Complication rates of selective percutaneous transfemoral coronary arteriography. A review of 1094 consecutive examinations

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.

Iatrogenic Cardiovascular Disease Secondary to Diagnostic and Therapeutic Procedures

The number of diagnostic and therapeutic procedures performed in cardiology continues to grow. These pro cedures are generally considered safe or of minimal risk to the patient. However, it is important to remember that significant complications may occur, and in each patient the risk: benefit ratio must be carefully weighed. In this review, the complications documented in the medical literature resulting from the use of cardiologic interventions and procedures are discussed. A thorough knowledge of these complications and their precipitat ing factors can help minimize the risk to the patient.

Intra-aortic Balloon Pump-Dependent Patient Transports by Critical Care Paramedics

OBJECTIVE

Transport of intra-aortic balloon pump (IABP)-dependent patients between hospitals is increasingly common. The transports are typically time-sensitive and require personnel familiar with IABP operation and management of a potentially unstable patient. This study examined transports performed by specially trained critical care paramedics in a large air medical and land critical care transport service.

METHODS

This retrospective, descriptive review prospectively collected data for IABP-dependent patient transports in Ontario, Canada in a 10-year interval beginning September 2003. Call records and patient care reports were reviewed to capture demographic, patient care, adverse events, and transport-related data. Adverse events, including resuscitation medication, procedure, and patient instability, were independently reviewed by 2 investigators.

RESULTS

There were 162 IABP-dependent patients transported. Seventy-one were performed by land critical care transport vehicles, 60 by helicopter, and 31 by fixed wing aircraft. The mean patient age was 63.7 ± 13.8 years; the majority (72.2%) were men. Fifty-nine patients (36.4%) were inotrope or vasopressor dependent, and 46 (28.4%) were intubated and mechanically ventilated. The most common indications for IABP insertion were acute myocardial infarction requiring prompt surgical intervention (n = 70), bridge to definitive care (n = 41), and cardiogenic shock (n = 37). The mean transport time was 92.7 ± 79.4 minutes. There were 48 adverse events in 35 patients, most commonly hypotension (systolic blood pressure < 90 mm Hg, n = 18) and tachyarrhythmia requiring therapy (n = 12). There were 3 IABP-related events and 3 cases in which the transport vehicle was inoperable resulting in a transport delay. One patient with cardiogenic shock died before departing the sending hospital. Paramedics managed all events without assistance from other health care personnel.

CONCLUSION

Specially trained critical care flight paramedics can safely transport potentially unstable IABP-dependent patients to definitive cardiac surgical care.

Complications of aortic atherosclerosis: Atheroemboli and thromboemboli

Patients with severe aortic atherosclerosis are at high risk for stroke and other embolic complications. Therapy to prevent emboli from aortic plaque is not yet established. Therefore, patients with atherosclerosis or risk factors for embolic disease should be identified and treated aggressively. Aspirin, smoking cessation, and control of blood pressure and glucose are important. Retrospective data in patients with severe aortic plaque support the use of statins to prevent stroke. Iatrogenic embolization can occur as a result of aortic manipulation during invasive vascular procedures or cardiovascular surgery. The risks and benefits of these procedures must be carefully weighed, and alternate approaches should be considered for patients with severe aortic atherosclerosis. For those who require coronary artery bypass graft (CABG) surgery, off-pump CABG is an option. Prophylactic aortic arch atherectomy should not be routinely performed. Aortic filters or stenting have been introduced but have not yet been fully evaluated. For patients who require angiography and have severe descending aortic, aortic arch, or abdominal aortic plaque, it is possible that a brachial (rather than a femoral) approach may avoid embolic complications.

Rescue left main coronary artery stenting for acute myocardial ischemia after coronary angiography in a 7-year-old girl with homozygous familial hypercholesterolemia

Homozygous familial hypercholesterolemia (HFH), resulting from mutation of the low-density lipoprotein (LDL) receptor gene with subsequent defective catabolism of the LDL cholesterol, leads to premature atherosclerosis and coronary artery disease. We report a successful urgent stent implantation in a 7-year-old patient with HFH and a severe left main coronary artery stenosis, who presented critical acute myocardial ischemia immediately after left coronary angiography. Percutaneous transluminal coronary angiography with stent implantation allowed for rapid coronary flow reestablishment without sequelae. Aggressive lipid-lowering therapy with high doses statins and LDL-apheresis was maintained, together with lifelong antiaggregant acetylsalicylic treatment with good short-term patency of the stent at 1-year follow-up. In conclusion, coronary artery stent implantation may be considered as a valid rescue therapeutic alternative for pediatric patients with HFH and severe ostial coronary stenosis in case of emergency.

