Intra-procedural arrhythmia during cardiac catheterization: A systematic review of literature

Table 1 Terms describing cardiac catheterization procedures and arrhythmias used in the combination for database search

Terms of procedures	Terms of arrhythmias
Cardiac catheterization	Cardiac arrhythmia
Left heart catheterization	Tachycardia
Right heart catheterization	Tachyarrhythmia
Pulmonary artery catheter	Ventricular fibrillation
Swan-Ganz catheter	Bradycardia
Coronary angiography	Heart block
Percutaneous coronary intervention	Conduction delay
Percutaneous transluminal coronary angioplasty	Bundle branch block

Table 2 List of studies reported the incidence rate of ventricular arrhythmia during right heart catheterization

Year	Number RHC	Types of arrhythmia	Incidence rate, n (%)	Setting	Study design	Procedural Outcomes	Ref.
1979	73	VA (> 1 PVCs in 4 beats)	27 (36.9)	OR	Prospective	All self-limited	Shaw et al[58]
					Randomized
1981	320	Overall	36 (16.4)	ICU	Prospective	3 VTs: Treatment	Sise et al[20]
		VA not treatment	33 (10)		Observational
		VA required treatment	3 (1)
1981	60	PVCs	29 (48)	ICU	Retrospective	2 VTs: Treatment	Sprung et al[56]
		VT	20 (33)		Observational	1 VF: Mortality
1982	107	VT (> 3 cPVCs, > 150 pbm)		OR	Prospective	All self-limited	Salmenpera et al[60]
		Lidocaine	8/53 (15)		Randomized
		Placebo	10/54 (19)
1982	150	Advanced VA	80 (53)	ICU	Prospective	3 VTs: Treatment	Sprung et al[17,56]
		Salvos (3-5 cPVCs)	45 (30)		Observational	2 VFs: Mortality
		NSVT (6-30 cPVCs)	30 (20)
		VT (> 30 cPVCs)	5 (3)
		VF	2 (1.3)
1983	67	Advanced VA	42 (63)	ICU	Prospective	All self-limited	Sprung et al[59]
		Lidocaine ppx	18/31 (58)		Randomized
		placebo	24/36 (67)
1983	528	PVCs	58 (11)	ICU	Prospective	8 VTs: Meds	Boyd et al[21]
		VT	8 (1.5)		Observational
		VF	0
1985	56	Advanced VA	7 (12.5)	ICU	Prospective	All self-limited	Iberti et al[22]
					Observational
1985	250	PVCs	162/250 (64.8)	OR	Prospective	All self-limited	Damen et al[14]
		VT (> 3 cPVC > 100 bpm)	11/250 (4.4)		Observational
		VF	0
1986	1400	Overall	880/1400 (62.9)	OR	Prospective	All self-limited	Damen et al[2]
		PVCs	838/1400 (59.9)		Observational
		VT (> 3 cPVC > 100 bpm)	42/1400 (3)
		VF	0
1986	142	Overall	64 (45)	ICU	Prospective	All self-limited	Patel et al[55]
		Benign (singlet PVCs)	24 (16.9)		Observational
		Malignant1	40 (28.1)
1989	68	Overall	55 (80.9)	OR	Prospective	All self-limited	Keusch et al[57]
		Benign (1-2 PVCs)	30 (44.1)		Observational
		Malignant2	25 (36.8)
2007	100	PAC insertion		OR	Prospective	All self-limited	Gwak et al[13]
		Overall	70 (70)		Observational
		Benign	33 (33)
		Malignant3	37 (37)
2012	139	Overall	76/139 (54.7)	OR	Prospective	All self-limited	Pipanmekaporn et al[28]
		Benign (1-2 PVCs)	58 (41.7)		Randomized
		Severe (≥ 3 PVCs)	28 (20.1)
2013	380	VT	0	Hybrid CCL	Retrospective	DCCV	Bergmann et al[19]
		VF	1 (0.26)		Observational
2017	174	Overall	149/174 (85.6)	OR	Prospective	All self-limited	Satol et al[23]
		Multiple PVCs ≥ 2	78/174 (44.8)		Observational

¹Malignant definition: Premature ventricular contractions (PVCs) with couples or > 3 consecutive PVCs.

