Increased risk of ventricular fibrillation associated with temporary pacemaker use during coronary arteriography

Temporary Transvenous Cardiac Pacing in Patients With Acute Myocardial Infarction Predicts Increased Mortality

Background

Temporary pacemakers (TP) are used in emergency situations for severe bradyarrhythmias secondary to acute myocardial infarction (AMI) and to non-AMI related cardiac disorders. TP have been studied previously in AMI patients treated with thrombolytic therapy; limited information is available on current outcomes in AMI patients treated with percutaneous coronary intervention.

Methods

We reviewed the indications, complications, and mortality associated with TP insertion over a four year period (2003 - 2007) at a university hospital.

Results

Seventy-three temporary pacemakers were inserted (47 men, 26 women) during this period. The mean age was 65.2 years. TP were used in 29 AMI patients (39.7 % of total) and 44 non-AMI patients (60.3% of total). The duration of TP use was 2.6 ± 0.4 days in the whole cohort, 2.46 % of all AMI patients (29/1180) admitted during this period required a TP. Six of these patients requiring a TP required a permanent pacemaker. Eight patients with AMI and a TP died (27.6%). In contrast 8.9 % of AMI patients not requiring a TP died (P < 0.01). There were no statistically significant differences between the AMI and non-AMI groups in the duration of temporary pacing (2.4 ± 0.6 days vs. 2.8 ± 0.4 days), in complications (27.6% vs. 29.5%), or in mortality (27.6% vs. 15.9%). The need for a permanent pacemaker (PPM) differed significantly between the AMI and non-AMI patients (20.7% vs. 54.5%; P < 0.05).

Conclusion

Our results indicate that AMI patients infrequently require a TP and that approximately 20% of these patients require a PPM. These results suggest that early revascularization of the conduction system with current interventional techniques has decreased the need for TP in AMI patients. However, this group requires more intensive monitoring as the mortality rate in this group of patients is significantly higher than the other AMI patients not requiring TP.

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.

Transient loss of sensing and capture during coronary angiography in two patients with permanent pacemakers

Two cases of transient pacemaker failure to sense and capture during angiography are reported. This phenomenon is due to a transient increase in sensing and pacing thresholds beyond the pacemakers programmed settings. The underlying mechanism may be related to blood displacement, the electrochemical properties of the injectate, the high concentration of the contrast media, or a combination of these properties. Even though the chambers in which sensing and pacing loss occurred differed (ventricle in the first and atria in the second), the episode occurred repeatedly after injection of contrast media into the artery supplying the respective electrode-tissue interface. In pacemaker dependent patients, provisions for external pacing should be implemented prior to injection of contrast into the coronary arteries.

Reduction of ventricular arrhythmias by atropine during coronary arteriography

Sustained ventricular arrhythmia is a well-recognized complication of cardiac catheterization, often occurring after selective coronary artery injection of contrast medium. The role of autonomic reflexes in the pathogenesis of this phenomenon is unclear. Although the muscarinic antagonist atropine is often administered prophylactically before coronary angiography to reduce the likelihood of sinus bradycardia and vasovagal reactions, its influence on ventricular arrhythmias in this setting has not been established. This case-control trial studied 648 patients undergoing coronary arteriography to investigate this issue. Eleven case subjects (those with ventricular tachyarrhythmia) were identified. Control subjects (those without ventricular tachyarrhythmia) were matched for baseline heart rate (+/- 6 beats/min), age (+/- 10 years), sex and calendar year of procedure using a 1:3 sampling ratio. All 26 potential clinical, anatomic and hemodynamic covariates were statistically similar between groups. Ventricular tachyarrhythmias were more likely to occur after selective right coronary injection (odds ratio 15.1, p = 0.0008) but not after multiple contrast injections (odds ratio 0.918, difference not significant). Most importantly, atropine sulfate was administered prophylactically to 18 of 33 control subjects (55 +/- 9%) but only 1 of 11 cases (9 +/- 9%), generating a significant odds ratio of 12.0 (p = 0.02). Thus, the odds of experiencing sustained ventricular tachyarrhythmias during coronary arteriography may potentially be reduced 12-fold by prior administration of atropine, even in patients with normal baseline heart rates.

