Serious and fatal complications of catheterization and angiocardiography in infants and children

Serious and

and

fatal

complications

angiocardiography

in infants

of catheterization and

children

L. Jerome Krovetz, M.D., Ph.D.* Douglas K. Shanklin, M.D.** Gerald L. Schiebler, M.D. Gn inesville, Flu.

T

he complications of selective angiocardiography may be divided into three areas (Table I) : (1) those related to the hazards of cardiac catheterization per se ; (2) those due to the mechanics of rapidly injecting a large volume of fluid into the heart and/or great vessels; and (3) those due to the hyperosmolarity of the contrast medium which produces physiologic and pathologic changes.’ A general classification of the complications encountered is shown in Table I. The risk of such complications is much higher in infants, because of (1) the smaller size and thinner walls of vessels and cardiac chambers, (2) the lesser mass of circulating blood and organs of impact, and (3) the higher frequency of severe congenital heart disease with attendant problems of cy-anosis, heart failure, and disturbed cardiopulmonary dynamics. This paper will report and discuss our morbidity and mortality experience resulting from 1,104 consecutive cardiac catheterization and angiocardiographic procedures on the pediatric cardiology service.

Materials

and

methods

All catheterization and angiocardiographic data with particular emphasis on complications were punched onto IBM cards for retrieval and analysis (Fig. 1). This series began with our first patients in 1959 and ended on June 30,1967. All patients who died following cardiac catheterization and/or angiocardiography were counted as a catheterization death if the procedure was considered to be a factor in the child’s demise. The elapsed time since catheterization was not the sole factor in this decision. In six cases, a causal relationship between the procedure and subsequent death appeared unlikely and they were not counted as fatalities. Two male infants, ages seven days and one month, with complete transposition of the great vessels, underwent angiocardiography without apparent ill effect. Both died, after seven days and three days, respectively, of massive infarction of the bowel. While this might have been related to the contrast medium injection, throm-

From

the Departments of Pediatrics and Pathology and the Human Development Center, University of Florida College of Medicine, Gainesville. Fla. Supported in part by grants from the Florida Heart Association (Palm Beach and Martin Counties), Developmental Physiology Training Grant (TI-HD-0054). and the Graduate Clinical Pediatric Cardiovascular Training Grant, l-T12-HE5774-01. Dr. Krovetz is the recipient of a Research Career Development Award (lK3.HE9761-02). Received for publication July 31. 1967. *Address: Department of Pediatrics, Johns Hopkins University Sctmol of Medicine. Baltimore, Md. **Pathologist-in-Chief at the Chicago Lying-In Hospital, Chicago, 111.

Vol. 76, No. 1, QP. 39-47

July, 1968

American Heart Journal

39

40

Krovetz, Shnnklin, and Schiebler

liable I. Complications of ccltheterimtion and angiocnrdiography Complications related to insertion and passage of the catheter Infection4 Perforation of vessel or heart6 Knotting or breakage of catheter Dislodgement of prior existing thrombus Arrhythmias Supraventricular tachycardia Cardiac arrest, either asystole or ventricular fibrillation Electric shock’s8 producing arrhythmias Air embolism Hypothermia Acidosis Complications of rapid injection Mechanical Dislodgement of thrombi Extrasystoles Extravasation into myocardium Rupture of coronary sinusI Chemical Thrombosis Cerebral edema Cardiorespiratory collapseIs

bosis occurs spontaneously in patients with cyanotic congenital heart disease.2 A one-year-old boy underwent aortography and angiocardiography and on the next day dislodged his endotracheal tube. Respiratory distress and cardiac arrest ensued before the tube could be replaced. Three additional cyanotic infants were also not considered to have died as a direct result of catheterization. A one-day-old cyanotic infant with pulmonary atresia had a catheter placed into the right atrium, preparatory to an angiocardiogram. The dose of digitalis due at this time was administered at 10 times the intended dose, but this error was not recognized until atrioventricular dissociation occurred two hours later. A selective right ventricular angiocardiogram was performed in a oneday-old infant with aortic atresia. He tolerated this procedure well, but over the next 24 hours, his condition became poor and he died approximately 26 hours after the procedure. A lo-month-old girl began having spells of paroxysmal hyperpnea followed by extreme cyanosis at six months of age. Angiography revealed a severe form of tetralogy of Fallot with valvar

