin administration

CPA, cardiopulmonary arrest; LCx, left circumflex coronary artery; MI, myocardial infarction; PFA, pulsed-field ablation; RFCA, radiofrequency catheter ablation; SN, sinus node; VF, ventricular fibrillation.

Recent studies have shown that catheter ablation for AF is superior to drug therapy, positively impacting quality of life, morbidity, and mortality.^34–38 In addition, cryoballoon ablation has become the first-choice treatment for paroxysmal AF.^3,39–43 Consequently, cryoablation for AF has become increasingly common, with reports of large cohort studies addressing associated coronary artery injury.^30,31 Miyazaki et al. reported a 0.17% incidence of coronary artery spasms with transient ST-segment elevation and no myocardial infarction due to cryoballoon ablation in 4,173 patients with AF (Table 1).³⁰ All patients recovered spontaneously or after the administration of intravenous or intracoronary nitroglycerin. Another study indicated a 0.34% incidence of coronary artery spasm with ST-segment elevation during cryoballoon ablation in 3,288 patients with AF (Table 1).³¹ In that study, all cases of artery occlusion or narrowing were relieved by intravenous or intracoronary nitroglycerin. Most patients initially underwent cryoablation of the left pulmonary vein, and more than half the spasms occurred during the ablation of the left superior pulmonary vein.³¹ Remarkably, Miyazaki et al. noted that left superior pulmonary vein cryoballoon ablation often provoked marked vagal responses; however, preceding right superior pulmonary vein ablation significantly suppressed this response.⁴⁴ Miyazaki et al. recommended targeting the left superior pulmonary vein after addressing the right pulmonary veins.⁴⁴ These findings suggest that coronary artery spasms caused by cryoballoons may be influenced by direct cooling, as well as by epicardial ganglionated plexi, which could lead to a sudden increase in sympathetic or vagal tone and trigger spasms.

More recently, PFA has emerged as a novel non-thermal energy modality that delivers ultrarapid electrical pulses (micro- to nanosecond duration) to electroporate target tissue,⁴⁵ causing less damage to the esophagus and phrenic nerve, and not causing pulmonary vein stenosis.^46–49 In Japan, PFA is currently used for pulmonary vein isolation. coronary artery spasms occurred in 0.14% (25/17,642) of patients undergoing AF ablation with PFA (Table 1).³² The majority of these events (n=22; 88%) occurred during PFA adjacent to a coronary artery during cavotricuspid isthmus or mitral isthmus ablation. The remaining spasms (n=3; 12% [0.017%; 3/17,640]) occurred during conventional pulmonary vein applications, remote from the location of a coronary artery.³² In that study, among the 25 patients with coronary artery spasms, most (92%) exhibited electrocardiogram changes, with ventricular fibrillation documented in 2 (8%) patients.³² Chest pain developed in 2 (8%) patients in the post-procedure recovery area, and intravenous or intracoronary nitroglycerin was administered in 21 (84%) patients. All patients recovered fully.³²

Other studies reported that coronary spasm did not occur when pulmonary vein isolation was first performed using PFA.^50,51 However, cavotricuspid isthmus ablation provoked severe spasm in 100% of patients without ST-segment elevation; no patients experienced severe spasm when intracoronary or intravenous nitroglycerin was administered beforehand.⁵⁰ In addition, mitral isthmus ablation was performed, and spasm did not occur if nitroglycerin was administered; however, spasm occurred in 9.7% of cases without it.⁵¹ Based on these data, Reddy et al. recommend considering the administration of intravenous nitroglycerin before PFA, particularly when performing ablation in proximity to a coronary artery, such as during cavotricuspid isthmus and mitral isthmus ablation.⁵⁰

Supraventricular Tachycardias

Coronary artery injury during RFCA for accessory pathways was recognized early on.¹⁸ Two prospective studies have reported that the incidence of coronary artery injury is approximately 1%.^52,53 In a cohort of 70 patients undergoing RFCA for accessory pathways, coronary angiography was performed before, immediately after, and several weeks after the procedure (Table 2).⁵² One (1.4%) of these 70 patients exhibited occlusion of the distal branch of the left circumflex coronary artery at the ablation site immediately after ablation without experiencing chest pain or elevation of myocardial enzymes.⁵² On the 6-week follow-up coronary angiogram, the occlusion had completely normalized; therefore, coronary spasms were considered. In another cohort of 117 patients undergoing RFCA or cryoablation for accessory pathways and 84 patients undergoing AVNRT ablation, coronary angiography was performed before and 30 min after ablation (Table 2).⁵³ Two (1.7%) patients experienced coronary artery narrowing adjacent to the site of RFCA, accompanied by ST-segment changes but no chest pain. In both patients, the electrocardiographic changes returned to normal within 1 week, without symptoms or elevated myocardial enzyme levels. No coronary artery injury was noted after an ablation for AVNRT or cryoenergy.⁵³

Table 2.

