Arrhythmias induced during intracardiac catheterization

Clinic al communications

Arrhythmias induced during intracardiac catheterization Robert S. Fraser, M.D.* W. D. Macaulay, M.D.** Richard E. Rossall, M.D.*** Edmonton, Canada

A

rrhythmias are induced frequently during cardiac catheterization. In most instances they are benign and short lived. Little information is available in most of the standard texts concerning this subject.‘v3 The mortality associated with catheterization is approximately 0.1 per cent; when deaths do occur, they are usually caused by arrhythmias. Because we found no recent studies on arrhythmias which occurred during catheterization, we reviewed 942 cardiac catheterizations done in the University of ,qlberta Hospital, in order to determine the relative frequency and duration of the various types of arrhythmia. Methods The ages of the patients in this series ranged from 2 weeks to 51 years. Six hundred and twenty-four patients had congenital heart disease, 115 had rheumatic valvular heart disease, and there were single patients with primary pulmonary hypertension, myxoma of the left atrium, and normal findings. Seven hundred and forty-two patients were catheterized, but, in addition, 200 of these patients had a second catheterization at a subsequent examination. Therefore, we have

considered that the population at risk for the purpose of this study was 942. Infants and children who weighed less than 45 pounds were sedated with a misture of meperidine, chlorpromazine, and promethazine, as recommended by Keith, Rowe and Vlad.4 Older children and adult patients were given secobarbital and meperidine. General anesthesia was not used. Catheters were sterilized with heat (250“F. for 10 minutes), and, although they maintained their form, they were not stiff. The size of the catheters used was either SF or 6F, depending upon the size of the patient. The electrocardiogram and a simultaneous pressure tracing were monitored on an oscilloscope during the catheterization. In addition to the usual photographic recording made of the various pressures the tracing was recorded when arrhythmias appeared. Short bursts of ventricular premature beats which occurred with considerable regularity when the tip of the catheter was in the right ventricle, as well as isolated atria1 and nodal premature beats, when the tip of the catheter was in the right atrium, were not classed as arrhythmias for the purpose of this study.

From the Department of Medicine, University of Alberta Hospital, Edmonton, This investigation was supported in part by a grant from the Alberta Heart Received for publication Feb. 12. 1962. *Muttart Associate Professor of Medicine. **Fellow in Cardiology. ***Assistant Professor of Medicine.

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Table I. ?‘yprs qf arrhythmias induced during catheterization of the right heart in O-L?patients

Arrhythmia conduction

or defect

I Sumber of patients 1 I

Sinus bradycardia Supraventricular tachycardia Atria1 flutter Atria1 fibrillation Nodal rhythm A-V block, incomplete Bundle branch block Bigeminal rhythm Ventricular tachycardia

* fSingle

patient

with

two

Catheterbation site

Diagnosis

Congenital 1

1

sot 1* 3 3 2 6t -4 5*

28 2 1 3 2 1 ‘I 2

) Rheumatic

I Other>

1

1 R.rl . ’ R. T’ . / Minutes 1

I 2 2

1 2

1

26 1 2 2

1 1

Duration

2 1

i Hours I

IDays I

1 4 1 1 2 6 2 1

24 2 2 2 2 5 1 5

0 1

1 1

1 1

arrhythmias.

The position of the tip of the catheter was determined by fluoroscopic examination and was confirmed by the intracardiac pressure tracing. Results Arrhvthmias occurred during the course of cardiac catheterization in 56 patients (6 per cent). 111 one instance, both a nodal tachycardia and a bundle branch block occurred at different times during the course of a single catheterization. In a ventricular tachycardia second patient, was succeeded by atria1 flutter. In both cases, each of the arrhythmias is listed in Table I, accounting for a total of 58 arrhythmias in 56 patients. The most ~omnon types of arrhythmias were supraventricular in origin. Because it was difficult to be certain of the exact type of supraventricular tachycardia when it was of short duration, we have included recognized nodal and atria1 tachycardias in a general group of supraventricular tachycardia which accounted for 52 per cent of the total. None of the eight other classes of arrhythmias or conduction defects occurred with any frequency. Bundle branch block which was induced during intracardiac catheterization involved the right bundle in 5 of 6 patients. A single intermittent left bundle branch block was observed in a patient with a mysoma of the left atrium.

Fewer patients with rheumatic than with congenital heart disease were catheterized. Despite the smaller number of patients with rheumatic heart disease the frequency of arrhythmias in this group during catheterization (6.6 per cent) was almost the same as that found in patients with congenital heart disease (5.7 per cent). It was obviously difficult to be sure of the precise position of the tip of the catheter at the moment an arrhythmia appeared. With this reservation, however, these data have been included in Table I. Most of the arrhythmias (65.5 per cent) occurred while the catheter was being manipulated in the right atrium. In man\ instances, it is probable that the tip was close to the tricuspid valve. In all patients who developed bundle branch block or &A-V block the tip of the catheter was in the cavity of the right ventricle. One patient developed a short bout of ventricular tachycardia while the catheter appeared to be in the right atrium. The single patient with sinus bradycnrdia developed this arrhythrnia when the catheter was passed from the right to left atrium through a patent foramen ovale. The arrhythmias induced by catheterization lasted only a few minutes in 47 of 58 episodes. In 3 patients who developed supraventricular tachycardia, and in 3 who had nodal tachycardia the rhythm

