Incidence and presumed etiology of ventricular fibrillation during coronary angioplasty

Intra-procedural arrhythmia during cardiac catheterization: A systematic review of literature

BACKGROUND

Cardiac catheterization is among the most performed medical procedures in the modern era. There were sporadic reports indicating that cardiac arrhythmias are common during cardiac catheterization, and there are risks of developing serious and potentially life-threatening arrhythmias, such as sustained ventricular tachycardia (VT), ventricular fibrillation (VF) and high-grade conduction disturbances such as complete heart block (CHB), requiring immediate interventions. However, there is lack of systematic overview of these conditions.

AIM

To systematically review existing literature and gain better understanding of the incidence of cardiac arrhythmias during cardiac catheterization, and their impact on outcomes, as well as potential approaches to minimize this risk.

METHODS

We applied a combination of terms potentially used in reports describing various cardiac arrhythmias during common cardiac catheterization procedures to systematically search PubMed, EMBASE and Cochrane databases, as well as references of full-length articles.

RESULTS

During right heart catheterization (RHC), the incidence of atrial arrhythmias (premature atrial complexes, atrial fibrillation and flutter) was low (< 1%); these arrhythmias were usually transient and self-limited. RHC associated with the development of a new RBBB at a rate of 0.1%-0.3% in individuals with normal conduction system but up to 6.3% in individuals with pre-existing left bundle branch block. These patients may require temporary pacing due to transient CHB. Isolated premature ventricular complexes or non-sustained VT are common during RHC (up to 20% of cases). Sustained ventricular arrhythmias (VT and/or VF) requiring either withdrawal of catheter or cardioversion occurred infrequently (1%-1.3%). During left heart catheterizations (LHC), the incidence of ventricular arrhythmias has declined significantly over the last few decades, from 1.1% historically to 0.1% currently. The overall reported rate of VT/VF in diagnostic LHC and coronary angiography is 0.8%. The risk of VT/VF was higher during percutaneous coronary interventions for stable coronary artery disease (1.1%) and even higher for patients with acute myocardial infarctions (4.1%-4.3%). Intravenous adenosine and papaverine bolus for fractional flow reserve measurement, as well as intracoronary imaging using optical coherence tomography have been reported to induce VF. Although uncommon, LHC and coronary angiography were also reported to induce conduction disturbances including CHB.

CONCLUSION

Cardiac arrhythmias are common and potentially serious complications of cardiac catheterization procedures, and it demands constant vigilance and readiness to intervene during procedures.

Contemporary analysis of predictors and etiology of ventricular fibrillation during diagnostic coronary angiography

OBJECTIVES

To assess the incidence, investigate the predictors and analyze the causes of ventricular fibrillation (VF) during coronary angiography (CA) on the condition of current techniques.

METHODS

From April 2004 to January 2007, a total 22,254 patients (27,798 procedures) received CA procedures in our center; 27 patients developed VF during CA. This report was to retrospectively analyze the clinical basic characteristics, coronary angiographic characteristics and CA procedure records of these patients.

RESULTS

The incidence of VF during CA was 0.097%. The incidence of VF in radial approaches and femoral approaches was 0.076% and 0.147% (p = 0.085). The VF patients had higher coronary artery bypass grafting (CABG) rates (11.1% vs 2.3%, p = 0.024) and were more likely to have a three-vessel disease (59.3% vs 31.2%, p = 0.002) and a total occlusion lesion (25.9% vs 11.1%, p = 0.014) than non-VF patients. On logistic regression analysis, three-vessel disease (OR: 2.582, 95% CI: 1.165-5.720, p = 0.019) and the history of CABG (OR: 3.959, 95% CI: 1.160-13.513, p = 0.028) were the two independent predictors of VF occurrences. Among 27 episodes of VF, 13 were ischemia-related; 11 were manipulation-related; two were contrast-related; one was hypokalemia-related; and the causes remain unclear in five episodes.

CONCLUSIONS

The incidence of VF during CA is low on the condition of current techniques. The severity of coronary artery disease (CAD) is an independent predictor of VF occurrence during CA. Acute ischemia and inappropriate manipulation may be the two main causes in VF development.

Outcome of ventricular fibrillation developing during percutaneous coronary interventions in 19,497 patients without cardiogenic shock

Ventricular fibrillation (VF) developing out of hospital or even in hospital has a reported prognosis for survival that is <50%. We examined the prognosis for VF in 19,497 patients undergoing percutaneous coronary intervention and identified 164 who had VF (0.84%). The time to defibrillation was <1 minute and was successful in all without sequelae. Thus, VF developing in the catheterization laboratory is unique in terms of prognosis.

