Pulsed-Field Ablation–Induced Coronary Vasospasm for Atrial Tachycardia Originating From the Lateral Tricuspid Annulus

TL;DR

Pulsed-field ablation can cause coronary vasospasm even with the PulseSelect system, requiring careful monitoring during heart rhythm treatments.

Contribution

This case report is the first to document PulseSelect-induced coronary vasospasm without electrocardiographic changes.

Findings

Pulsed-field ablation with the PulseSelect system caused 75% stenosis in the right coronary artery.

Vasospasm resolved after intracoronary nitroglycerin but occurred without ECG changes.

PFA near atrioventricular annuli can induce silent coronary vasospasm regardless of catheter design.

Abstract

Pulsed-field ablation (PFA) is a novel nonthermal technique that achieves myocardial ablation with high tissue selectivity and fewer complications than conventional thermal methods. Coronary vasospasm has been increasingly reported with the Farawave catheter, but data on the PulseSelect system are limited.

A 67-year-old man with paroxysmal atrial fibrillation and atrial tachycardia (AT) underwent catheter ablation. Pulmonary vein isolation was successfully achieved with the PulseSelect system. Subsequent mapping localized the AT to the lateral tricuspid annulus. Radiofrequency ablation repeatedly terminated the AT but was followed by immediate reinduction, failing to provide durable elimination. PulseSelect PFA was then applied to the same site, resulting in immediate AT termination and complete noninducibility thereafter. However, repeat coronary angiography revealed 75% stenosis in the right coronary artery, consistent with vasospasm, which promptly resolved after intracoronary nitroglycerin administration.

This case demonstrates that PFA-induced coronary vasospasm can also occur with the PulseSelect system, often without electrocardiographic changes, warranting careful coronary assessment during ablation near atrioventricular annuli.

When using the PulseSelect system for ablation of atrioventricular annulus–origin arrhythmias, silent coronary vasospasm can occur regardless of catheter design, necessitating vigilance near the coronary arteries.

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