Arrhythmias

induced during intracardiac

reverted to normal only after several hours. One patient with atria1 flutter and one with a nodal rhythm also had prolonged arrhythmias. Three patients had persistent arrhythmias which lasted more than 3 days-one patient had atria1 flutter, one had atria1 fibrillation, and one had a right bundle branch block. Most arrhythmias reverted to normal spontaneously (69 per cent). Sometimes, normal rhythm was restored by further manipulation of the catheter in the right atrium. Less frequently, the arrhythmia ceased after premature ventricular beats occurred during withdrawal of the catheter through the right ventricle. Specific treatment was used in 18 patients (31 per cent). This consisted of lanatoside C in 10, procaine amide in 5, quinidine and procaine amide in 2, and lanatoside C with procaine amide in 1. In only one instance was treatment urgently required because of the rapid appearance of shock associated with a supraventricular tachycardia. This patient, a lo-year-old girl, was catheterized 2 days postoperatively because disruption of a repaired ventricular septal defect was suspected. The arrhythmia was converted to normal rhythm within 10 minutes after partial digitalization. The various methods for inducing vagotonia were used with indifferent success for the treatment of arrhythmias which persisted longer than a few minutes. Better results were usually obtained with the use of intravenous fast-acting digitalis. Discussion The incidence of significant arrhythmias which occurred during the course of catheterization has been reported in only a few large series of patients. Kjellbergl reported 22 arrhythmias in 837 catheterizations (2.6 per cent) ; Wood5 noted 111 arrhythmias in 1,000 catheterizations (11.1 per cent), and Keith,4 107 in 700 (15.3 per cent). The earlier studies on arrhythmias during catheterization were carried out on small groups of patients and provide little valid basis for analysis.6-9 It is difticult to compare results from different centers because the criteria for reporting arrhythmias during catheterization are variable. \&Te have not included minor

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and momentary arrhythmias, as stated earlier. The occurrence of 58 arrhythmias in this report of 942 catheterizations (6 per cent) was somewhat less frequent than that found by either Keith or Wood, but exceeded the incidence reported by Kjellberg. However, Kjellberg’s observations were not presented in detail and ma) have excluded arrhythmias which were included in the other series. Arrhythmias probably occur in 5 to 15 per cent of the patients who undergo cardiac catheterization. Michel aild associates” found the highest incidence of arrhythmias during catheterization in those patients with congenital heart disease. However, his series consisted of only 23 patients with congenital, and 5 patients with rheumatic valvular, heart disease. The other 105 patients had hypertensive heart disease, coronary arter) heart disease, toxemia of pregnant!-, and car pulmonale. From a review of his data there appeared to be no difference ill the number of arrhythmias produced in patients with congenital heart disease when compared with patients with rheumatic heart disease. In our series, which included 121 catheterizations of 115 patients with rheumatic valvular heart disease, and catheterization of more than 700 with congenital heart disease, no difference in the incidence of arrhythmias in these two groups was found. Further study of the 200 patients who had a second catheterization indicated that the appearance of an arrhythmia during the first procedure did not enhance the possibility of the same or another arrhythmia at a second catheterization. We have no information from this study which would enable us to relate the incidence of arrhythmias to the size of the catheter. However, Keith4 found that paroxysmal atria1 tachycardia occurred twice as often with the use of a 61; catheter as with a SF, and that no complete atrioventricular blocks were produced during catheterization with a 5F catheter. It is obvious that the resilience as well as the size of the catheter must be taken into consideration. The method chosen for sterilizing cardiac catheters appreciably affects their stiffness. For this reason it is difficult to assess the importance of the

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size of the catheter in relation to arrhythmias when data are obtained from different centers in which various methods of sterilization and preparation are used. In our experience, most arrhythmias occurred when the catheter lay in the right atrium. The exceptions were in patients who developed atrioventricular block, bundle branch block, bigeminal rhythm, and ventricular tachycardia. As might be expected, these usually occurred when the catheter was in the right ventricle. Reference has already been made to the single patient who developed sinus bradycardia on each occasion when the catheter was passed through a foramen ovale. In an earlier study,” we found that arrhythmias occurred five times more frequently in patients who were catheterized through a left persistent superior vena cava (with 38 per cent developing arrhythmias), when compared with the whole group. Those patients with a left superior vena cava who developed arrhythmias are included in this study but have not been categorized separately. Keith4 found that bundle branch block occurred five times more often in patients less than 1 year old, when compared with the other patients in his series. Only one of our 6 patients who developed a bundle branch block was less than 1 year old (2 weeks); the others were l?,$, 10, 35, 40, and 51 years old. Fowler8 described the appearance of right bundle branch block in 7 patients during the course of venous catheterization of the heart in 110 patients. The incidence of 6.4 per cent in his series is ten times that found in our patients, but the esplanation for this difference is not apparent. One would suspect that arrhythmias and conduction defects might be induced more frequently in patients with cardiac abnormalities. In fact, none of Fowler’s patients had primary cardiac disease. Simonson’” attributed the transient appearance of right bundle branch block, which appeared during catheterization of a SO-year-old man, to impingement of the catheter on and cited experimental evithe septum, dence in support of this explanation. In addition, right bundle branch block (both complete and incomplete) has been produced recently in normal subjects by ap-

