Coronary spasm during outpatient fiberoptic laser bronchoscopy

Safety of interventional bronchoscopy through complication review at a cancer center

BACKGROUND AND AIMS

There have been rapid advances in the area of interventional bronchoscopy over the past 15 years, but associated complications have been rarely discussed. A longitudinal evaluation of the same operator's performance at a cancer center is reported.

METHODS

A detailed record review of diagnostic and therapeutic bronchoscopy between January 1997 and March 2013 was conducted.

RESULTS

Among the 1358 diagnostic bronchoscopies, there were nine major complications requiring premature termination and three pneumothoraces found during follow-up (0.88%). An escalation in the level of care was required for four patients with massive bleeding, asthma attack, sedation intoxication and myocardial ischemia, respectively. Six cases occurred after brushing (0.71%), and five cases before any sampling procedure was conducted. The complication rate was highest for peripheral lesions (1.03%). Among the 109 therapeutic bronchoscopies, no major patient-specific complication occurred except for excessive granulation tissue formation following metallic stenting in one patient with benign tracheal stenosis.

CONCLUSION

The complication rate with regard to bronchoscopy is comparable with historical controls according to the related literature, and their occurrence appears to be sporadic, not relevant to patient characteristics and mostly related to the bronchoscopy itself rather than the introduction of new techniques. Bronchoscopy remains safe along with technical innovations. However, risk recognition and effective prevention is essential.

Incidence of serious adverse events during nocturnal polysomnography

OBJECTIVES

The purpose of the study was to verify whether minimal concern is warranted in regard to serious adverse effects in the sleep laboratory.

DESIGN

A prospective multicenter study

PARTICIPANTS

Three scoring teams for 17 sleep laboratories.

METHODS

Reports of adverse events occurring during polysomnography or identified upon scoring a study were collected over an 18-month time period. Incidence of mortality and adverse events were evaluated using a binomial distribution based on the Bernoulli process.

RESULTS

Of 16,084 studies, the mortality rate during or 2 weeks after an adverse event, as noted, was 0.006%, and the overall rate of adverse events was 0.35%.

CONCLUSIONS

Adverse event rates are low; however, procedures for handling medical emergencies or adverse events during or after polysomnography are prudent, and those studies performed for research should include preparedness for the possibility of adverse events.

Coronary ischemia induced by radiofrequency ablation in the left atrium

INTRODUCTION

We report three cases of transient, reversible coronary ischemia occurring after radiofrequency ablation in the left atrium.

METHODS AND RESULTS

A 56-year-old man with a left atrial tachycardia that was mapped to the septum and roof of the atrium using a noncontact mapping developed 5-mm ST elevation in the anterolateral leads. Coronary angiography showed an occluded diagonal that was opened using intracoronary nitrate, which led to resolution of the ST changes. A 57-year-old man undergoing right upper pulmonary vein ablation developed 6-mm ST elevation in leads V1-V4, II, III, and aVF. Coronary angiography showed normal coronaries with slow flow into the left anterior descending artery, which resolved with nitrates. A 50-year-old man undergoing left lower pulmonary vein ablation developed 3-mm reversible inferior ST elevation. All patients were adequately anticoagulated after transseptal access to the left atrium.

CONCLUSION

Ablation in the left atrium, at the roof, septum, and left inferior wall, can cause transient coronary ischemia, possibly due to spasm, which can be reversed with intracoronary nitrates. This phenomenon has not been previously described.

The effect of clonidine premedication on hemodynamic responses to microlaryngoscopy and rigid bronchoscopy

The usual hemodynamic response to laryngoscopy and bronchoscopy is an increase in heart rate and arterial blood pressure. Previous work has reported that 10%-18% of the patients develop ischemic ST segment changes during the procedure. Therefore, we performed a prospective, randomized, double-blinded study in 36 patients scheduled for elective microlaryngeal and bronchoscopic surgical procedures to evaluate the effects of 300-microg oral clonidine premedication (n = 18) or placebo (n = 18) on the hemodynamic alterations and the incidence of perioperative myocardial ischemic episodes. Myocardial ischemia was assessed by using continuous electrocardiographic monitoring, beginning 30 min before, and lasting until 24 h after the operation. During the procedure, patients receiving placebo exhibited a significant increase (mean +/- SD) in arterial blood pressure (the systolic increasing from 137+/-11 to 166+/-17 mm Hg, the diastolic increasing from 80+/-11 to 97+/-14 mm Hg) and heart rate (increasing from 79+/-15 to 97+/-12 bpm) compared with the baseline and with the clonidine group. A dose of 300-microg clonidine blunted the hemodynamic response to endoscopy. Ventricular arrhythmias were more frequent in patients who were not premedicated with clonidine. Two patients in the control group, but none in the clonidine group, had evidence of myocardial ischemia. These data should encourage routine premedication with clonidine in patients undergoing microlaryngoscopic and bronchoscopic procedures.