1. 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.

2. Research Support : Boston Scientific Cordis ( J&J ) Medtronic Abbot
Fayaz Shawl, MD
Research Support :
Boston Scientific
Cordis ( J&J )
Medtronic
Abbot

3. Cath Lab Catastrophes Crash bypass Urgent bypass P value Results:
OR mortality 6/19 (32%) 1/56 (2%) *
Hospital stay (8.04) (8.86)
In-hospital mortality9/19 (47%) /56 (5%) *
JA Carey,et al, Br Heart J 1994;72:

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

5. Management of Cath lab Catastrophes
Don’t Panic
BP support ; Airway
Call for an extra-hand
QUICK -- Underlying Etiology

6. Cath Lab Catastrophes:
Clinical Features:
♥ Refractory Hypotension ♥ Loss of consciousness ♥ Respiratory arrest ♥ Wide QRS rhythm / PEA ♥ Ventricular Fibrillation ( Refractory) ♥ Chest compressions

7. 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

8. Cath Lab Catastrophes:
LVAD ( indications )
Absence of intrinsic rhythm

9. Historical Perspectives- LVAD
Impella
70’s 80’s 90’s ’s

10. Approved Percutaneous LVADs:
1. IABP
2. CPS ( ECMO)
3. Tandem Heart
4. Impella

11. 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

12. 56 yr. Old F, CTO LCX, RCA

13. 75yr..male –CTO RCA, for PCI to LAD

16. CORONARY AIR EMBOLUS

17. CORONARY AIR EMBOLUS

20. 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

21. 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)

22. 85 yr. female – Class III – PCI - LAD

23. DES X 23mm- 16 Atm-

24. Type III…………

25. Prolonged Balloon Inflation

26. Refractory Cardiac Arrest- VF

27. Covered Stent- with CPS

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

29. Post – Covered Stent – Defib. To NSR

31. 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

32. 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

33. 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

34. 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

35. 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.)

36. 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%)

38. 74 yr. old male – NSTMI – PCI to mid LAD