Right ventricular perforation with cardiac tamponade associated with use of a temporary pacing wire and abciximab during complex coronary angioplasty

Pericardial tamponade as a complication of invasive cardiac procedures: a review of the literature

Cardiac tamponade (CT) is a rare but often life-threatening complication after invasive cardiac procedures. Some procedures favor CT. Furthermore, the incidence depends on patients’ comorbidities, sex and age and operators’ skills. In this paper we review studies and meta-analyses concerning the rate of iatrogenic CT. We define the risk factors of CT and show concise characteristics for each invasive cardiac procedure separately. According to our analysis CT occurs especially after procedures requiring transseptal puncture or perioperative anticoagulation. The overall rate of CT after such procedures varies among published studies from 0.089% to 4.8%. For this purpose we searched the PubMed database for clinical studies published up to December 2018. We included only those studies in which a defined minimum of procedures were performed (1000 for atrial fibrillation ablation, 6000 for percutaneous coronary intervention, 900 for permanent heart rhythm devices, 90 for left atrial appendage closure, 300 for transcatheter aortic valve implantation and percutaneous mitral valve repair with the Mitra-Clip system). The search was structured around the key words and variants of these terms. In addition, secondary source documents were identified by manual review of reference lists, review articles and guidelines. The search was limited to humans and adults (18+ years).

Rapid ventricular pacing for a basilar artery pseudoaneurysm in a pediatric patient: case report

Large cerebral aneurysms of the basilar apex are difficult to treat. Recently, endovascular treatment has mitigated much of the morbidity associated with treating these lesions. However, the morphology of aneurysms of the vertebrobasilar system can preclude endovascular treatment. Rapid ventricular pacing (RVP) facilitates open surgical treatment of cerebral aneurysms. It can assist in reducing the pressure of the neck of the aneurysm, allowing safe application of a clip. The authors present a case of a pediatric patient who developed a basilar artery pseudoaneurysm that required surgery. Given the large size of the aneurysm, RVP was performed, allowing the surgeons to dissect the dome of the aneurysm from the surrounding tissue and pontine perforating branches away from the lesion to safely clip the lesion. The patient had an uneventful recovery. To the authors' knowledge, this represents the first known case of RVP to aid in basilar artery clip occlusion in a pediatric patient.

Rapid ventricular pacing assisted hypotension in the management of sudden intraoperative hemorrhage during cerebral aneurysm clipping

Sudden intraoperative hemorrhage during intracranial aneurysm surgery from vascular injury or aneurysmal rupture has been known to dramatically increase the associated morbidity and mortality. We describe the first reported use of rapid ventricular pacing (RVP) assisted hypotension to control sudden intraoperative hemorrhage during intracranial aneurysm surgery where temporary arterial occlusion was not achievable.

Rapid Ventricular Pacing for Flow Arrest During Cerebrovascular Surgery: Revival of an Old Concept

BACKGROUND:

Intraoperative rupture of a cerebral aneurysm can be a devastating event that increases operative morbidity and mortality. Rapid ventricular pacing (RVP) is a technique used in interventional cardiology to obtain flow arrest for short periods of time.

OBJECTIVE:

To present our experience using RVP for flow arrest during cerebrovascular surgery.

METHODS:

We used RVP to produce flow arrest for periods of 40 seconds in 12 patients who underwent craniotomy for a cerebrovascular disorder (11 aneurysms and 1 arteriovenous malformation).

RESULTS:

During RVP, there was an immediate and significant reduction of blood pressure in each patient. The maximum degree of hypotension was obtained 3.2 ± 0.7 seconds (mean ± SD) after the start of RVP. When RVP was terminated, normal sinus rhythm returned instantaneously, along with recovery of indexes of hemodynamic function. Subjectively, the decrease in blood pressures facilitated dissection, and during clipping, the aneurysm sac felt softer and was easier to manipulate. No complications related to RVP occurred.

CONCLUSION:

Rapid ventricular pacing during cerebrovascular surgery is an effective method for lowering the arterial blood pressure in a controlled and directly reversible manner. Advances in cardiology now make RVP a promising and safe technique that can facilitate complex cerebrovascular surgery.

Coronary stent immobilization during angioplasty by transcoronary ventricular pacing via a guidewire

INTRODUCTION AND OBJECTIVES

In some patients, cardiac contractions cause the coronary artery segment adjacent to a stent to move in such a way that accurate stent positioning is difficult. A number of techniques have been described for immobilizing the stent at the target site by inducing periods of either asystole or tachycardia. This study shows how pulsatile motion can be controlled by means of rapid ventricular pacing via an angioplasty guidewire.

