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Anesthesiology Charles D. Collard, M.D., Editor Alan Jay Schwartz, M.D., M.S. Ed., Associate Editor
Ventricular Asystole during Pulmonary Artery Catheter Insertion David W. Barbara, M.D., Roger D. White, M.D.
A
lthough the overall pulmonary artery catheter (PAC) use has decreased, it remains a valuable tool in select patients. PAC insertion may result in ventricular or supraventricular dysrhythmias due to contact of the catheter with the cardiac chamber walls. The use of balloon-tipped catheters during insertion serves to increase the catheter tip surface area, thereby mitigating applied pressure (and potential injury) should the catheter tip contact endocardium.1 The right bundle branch is located superficially in the endocardium of the right ventricle and is susceptible to trauma. Transient right bundle branch block may result and has been reported in 0 to 12% of patients undergoing right heart catheterization.2,3 In patients with preexisting left bundle branch block, iatrogenic right bundle branch block with PAC placement results in complete heart block. As noted in figure A and B, complete heart block may present as regular p waves with ventricular asystole and cardiac arrest (fig. A). Although typically transient, complete heart block occurring during PAC placement can cause hemodynamic instability warranting immediate treatment. Prompt removal of the PAC may result in resolution of the complete heart block and hemodynamic stability (fig. B, total duration of ventricular asystole 10 s). Advanced cardiac life support and pacing should be provided as indicated. Previously, prophylactic temporary transvenous pacemaker placement was recommended in left bundle branch block patients undergoing PAC placement, but concerns of risks outweighing benefits of this approach have caused it to fall out of favor.2,3
Competing Interests The authors declare no competing interests.
Correspondence Address correspondence to Dr. Barbara: [email protected]
References 1. Swan HJ, Ganz W, Forrester J, Marcus H, Diamond G, Chonette D: Catheterization of the heart in man with use of a flow-directed balloon-tipped catheter. N Engl J Med 1970; 283:447–51 2. Morris D, Mulvihill D, Lew WY: Risk of developing complete heart block during bedside pulmonary artery catheterization in patients with left bundle-branch block. Arch Intern Med 1987; 147:2005–10 3. Sprung CL, Elser B, Schein RM, Marcial EH, Schrager BR: Risk of right bundle-branch block and complete heart block during pulmonary artery catheterization. Crit Care Med 1989; 17:1–3
From the Department of Anesthesiology, Mayo Clinic College of Medicine, Rochester, Minnesota. Copyright © 2014, the American Society of Anesthesiologists, Inc. Wolters Kluwer Health, Inc. All Rights Reserved. Anesthesiology 2015; 123:669
Anesthesiology, V 123 • No 3 669
September 2015
Copyright © by the American Society of Anesthesiologists. Unauthorized reproduction of this article is prohibited.
in
Anesthesiology Charles D. Collard, M.D., Editor Alan Jay Schwartz, M.D., M.S. Ed., Associate Editor
Ventricular Asystole during Pulmonary Artery Catheter Insertion David W. Barbara, M.D., Roger D. White, M.D.
A
lthough the overall pulmonary artery catheter (PAC) use has decreased, it remains a valuable tool in select patients. PAC insertion may result in ventricular or supraventricular dysrhythmias due to contact of the catheter with the cardiac chamber walls. The use of balloon-tipped catheters during insertion serves to increase the catheter tip surface area, thereby mitigating applied pressure (and potential injury) should the catheter tip contact endocardium.1 The right bundle branch is located superficially in the endocardium of the right ventricle and is susceptible to trauma. Transient right bundle branch block may result and has been reported in 0 to 12% of patients undergoing right heart catheterization.2,3 In patients with preexisting left bundle branch block, iatrogenic right bundle branch block with PAC placement results in complete heart block. As noted in figure A and B, complete heart block may present as regular p waves with ventricular asystole and cardiac arrest (fig. A). Although typically transient, complete heart block occurring during PAC placement can cause hemodynamic instability warranting immediate treatment. Prompt removal of the PAC may result in resolution of the complete heart block and hemodynamic stability (fig. B, total duration of ventricular asystole 10 s). Advanced cardiac life support and pacing should be provided as indicated. Previously, prophylactic temporary transvenous pacemaker placement was recommended in left bundle branch block patients undergoing PAC placement, but concerns of risks outweighing benefits of this approach have caused it to fall out of favor.2,3
Competing Interests The authors declare no competing interests.
Correspondence Address correspondence to Dr. Barbara: [email protected]
References 1. Swan HJ, Ganz W, Forrester J, Marcus H, Diamond G, Chonette D: Catheterization of the heart in man with use of a flow-directed balloon-tipped catheter. N Engl J Med 1970; 283:447–51 2. Morris D, Mulvihill D, Lew WY: Risk of developing complete heart block during bedside pulmonary artery catheterization in patients with left bundle-branch block. Arch Intern Med 1987; 147:2005–10 3. Sprung CL, Elser B, Schein RM, Marcial EH, Schrager BR: Risk of right bundle-branch block and complete heart block during pulmonary artery catheterization. Crit Care Med 1989; 17:1–3
From the Department of Anesthesiology, Mayo Clinic College of Medicine, Rochester, Minnesota. Copyright © 2014, the American Society of Anesthesiologists, Inc. Wolters Kluwer Health, Inc. All Rights Reserved. Anesthesiology 2015; 123:669
Anesthesiology, V 123 • No 3 669
September 2015
Copyright © by the American Society of Anesthesiologists. Unauthorized reproduction of this article is prohibited.