pulmonic atresia. Three da1.s after the procedure, she had a severe cyanotic episode and died. In five cases, there was a tenuous relationship between the procedure and death, but these were counted as such for purposes of analysis. Case reports Case 1. A S-month-old boy with pulmonic valvar stenosis and right-to-left shunt at the atria1 level became severely ill following catheterization and angiocardiography, after which a surgical attempt was made to relieve his pulmonic stenosis. The child died during the operation. This was counted as a catheterization death since his degree of cardiopulmonary distress increased enormously during and following catheterization. Case 2. A 3-day-old boy entered the hospital in severe congestive heart failure. A patent ductus arteriosus was suspected because of the location of the systolic murmur and bounding pulses. In spite of his critical condition, it was felt that his only chance for survival was to prove the diagnosis. As further evidence of the severity of his condition, the mean left atria1 pressure was 28 mm. Hg. He died almost immediately after an angiocardiogram. Case 3. A diagnosis of aortic atresia had alread) been established in a 21-day-old girl by a previous retrograde aortogram.3 ,4n attempt was made to obtain hemodvnamic clata by right heart catheterization to see If a Blalock-Hanlon procedure would be feasible. She died during the course of this catheterization. Case 4. A 2-year-old girl, with a history of syncopal attacks, had a diagnosis of primary pulmonary hypertension established at an uneventful right heart catheterization. She returned home and died there on the third postcatheterization day during such a syncopal attack. Case 5. In soite of an obviouslv critical condition and a clinical diagnosis of periistent truncus arteriosus, an g-day-old girl had a thoracic aortogram performed. She died 5 hours after the procedure.

Using these stringent criteria, we have had a total of 27 deaths following catheterization and/or angiocardiography. All the deaths except three occurred in children under one year of age. These older patients were (1) a 2-year-old child with a complete atrioventricular canal, a reversed central arterial shunt, and a posteroanterior (PA) pressure of 155/90, (2) a 6-year-old child with a complete atrioventricular canal, who died of air embolism, and (3) the child described above in Case 4. Results

Table II lists our fatalities by year of occurrence. In the last 1; :! years the mor-

CbmpliccltZons

of cutheterimtion

and angiocardiography

41

PEDIATRIC CARDIOLOGY J. Hillis Miller He.l,h Center Unirarrirl of Flmid.

Fig. 1. This card is initially filled out at catheterization note is signed. This helps ensure that late complications punched onto an 80 column IBM card.

tality rate has been 1.3 per cent, compared to 2.9 per cent prior to that time. Mortality rates were highest for the younger patients (Table III). Therefore, our analysis concentrated on patients under six months of age, since it was felt that this would more likely point out any adverse effects of the procedures. General anesthesia was not used in any infant under one year of age. No adverse effect of sedation on mortality rate was noted. If anything, patients who were

and then corrected when the final typed catheterization will be coded. The data from this card are then key-

sedated actually had a slightly lower mortality rate of 5.5 per cent as against 9.1 per cent for those with no sedation. This is most likely due to our tendency to omit sedation in severely cyanotic or acutely ill infants. Thus, patients who were sedated were generally better risk cases. Analysis of mortality rates by the number of injections of contrast medium utilized in children under six months of age is given in Table IV. The highest mortality

42

Am. Heart

Krovetz, Shanklin, and Schiebler

Table II. Cardiac catheterization clnd nngiocardiographic mortality by year

1959 1960 1961 1962 1963 1964 1965 1966 To July 1, 1967

7 51 93 123 151 171 189 200 119 1,104

.._.