METHODS

The study involved 27 consecutive patients in whom excessive stent movement during angioplasty complicated accurate stent implantation. In these selected patients, myocardial tachycardia was induced by transcoronary ventricular pacing via an angioplasty guidewire with the aim of reducing the pulsatile motion of the stent.

RESULTS

At baseline, the median displacement was 4.08 mm (interquartile range 2.75 mm). During pacing at 100 and 150 beats per minute, the median displacement was 1.39 mm and 0.54 mm, respectively (interquartile range 1.66 mm and 0.54 mm, respectively). Transcoronary myocardial pacing was effective in 96% of cases. No complications associated with pacing were reported.

CONCLUSIONS

Transcoronary ventricular pacing via an angioplasty guidewire was an effective and safe method for achieving stent immobilization in cases where there was excessive pulsatile motion.

Feasibility and safety of the transradial approach for the intracoronary spasm provocation test

An angiography-based spasm provocation test is an accurate diagnostic test of coronary vasospastic angina, but is associated with high patient morbidity, mainly because of the femoral approach and the need for a temporary pacemaker. The purpose of this study was to investigate the safety and feasibility of a transradial ergonovine spasm provocation test. The test was performed prospectively in 174 consecutive patients who were under suspicion of coronary vasospasm at our institution from April 2002 to June 2003. Seventy-eight out of 174 procedures (45%) were performed in an outpatient department. The procedural success rate was 168/174 (96%). All failures were because of access failures, and no major complications were noted. Minor complications were observed in nine patients (severe bradycardia in three, hypotension in two, both in two, and nonsustained ventricular tachycardia in two). The incidence of complications was higher in patients showing prolonged spasm in the right coronary artery. No major local complication was noted other than rebleeding in the puncture site during hemostasis in one patient. The transradial spasm provocation test performed without using a temporary pacemaker may be feasible and safe, with a high success rate and low complication rate as well as low patient morbidity.

Temporary Pacemakers in Critically Ill Patients

Temporary cardiac pacing provides electrical stimulation to a heart compromised by disturbances in the conduction system causing hemodynamic instability. The use of a temporary pacemaker to treat a bradydysrhythmia or in some cases, a tachydysryhthmia, is undertaken when the condition is temporary and a permanent pacemaker is not necessary or available in a timely fashion. Temporary cardiac pacing is utilized in acute situations and for critically ill patient populations requiring immediate therapy. This article discusses the various indications and contraindications to temporary cardiac pacing therapy, reviews the different modalities of temporary pacemakers, and outlines critical considerations in the management of patients being treated with a temporary pacemaker.

Cardiac tamponade in the "new device" era: evaluation of 6999 consecutive percutaneous coronary interventions

BACKGROUND

The incidence of cardiac perforation and pericardial tamponade appears to be increasing in the era of new coronary interventional devices compared with coronary balloon angioplasty.

METHODS AND RESULTS

We reviewed 6999 consecutive percutaneous coronary interventions performed during 1994 to 1996 in a single urban university hospital catheterization laboratory. Data had been collected prospectively as part of an ongoing quality assurance program. Fifteen patients had cardiac tamponade within 36 hours of the procedure. Only 6 of these occurred during the interventional procedure; the others occurred 2 to 36 hours later. The median patient age was 72 years. Nine (60%) patients were female. Three patients received abciximab. Five perforations were at the target coronary artery site, 3 were caused by a guide wire tip in the distal part of the target artery, and 7 represented right ventricular perforations caused by a temporary pacemaker wire. Five of the 7 right ventricular perforations occurred during rotational atherectomy procedures. Diagnosis was aided by immediate echocardiography. Treatment was medical, including pericardiocentesis, in 6 cases. The other 9 patients required surgical drainage and repair. All patients survived the index hospitalization. At 18-month follow-up, 1 patient had died, and all others were without apparent sequelae.

CONCLUSIONS

Tamponade after percutaneous coronary intervention is not rare in the "new device" era (overall incidence 0.2%); tamponade after percutaneous coronary intervention is often delayed and may occur outside the catheterization suite; patients are more likely to be female and elderly; immediate echocardiography is an essential aid to diagnosis and prompt treatment; and the use of temporary right ventricular pacing catheters must be reexamined.