Atheromas of the thoracic aorta: clinical and therapeutic update

Atherosclerotic lesions of the thoracic aorta have recently been recognized as an important cause of stroke and peripheral embolization, which may result in severe neurologic damage as well as multiorgan failure and death. Their prevalence is approximately 27% in patients with previous embolic events. Transesophageal echocardiography is the modality of choice for the diagnosis of these atheromas, although computed tomography, magnetic resonance imaging and intraoperative epiaortic ultrasound are complementary. Two clinical syndromes account for the embolic phenomena, atheroemboli and, more commonly, thromboemboli. In addition to such superimposed thrombi, plaque thickness (especially > or =4 mm) also correlates with embolic risk. This risk is high, with 12% of patients having a recurrent stroke within approximately one year, and up to 33% of patients having a stroke or peripheral embolus. In addition, aortic atheromas (as seen with intraoperative transesophageal echocardiography and intraoperative epiaortic ultrasound) are an important cause of stroke during heart surgery requiring cardiopulmonary bypass. Such strokes occur during approximately 12% of cardiac operations employing cardiopulmonary bypass when aortic arch atheromas are seen with transesophageal echocardiography (six times the general intraoperative stroke rate). Although anticoagulant strategies have been reported with encouraging results in nonrandomized studies, prospective, randomized data must be developed before an effective and safe treatment strategy can be determined. This review details the current state of knowledge in this area, including the clinical and pathologic evidence that thoracic aortic atherosclerosis is an important embolic source, data which guide current therapy and future directions for clinical investigation.

Safety of the nonionic contrast medium omnipaque in coronary angiography

The low osmolar nonionic contrast medium Omnipaque was used in 5,339 consecutive coronary angiographies and serious complications were registered. Myocardial infarction occurred in 4 patients, of whom 2 died, and ventricular fibrillation in 1. Cerebral embolism occurred in 11 patients, all of whom survived. The results are compared with those of previous series of coronary angiography with high osmolar ionic media. It is concluded that use of the nonionic medium Omnipaque resulted in a significant reduction of the frequency of serious complications.

The efficacy of ambulatory cardiac catheterization in the hospital and free-standing setting

The optimal site for performing cardiac catheterization depends upon complications of the procedure, access to care in the event of complications, costs, quality of the catheterization studies, access to the procedure, and patient satisfaction. Performing ambulatory cardiac catheterization at or adjacent to a hospital may assume equivalent access to emergent or urgent services, equivalent quality, and improved patient satisfaction at reduced cost for low-risk patients (stable coronary symptoms, no active congestive heart failure, no significant arrhythmias, and no significant comorbid factor--bleeding diathesis, renal insufficiency, uncontrolled systolic hypertension). However, moving an outpatient catheterization from the hospital site to a free-standing unit, physically remote from a hospital, may be associated with a reduction in access to emergency care and less standardized quality assurance.

How safe is the coronary angiogram?

The pertinent literature on complications of selective coronary angiography has been reviewed. Three reports that describe the incidence of major complications in large patient groups are presented for comparative analysis of their results and used as a baseline for consideration of factors that may affect variations between the actual and reported rate of complications. It is recommended that agreement be reached on formulating national standards for the performance of the examination, taking into account the best data available.

Mortality related to cardiac catheterization and angiography

During a 14-month period, 75 deaths occurring in relation to 53,581 cardiac catheterizations were consecutively and prospectively reported to the Registry Committee of the Society for Cardiac Angiography. Three of the patients died several days after their catheterization from an unrelated cause and are excluded from this analysis. There were 21 patients (group I) who arrived at the laboratory in extremis and whose deaths were expected irrespective of the catheterization. Most of these patients suffered from recent myocardial infarctions and cardiogenic shock, or had complex congenital malformations. In 35 patients (group II), a cardiovascular complication occurring during the catheterization resulted in death. In 16 patients (group III) catheterization seemed uneventful, but death occurred suddenly 10 min to 10 h after the procedure. Of these 16 patients, eight had left main coronary artery obstruction greater than or equal to 90%, five had three-vessel disease all with 90% obstructions, one had 2-vessel disease both with 90% obstructions, and who had critical aortic stenosis. The 51 unexpected deaths (groups II and III) were considered to be causally related to the procedure, a mortality rate of 0.10%. Subsets with an increased mortality rate (M), were patients with: a) left main disease greater than 50% (M = 0.94%); b) ejection fraction less than 30% (M = 0.54%); c) NYHA class III or IV (m = 0.24%); d) age over 60 years (M = 0.23%); or e) three-vessel disease (M = 0.13%). In conclusion, catheterization related mortality occurs mostly in patients with far advanced cardiac disease. Nearly 1/3 of the unexpected deaths occurred suddenly after a seemingly uneventful procedure. Close monitoring after catheterization of patients with similar characteristics (left main disease greater than or equal to 90%, or three-vessel disease all greater than or equal to 90%) might disclose avenues for reducing mortality occurring after catheterization.