Key Studies on Coronary Artery Injury in Patients Undergoing Catheter Ablation for Supraventricular Tachycardia

Study	Publication year	Sample size	Energy type	Target	Clinical presentation	Incidence (%)	Timing of the change	Angiographic finding	Suspected mechanism of injury	Treatment
Solomon et al.52	1993	70	RFCA	Accessory pathway	None	1.4	After successful ablation	Occlusion of distal branch of LCx	Spasm due to thermal injury to the artery	Nifedipine administration for 6 weeks
Schneider et al.53	2009	212	RFCA, n=118; cryoablation, n=48; both, n=46	Accessory pathway, n=112; AVNRT, n=84; both, n=16	ST-segment elevations	All, 0.94; accessory pathway, 1.7; AVNRT, 0	After successful ablation	Stenosis of distal RCA or LCx	Spasm due to RFCA thermal injury to the artery	None

AVNRT, atrioventricular nodal re-entrant tachycardia; LCx, left circumflex coronary artery; RCA, right coronary artery; RFCA, radiofrequency catheter ablation.

A subsequent prospective study reported acute subclinical coronary artery injury and examined the distance between the ablation site and the coronary artery during ablation of the epicardial posteroseptal accessory pathway in 169 patients.⁵⁴ Coronary artery injury occurred in 50% (11/22) of patients when the distance between the ablation site and the coronary artery ≤2 mm, in 7% (1/15) of patients when the distance was 3–5 mm, and in 0% (0/41) of patients when the distance exceeded 5 mm.⁵⁴ In contrast, no damage was observed with cryoablation for accessory pathways, regardless of whether the distance was ≤2 mm or 3–5 mm.⁵⁴ These transient coronary artery lesions suggest a direct effect on the coronary arteries.

Large studies have not reported coronary artery injury associated with AVNRT ablation; however, some cases have been documented.⁵⁵ The proximity of the posterolateral branch of either the right or left coronary artery to the coronary sinus ostium at the slow pathway ablation site may increase the risk of injury.

Other Clinical Data

Although the exact occurrence is unknown, 61 patients with coronary artery injury have been reported in a review article summarizing case reports of coronary artery stenosis, occlusion, dissection, thrombotic occlusions, and air embolism from 1992 to 2017.⁵⁶ Most (91.8%) coronary artery injuries result from anatomic proximity to the target ablation site. The most common type of arrhythmia for ablation was posteroseptal accessory pathway ablation, followed by cavotricuspid isthmus-dependent flutter.⁵⁶ Approximately 50% of patients with coronary artery injury manifest symptoms after procedures; however, the occurrence can range from 30 min to 2 years following the procedure. Coronary intervention was performed in one-third of cases, and 3 patients died due to coronary artery injury.⁵⁶ Moreover, a review article summarizing case reports from 1987 to 2018 reported 22 patients with left main coronary injury and 4 patients with injuries to the left anterior descending or circumflex coronary arteries.⁵⁷ Typically, 86% of coronary artery injuries presented as acute or subacute complications of retrograde ablation in the left ventricle, left ventricular outflow tract, or aortic cusps. Most damage was attributed to direct thermal injury near the ablation site; however, coronary artery injury was also noted 10 mm away from the coronary arteries in 2 patients.⁵⁷ At least 86% of patients presented with life-threatening arrhythmia, cardiogenic shock, or severe hypotension requiring nitroglycerin administration during hospitalization.⁵⁷ These conditions can also manifest later, such as angina due to coronary artery stenosis 2 or 4 months later, chronic coronary artery occlusion resulting in exertional angina 2 years later, and anterior descending coronary artery occlusion leading to worsening heart failure 8 years later.⁵⁷

Furthermore, epicardial ablation carries a higher risk of complications than endocardial ablation, including direct injury to the coronary arteries, subcostal vessels, chest wall vessels including the internal mammary artery and its branches, and the right ventricle.^58–60 Among patients with epicardial access, 2.6% (3/115) required surgical repair due to vessel injuries.⁵⁹ These direct injuries can lead to severe complications. However, a recent study showed that none of the punctures was complicated by inadvertent damage to the coronary artery or right ventricular puncture when using intentional coronary vein exit and carbon dioxide insufflation methods.⁶¹ It has been reported that preprocedural volume rendered computed tomography images can guide epicardial access, helping to avoid direct injury to the internal mammary and superior epigastric arteries.⁶²

