Abstract
Coronary sinus thrombosis is an extremely rare clinical syndrome with a high fatality rate. It is associated with procedures in the right heart, including insertion of pacemaker wires, Swan-Ganz catheters, and central venous lines. Recognition is often late, and treatment options are not well characterized. We present a case of acute coronary sinus thrombosis and occlusion associated with electrophysiologic ablation for supraventricular tachycardia in an 11-year-old boy. He developed chest pain, ST elevation, a large pericardial effusion, and cardiogenic shock. Emergent cardiac catheterization and percutaneous intervention with rheolytic aspiration thrombectomy resulted in a dramatic recovery. With the advent of new technologies and procedures involving the right heart and coronary sinus, an appreciation of this potentially lethal complication and possible treatment strategies is important.
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Introduction
Coronary sinus thrombosis is an extremely rare clinical syndrome associated with procedures involving the right heart such as central venous line insertion and coronary sinus manipulations. The syndrome is associated with a high fatality rate, often due to delayed diagnosis. Because of rarity and often fatal outcome of this disease entity, treatment options have not been well described. We herein describe a case report of coronary sinus thrombosis complicating an electrophysiologic ablation procedure and the subsequent management strategy.
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Case history
An 11-year-old boy with no significant prior medical history had symptomatic supraventricular tachycardia (SVT) diagnosed on 24-h Holter monitor. Because of recurrent symptoms, he was referred for an electrophysiologic study with possible ablation.
Multiple electrode catheters were placed (high right atrium, right ventricular apex, His bundle, coronary sinus) under fluoroscopic guidance and standard electrophysiologic evaluation was performed. Atrioventricular nodal reentry tachycardia was diagnosed. Three-dimensional mapping and ablation were performed with a cryoablation catheter. Prior to ablation, heparin was administered according to protocol. Despite several ablations eliminating reproducibly inducible tachycardia, SVT continued to recur after a period of observation. The ablations were performed in close proximity to the ostium of the coronary sinus. Radiofrequency ablation was then performed. Transient ST-elevation was noted in the inferior-lateral leads of the electrocardiograph (ECG) during radiofrequency ablation. Ablation was immediately stopped with the ECG reverting to baseline appearance rapidly. After completion of RF ablation, a repeat electrophysiologic study was performed without evidence of inducible SVT.
Initially, recovery was uneventful. Five hours after his procedure, he developed chest discomfort and the ECG showed diffuse 3- to 4-mm ST elevation, which was worse inferior-laterally ( Fig. 1 ). His condition rapidly deteriorated to cardiogenic shock and required inotropic support with intravenous dopamine and milrinone. Circumflex coronary artery thrombosis or injury was suspected and he was emergently referred for coronary angiography.
