Download Cath Lab Catastrophes

CRT 2013 , Washington DC
February 23-26th,2013
Cath Lab Catastrophes :
Prevention & Management Strategies
Fayaz Shawl, M.D., F.A.C.C.
Director Interventional Cardiology
Washington Adventist Hospital - Takoma Park,
Maryland
Clinical Professor of Medicine
George Washington University - Washington, D.C.
Fayaz Shawl, MD
Research Support :
Boston Scientific
Cordis ( J&J )
Medtronic
Abbot
Cath Lab Catastrophes
Crash bypass
Urgent bypass
P value
Results:
OR mortality
6/19 (32%)
1/56 (2%)
0.0001*
Hospital stay
8.06(8.04)
11.57(8.86)
0.1420
In-hospital mortality9/19 (47%)
3/56 (5%)
JA Carey,et al, Br Heart J 1994;72:428-435.
0.0001 *
Etiology : Cath lab Catastrophes
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Vessel closure
(Dissection,thrombus,Spasm,
and no-reflow)
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Introduction of Air, thrombus
Perforations
Anaphylaxis
Major Bleed
High Risk Patient
Management of Cath lab Catastrophes
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Don’t Panic
BP support ; Airway
Call for an extra-hand
QUICK -- Underlying Etiology
Cath Lab Catastrophes:
Clinical Features:
♥ Refractory Hypotension
♥ Loss of consciousness
♥ Respiratory arrest
♥ Wide QRS rhythm / PEA
♥ Ventricular Fibrillation ( Refractory)
♥ Chest compressions
Cath Lab Catastrophes:
Angiographic and Hemodynamic Features
♥ Occluded vessel (large viable area)
♥ Left main dissection
♥ No reflow in a major vessel (SVG)
♥ Poor clearance of dye (aortic root)
♥ Major Perforation / thrombosis/Air
♥ Narrow pulse pressure
♥ Pulmonary hypertension
♥ Worsening metabolic acidosis
Cath Lab Catastrophes:
LVAD ( indications )
Absence of intrinsic rhythm
Historical PerspectivesLVAD
Impella
70’s
80’s
90’s
00’s
Approved Percutaneous LVADs:
1. IABP
2. CPS ( ECMO)
3. Tandem Heart
4. Impella
Cath Lab Catastrophes:
? When Death is Imminent
Management
(Requiring chest compressions)
♥ Intubation
♥ Continuation of chest compressions
♥ Emergency institution of cardiopulmonary bypass
support ( ECMO )
♥ Replace angiographic access site with CPS cannulae
♥ Flow rate 50 ml/kg/min
♥ Contralateral groin access to re-assess anatomy
♥ Re-Intervention / Emergency Surgery
56 yr. Old F, CTO LCX, RCA
75yr..male –CTO RCA, for PCI to LAD
CORONARY AIR EMBOLUS
CORONARY AIR EMBOLUS
Air Embolus
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Often from manifold injections
(contrast or flush )
and during introduction of devices - TB)
Prevention
 Avoid pressurized flush
 Back bleed before injecting
Small amounts are well tolerated
Large amounts cause “Air Lock”
 Chest Pain
 Bradycardia
 Hypotension / Hemodynamic Collapse
Air Lock: Management
Don’t Panic
 100% O2
 Morphine, Atropine
 Neo-synephrine 0.1 mg. IV
 I/C Epinephrine 1:10,000 dil.
 Turn patient
 Suction / Flushing
 IABP
 LV assist Devices (for refractory
hemodynamic collapse)

85 yr. female – Class III – PCI - LAD
DES 3.0 X 23mm- 16 Atm-
Type III…………
Prolonged Balloon Inflation
Refractory Cardiac Arrest- VF
Covered Stent- with CPS
Long Sheath
Long Sheath
Still in VF- stable Hemodynamics'…
On CPS – 4L/minNote long sheath
Post – Covered Stent – Defib. To NSR
Coronary Perforation
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Occurs in between 0.1% - 0.7%
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More with ablative devices
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More with oversizing the devices
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Hydrophilic guide wire, Temp. Pacemaker
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Early recognition is key to a successful
outcome
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Highest mortality among all PCI complications
JOSTENT (PTFE) To Treat
Coronary Perforations
Overall Perforation Rate 0.45% (49 / 10,945)
PTFE (n=12)
Non-PTFE (n=37)
P-value
In-Hospital Outcome
QMI (%)
8
23.5
0.29
Cardiac Tamponade (%)
8
82
<0.001
Bypass Surgery (%)
18
88
<0.001
Death (%)
18
35
0.28
C. Briguori et al, Circulation 2000
Coronary Perforation
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Rapid recognition is key
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Cardiac tamponade and hemodynamic collapse can
occur in minutes.
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Prolonged inflation- ( up to 10 min) of an oversized
balloon at low pressure. Reversal of anticoagulation
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pericardiocentesis
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Coils, Covered stents (require post-dilation, high
pressure)
Javaid et al Am J Cardiol 2006; 98: 911-4
Preventive Measures
Make sure – indication for PCI
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Watch the tip of the guide wire
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Sizing of the device( small vessel, tortuous , Bend points)
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During CTO: (confirm the distal end of balloon).
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Undersize- CB, ROTO, ( Bends)
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Do not oversize Stent ( small vessels)-do simple balloon or leave
them alone-
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ALWAYS CHECK ANGIO, before removing stent balloon– if you
see—just inflate the same balloon
Standby CPS for Elective Interventions
Total Number of Interventions at Washington Adventist Hospital
from 4/1988 to 2/2000 N = 23,472
Refractory Cardiopulmonary Arrest in the cath lab
N=39 (0.2%)
Abrupt closure
N=26*
Perforation
N=7
LM dissection
N=5
*(no reflow in 8 & air E in one)
Surgery N=10
Survived
N=7
Expired
N=3
Pulmonary
edema
N=1
Re-intervention N=29
Survived
N=24
Shawl, et al., J ACC 2001( Abs.)
Expired
N=5
Standby CPS for Elective Interventions
N = 23,472
Cardiopulmonary Arrest
(Imminent death)
 Overall survival
 Percutaneous interventions
 Emergency surgery
39 (0.2%)
31/39 (79%)
24/29 (83%)
7/10 (70%)
74 yr. old male – NSTMI – PCI to mid LAD