The Clinical Value of the ECG in Noncardiac Conditions

The ECG is an indispensable tool in the ICU for the detection and diagnosis of heart disease. ECG abnormalities however can be present in a wide variety of noncardiac conditions, complicating the differential diagnosis with primary cardiac pathology. This overview discusses the ECG abnormalities and their pathophysiologic basis in the most frequently encountered noncardiac conditions, such as electrolyte abnormalities, pulmonary embolism, CNS diseases, esophageal disorders, hypothermia, and drug-related and other conditions. Knowledge of the characteristic ECG changes may provide early clues to the presence of these disorders, the prompt recognition of which can be life saving.

Mechanisms of ventricular fibrillation during coronary angioplasty: increased incidence for the small orifice caliber of the right coronary artery

BACKGROUND

Ventricular fibrillation (VF) is not an infrequent complication of percutaneous transluminal coronary angioplasty (PTCA). However, it is not clear why there is a marked discrepancy in the higher incidence of VF during right coronary artery (RCA) approach.

METHODS AND RESULTS

We analyzed in detail every case of VF occurring in 905 consecutive PTCA procedures to investigate possible mechanisms. Sixteen patients (M/F=15/1, mean age: 71 +/- 8 years) with VF during PTCA for the RCA as Group I. Those 51 patients (M/F=48/3, mean age: 70 +/- 9 years) without VF during PTCA for the RCA engagement were designated as Group II. Patients were equipped with cardiac event recorder (CardioCall, Reynolds Medical, UK) before the PTCA, and we set the time period 1 min before and after the event. The lead II was selected to check the QRS width, QTc interval, ST segment change and RR interval before and after event. A total of 905 PTCA procedures were included. There were 561 procedures for the left coronary artery and three events (0.5%) with spontaneous VF. However, there were 16 events (4.6%) of VF during 344 PTCA procedures for the right coronary artery. The incidence of VF for the right side PTCA was significantly higher than for the left side. The orifice of RCA in Group I was smaller than Group II (orifice of RCA in Group I vs. Group II - 2.7+/-0.8 vs. 4.1+/-1.2 mm, P<0.001). Most cases (68.7%) presented with ST segment depression before the onset of VF.

CONCLUSION

A small caliber of RCA and associated ST segment changes played important roles in the patients with VF during the PTCA.

Emergency extracorporeal membrane oxygenation (ECMO)-supported percutaneous coronary interventions in the fibrillating heart

We describe two cases of refractory ventricular fibrillation complicating transcatheter interventional procedures. Extracorporeal membrane oxygenation was used in each to support percutaneous coronary revascularization in the fibrillating heart as a means of facilitating successful restoration of sinus rhythm. Cathet. Cardiovasc. Intervent. 48:402-405, 1999.

Refractory ventricular fibrillation complicating acute myocardial infarction terminated by intracoronary stenting

We report on a case of intractable recurrent ventricular fibrillation that responded poorly to antiarrhythmic medication and balloon angioplasty, but resolved instantaneously following intracoronary stenting.

Sodium-calcium relationships and cardiac function during coronary bolus perfusion

The present review deals with the side-effects of contrast media (CM) on cardiac function during coronary angiography. A physiological approach is used to redefine existing concepts of CM osmotoxicity and chemotoxicity in terms of osmolal, ionic and molecular effects. The main idea conveyed is that purely ionic effects are of central importance during and immediately following the transit of a brief coronary bolus. Ionic effects result largely from rapid transient washout of normal extracellular ions, but are also influenced by ions present in the CM. In particular, the calcium (Ca) and sodium (Na) ions controlling cardiac function are easily affected. The myocardial Na-Ca exchange, which is mainly a physiological mechanism for cellular Ca efflux during cardiac relaxation, is therefore highlighted in detail. The importance of avoiding a potential Na-Ca mismatch is shown by examples from basic physiology, cardiac surgery and coronary angiography and by results of experiments with Visipaque. In the isomolal and isotonic CM Visipaque, which is based on the dimer isodixanol (320 mg I/ml), an available osmolal space is filled with an appropriately balanced supplement consisting of NaCl (19mM) and CaCl2 (0.3 mM).