Mechanism of Coronary Artery Injury and Contributing Factors

Most coronary artery injuries occur due to the close proximity of the coronary artery to the ablation sites.⁶³ Ablation delivery not only affects the target tissues but also undermines the integrity and function of blood vessels. This can result in coronary artery spasm, direct vessel trauma, or thromboembolism. However, the precise mechanisms involved have not yet been fully elucidated. Coronary spasm is thought to be linked to changes in autonomic activity at nerve terminals in the densely innervated left atrium.⁴⁴ This scenario suggests that the coronary artery does not need to be in close proximity to the ablation site.

In animal models, RFCA has been shown to induce coronary endothelial dysfunction and morphological damage when applied less than 5 mm from the coronary artery,⁶⁴ leading to severe intimal hyperplasia and intravascular thrombosis 14 days later.⁶⁵ Cryoablation is reported to be safer than RFCA when performed near the coronary artery;^54,56 however, clear standards for its use are lacking. Coronary artery injury typically occurs in the acute phase (during application or several hours later) and rarely presents as a late consequence (12–24 months later).⁵⁶

Diagnostic Strategies and Prevention of Coronary Artery Injury

First, it is essential to understand the relationship between the coronary arteries and the location of the target ablation sites.^4,5,66,67

If the ablation target is near a coronary artery, it is recommended that coronary angiography, computed tomography,^62,67,68 intracardiac echocardiography,^69–71 and 3-dimensional (3D) mapping imaging⁶⁸ findings be reviewed before the ablation. Intracardiac echocardiography is particularly useful when targeting the ventricular outflow tract or aortic cusps.^69,70 Moreover, integration of 3D mapping system with fluoroscopic images of the coronary arteries is useful in providing the distance between the ablation site and coronary artery in real time.⁷² Applying RFCA within 5 mm of the coronary artery carries a high risk of coronary artery injury.^33,54 It is advisable to maintain a minimum distance of 5 mm between the coronary artery and the ablation site; however, instances of coronary artery injury have been documented even at distances of 10 mm,⁵⁷ indicating a lack of definitive criteria.

For pulmonary vein isolation using cryoablation, it is preferable to begin with the right pulmonary vein. Nitroglycerin should be prepared for immediate administration in case of coronary spasm, and atropine may also be beneficial for some patients; therefore, it is advisable to have both medications readily available during the procedure.^73,74

During pulmonary vein isolation using PFA, it is crucial to ensure that the catheter does not shift towards the mitral annulus during left pulmonary vein isolation when the pulse is delivered. Although PFA is currently approved for pulmonary vein isolation in Japan, preadministration of nitroglycerin is recommended in cases of mitral or cavotricuspid isthmus ablation to mitigate potential risks.⁵⁰

One possible method for epicardial access is to select an intentional coronary vein exit and perform carbon dioxide insufflation.

Although clinically significant coronary artery injury is rare, there remains a risk of complications, such as ventricular fibrillation, atrioventricular block, or myocardial infarction. Electrocardiogram monitoring during and after the procedure in the hospital is also valuable. If ST-segment elevation is detected, immediate coronary angiography should be performed, with a plan to administer intracoronary nitroglycerin and provide oral nitroglycerine. If the coronary artery occlusion is not released, percutaneous coronary intervention, including aspiration of thrombi or stenting, may be required. Although very rare, late-term complications may also occur, underscoring the importance of continued electrocardiographic follow-up and symptom monitoring for at least 2 years.

Conclusions

Clinically significant coronary artery injury is rare in catheter ablation using RFCA, cryoablation, and PFA, although subclinical coronary spasm is relatively common. Physicians performing catheter ablation should ensure appropriate preparations are in place to address any clinical interventions that may become necessary.

Disclosures

K.H. has nothing to disclose. H.T. has received honoraria for lectures or speakers bureaus from Daiichi Sankyo Company, Ltd, Novartis Pharma K.K., Medtronic Japan Co., Ltd., Biotronik Japan, Inc., Bristol Myers Squibb, and Boston Scientific Japan K.K. H.T. has also received grants (investigator-initiated study unrelated to this review topic) from Abbott Medical Japan LLC, Daiichi Sankyo Company, Ltd, Nippon Boehringer Ingelheim Co., Ltd, Otsuka Pharmaceutical Co., Ltd., Eli Lilly Japan K.K., and Marubun Tsusyo K.K. H.T. is also an Associate Editor of Circulation Journal.

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