0 1 4 0 5 5 8 2 1

2.0 42 3 3 2 .o 1.1 1 .o 1.7

27

2.4

Table III. Cardiac catheterization and nngiocardiographic mortality by age Kate Age

~ Procedures

IJnder 1 month 1 to 5 months 6 to 11 months

~ Fatalities

( ‘,‘i )

71 204 81

7 15 2 -

9.8 7.4 2.5

356

24

6.7

1 to 5 years 6 to 10 years 11 to 1.5 years Over 15 years

340 259 13.5 14

2 1 0 0

0.6 0.4 0 0

Subtotal 1 year

748

3

0.4

27

24

Subtotal 1 year

under

-

over

Total

1,104

Table IV. Mortality by number of injections, in patients 0 to 6 months of age

Injections None 1 2 3 1 or more Totals

~ Procedures

1 Deaths

36 119 78 29 13

7 8 4 2 1

275

22

)

F{Ly 19.5 6.7 5.1 6.9 7.7 8 0

Jzdy,

J. 1968

rates occurred in patients who underwent catheterization alone. However, angiocardiography was planned for four of these seven infants and would have been carried out if these infants had not become severelyill during the catheterization. There was no significant increase in mortality rates after the first injection. Thus, it would appear that, if an infant can tolerate one injection, one or two additional injections carry little additional risk. Several significant correlations were found with data obtained early in the catheterization and prior to angiocardiography. All except four of the patients who died had arterial clesaturation, ranging from 3.5 to 91 per cent. -4 total of 22 of the 24 measured right ventricular enddiastolic pressures and nine of 17 left ventricular end-diastolic pressures were elevated. Right ventricular end-diastolic pressures averaged 15.6 mm. Hg (range 6 to 30) and left ventricular end-diastolic pressures averaged 13.5 111111. Hg (range 4 to 2X). Finally, in all 22 instances where the children who died had measured, either pulmonary or right ventricular hypertension (ranging from 53 to 126 per cent of s\,stemic). Not surprisingly, the striking correlation of mortality most rates was with severit). of the cardiac pathophysiology. Discussion We have chosen to classify complications into two groups. First, those related to the insertion and passage of the catheter itself and, second, those due to the rapid injection of a bolus of contrast medium (Table I). Introduction of the catheter of necessity involves violating the integrity of the skin and carries a risk of introducing infectious agents. We have had only one serious local infection. This occurred in a fourmonth-old male infant with complete transposition of the great vessels. An infection of the cutdown site in the groin delayed operation and he died seven days after the catheterization. Bacterial endocarditis following catheterizations is fortunately rare4 and we have not seen this complication in our group of patients. None of our patients are given “proph>,-

Complictltions

of cutheteriztrtio,n and (lngiocclvdiography

43

Fig. 2. Perforation of the aorta by a guide wire. This 0.025 inch diameter wire was inserted into a PE90 polyethylene catheter to visualize and guide the catheter. This 3-month-old boy died 3 hours later. Nerropsy revealed pulmonary atresia and an intact ventricular septum.

Fig. 3. This S-month-old girl had a venous catheter inserted into the S\‘C and an angiocardiogram performedlusing only hand-generated pressure on a syringe. She died within 10 minutes of a massive pulmonary embolus (arrow). Necropsy revealed that the entire SVC jugular system and parts of the right atrium were tilled with a thrombus. Previous meningitis had caused thrombosis of the jugular veins with subsequent propagation into the S1.C and right atrium.

