1. The Icahn School of Medicine at Mount Sinai, Mount Sinai Beth Israel
Left Ventricular Perforation during Ventriculogram using a Universal Jacky Radial Catheter
Dr. Ramesh M. Gowda, M.D.
The Icahn School of Medicine at Mount Sinai, Mount Sinai Beth Israel

2. Ramesh M. Gowda, M.D.
I have no relevant financial relationships

3. Learning objectives
To illustrate the risk of left ventricular perforation as a complication of coronary angiography.
The elucidate proper catheter selection for left ventriculograms.

4. Clinical Presentation
A 65 year old Burmese gentleman, with a history of hypertension and unstable angina.
Referred for a cardiac catheterization.

5. EKG

6. Clinical Presentation
A universal Jacky radial catheter (Terumo, Somerset, New Jersey) was placed in the left ventricle via trans-radial approach.
After confirming free floating catheter position and obtaining adequate pressure waveforms, a gentle hand injection of about 3 cc of contrast dye was given.
Abnormal opacification of the left ventricular myocardial wall without any immediate clinical or hemodynamic sequelae was noted.

7. Cath video
The presentation, including videos, was too large to attach (as stated in the s to and however the complete presentation was ed - thank you for your consideration.
Abnormal opacification of the left ventricular myocardial wall without any immediate clinical or hemodynamic sequelae was noted.

8. Clinical Presentation
Angiography was completed, showing:
subtotal occlusion of the mid right coronary artery (RCA)
a non-obstructive left system

9. Cath video
The presentation, including videos, was too large to attach (as stated in the s to and however the complete presentation was ed - thank you for your consideration.
subtotal occlusion of the mid right coronary artery (RCA)

10. Cath video
The presentation, including videos, was too large to attach (as stated in the s to and however the complete presentation was ed - thank you for your consideration.
a non-obstructive left system

11. Clinical Presentation
Upon review of the CINE loop:
contrast layering in the inferior and diaphragmatic locations was noted.

12. Cath video
The presentation, including videos, was too large to attach (as stated in the s to and however the complete presentation was ed - thank you for your consideration.

13. Clinical Presentation
A stat bedside echocardiogram then performed revealed a small pericardial effusion.
Therefore, the plan to proceed with PCI was aborted.

14. Clinical Presentation
The decision was made to keep the patient on the catheterization table for continual evaluation until it was determined that the size of the effusion was not increasing.
Cardiothoracic surgery was made aware of the case, in case emergent surgical intervention was required.
The patient was chest pain free but rapidly became hemodynamically unstable.
An emergent pericardiocentesis was performed via the subxiphoid approach.
The pericardial drain was left in place and the patient was monitored in the CCU.
He had serial echocardiograms that did not show reaccumulation of fluid and the drain was removed in about 24 hours.

15. Imaging Studies
The presentation, including videos, was too large to attach (as stated in the s to and however the complete presentation was ed - thank you for your consideration.
a small pericardial effusion.

16. Imaging Studies
The presentation, including videos, was too large to attach (as stated in the s to and however the complete presentation was ed - thank you for your consideration.
serial echocardiograms that did not show reaccumulation of fluid

17. Take Home Messages
Left ventricular perforation during ventriculogram is a known complication of coronary angiography.
However, it is not well documented in the literature as it is only now that transradial multipurpose catheters are being universally adopted.
With increasing use of transradial catheters, it is imperative to be cognizant of this complication. 
Hand injections for left ventriculograms are not recommended with end-hole catheters.
A pigtail multi-hole catheter should be used.