²Malignant definition: PVC couples, or ≥ 3 consecutive PVCs with heart rate > 120 bpm).

³Malignant definition: ≥ 3 consecutive PVCs with heart rate > 100 bp. RHC: Right heart catheterization; VA: Ventricular arrest (asystole); OR: Operating room; ICU: Intensive care units (including medical ICU, surgical ICU and cardiac ICU); PVC: Premature ventricular contractions; VT: Ventricular tachycardia; PAC: Pulmonary artery catheter; VF: Ventricular fibrillation; CCL: Cardiac catheterization laboratory; cPVCs: Consecutive PVCs; DCCV: Direct current cardioversion; NSVT: Non-sustained VT.

Table 3 Incidence rate of arrhythmia in coronary angiography and percutaneous coronary interventions

Year	Tachyarrhythmias required interventions					Bradycar-dias, asystole, and conduction distur-bance (%)	Procedure types	Study designs (incidence/ total subjects)		Ref.
	Ventricular arrhythmia				Atrial arrhythmia (%)
	VF (%)	VT (%)	VA (%)	Overall (%)
1967	1.3	N/R	N/R	1.3	N/R	N/R	CAG	Single center (Sones) 84/6400		McGuire et al[85]
1968	1.33	N/R	N/R	1.33	N/R	N/R	CAG	Meta-analysis (5/535; 22/1500)		Takaro et al[86]
1968	0.7	0	0	0.7	N/R	N/R	CAG	Multicenter, CASS registry 23/3312		Ross et al[87]
1970	12	0	0	12	N/R	N/R	CAG	Single center 9/75		Gau et al[29]
1972	0.22	0	0	0.22	0	0.22%	CAG	Single center 1/445		Green et al[88]
1973	1.281			1.28	N/R	N/R	CAG	Multicenter, survey; 600/46904		Adams et al[89]
1975	1.14	0	0	1.14	N/R	N/R	CAG	Single center, 4/351		Shah et al[90]
1976	0.36	0.11	0.32	0.8	0.19	0.24	CAG	Single center 19/5250 VF; 6/5250 VT; 17/5250 VA		Bourassa et al[37]
1976	1.01	N/R	N/R	1.01	N/R	0.46	CAG	Single center 11/1094		Nitter-Hauge et al[91]
1976	1.5	N/R	N/R	1.5	N/R	N/R	CAG	Single center 22/1500		Pridie et al[92]
1979	0.63	0	0	0.63	0	4.3	CAG	Multicenter registry 48/7553		Davis et al[93]
1979	0.11	0	0	0.11	0	0	CAG	Single center 10/10000		Vijay et al[38]
1983	1.6	0.5	0	2.1	N/R	N/R	PTCA	Registry 24/1500 VF; 8/1500 VT		Dorros et al[30]
1984	0.51			0.5	N/R	N/R	CAG	Single center 39/7915		Nishimura et al[39]
1985	1.7			1.7	N/R	N/R	CAG	Single center 66/3906		Lehmann et al[94]
1985	0.78a			0.78	N/R	N/R	CAG	Single center 63/8081		Murdock et al[95]
1987	1.28	N/R	N/R	1.28	N/R	N/R	CAG	Single center 26/2025		Arrowood et al[96]
1989	0.27	0	0.03	0.3	0	0.03	CAG	Single center 11/3656		Armstrong et al[97]
1989	1.71		0	1.7	N/R	N/R	CAG	Single center 11/648		Lehmann et al[98]
1990	1			1.0	N/R	N/R	CAG	Single center, 2 cohorts		Missri et al[64]
	0.4			0.4	N/R	N/R	CAG	Renografin-76 (20/2000) vs Isovue-370 (8/2000)
1990	0.54			0.54	N/R	N/R	CAG	Multicenter, CASS registry (108/20142)		Epstein et al[40]
1991	2.06			2.06	N/R	N/R	PTCA	Single center, (19/922)		Brennan et al[32]
1991	0.4	0.8	0	1.2	0	0	PTCA	Iopamidol (6/507, 1.2%)	Single center, double blinded, RCT	Lembo et al[33]
	0.7	2.0	0	2.7	0	0		Diatrizoate (15/551, 2.7%)
2002	2.1	0	0	2.1	N/R	N/R	PTCA	Single center 19/905		Huang et al[99]
2004	4.3			4.3	N/R	N/R	PTCA	Multicenter, PTCA (133/3065, PAMI study, STEMI		Mehta et al[35]
2005	0.84	N/R	N/R	0.84	N/R	N/R	PTCA	Single center, (164/19497)		Addala et al[31]
2008	0.08	0.05	0	0.13	N/R	N/R	CAG	Single center 24/18365		Chen et al[100]
2009	0.1	N/R	N/R	0.1	N/R	N/R	CAG	Single center 27/27798 (radial 0.076%, femoral 0.147%)		Chen et al[101]
2017	4.1		N/R	4.1	N/R	N/R	PCI	Multicenter, APPROACH trial, 158/3814 STEMI		Har et al[36]
Summary	Total reported CAG cases: 163090; total of 1260 with overall VT/VF/VA rate 0.77% for diagnostic CAG.
	Total reported non-AMI PTCA cases: 2388; total of 255 VT/VF with VT/VF rate 1.1% for PTCA.