lactic antibiotics” for catheterization or angiocardiographic procedures. The relatively thin vessel walls and small cardiac structures in infants increase the possibility of perforation by a stiff catheter. In one three-month-old child, a polyethylene catheter was introduced into the right brachial artery but could not be passed into the ascending aorta. A guide wire was inserted to aid in visualization and placement of the catheter. When this proved unsuccessful, the catheter and wire were removed and it was noted that the guide wire had perforated the catheter wall. Shortly after this, the infant’s blood pressure dropped rapidly and he died in spite of repeated intravenous blood transfusions. At necropsy, a small tear in the aorta was found (Fig. 2). Perforation of a vessel or of the heart may be recognized by the abnormal position of the catheter, failure to withdraw blood, or a change in the pressure tracing.5 If a 5 French or smaller catheter penetrates the aortic arch, Dr. Robert 5liller of Chicago6 recommends that a needle be placed in the pericardial space, after which the catheter can be withdrawn back into the aorta to monitor pressure. If the cardiac

silhouette enlarges or the pressure drops, blood is withdrawn from the pericardiac sac and returned intravenously. This process is continued until fluid stops accumulating and the pressure is stable. The puncture site will usually close spontaneously. If the catheter is 6F or larger, it should be left in place and provisions made for closing the perforation at thoracotomy. Perforations of the atria, especial11 the left atrium, are not as predictable, while ventricular perforations will usuall) seal spontaneously without serious sequelae. Knotting or breaking of a catheter, Seldinger wire, or transeptal needle tip have all been reported. These incidents are particularly unfortunate, since little can be done to prevent them after the catheter is inserted. All such equipment should be inspected prior to use and discarded if there are any indications of cracking or other damage. In our two experiences with catheter breakage, both catheters were of the IXIH t>‘pe. In each instance, the end section broke on withdrawal of the catheter; fortunately the broken piece was in a peripheral vein and was easily removed with a forceps. Transient arrhythmias such as prema-

44

Krovetz,

Shunklin,

und Schieblrr

.4m.

Hravt J. July, 1968

Fig. 4. Myocardial infiltration of the right ventricle in a T-day-old boy with complete transposition of the great vessels. In the AI’ view the No. 5, 50 cm. NIH catheter (closed tip with six side holes) appears to lie at the center of the right ventricle. The lateral view, however, shows that the catheter is caught in the trabeculations of the anterior wall.

Fig. 5. Massive infiltration of the myocardium in a 3-day-old boy with situs solitus dextroversion and complete transposition of the great vessels. Abnormal cardiac positions increase the risk of injecting into the myocardium. The catheter utilized in this study was a No. 5, SO cm. Eppendorf catheter (closed tip with six side holes).

ture atria1 or ventricular contractions occur so frequently that it is difficult to classify these as complications. Arrhythmias persisting for an hour or more occurred in 33 children. The dangers of current leakages and inadequate ground systems leading to ventricular fibrillation have been stressed in recent articles7zs Fortunately, early projects in our laboratory stressed the need for an adequate ground for research purposes and the laboratory was rewired. No instances of ventricular fibrillation in children were seen by either our group or Venables and Hiller” although Vlad and associates9 reported four

instances with two successful defibrillations. When cardiac arrest occurred, it has been due to ventricular asystole, following a period of gradually decreasing heart rates. External cardiac massage and mouth-tomouth breathing succeeded in reviving two of these infants. Ilse of a pressure flush system where the fluid for clearing the catheter is under constant pressure of about 300 mm. Hg carries a danger of air embolism. We have had this occur on one occasion resulting in a fatal outcome. Since that time, we have devised an automatic alarm system t-o prevent its recurrence.‘”

Complicntions

of catheterization

and angiocardiogmphy

45

Fig. 6. A, Epicardial hematoma viewed 12 hours after infiltration of right ventricular tnyocardium with contrast media. (Hematoxylin and eosin; photograph reduced from X75.) 23, Acute necrosis and lysis of myocardial fibers surrounding myocardial sinusoid. Appearance 1.5 hours following injection of contrast media into right ventricle. (Hematoxylin and eosin; X275.) C, Hemorrhage and peculiar pseudohyalin-like contractureof myocardial artery, 1.5 hours following injection. This type of change was seen commonly throughout the right ventricular myocardium at this time. (Hematoxylin and eosin; X 17.5.) D, Late scar in right ventricular myocardium 6 weeks following injection. Some secondary hemorrhage is apparent in the lower portion of the field and the relationship of scar tissue to the sinusoidal and trabecular system is apparent. (Masson trichrome; X8.)

