An analysis of the factors producing multiple ventricular arrhythmias during pulmonary artery catheterization

Efficacy and safety of pulmonary artery catheterization with combined transesophageal echocardiography and pressure waveform: A prospective observational study

Objective

This study investigated whether pulmonary artery catheter placement method with combined transesophageal echocardiography and pressure waveform measurement improve the placement success rate within 5 min and reduce the incidence of arrhythmia during pulmonary artery catheter placement compared to conventional pulmonary artery catheter placement with pressure waveform measurement only.

Methods

This single center prospective observational study included 129 patients scheduled for cardiac surgery. Patients were divided into two groups. In the conventional group, the pulmonary artery catheter was placed by monitoring the pressure waveform and the length of placement; in the combination group, not only were the pressure waveform and the length monitored but also the following transesophageal echocardiography images: "mid esophageal bicaval view," " mid esophageal modified bicaval view," a mirror image of "mid esophageal 4 chamber view," "mid esophageal right ventricular inflow-outflow view," and "mid esophageal ascending aortic short axis view."

Results

A 1:1 propensity score matching was used to adjust for confounding factors. The success rates of pulmonary artery catheter placement within 5 min in the conventional and combination groups were 85.5 % vs. 97.8 % (p = 0.032) before matching, and 73.7 % vs. 100 % (p = 0.001) after matching. The incidences of arrhythmias in the conventional and combination groups were 28.9 % vs. 17.4 % (p = 0.20) before matching, and 28.9 % vs. 18.4 % (p = 0.42) after matching.

Conclusion

Pulmonary artery catheter placement with transesophageal echocardiography had a significantly higher rate of successful placement within 5 min, but no significant differences were observed in the incidences of arrhythmias.

Biventricular Compared to Left Ventricular Impella and Norepinephrine Support in a Porcine Model of Severe Cardiogenic Shock

Contemporary management of cardiogenic shock (CS) with vasopressors is associated with increased cardiac workload and despite the use of unloading devices such as the Impella pump, concomitant vasopressors are often necessary. Therefore, we compared if cardiac workload could be reduced and end-organ perfusion preserved with biventricular support (Bipella) compared to ImpellaCP and norepinephrine in pigs with left ventricular (LV) CS caused by left main coronary microembolization. Cardiac workload was calculated from heart rate × ventricular pressure-volume area obtained from conductance catheters placed in the LV and right ventricle (RV), whereas organ perfusion was measured from venous oxygen saturation in the pulmonary artery (SvO 2 ) and the kidney- and the cerebral vein. A cross-over design was used to access the difference after 30 minutes of ImpellaCP and norepinephrine 0.1 µg/kg/min versus Bipella for 60 minutes. Bipella treatment reduced LV workload ( p = 0.0078) without significant difference in RV workload from ImpellaCP and norepinephrine, however a decrease in SvO 2 (49[44-58] vs . 66[63-73]%, p = 0.01) and cerebral venous oxygen saturations (62[48-66] vs . 71[63-77]%, p = 0.016) was observed during Bipella compared to ImpellaCP and norepinephrine. We conclude that Bipella reduced LV workload but did not preserve end-organ perfusion compared to ImpellaCP and norepinephrine in short-term LV CS.

An analysis of factors influencing pulmonary artery catheter passage through the tricuspid and pulmonary valves

Purpose

A pulmonary artery catheter (PAC) has to pass the tricuspid and pulmonary valves for its proper placement. Although several factors were reported to hinder the placement, there have been no reports to identify the factors that prolong the individual time for passing through each valve.

Method

We individually measured the time required for a PAC to pass through the tricuspid and pulmonary valves. We examined the effect of the following factors on those times: the patient’s age, sex, height, weight, cardiothoracic ratio, tricuspid regurgitation, left ventricular ejection fraction, and the diameters of the sinus of Valsalva and of the sinotubular junction divided by the body surface area which represent the diameter of the aorta. Data were analyzed by multiple linear regression analysis after univariate analysis.

Results

The placement of a PAC was successful in all of 100 patients. The time required to pass through the pulmonary valve was significantly longer than that through the tricuspid valve (15 [10–28] s vs 9 [5–16] s, median [range], P < 0.01). The incidence of ventricular arrhythmias during passage through the pulmonary valve was significantly higher than that through the tricuspid valve (17% vs 0%, P < 0.01). Tricuspid regurgitation and the diameter of sinotubular junction had a significant positive association with the time required to advance a PAC through the pulmonary valve, although there was no significant factors that increased the time required to advance a PAC through the tricuspid valve.

