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Malignant ventricular arrhythmias during coronary angiography
International Journal of Cardiology 89 (2003) 111–113 www.elsevier.com / locate / ijcard
Letter to the Editor
Malignant ventricular arrhythmias during coronary angiography a a b, a Narpinder Singh , Ramesh M. Gowda , Ijaz A. Khan *, Sudarsanam Konka a
Divisions of Cardiology, Long Island College Hospital, Brooklyn, NY, USA b Creighton University School of Medicine, Omaha, NE, USA Received 11 June 2002; accepted 23 July 2002
Keywords: Cardiac catheterization; Coronary angiography; Ventricular fibrillation; Ventricular tachycardia; Complications
Cardiac catheterization is a relatively safe procedure with a small risk of morbidity and mortality. Coronary arteriography is known to rarely produce electrical perturbations including conduction disturbances and malignant arrhythmias, which are more common with right coronary artery injection [1–10]. To ensure prompt detection and treatment, malignant ventricular arrhythmias, although rare, should be anticipated during coronary angiography. We describe a patient who developed malignant ventricular arrhythmias during coronary angiography, and elaborate the possible underlying mechanisms and prevention of this complication. A 74-year-old male was admitted with acute shortness of breath and ruled in for a non-ST segment elevation myocardial infarction based on elevation of myocardial enzyme markers. The postinfarction left ventricular ejection fraction was 27%. On telemetry monitoring he was found to have episodes of nonsustained ventricular tachycardia. Elective coronary angiography was performed. No problem was encountered during left coronary angiography. On selective cannulation of the right coronary artery and injection of the contrast agent, there was damping and ventricularization of the pressure tracing. The patient *Corresponding author. Creighton University Cardiac Center, 3006 Webster Street, Omaha, NE 68131, USA. Tel.. 11-402-280-4573; fax: 11-402-280-4938. E-mail address: [email protected] (I.A. Khan).
developed sustained ventricular tachycardia, which immediately degenerated into ventricular fibrillation with hemodynamic instability and loss of consciousness. With an external defibrillator, an asynchronous countershock was administered with immediate return to normal sinus rhythm and regain of hemodynamic stability and consciousness. On subsequent analyses he was found to have noncritical coronary artery disease. He has been doing well on maximal medical therapy with a beta-blocker, an angiotensin converting enzyme inhibitor, a long-acting nitrate and diuretics, when last seen 4 months after the initial presentation. Diagnostic cardiac catheterization can be performed very safely so that the benefits far outweigh the risks. The frequency of the major complications of death, nonfatal myocardial infarction or cerebrovascular accident is approximately 1 per 1000 patients [1,2]. Although ventricular arrhythmias in the form of ectopy and short runs of nonsustained ventricular tachycardia are not uncommon during the procedure, there is a progressive decline in the incidence of ventricular fibrillation over the past 3 decades with the changes in the injection technique and formulation of the contrast agents. The incidence reported in 1973 was 1.28% [1], which decreased to ,0.4% as reported in 1991 [2]. Malignant ventricular arrhythmia is a rare but wellrecognized procedure related to complication of
0167-5273 / 02 / $ – see front matter 2002 Elsevier Science Ireland Ltd. All rights reserved. doi:10.1016/S0167-5273(02)00460-6
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N. Singh et al. / International Journal of Cardiology 89 (2003) 111–113
cardiac catheterization, often occurring after selective coronary artery injection of contrast medium [3–6]. Ventricular fibrillation during coronary angiography is usually associated with contrast-induced changes in repolarization, and a study using prolonged right coronary exposures to contrast media has demonstrated a higher incidence of ventricular fibrillation with dilute low sodium contrast media than with dilute contrast media containing more physiologic levels of sodium [5]. Therefore, the incidence of ventricular fibrillation was suggested to correlate with hyperosmolality and the absence of sodium ions, even in low-osmolality contrast media [5]. Furthermore, this incidence has been reported to be higher in patients with baseline prolonged QT