Cath Lab Catastrophes : Prevention & Management Strategies 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.

Research Support : Boston Scientific Cordis ( J&J ) Medtronic Abbot 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%) 0.0001 * JA Carey,et al, Br Heart J 1994;72:428-435.

Etiology : Cath lab Catastrophes Vessel closure (Dissection,thrombus,Spasm, and no-reflow) Introduction of Air, thrombus Perforations Anaphylaxis Major Bleed High Risk Patient

Management of Cath lab Catastrophes 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 Perspectives- LVAD 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 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

Still in VF- stable Hemodynamics'… On CPS – 4L/min- Note long sheath

Post – Covered Stent – Defib. To NSR

Coronary Perforation Occurs in between 0.1% - 0.7% More with ablative devices More with oversizing the devices Hydrophilic guide wire, Temp. Pacemaker Early recognition is key to a successful outcome 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 (%) 82 <0.001 Bypass Surgery (%) 18 88 Death (%) 35 0.28 C. Briguori et al, Circulation 2000

Coronary Perforation Rapid recognition is key Cardiac tamponade and hemodynamic collapse can occur in minutes. Prolonged inflation- ( up to 10 min) of an oversized balloon at low pressure. Reversal of anticoagulation pericardiocentesis 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 Watch the tip of the guide wire Sizing of the device( small vessel, tortuous , Bend points) During CTO: (confirm the distal end of balloon). Undersize- CB, ROTO, ( Bends) Do not oversize Stent ( small vessels)-do simple balloon or leave them alone- 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* *(no reflow in 8 & air E in one) Perforation N=7 LM dissection N=5 Pulmonary edema N=1 Surgery N=10 Survived N=7 Expired N=3 Re-intervention N=29 Survived N=24 Expired N=5 Shawl, et al., J ACC 2001( Abs.)

Standby CPS for Elective Interventions 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