Rapid injection of contrast medium resulted in the dislodgement of a preexisting thrombus and massive, fatal pulmonary embolus in one case (Fig. 3). Extravasation of contrast medium into the myocardium tends to occur (1) in cases where there is marked hypertrophy of the myocardium and exaggeration of the trabecular pattern (Fig. 4) and (2) in cases where the anatomy of the heart is complex and the physician uncertain of the exact location of the catheter tip (Fig. 5). Some of the later consequences of myocardial infiltrations are shown in Fig. 6. Myocardial infiltrations occurred in 12 children, five of whom died shortly thereafter. This can best be avoided by using only catheters with a closed end and

multiple side holes and preliminary injections of contrast medium with the use of manual pressure to check the exact location of the catheter tip. Rupture of the coronary sinus has been reported” following rapid injection of contrast material. With the catheter high in the coronary sinus, it may impinge on the right ventricular (RV) wall and an RV pressure tracing may be recorded. The oxygen saturation of the coronary sinus is lower than that found elsewhere on right heart catheterization. The catheter usually passes closer to the diaphragm when entering the coronary sinus than when entering the tricuspid valve and withdrawal of the catheter a short distance results in a markedly different pressure

46

.4m. Heart I. July, 1968

Krovetz, Shanklin, and SchieOIer

contour. Furthermore, the catheter tip does not induce premature beats in this location. Although this complication has been reported by others,” we have been fortunate enough to have avoided it. Conclusians A number of investigators have quoted extremely low or virtually nonexistent cardiac catheterization mortality rates.” However, Venables and Hiller” stated that, in 5 per cent of 837 catheterizations performed in infants less than six months of age, there were five deaths. Thus, in this age group the mortality rate was 12 per cent. (Our comparable mortalit\rate in this age group was 8 Fer cent.) Lambert and associates’” reported seven deaths following catheterization in 165 infants under one month of age. In a personal communication to the authors’” he stated that these occurred in a total of 73 catheterization procedures, for a mortalit)rate of 9.6 per cent; this is virtuall), identical to the seven deaths in 71 procedures of the present series. Lambert goes on to say “Since we submitted this article our incidence of death from this form of cardiac catheterization has ranged from 10 to 15 per cent. I should mention that an>. patient who dies within 24 hours after cardiac investigation is considered a catheterization death.” The most significant correlations of death rate were with severity of the illness (Figs. 1 to 3). As a further proof of this statement, Table VI illustrates the spectrum of anomalies found in 26 infants who died during the same time period while awaiting cardiac catheterization. The entities in this group are similar to those found in patients who died following catheterization (Table 1’). We are faced then with a dilemma, namely, that the highest risk of cardiac investigation occurs in those sick infants who, for the most part, will not survive unless successful operation can be performed. Adequate surgical management often requires prior cardiac catheterization and angiocardiography, both of which impose additional risks. We have adopted several procedures as a result of our experience: 1. Infants under six months of age are

Tuble V. Influence of cardiac anatomy on mortcrlity rates in children under 6 months of age, 1959 to 1967

Cardiac

anomaly

I

Procedwes

I Deaths

Rate (57:)

CJlanotic entities Aortic atresia Complete transposition of great vessels Severe tetralogy of Fallot Other ‘fotals

4

2

50

32 18 56 Ei

4 4 1 11

12 22 2 iii

Not ordinarily cyunotic \:entricular septal defect Atrioventricular canal Patent ductrls arteriosus Other Totals