interval [6]. Although precatheterization QT prolongation was associated with ventricular fibrillation during coronary angiography, the occurrence of ventricular fibrillation did not necessarily portend a worse longterm prognosis [6]. Interestingly, ventricular fibrillation can be caused by coronary artery spasm induced by the intracoronary injection of acetylcholine in patients without overt coronary artery disease [7]. In addition, malignant ventricular arrhythmias can be precipitated by mechanical stimulus when the tip of a catheter or guidewire is placed into a small intramyocardial branch of the coronary artery during coronary angiography. Mechanically induced arrhythmias usually revert after repositioning the catheter or guidewire into the main coronary arterial lumen. Ventricular fibrillation, although it may result from excess catheter manipulation, is commonly seen as a result of intracoronary injection of high-osmolar ionic contrast agents into the right coronary artery, particularly with prolonged injection time and damped catheter pressure, which is more common with right coronary artery catheterization. The reasons for the higher chances of damped catheter pressure in the right coronary artery include a smaller vessel caliber, ostial spasm around the catheter tip, true ostial stenosis or selective engagement of the conus branch. Ventricular fibrillation in the past was reported to be induced by leakage of electrical currents via the catheter into the heart [8], a complication that could be eliminated by proper grounding systems. Moreover, sustained ventricular tachycardia and fibrillation during coronary angiography can also occur in the
setting of profound myocardial ischemia or evolving or early myocardial infarction, and metabolic problems such as hypoxia, hypercarbia, or electrolyte imbalances. The problems associated with right coronary artery engagement can usually be eliminated by nonselective injections into the right sinus of Valsalva or, if damped, by using cautious injection of contrast with immediate withdrawal of the catheter postinjection. 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, but with atropine pretreatment, there is a risk of precipitating sinus tachycardia and myocardial ischemia in the usual patient population with acute coronary syndrome who undergo cardiac catheterization [4]. The incidence of ventricular fibrillation during coronary angiography can be reduced by using low osmolar nonionic contrast media lacking calcium-binding additives [9,10]. In addition, the staff in cardiac catheterization laboratories should be aware of the procedure related complications, their recognition, and the appropriate treatment to alleviate any enduring long-term effects.
Acknowledgements No financial support was received for this paper.
References [1] Adams DF, Fraser DB, Abrams HL. The complications of coronary arteriography. Circulation 1973;48:609–18. [2] Noto TJ, Johnson LW, Krone R, Weaver WF, Clark DA, Kramer JR, Vetrovec GW. Cardiac catheterization 1990: a report of the registry of the Society for Cardiac angiography and interventions. Cathet Cardiovasc Diagn 1991;24:75–83. [3] Armstrong SJ, Murphy KP, Wilde P, Hartnell GG. Ventricular fibrillation in coronary angiography: what is the role of contrast medium. Eur Heart J 1989;10:892–5. [4] Lehmann KG, Chen YC. Reduction of ventricular arrhythmias by atropine during coronary arteriography. Am J Cardiol 1989;63:447– 51. [5] Hayakawa K, Yamashita K. Contrast media-induced ventricular fibrillation. Invest Radiol 1988;23(Suppl. 1):S144–6.
N. Singh et al. / International Journal of Cardiology 89 (2003) 111–113 [6] Arrowood JA, Mullan DF, Kline RA, Engel TR, Kowey PR. Ventricular fibrillation during coronary angiography: the precatheterization QT interval. J Electrocardiol 1987;20:255–9. [7] Nii T, Noda Y, Mori T. Ventricular fibrillation induced by coronary spasm during noncardiac surgery. Int J Cardiol 1999;70:241–4. [8] Starmer CF, McIntosh HD, Whalen RE. Electrical hazards and cardiovascular function. New Engl J Med 1971;284:181–6.
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[9] Murdock DK, Johnson SA, Loeb HS, Scanlon PJ. Ventricular fibrillation during coronary angiography: reduced incidence in man with contrast media lacking calcium binding additives. Cathet Cardiovasc Diagn 1985;11:153–9. [10] Missri J, Jeresaty RM. Ventricular fibrillation during coronary angiography: reduced incidence with nonionic contrast media. Cathet Cardiovasc Diagn 1990;19:4–7.
