Spastic occlusion of coronary artery during cryoballoon pulmonary vein isolation

Introduction Recently, pulmonary vein isolation (PVI) with cryoballoon (CB) has been widely accepted as treatment for atrial fibrillation (AF). Especially, second-generation CB (Arctic Front Advance, Medtronic, Inc, Minneapolis, MN) has a high cooling effect, which can achieve durable lesions of pulmonary vein (PV) antrum and better clinical outcomes. On the other hand, several complications, such as esophageal erosions and phrenic nerve injuries, have been reported with AF ablation using secondgeneration CB. Lehrmann and colleagues have reported a case of near-fatal coronary artery spasm during PVI using second-generation CB. In this case, the mechanism of coronary artery spasm was speculated as cryoenergyinduced blood cooling, which was attributable to the close proximity between the CB and coronary artery spasm site. We experienced a case in which coronary artery spastic occlusion occurred in the distal right coronary artery during CB application at the left common PV, far from the coronary spasm site.