¹Ventricular fibrillation and sustained ventricular arrhythmias were reported together. VF: Ventricular fibrillation; VT: Ventricular tachycardia; VA: Ventricular arrest (asystole); CAG: Coronary arteriography or angiography; PTCA: Percutaneous transluminal coronary angioplasty; PCI: Percutaneous coronary intervention; RCT: Randomized controlled trial; STEMI: ST segment elevation myocardial infarction. N/R: Not reported.

Table 4 Known risk factors for ventricular tachycardia / ventricular fibrillation during coronary angiography and percutaneous coronary intervention and approaches to mitigate the risk

Risk factors	Approaches to mitigate risk
Catheter wedging coronary ostium, damping pressure causes ischemia and stagnation of contrast medium[32].	1 Smaller caliber catheter to avoid damping
	2 Catheters with sideholes to avoid damping
	3 Dis-engage catheter, clear contrast before next injection to minimize ischemia
	4 Avoid prolonged injection or large amount CM injection
Contrast medium toxicity[33,64,97]	1 Use non-ionic, low osmolar contrast
Non-ionic CM has lower risk than ionic CM	2 Eliminating calcium-binding additive in CM
Low osmolarity CM has lower risk than high Osmolarity CM	3 Use electrolytes optimized CM
Calcium-binding additive in CM increase the risk of VT/VF
Catheter or wire tip irritation of LV[88]	1 Meticulously manipulating equipment
	2 More practice
High risk in RCA and bypass graft CAG[99]	Pay more attention to avoid or minimize ischemia during procedure
Direct injection into conus branch leading to VF[102,103]	Early recognition of conus branch engagement and avoid injection or abort injection
Increased risk of VF/VT in patients with severe CAD and cardiomyopathy	1 Pre-procedural workup to understand the risk
	2 Meticulous procedural technique
	3 Operators training and competency
	4 Close monitoring
	5 Early reperfusion therapy
Acute myocardial infarction and primary PCI patients have high risk of VF/VT	6 Consider mechanic circulatory support for AMI patients with cardiogenic shock or extensive CAD with severely reduced EF (high risk patients with high risk CAD)

CM: Contrast medium; VT: Ventricular tachycardia; VF: Ventricular fibrillation; LV: Left ventricular; CAG: Coronary angiography; CAD: Coronary artery disease; RCA: Right coronary artery; PCI: Percutaneous coronary intervention; EF: Ejection fraction.