Cardiac Catheterization Complication

Cath Lab Complications Death AMI Dysrhythmia Stroke Bleeding Hematoma Vascular Injury Contrast Induced Nephrotoxicity Allergic reactions/Anaphylaxis Pulmonary Edema Air/clot embolism Renal Failure (CIN) Vagal reaction

Arrhythmias Arrhythmias and conduction disturbances Premature ventricular contractions VT and V-Fib Atrial arrhythmias Bradycardia Varying clinical consequences depending upon severity of coronary artery disease, valvular heart disease, LV dysfunction, LVEDP

Premature Ventricular Contractions Can be common without any clinical significance Can be induced by catheter introduction into right or left ventricle

Ventricular Tachycardia and Ventricular Fibrillation Results from excess catheter manipulation and intracoronary contrast injection (esp. in RCA) Still occurs with contrast media if prolonged injection or performed with partially damped pressures Incidence is higher in patients with baseline prolonged QT interval Refractory ventricular ectopy is seen in the setting of profound transmural ischemia or early myocardial infarction

Ventricular Tachycardia and Ventricular Fibrillation.. If run of ventricular tachycardia initiated, the offending catheter must be repositioned immediately so that baseline cardiac rhythm is restored Ventricular fibrillation or unstable ventricular tachycardia should be treated with prompt electrical cardioversion Hemodynamically stable VT can be treated pharmacologically with lidocaine, amiodarone or procainamide MgSO4 in patients with Torsades

Atrial Arrhythmias Pre atrial contractions in response to catheter placement in or out of right atrium Subsided when catheter is repositioned May progress to atrial flutter and A-Fib in sensitive patients Atrial flutter usually well tolerated Usually do not require immediate treatment unless they produce hemodynamic instability In patients with mitral stenosis, hypertrophic cardiomyopathy and diastolic LV dysfunction

Atrial Arrhythmias.. Treated with burst atrial pacing, electrical or pharmacological cardioversion ( Beta blocker, calcium channel blockers) Care must be taken as catheter advancement into the ventricle can trigger VF Atrial fibrillation- can results in rapid ventricular response and loss of atrial systole- results in hypotension Synchronized cardioversion immediately if hemodynamic instability

Atrial Arrhythmias.. Other narrow complex tachycardia e.g., paroxysmal supraventricular tachycardia can be treated with vagal maneuver (carotid sinus message), IV adenosine, beta blocker, verapamil, or amiodarone Synchronized cardioversion if prolonged episode or producing hemodynamic instability

Bradycardia Can be secondary to the injection of contrast into the right coronary artery Can occur with contrast media if prolonged injection in the RCA or performed with partially damped pressures Forceful coughing can help clear the contrast, support perfusion, and restore normal cardiac rhythm

Vasovagal Reaction Vasovagal reactions- include bradycardia, hypotension, yawning and/or sweating Suspected when bradycardia is prolonged Seen in 3% of patients especially if they have pain or anxious in setting of hypovolemia Can be the early sign of cardiac perforation Landau et al. quoted as more than 80% of such reactions occurred as vascular access was being obtained, with 16% occurring during sheath removal Prevented by pre-procedural sedation and administration of adequate local anesthetic before catheter insertion Rx: volume administration, atropine and removal of painful stimulus Landau C, Lange RA, Glamann DB, Willard JE, Hillis LD. Vasovagal reactions in the cardiac catheterization laboratory. Am J Cardiol 1993;73:95.

Prevention of Complications Proper patient preparation Attention to details Experience Skills

Summary Although procedures may seem routine, there are no routine procedures Monitor all patients closely Never force equipment Always notify physician of complications

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