
==== Front
Oxf Med Case Reports
Oxf Med Case Reports
omcr
Oxford Medical Case Reports
2053-8855
Oxford University Press

10.1093/omcr/omae110
omae110
Case Report
AcademicSubjects/MED00010
omcrep/200
Iatrogenic acute type A aortic dissection during catheter ablation for idiopathic ventricular premature contraction
https://orcid.org/0000-0001-6030-184X
Ishida Shinichi Department of Cardiac Surgery, Gifu Prefectural Tajimi Hospital, 5-161 Maebata-cho, Tajimi-city, Gifu 507-8522, Japan

Takemoto Yoshio Department of Cardiology, Gifu Prefectural Tajimi Hospital, 5-161 Maebata-cho, Tajimi-city, Gifu 507-8522, Japan

Kimata Ryutaro Department of Cardiac Surgery, Gifu Prefectural Tajimi Hospital, 5-161 Maebata-cho, Tajimi-city, Gifu 507-8522, Japan

Yagami Kei Department of Cardiac Surgery, Gifu Prefectural Tajimi Hospital, 5-161 Maebata-cho, Tajimi-city, Gifu 507-8522, Japan

Corresponding author. Department of Cardiac Surgery, Gifu Prefectural Tajimi Hospital, 5-161 Maebata-cho, Tajimi-city, Gifu 507-8522, Japan. E-mail: shin1dinho@yahoo.co.jp
9 2024
22 9 2024
22 9 2024
2024 9 omae11002 4 2024
17 5 2024
© The Author(s) 2024. Published by Oxford University Press.
2024
https://creativecommons.org/licenses/by-nc/4.0/ This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com

Abstract

Acute aortic dissection type A during cardiac catheterization has been reported as a rare but fatal complication. We present a case of acute aortic dissection type A occurring during catheter manipulation in the ascending aorta during mapping of ventricular premature contraction via the retrograde approach. In the present case, transthoracic echocardiography showed no pericardial effusion and no flap of the aorta, but intracardiac echo clearly showed the flap. Enhanced computed tomography revealed the aortic dissection, which extended from the ascending aorta to the bilateral common iliac artery, and the false lumen was thrombosed completely. Emergent surgery was performed and the postoperative course was uneventful, and he was discharged with no complications. Aortic dissection is a rare complication of cardiac catheterization, and early detection could prevent a fatal outcome. It is important to detect the signs and symptoms as quickly as possible and perform various diagnostic examinations.

acute aortic dissection
catheter ablation
==== Body
pmcIntroduction

Acute aortic dissection type A (AADA) during cardiac catheterization has been reported as a rare but fatal complication, with a few cases occurring during catheter ablation. We present a case of AADA occurring during catheter manipulation in the ascending aorta during mapping of ventricular premature contraction (VPC) via the retrograde approach.

Case report

A 65-year-old male presented with intermittent chest discomfort. He had a medical history of hypertension, dyslipidemia, and cerebral infarction without sequelae. Preoperatively performed echocardiography and coronary angiography showed no underlying structural heart disease. Twenty-four-hour-Holter electrocardiography showed 13% single VPCs, which explained his cardiac discomfort. He refused medical therapy and was thus referred for catheter ablation for VPCs. In the morphology of the electrocardiogram of VPC (Fig. 1), large R waves were observed in the inferior leads (II, III, aVF), and an R or Rs pattern was demonstrated in the precordial leads V3 to V6. Deep S waves were demonstrated in lead V2. These findings indicate that the VPCs originated from the left ventricular outflow tract (LVOT).

Figure 1 Electrocardiogram before catheter ablation.

