Cardiac Tamponade During PCI
Abstract & Commentary
Synopsis: Cardiac tamponade following percutancous coronary intervention occurs 0.2% of the time and often occurs later outside the catheterization laboratory. Since about half were related to temporary pacing wires, this practice needs to be reexamined.
Source: Von Sohsten R, et al. Am Heart J 2000; 140:279-283.
Although cardiac tamponade is a rare complication of cardiac catheterization, many believe it is occurring more frequently in the modern percutaneous coronary intervention (PCI) era. Thus, Von Sohsten and associates prospectively analyzed their PCI complication registry for cardiac tamponade between 1994 and 1996 in 6999 patients undergoing PCI at a single university hospital. Within 36 hours of PCI, 15 patients experienced cardiac tamponade (0.2%)—six during the procedure. The median age of the patients was 72 years and 60% were women. All had received heparin, but only three received abciximab. None of the 14,927 diagnostic catheterizations during the same period resulted in tamponade. The site of perforation could be identified in 13 of the 15 cases: coronary lesion site in five; distal coronary wire perforation in three; and right ventricular perforation by a temporary pacing wire in five. The two in whom the site of perforation could not be visualized also had temporary pacing wires. The incidence of tamponade per 1000 patients was 0.3 for balloon angioplasty, 2.3 for stents, 3.2 for either DCA or TEC, and 10.8 for rotational atherectomy. Echocardiography was useful for diagnosis and surgical treatment was required in 60% of the patients. There were no in-hospital deaths. Von Sohsten et al concluded that cardiac tamponade following PCI occurs 0.2% of the time and often occurs later outside the catheterization laboratory. Since about half were related to temporary pacing wires, this practice needs to be re-examined.
Comment by Michael H. Crawford, MD
The experience of this group suggests that cardiac tamponade complicating cardiac catheterization procedures has increased 5- or 6-fold in the multiple device coronary intervention era. Of interest, half of the cardiac tamponade complications they observed were probably due to right ventricular perforation by a temporary pacing wire. The risk of perforation by pacemaker wires and other electrodes is well known. Some reports in the early years of electrophysiology procedures suggested incidences as high as 5%! Thus, in the precoronary device era, prophylactic pacemaker use had declined; however, the advent of complex coronary device interventions has increased prophylactic pacing use again. After this study, Von Sohsten et al’s group re-evaluated their use of prophylactic pacing. They are now more selective in whom they use pacing back-up and they use five or six Fr balloon tipped catheters, leaving the balloon up unless they need to pace.
Other factors may play a role in the risk of cardiac tamponade. They noted that it was more frequent in the elderly and women. Therefore, the approach to these patients should take this risk into consideration. Increased use of anticoagulants, antithrombics and thrombolytics could explain the increased frequency, but it did not appear so in this study. Finally, two-thirds of the cases occurred after the patient left the lab, usually in the first eight hours. They recommend that tamponade be suspected if a post-procedure patient becomes hypotensive and an echocardiogram done immediately. Also, early discharge of patients after aggressive PCI procedures is probably not a good idea.