Letter to the Editor
Malignant ventricular arrhythmias during coronary angiography a a b, a Narpinder Singh , Ramesh M. Gowda , Ijaz A. Khan *, Sudarsanam Konka a
Divisions of Cardiology, Long Island College Hospital, Brooklyn, NY, USA b Creighton University School of Medicine, Omaha, NE, USA Received 11 June 2002; accepted 23 July 2002
Keywords: Cardiac catheterization; Coronary angiography; Ventricular fibrillation; Ventricular tachycardia; Complications
Cardiac catheterization is a relatively safe procedure with a small risk of morbidity and mortality. Coronary arteriography is known to rarely produce electrical perturbations including conduction disturbances and malignant arrhythmias, which are more common with right coronary artery injection [1–10]. To ensure prompt detection and treatment, malignant ventricular arrhythmias, although rare, should be anticipated during coronary angiography. We describe a patient who developed malignant ventricular arrhythmias during coronary angiography, and elaborate the possible underlying mechanisms and prevention of this complication. A 74-year-old male was admitted with acute shortness of breath and ruled in for a non-ST segment elevation myocardial infarction based on elevation of myocardial enzyme markers. The postinfarction left ventricular ejection fraction was 27%. On telemetry monitoring he was found to have episodes of nonsustained ventricular tachycardia. Elective coronary angiography was performed. No problem was encountered during left coronary angiography. On selective cannulation of the right coronary artery and injection of the contrast agent, there was damping and ventricularization of the pressure tracing. The patient *Corresponding author. Creighton University Cardiac Center, 3006 Webster Street, Omaha, NE 68131, USA. Tel.. 11-402-280-4573; fax: 11-402-280-4938. E-mail address: [email protected] (I.A. Khan).
developed sustained ventricular tachycardia, which immediately degenerated into ventricular fibrillation with hemodynamic instability and loss of consciousness. With an external defibrillator, an asynchronous countershock was administered with immediate return to normal sinus rhythm and regain of hemodynamic stability and consciousness. On subsequent analyses he was found to have noncritical coronary artery disease. He has been doing well on maximal medical therapy with a beta-blocker, an angiotensin converting enzyme inhibitor, a long-acting nitrate and diuretics, when last seen 4 months after the initial presentation. Diagnostic cardiac catheterization can be performed very safely so that the benefits far outweigh the risks. The frequency of the major complications of death, nonfatal myocardial infarction or cerebrovascular accident is approximately 1 per 1000 patients [1,2]. Although ventricular arrhythmias in the form of ectopy and short runs of nonsustained ventricular tachycardia are not uncommon during the procedure, there is a progressive decline in the incidence of ventricular fibrillation over the past 3 decades with the changes in the injection technique and formulation of the contrast agents. The incidence reported in 1973 was 1.28% [1], which decreased to ,0.4% as reported in 1991 [2]. Malignant ventricular arrhythmia is a rare but wellrecognized procedure related to complication of
0167-5273 / 02 / $ – see front matter 2002 Elsevier Science Ireland Ltd. All rights reserved. doi:10.1016/S0167-5273(02)00460-6
112
N. Singh et al. / International Journal of Cardiology 89 (2003) 111–113
cardiac catheterization, often occurring after selective coronary artery injection of contrast medium [3–6]. Ventricular fibrillation during coronary angiography is usually associated with contrast-induced changes in repolarization, and a study using prolonged right coronary exposures to contrast media has demonstrated a higher incidence of ventricular fibrillation with dilute low sodium contrast media than with dilute contrast media containing more physiologic levels of sodium [5]. Therefore, the incidence of ventricular fibrillation was suggested to correlate with hyperosmolality and the absence of sodium ions, even in low-osmolality contrast media [5]. Furthermore, this incidence has been reported to be higher in patients with baseline prolonged QT interval [6]. Although precatheterization QT prolongation was associated with ventricular fibrillation