plying pressure on the right ventricular septal surface with an electrode catheter.13 The electrocardiographic changes lasted only a few minutes in each instance. We suspect that more persistent forms of block might well occur if more pressure were to be exerted on the septum during catheterization. In all 5 of our patients who developed a right bundle branch block the conduction defect appeared when the catheter was in the right ventricle. We believe that differences in the incidence of right bundle branch block may be accounted for b> variations in individual techniques of catheterizing the right ventricle and b> the properties of the catheter used. The treatment of arrhythmias induced during catheterization usually presented no problem. Man>- arrhythmias reverted spontaneously upon withdrawal of the catheter, manipulation of the catheter in the right atrium, or after one or two ventricular premature beats. Eighteen of the patients required specific treatment for their arrhythmias, as outlined in the section on results. Reference has already been made to the only patient for whom treatment was urgently required. However, the production of rapid arrhythmias in patients with severe valvular obstruction or in infants under 18 months of age ma! lead to acute heart failure. Although his was uneventful, cardiac catheterization a 4-\.ear-old boy with severe pulmonar> valvular stenosis spontaneously developed supraventricular tachycardia (2.50 per minute) and presented with acute cardiovascular collapse on one occasion prior to investigation. He recovered uneventfull\after his rhythm was restored to normal. In addition, a second child was treated several times up to the age of 2 years for acute failure which was precipitated on each occasion by supraventricular tachycardia in the absence of any congenital cardiac disease.lJ The induction of arrhythmias during a catheterization could be expected to precipitate failure in both of these types of patient during cardiac catheterization and would require immediate treatment. Summary The occurrence appeared during

of arrhythmias which the course of catheteri-

l.olume .\-umber

64 -I

Arrhythmias

induced during intracardiac

zation of the right side of the heart was reviewed in 942 catheterizations of 742 Significant arrhythmias, apart patients. from occasional atrial, nodal, and ventricular premature beats, appeared in 58 patients (6 per cent). The arrhythmias lasted for a matter of minutes in 81 per cent, for several hours in 14 per cent, and for longer than 1 day in 5 per cent. Seventeen per cent of the patients who developed arrhythmias were treated with intravenous lanatoside C. The other patients developed a normal rhythm spontaneously. No fatal arrhythmias occurred. REFERENCES 1. Kjellberg, S. Ii., Mannheimer, E., Rudhe, U., and Jonsson, B.: Diagnosis of congenital heart disease, ed. 2, Chicago, 1959, Year Book Publishers, Inc. 2. Nadas, A. S.: Pediatric cardiology, Philadelphia, 1957, W. B. Saunders Company. 3. Cournand, A., Baldwin, J. S., and Himmelstein, A.: Cardiac catheterization in congenital heart disease, New York, 1959, The Commonwealth Fund. 4. Keith, J. D., Rowe, R. D., and Vlad, P.: Heart disease in infancy and childhood, New York, 1958, The Macmillan Company. P. H.: Diseases of the heart and circu5. Wood, lation, ed. 2. London, 1956. Eyre and Spottiswoode.

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6. Landtman, B.: Mechanically induced disturbances in the heart action: observations made on heart catheterization of 142 children, Acta pediat. 39:1, 1950. 7. Goldman, I. R., Blount, S. G., Jr., Friedlich, A. L., and Bing, R. J.: Electrocardiographic observations during cardiac catheterization, Bull. Johns Hopkins Hosp. 86:141, 1950. N. O., Wescott, R. N., and Scott, 8. Fowler, R. C.: Disturbances in cardiac mechanism of several hours duration complicating cardiac venous catheterization, AM. HEART J, 46:652, 1951. W. T.: Disorders of the cardiovascu9. Zimdahl, lar system occurring with catheterization of the right side of the heart, AM. HEART J. 41:204, 1951, 10. Michel. J., Johnson, A. D., Bridges, W’. C.. Lehman, J. H., Gray, F., Field, L., and Green, D. M.: Arrhythmias during intracardiac catheterizations, Circulation 2:240, 19.50. 11. Fraser, R. S., Dvorkin, J., Rossall, R. E., and Eidem, K.: Left superior vena cava, Am. J. Med. 31:711, 1961. E.: Transient right bundle branch 12. Simonson, block produced by heart catheterization in man, AM. HEART J. 41:217, 1951. 13. Pefialoza, D., Gamboa, R., and Sime, F.: Experimental right bundle branch block in the normal human heart, Am. J. Cardiol. 8:767, 1961. 14. Wilde, H., and Fraser, R. S.: Paroxysmal supraventricular tachycardia with congestive heart failure, Acta cardiol. 14:532, 1959.