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Outcome of Ventricular Fibrillation Developing During Percutaneous CoronaryInterventions in 19,497 Patients Without Cardiogenic Shock

Srinivas Addala, MD, Joel K. Kahn, MD*, Thomas F. Moccia, DO, Kishore Harjai, MD,Gregory Pellizon, MD, Anthony Ochoa, MD, and William W. O’Neill, MD

Ventricular fibrillation (VF) developing out of hospital or even in hospital has areported prognosis for survival that is <50%. We examined the prognosis for VF in19,497 patients undergoing percutaneous coronary intervention and identified 164who had VF (0.84%). The time to defibrillation was <1 minute and was successful inall without sequelae. Thus, VF developing in the catheterization laboratory is uniquein terms of prognosis. © 2005 Elsevier Inc. All rights reserved. (Am J Cardiol 2005;

96:764–765)

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e sought to assess the frequency and prognosis of ven-ricular fibrillation (VF) during percutaneous coronary in-ervention (PCI) in a large group of patients treated withontemporary techniques.

• • •e reviewed the catheterization laboratory computerized da-

abase at William Beaumont Hospital from June 1996 to Sep-ember 2001. Patients coded in the database with cardiogenichock on presentation to the catheterization laboratory werexcluded. During these 60 months, 44,451 catheterization pro-edures were done, including 24,954 diagnostic proceduresnd 19,497 PCIs. Independent chart auditors within the Divi-ion of Cardiology prospectively collected the database for theCI procedures. All statistical analyses were performed usingtatistical Analysis System software (SAS Institute, Caryorth Carolina). A p value of �0.05 was considered signifi-

ant.A total of 164 patients had VF during PCI in the cardiac

atheterization laboratory (0.84%). VF developed duringight coronary injection in 98 patients, left coronary injec-ion in 64 patients, and during bypass graft injection in 2atients (p � 0.05). Of the 164 patients experiencing VF, 1911%) had Thrombolysis In Myocardial Infarction grade 0o 1 flow in the coronary injected at VF. All patients re-eived defibrillation within �1 minute, and all were suc-essfully returned to sinus rhythm. All patients were dis-harged alive without neurologic damage from the VFpisode.

Table 1 lists the clinical characteristics of the patientseveloping and not developing VF during PCI. Patientseveloping VF during PCI were more likely to have aistory of hypertension and were less likely to have aistory of bypass surgery, diabetes mellitus, or renal insuf-

William Beaumont Hospital, Royal Oak, Michigan. Manuscript re-eived February 25, 2005; revised manuscript received and accepted April5, 2005.

* Corresponding author: Tel: 248-267-5050; fax: 248-267-5051.

mE-mail address: jkahn@mhgpc.com (J.K. Kahn).

002-9149/05/$ – see front matter © 2005 Elsevier Inc. All rights reserved.oi:10.1016/j.amjcard.2005.04.057

ciency. A trend was noted toward more frequent episodesf VF during angiography with ionic contrast agents.

• • •F during diagnostic cardiac catheterization is a well-nown risk and may occur in approximately 0.5% to 1.0%f procedures.1–3 VF most commonly develops during in-racoronary injection of contrast media but may also resultrom acute ischemia due to coronary dissection, embolism,r spasm or manipulation of a catheter in the right or leftentricle.3 Early results in patients who have undergone PCIuggest a higher incidence of VF of around 1.5%,4 althoughore recent series have reported an incidence that is lower

nd around 0.5%.5,6 In the setting of PCI for acute myocar-ial infarction, an incidence of ventricular tachycardia orF of 4.3% was recently reported.7

We observed VF in 0.84% of �19,000 PCIs performedsing relatively contemporary techniques and pharmacol-gy. The higher incidence of VF in patients with a historyf hypertension has not been previously described, andhether it relates to an increased mass of left ventricular

able 1haracteristics of percutaneous coronary intervention (PCI) patientseveloping ventricular fibrillation (VF)

ariable VF p Value

No(n � 19,333)

Yes(n � 164)

en 13,110 (68%) 101 (62%) 0.08ge (yrs)�65 9,326 (48%) 66 (40%) 0.1165–75 6,395 (33%) 61 (37%)�75 3,562 (19%) 37 (23%)reatinine �1.5 mg/dl 1477 (8%) 3 (2%) 0.002revious myocardial infarct 6,979 (36%) 55 (34%) 0.50revious coronary bypass 4,294 (22%) 20 (12%) 0.002iabetes mellitus 5,362 (28%) 24 (15%) �0.001jection fraction �40% 2,127 (15%) 19 (12%) 0.18ypertension 8,277 (43%) 124 (76%) �0.001

onic contrast 11,555 (60%) 109 (66%) 0.08

yocardium susceptible to ischemia is unknown. Further-

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765Coronary Artery Disease/Ventricular Fibrillation in Catheterization Laboratory

ore, the observation that VF occurred less frequently inatients with previous diabetes mellitus, bypass surgery,nd renal insufficiency is unexplained and may deserveurther study.

VF developing in patients during PCI outside the settingf cardiogenic shock responds in a dramatically superioranner compared with reports of VF occurring in patients

utside the hospital or even in other hospital settings. Thextremely short time to defibrillation and access to othermergency equipment likely explains the difference.

. Morris TW. A review of coronary arteriography and contrast media in-duced ventricular fibrillation. Acta Radiol 1995;36(suppl)S399:100–104.

. Nishimura RA, Holmes DR, McFarland TM, Smith HC, Bove AA.Ventricular arrhythmia during coronary angiography in patients withangina pectoris and chest pain syndromes. Am J Cardiol 1984;53:1496–

1499.

. Missri J, Jeresaty RM. Ventricular fibrillation during coronary angiog-raphy: reduced incidence with nonionic contrast media. Cathet Cardio-vasc Diagn 1990;19:4–7.

. Dorros G, Cowley MJ, Bentivoglio LG, Block PC, Bourassa M, DetreK, Gosselin AJ, Gruentzig AR, Kelsey SF, Kent KM, et al. Percutane-ous transluminal coronary angioplasty: report of complications from theNational Heart, Lung and Blood Institute PTCA registry. Circulation1983;67:723–730.

. Huang JL, Ting CT, Chen YT, Chen SA. Mechanisms of ventricularfibrillation during coronary angioplasty: increased incidence for thesmall orifice caliber of the right coronary artery. Inter J Cardiol 2002;82:221–228.

. Brennan E, Mahrer PR, Aharonian VJ. Incidence and presumed etiologyof ventricular fibrillation during coronary angioplasty. Am J Cardiol1991;67:769–770.

. Mehta RH, Harjai KJ, Grines L, Stone GW, Boura J, Cox D, O’Neill W,Grines CL. Sustained ventricular tachycardia or fibrillation in the car-diac catheterization laboratory among patients receiving primary per-

cutaneous intervention. J Am Coll Cardiol 2004;43:1765–1772.