Multivessel Coronary Vasospasm Causing Cardiogenic Shock After Anatomically Remote Pulsed Field Ablation for Atrial Fibrillation

BACKGROUND: Coronary vasospasm is an uncommon but serious complication after pulsed field ablation (PFA). Localized spasm is recognized near coronary-adjacent lesions, but generalized multivessel vasospasm after anatomically remote left atrial PFA is less defined. CASE SUMMARY: A 68-year-old man with persistent atrial fibrillation underwent pulmonary vein and posterior wall isolation with a 31-mm pentaspline PFA catheter. Immediately postprocedure, refractory hypotension and evolving ischemic electrocardiographic changes developed, initially in the inferior leads and subsequently in the anterior leads. Emergency coronary angiography revealed diffuse bilateral coronary vasospasm remote from treated sites on fluoroscopic and computed tomography/FARAVIEW assessment. Vasospasm rapidly resolved after intracoronary nitroglycerin, followed by continuous nicorandil and hemodynamic recovery. DISCUSSION: Anatomical remoteness, dynamic electrocardiographic evolution, and nitrate reversibility supported generalized vasospastic reactivity rather than focal coronary injury. Autonomic, endothelial, hemolytic, and anesthetic factors may have contributed. TAKE-HOME MESSAGES: Severe but reversible coronary vasospasm can occur after anatomically remote left atrial PFA. When hypotension or evolving ischemic ST-segment changes occur after PFA, immediate coronary angiography and intracoronary vasodilator treatment should be considered.