57 15 11 65 148

6 1 1 3 11

11 7 9 5 -7

l’uble \#‘I. Patients dying prior to ctudiuc investigation under 1 yew of uge, 1959 to 1967

Cardiac

No. of patients

alromaly

Cvaxot ic Aortic atresia Complete transposition ‘l‘etraloev of Fallot Single ventricle Truncus arteriosus Tricuspid atresia Total Not ordinarily cyanotic Ventricular septal defect Patent ductus arteriosus Pulmonic stenosis Endocardial fibroelastosis Anomalous left coronary Coarctation of the aorta Total

of great

artery

vessels

4 4 2 1 1 1 13

6 3 1 1 1 1 13

seen bq a pediatric cardiologist and a thoracic surgeon within 24 hours of admission. III many instances they are offered a 24 hour trial of medical management and stabilization prior to further procedures. 2. If the type of operation to be performed can be decided zuithoz.lt further diagnostic procedures, these are omitted.

C’omplications

For example, in. small cyanotic infants the only logical operations are either (1) to increase pulmonary blood flow or (2) to increase mixing at the atria1 level. The exact intracardiac anatomy is rarely of interest at this time. 3. Infants are catheterized with a clear plan of action. The procedure is kept to the minimum compatible with obtaining the information needed to establish the course of future management.

of cutheterizution

8.

9.

10.

11.

REFERENCES 1. Giammona, S. T., Lurie, I’. Ii., and Segar, 1%‘. E.: Hypertonicity following selective angiocardiography, Circulation 28:1096, 1963. 2. Venables, A. II:., and Hiller, H. G.: Complications of cardiac investigation, Brit. Heart J. 25:334, 1963. L. P., Best, E. B., and Schiebler, G. L.: 3. Elliott, Aortic atresia. A case report and a review, AM. HEART J. 62:821, 1961. 4. \Vinchell, P.: Infectious endocarditis as a result of contamination during cardiac catheterization, New England J. Med. 248:245, 1953. 5. Lurie, P. R., and Grajo, M. Z.: Accidental cardiac puncture during right heart catheterization, Pediatrics 29:283, 1962. K. : Personal communication. 6. Miller, 7. Weinberg, D. I., Artley, J. L., Whalen, R. E., and McIntosh, H. D.: Electricshock hazards

12.

13.

14. 15.

und clngiocclrdiogvclplt?l

47

in cardiac catheterization, Circulation Kes. 11:1104, 1962. Starmer, C. F., \Vhalen, R. E., and IMcIntosh, H. D.: Hazards of electric shock in cardiology, Am. J. Cardiol. 14:537, 1964. Vlnd, P., Hahn, .q., and Lambert, E. C.: Retrograde arterial catheterization of the left heart: Experience with 500 infants and children, Circulation 29:787, 1964. Benson, Ii. LIT., Schiebler, G. I,., Krovetz, L. J., and Stutterer, \V. F.: An electro-optical meniscus-sen.iilIg system for a pressurized flush bottle, J. Appl. Physiol. 20:569, 1965. Keith, J. I)., and Moes, C. A. F.: Selective angiocardiography, in Zimmerman, H. A., editor: Intravascular catheterization, ed. 2, Springiield, 1966, Charles C Thomas, Publisher, Chap. 3, p. 225. Zimmerman, H. A.: The technique of right cardiac catheterization, in Zimmerman, H. il., editor: Intravascular catheterization, ed. 2, Springfield, 1966, Charles C Thomas, Publisher, chap. 1, p. 3. Lambert, E. C., Canent, Ii. \‘., and Hohn, .A. R.: Congenital cardiac anomalies in the newborn. A review of conditions causing death or severe distress in the first month of life, Pediatrics X:343, 1966. Lambert, E. C.: Personal communication. Read, R. C.: Cause of death in cardioangiography, J. Thoracic & Cardiovas. Surg. 38:685, 1959.