After placing 2 sheaths each in the right femoral vein and artery, and 1 sheath in the left subclavian vein, a 10-polar straight deflectable mapping catheter “DECANAV” (Biosense Webster, Yokneam Illit, Israel) was advanced into the right ventricle outflow tract (RVOT). An activation map and pace map under 3D anatomical mapping using the CARTO system (Biosense Webster) indicated that the origin was not in the RVOT. Before placing the DECANAV catheter in the aorta, the geometry around the aortic valve cusps and LVOT were created using CARTO SOUND (Biosense Webster). During the manipulation of mapping in the aorta via the retrograde approach, the patient complained of pain, which occurred in the chest and moved to the back. It happened before delivering any radiofrequency applications. Coronary angiography was performed and revealed normal findings. Transthoracic echocardiography showed no pericardial effusion. Intracardiac echo CARTO SOUND demonstrated the presence of aortic dissection. The catheter procedure was stopped. Enhanced computed tomography (eCT) revealed AADA, which extended from the ascending aorta to the bilateral common iliac artery, and the false lumen was thrombosed completely (Fig. 2). Emergent surgery was performed. A tear of the intima was confirmed at a slight cranial sinotubular junction on the right coronary cusp side of the ascending aorta (Fig. 3), but the coronary arteries were intact. Thus, ascending aortic replacement was performed. The postoperative course was uneventful, and he was discharged with no complications after 3 weeks.

Figure 2 Enhanced computed tomography showing a type A aortic dissection. The dissection extended from the ascending aorta (A, arrow) to the bilateral common iliac artery (B, arrows). The false lumen was completely thrombosed.

Figure 3 Intraoperative images obtained from the surgeon’s perspective. A tear of the intima was confirmed at a slight cranial sinotubular junction on the right coronary cusp side of the ascending aorta (arrow).

Discussion

Iatrogenic aortic dissection is a rare complication of cardiac procedures, with an incidence of 0.06% for open surgery and 0.01% for cardiac catheterization [1], as well as a mortality rate of 35% [2]. In this case, AADA occurred during the manipulation of the mapping catheter. It was likely precipitated by mechanical injury to the intima of the ascending aorta, which was repaired by emergent surgery. The preoperative hemodynamics were relatively stable despite the presence of AADA, which may be explained by the situation that the false lumen of the aorta was occluded due to the thrombus formation. The past few reports describing aortic dissection during catheter ablation also indicate an occlusion of the false lumen [3–5]. Aortic dissection is difficult to diagnose compared to apparent complications such as cardiac perforation. In the present case, transthoracic echocardiography showed no pericardial effusion and no flap of the aorta, but intracardiac echo clearly showed the flap, which was confirmed by eCT, thus leading to management with cardiac surgery.

In conclusion, aortic dissection is a rare complication of cardiac catheterization, and early detection could prevent a fatal outcome. It is important to detect the signs and symptoms as quickly as possible and perform various diagnostic examinations.

Acknowledgements

There is no financial support for this publication.

Conflict of interest

We have no conflict of interest to declare.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Ethical approval

No ethical approval is required for case report in our institusion.

Content

Informed consent for publication of their details was obtained from the patient.
==== Refs
References

1. Leontyev S , BorgerMA, LegareJF. et al. Iatrogenic type A aortic dissection during cardiac procedures: early and late outcome in 48 patients. Eur J Cardiothorac Surg 2012;41 :641–6.22345184
2. Januzzi JL , SabatineMS, EagleKA. et al. Iatrogenic aortic dissection. Am J Cardiol 2002;89 :623–6.11867057
3. Yeshwant SC , TsaiMH, JonesBR. et al. Iatrogenic type A aortic dissection during idiopathic ventricular tachycardia ablation. HeartRhythm Case Rep 2017;3 :396–9.28840108
4. Kuroki K , SatoA, YamagamiF. et al. Life-threatening aortic dissection with cardiac tamponade during catheter ablation for ventricular tachycardia originating from left coronary cusp. J Cardiovasc Electrophysiol 2017;28 :1224–5.28635147
5. Keegan R , HaseebS, OnettoL. et al. Fatal aortic dissection associated with catheter ablation. EP Europace 2021;23 :215.
