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EM Cardiac Catheterization Risks article and Summary

The patient from my HPI tolerated his cardiac catheterization procedure well. However, later this week I saw another patient for whom the outcomes were way less favorable. During the catheterization he developed a pericardial effusion which quickly turned into a tamponade, he then required a pericardiocentesis resulting in V-fib, cardioversion and a pacemaker placement.

This article published on June 22, 2020 reviews Catheterization Risks and Complications

Cardiac catheterization is one of the most widely performed cardiac procedures. In the United States, more than 1,000,000 cardiac catheterization procedures are performed annually. As expected, in any invasive procedure, there are some patient related and procedure-related complications.

The procedure can be either diagnostic or therapeutic, and interventional cardiologists can perform a variety of interventions depending on the clinical need.

The procedure is done in the evaluation and the treatment of the following conditions.

  • Coronary artery disease
  • Measuring the hemodynamics in the right and left side of the heart
  • Evaluating the left ventricular function
  • Evaluation and treatment of cardiac arrhythmias
  • Evaluation and treatment of valvular heart disease
  • Assessment pericardial and myocardial diseases
  • Assessment of the congenital heart diseases
  • Evaluation of heart failure

Before planning for this procedure, the clinician should have a clear understanding of the clinical question that needs to be answered.

Basic workup includes a complete blood count (CBC), basic metabolic panel (BMP), prothrombin time, electrocardiogram and chest x-ray.

The risk of major complications during diagnostic cardiac catheterization procedure is usually less than 1%, and the risk and the risk of mortality of 0.05% for diagnostic procedures. For any patient, the complication rate is dependent on multiple factors and is dependent on the demographics of the patient, vascular anatomy, co-morbid conditions, clinical presentation, the procedure being performed, and the experience of the operator. The complications can be minor as discomfort at the site of catheterization to major ones like death.

Complications

~Hematoma/Retroperitoneal bleeding/Pseudoaneurysm

~Poorly controlled hemostasis post sheath removal

~AV fistula

~Thrill or continuous bruit, likely to need surgery

~Dissection/Perforation of Aorta or cardiac chambers

~Coronary or cardiac chamber perf – tamponade

~Thrombosis and embolism (Including atheroembolism)

~ Death – less than 0.05%, up to 1% in some subsets

~ MI – less than 0.1%

~ Stroke – up to 0.4% in clinical intervention, less if diagnostic

~ Arrhythmias

The occurrence of the ventricular fibrillation or ventricular tachycardia during the procedure could be related to irritation or ischemia of the myocardium by the catheter, contrast material or occlusive balloons.

These arrhythmias occur more frequently in people presenting with acute ST- elevation myocardial infarction and treatment includes cardioversion along with anti arrhythmic drugs and restoration of the flow to the occluded artery.

Atrial tachyarrhythmias can occur following the irritation of the right atrium during right heart catheterization and is usually self- limiting.

Transient brady arrhythmias are also a common occurrence in the cardiac cath lab. Prolonged episodes resulting in hypotension will need treatment with intravenous atropine, or temporary transvenous pacing.

In people with preexisting right bundle branch block, development of the left bundle branch block during right heart catheterization may result in complete heart block, and this can be avoided by minimal catheter manipulation in right ventricular outflow tract.

With the advent of the small catheters, increased use of the transradial approach, and improving technical skills of the operators, the risks and complications associated with cardiac catheterization have decreased significantly.

There is increasing evidence that transradial approach for cardiac catheterization reduces associated complications and improves patient comfort compared to transfemoral approach.

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