Use of balloon flotation pacing catheters for prophylactic temporary pacing during diagnostic and therapeutic catheterization procedures

The use of prophylactic temporary pacemakers during diagnostic catheterization, coronary angioplasty and percutaneous balloon valvuloplasty was investigated retrospectively over an 18-month period. Balloon flotation temporary pacemaker leads were placed in 193 (12%) of 1,609 patients undergoing diagnostic catheterization, 641 (65%) of 993 patients undergoing coronary angioplasty and 199 (100%) of 199 patients undergoing aortic or mitral valvuloplasty. There were no perforations or significant arrhythmic complications related to pacemaker placement in these 1,033 cases, and pacing was initiated promptly when required by withdrawal of the catheter tip into the right ventricle. Significant bradycardia or new conduction defects developed in 17 patients (1%) during diagnostic catheterization, 10 patients (1%) during angioplasty and 20 patients (10%) during valvuloplasty, but were severe enough to require initiation of temporary pacing in only 1 (0.06%), 4 (0.4%) and 5 (2.5%) patients, respectively. No patient undergoing diagnostic catheterization or angioplasty (but 5 patients undergoing valvuloplasty) required immediate pacing support to treat a life-threatening bradycardia. The total cost of prophylactic pacemakers was $103,300, with a cost per actual use of $19,300 for diagnostic cases, $16,025 for angioplasty and $3,980 for balloon valvuloplasty. These data suggest that prophylactic temporary pacing is not indicated during either diagnostic catheterization or coronary angioplasty, but should be used routinely during balloon valvuloplasty.

Use of temporary pacemakers during coronary angioplasty: an evolving experience with ventricular fibrillation in 400 cases

Because of a perceived high frequency of ventricular fibrillation when a pacemaker catheter was placed in the right ventricular apex during PTCA, we reviewed our first 400 cases for this complication. The incidence of ventricular fibrillation in the entire group was 10 of 400 cases (2.5%) compared with 17 of 3,806 (0.4%) diagnostic coronary arteriograms performed in our laboratory during the same time period (P less than .001). Ventricular fibrillation occurred more frequently during PTCA when the pacemaker catheter tip was placed in the right ventricular apex (8 of 63 cases, 12.6%) than when it was positioned in either the pulmonary artery, vena cava, or when a pacemaker catheter was not used (2 of 337 cases, 0.6%, P less than .001). Based on these data we have developed a policy of inserting temporary pacemakers prophylactically during PTCA only for patients undergoing dilation of dominant right or dominant left circumflex coronary arteries and in patients with acute myocardial infarction.

Effect of calcium-binding additives on ventricular fibrillation and repolarization changes during coronary angiography

Ventricular fibrillation during coronary angiography with Renografin-76 (meglumine sodium diatrizoate) has been attributed to the calcium-binding additives sodium citrate and sodium ethylenediaminetetraacetic acid (EDTA), which may produce repolarization changes manifested as prolongation of the QT interval. Angiovist-370 is a newer form of meglumine sodium diatrizoate that contains calcium EDTA as its additive and thus has a decreased calcium-binding effect. Eight hundred sixteen patients were prospectively randomized to receive either Renografin-76 or Angiovist-370. Ventricular fibrillation occurred in 10 of 410 patients receiving Renografin-76 and in 0 of 406 patients given Angiovist-370 (p less than 0.0005). Clinical data were analyzed without knowledge of other data in the 10 patients treated with Renografin-76 who had ventricular fibrillation (Group I), 103 randomly selected patients who also received Renografin-76 but had no ventricular fibrillation (Group II) and 108 randomly selected patients given Angiovist-370 (Group III). Of several variables examined, only the QT interval differentiated patients receiving Renografin-76 and Angiovist-370. The mean corrected QT interval (QTc interval) before coronary angiography was slightly but not significantly (p = 0.7) higher in Group I than in Groups II and III. Ten seconds after the first left coronary artery injection it was more prolonged in Groups I and II (0.552 and 0.561 second, respectively) than in Group III (0.448 second) (p less than 0.00005). Similarly, 10 seconds after the first right coronary artery injection it was significantly longer in Groups I and II (0.545 and 0.544 second) than in Group III (0.477 second) (p less than 0.00005).(ABSTRACT TRUNCATED AT 250 WORDS)