Conclusion

The time required to advance a PAC through the pulmonary valve is much longer than that to pass through the tricuspid valve. The diameter of aortic root and tricuspid regurgitation are significant factors that increased the time required to advance a PAC through the pulmonary valve.

Intra-procedural arrhythmia during cardiac catheterization: A systematic review of literature

BACKGROUND

Cardiac catheterization is among the most performed medical procedures in the modern era. There were sporadic reports indicating that cardiac arrhythmias are common during cardiac catheterization, and there are risks of developing serious and potentially life-threatening arrhythmias, such as sustained ventricular tachycardia (VT), ventricular fibrillation (VF) and high-grade conduction disturbances such as complete heart block (CHB), requiring immediate interventions. However, there is lack of systematic overview of these conditions.

AIM

To systematically review existing literature and gain better understanding of the incidence of cardiac arrhythmias during cardiac catheterization, and their impact on outcomes, as well as potential approaches to minimize this risk.

METHODS

We applied a combination of terms potentially used in reports describing various cardiac arrhythmias during common cardiac catheterization procedures to systematically search PubMed, EMBASE and Cochrane databases, as well as references of full-length articles.

RESULTS

During right heart catheterization (RHC), the incidence of atrial arrhythmias (premature atrial complexes, atrial fibrillation and flutter) was low (< 1%); these arrhythmias were usually transient and self-limited. RHC associated with the development of a new RBBB at a rate of 0.1%-0.3% in individuals with normal conduction system but up to 6.3% in individuals with pre-existing left bundle branch block. These patients may require temporary pacing due to transient CHB. Isolated premature ventricular complexes or non-sustained VT are common during RHC (up to 20% of cases). Sustained ventricular arrhythmias (VT and/or VF) requiring either withdrawal of catheter or cardioversion occurred infrequently (1%-1.3%). During left heart catheterizations (LHC), the incidence of ventricular arrhythmias has declined significantly over the last few decades, from 1.1% historically to 0.1% currently. The overall reported rate of VT/VF in diagnostic LHC and coronary angiography is 0.8%. The risk of VT/VF was higher during percutaneous coronary interventions for stable coronary artery disease (1.1%) and even higher for patients with acute myocardial infarctions (4.1%-4.3%). Intravenous adenosine and papaverine bolus for fractional flow reserve measurement, as well as intracoronary imaging using optical coherence tomography have been reported to induce VF. Although uncommon, LHC and coronary angiography were also reported to induce conduction disturbances including CHB.

CONCLUSION

Cardiac arrhythmias are common and potentially serious complications of cardiac catheterization procedures, and it demands constant vigilance and readiness to intervene during procedures.

An analysis of prior experience influencing quality of pulmonary artery catheter placement in residents

Background:

Prior experience may be important for successful placement of a pulmonary artery catheter (PAC). However, there is no report about the minimum number of the placement to reach acceptable technique for the catheter placement during residency.

Aims:

This study was designed to examine quality of the catheter placement and to assess the effect of prior experience.

Setting and Design:

Prospective, observational, cohort study.

Methods:

This study included eight residents and one experienced staff in our hospital. We prospectively examined the performance of placement of a PAC in eight residents for the first 2 months of their training period and one staff for previous 2 years. We examined the time required for the catheter placement and probability of ventricular arrhythmias during the placement. Each resident and the staff reported approximate number of past experience of the catheter placement according to the self-statement. In addition, we continued to examine the placement of a PAC in one resident with zero experience to show his improvement.

Statistical Analysis:

Statistical analysis was performed by Kruskal–Wallis test, Mann–Whitney test, or Fisher's exact test as appropriate and Benjamini and Hochberg method was used for multiple comparisons.

Results:

The catheter placement time and probability of the ventricular arrhythmias of two residents with zero experience of the placement were significantly larger than those of the staff. On the other hand, the placement quality of the other residents who experienced at least 20 PAC placements was not significantly different from that of the staff. The placement quality of one resident with zero experience became comparable with that of the staff after 20 placements.

Conclusion:

Our data suggested that about 20 catheter placements may be required to reach acceptable technical level for the PAC placement.