during coronary angiography, the occurrence of ventricular fibrillation did not necessarily portend a worse longterm prognosis [6]. Interestingly, ventricular fibrillation can be caused by coronary artery spasm induced by the intracoronary injection of acetylcholine in patients without overt coronary artery disease [7]. In addition, malignant ventricular arrhythmias can be precipitated by mechanical stimulus when the tip of a catheter or guidewire is placed into a small intramyocardial branch of the coronary artery during coronary angiography. Mechanically induced arrhythmias usually revert after repositioning the catheter or guidewire into the main coronary arterial lumen. Ventricular fibrillation, although it may result from excess catheter manipulation, is commonly seen as a result of intracoronary injection of high-osmolar ionic contrast agents into the right coronary artery, particularly with prolonged injection time and damped catheter pressure, which is more common with right coronary artery catheterization. The reasons for the higher chances of damped catheter pressure in the right coronary artery include a smaller vessel caliber, ostial spasm around the catheter tip, true ostial stenosis or selective engagement of the conus branch. Ventricular fibrillation in the past was reported to be induced by leakage of electrical currents via the catheter into the heart [8], a complication that could be eliminated by proper grounding systems. Moreover, sustained ventricular tachycardia and fibrillation during coronary angiography can also occur in the
setting of profound myocardial ischemia or evolving or early myocardial infarction, and metabolic problems such as hypoxia, hypercarbia, or electrolyte imbalances. The problems associated with right coronary artery engagement can usually be eliminated by nonselective injections into the right sinus of Valsalva or, if damped, by using cautious injection of contrast with immediate withdrawal of the catheter postinjection. 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, but with atropine pretreatment, there is a risk of precipitating sinus tachycardia and myocardial ischemia in the usual patient population with acute coronary syndrome who undergo cardiac catheterization [4]. The incidence of ventricular fibrillation during coronary angiography can be reduced by using low osmolar nonionic contrast media lacking calcium-binding additives [9,10]. In addition, the staff in cardiac catheterization laboratories should be aware of the procedure related complications, their recognition, and the appropriate treatment to alleviate any enduring long-term effects.
Acknowledgements No financial support was received for this paper.
References [1] Adams DF, Fraser DB, Abrams HL. The complications of coronary arteriography. Circulation 1973;48:609–18. [2] Noto TJ, Johnson LW, Krone R, Weaver WF, Clark DA, Kramer JR, Vetrovec GW. Cardiac catheterization 1990: a report of the registry of the Society for Cardiac angiography and interventions. Cathet Cardiovasc Diagn 1991;24:75–83. [3] Armstrong SJ, Murphy KP, Wilde P, Hartnell GG. Ventricular fibrillation in coronary angiography: what is the role of contrast medium. Eur Heart J 1989;10:892–5. [4] Lehmann KG, Chen YC. Reduction of ventricular arrhythmias by atropine during coronary arteriography. Am J Cardiol 1989;63:447– 51. [5] Hayakawa K, Yamashita K. Contrast media-induced ventricular fibrillation. Invest Radiol 1988;23(Suppl. 1):S144–6.
N. Singh et al. / International Journal of Cardiology 89 (2003) 111–113 [6] Arrowood JA, Mullan DF, Kline RA, Engel TR, Kowey PR. Ventricular fibrillation during coronary angiography: the precatheterization QT interval. J Electrocardiol 1987;20:255–9. [7] Nii T, Noda Y, Mori T. Ventricular fibrillation induced by coronary spasm during noncardiac surgery. Int J Cardiol 1999;70:241–4. [8] Starmer CF, McIntosh HD, Whalen RE. Electrical hazards and cardiovascular function. New Engl J Med 1971;284:181–6.
113
[9] Murdock DK, Johnson SA, Loeb HS, Scanlon PJ. Ventricular fibrillation during coronary angiography: reduced incidence in man with contrast media lacking calcium binding additives. Cathet Cardiovasc Diagn 1985;11:153–9. [10] Missri J, Jeresaty RM. Ventricular fibrillation during coronary angiography: reduced incidence with nonionic contrast media. Cathet Cardiovasc Diagn 1990;19:4–7.