Temporary pacemaker use during coronary arteriography

The risk of life-threatening ventricular arrhythmias complicating coronary angiography is reportedly increased in patients in whom temporary righ ventricular pacemakers are used. Placement of the temporary pacing electrode in the right atrium or vena cava during angiography theoretically removes from the vulnerable ventricle a source of mechanically or electrically induced ventricular arrhythmias. This hypothesis was evaluated in 7,648 consecutive patients who underwent cardiac catheterization with selective coronary angiography, including 103 with life-threatening ventricular arrhythmic complications. The prevalence of ventricular arrhythmias was 6.4 times greater in patients with temporary pacemakers than in those without (7% vs 1.1%, respectively, p less than 0.001). Analysis of 369 cardiac catheterizations concurrently using temporary pacemakers revealed a greater than 4-fold decrease in the frequency of ventricular arrhythmias when the pacing electrodes were located in the right atrium or vena cava rather than the right ventricle (2% vs 9%, respectively, p less than 0.01). No significant difference in indications for temporary pacing could be distinguished between the groups based on location of the pacing electrode or occurrence of ventricular arrhythmias. These findings confirm that there is an increased risk of ionic contrast agent-induced ventricular arrhythmias in patients with chronic underlying conduction disturbances undergoing coronary angiography with concurrent right ventricular temporary pacemakers. This risk can be significantly decreased by placing the pacing electrode in the right atrium or vena cava.

Ventricular fibrillation during coronary angiography: the precatheterization QT interval

Ventricular fibrillation during coronary angiography is associated with contrast-induced changes in repolarization and thus pre-catheterization abnormalities could predispose to this event. We retrospectively examined angiograms, pre-catheterization electrocardiograms and records of 26 consecutive patients who had ventricular fibrillation during coronary angiography, and compared these patients to controls matched for age, sex, and left ventricular function. Diatrizoate meglumine was used as the angiographic contrast agent in all instances. Catheterization findings and the prevalence of prior myocardial infarction were similar in both groups. However, pre-catheterization QT intervals in the ventricular fibrillation group (0.43 +/- 0.05 sec) were significantly longer than in control patients (0.39 +/- 0.04 sec, P less than 0.005) as were their QT intervals corrected for heart rate (QTc) (0.47 +/- 0.04 vs 0.42 +/- 0.03 sec; P less than 0.001). Only seven of the 16 patients (44%) with ventricular fibrillation who had a precatheterization QTc greater than 0.44 sec had the arrhythmia during angiography of a critically stenosed (greater than 75%) coronary artery, whereas VF followed injection of critically stenosed vessels in eight of 10 (80%) of those with a normal QTc (p NS). After a follow-up period of 24 to 54 months (mean 39), two ventricular fibrillation patients have died (one suddenly), as compared to five in the control group (two suddenly) (p NS). Therefore, pre-catheterization QT prolongation was associated with ventricular fibrillation during coronary angiography, but ventricular fibrillation did not necessarily portend a worse long-term prognosis.

Cardiac arrhythmias associated with prophylactic pacing during coronary angiography

Data from 518 consecutive cardiac catheterizations were analyzed to test the value of prophylactic pacemaker insertion during coronary angiography and to compare the incidence of arrhythmic complications in patients with and without pacemakers. In patients without pacing (n = 273), 1 episode of ventricular fibrillation occurred, which responded promptly to defibrillation. Sinus bradycardia (fewer than 30 beats/min for 10 seconds) was recorded in 74 patients (27%) and required treatment in 30 (11%). No patient required or would have benefited from pacemaker placement. Of the 245 patients with prophylactic pacemakers, there was an increased incidence of all ventricular (9 vs 1; p less than 0.013) and supraventricular (5 vs 0; p less than 0.046) arrhythmias. Pacemaker-associated induction of ventricular fibrillation occurred in 2 patients and was clearly related to electrical stimulation during a normally non-vulnerable period of the cardiac cycle. In conclusion, routine prophylactic pacemaker insertion during coronary angiography is not warranted in patients with normal sinus rhythm and normal atrioventricular conduction. More information is needed to determine if pacing is needed in patients with conduction system disease.