The Case

A patient was referred to a cardiologist for elective diagnostic cardiac catheterization for possible coronary artery disease. During the first part of the angiographic procedure, using a multipurpose A (MPA) catheter, the cardiologist unintentionally perforated the patient’s left ventricular wall with the catheter and injected radiocontrast into the ventricular muscle. The tear and perforation in the left ventricular wall caused radiocontrast staining outside the ventricular cavity, indicating hemorrhagic injury. The cardiologist did not recognize the perforation and continued with the cardiac catheterization, including coronary angiographic imaging.

Twenty minutes after the end of the procedure, the patient complained of “10/10” chest pain. The cardiologist obtained and reviewed echocardiographic images, which revealed bleeding around the heart caused by the catheter-related ventricular wall perforation. The patient underwent emergency exploratory surgery to fix the perforation within 40 minutes thereafter, but 1 liter of blood was removed from his pericardium, and he did not survive, despite maximal interventions. The patient was pronounced dead three hours after the initial diagnostic procedure. 

The Commentary

By Tai Huu Pham, MD and Surabhi Atreja, MD

Background

Since Mason Sones first described left heart catheterization and selective coronary angiography in the early 1960s, these have been powerful tools for assessing left ventricular (LV) function and coronary artery disease, respectively.¹ Contemporary techniques involve percutaneous ultrasound-guided arterial access via a radial or common femoral approach. A sheath is then inserted, and various catheters are advanced over a guidewire. Once the coronary arteries are engaged, contrast is injected, and fluoroscopic images are obtained in various projections. Left ventricular pressures can be measured with a catheter advanced across the aortic valve. From there, ventricular function can be assessed with contrast imaging, either by hand injection or, more typically, via powered injection through a purpose-built catheter. The results of these studies can help guide the management of multiple cardiovascular pathologies, including valvular and coronary disease.

Risks of diagnostic cardiac catheterization

Although it is a relatively safe procedure, cardiac catheterization is not without risk. In a recent contemporary review of more than 1.09 million diagnostic left heart catheterizations in patients not presenting with acute ST-elevation myocardial infarction, the cumulative risk of all adverse events was 1.35%. The rates of death, myocardial infarction, and stroke were even less, generally well below 1%.^2,3 One often-discussed complication of cardiac catheterization, particularly percutaneous coronary intervention (PCI), is periprocedural bleeding, which is directly associated with increased mortality in-hospital and at 30 days, major adverse cardiovascular events, and bleeding-related readmissions.⁴ The femoral artery and, by extension, the retroperitoneal space and the gastrointestinal tract are the most common sites of major periprocedural bleeding.⁷ Very rarely, bleeding complications can present as coronary dissection/perforation or left ventricular (LV) perforation. Although there is little published information on these rare events, the risk of all bleeding complications leading to cardiac tamponade may be around 0.03% with diagnostic cardiac catheterization and 0.07-0.15% with PCI.⁸

Multiple factors contribute to these peri-procedural bleeding complications and can be divided into patient-related and procedure-related factors. Patient-related factors associated with increased risk of periprocedural bleeding include therapeutic anticoagulation, intrinsic coagulopathies, chronic kidney disease, female sex, and age over 75 years.^5,6

Opportunities for Improving Safety

This case represents an example of cardiac tamponade secondary to LV perforation caused by injury from a diagnostic catheter; patient-related factors played no apparent role. More often associated with iatrogenic coronary dissection, tamponade due to LV perforation is exceedingly rare, with only case reports published.^10,11 Unfortunately, in this case, the complication was compounded by several key factors that contributed to the patient’s death.

The most evident issue is the initial device and technique used for left heart catheterization and cineangiography. To cross the aortic valve, two standard techniques involve either prolapsing an atraumatic pigtail catheter across the valve or using a J-tipped guidewire to cross first, followed by advancement of a pigtail catheter. Although these pigtail catheters have an established safety record, at least one such product was recalled after 8 reports of device separation during injection.¹² Other catheters can be used but with great caution. The multipurpose A (MPA) catheter, in this case, is rarely used except in particular circumstances, such as engaging a vein graft to the right coronary artery or posterior descending artery, assessing gradients in hypertrophic cardiomyopathy with possible dynamic left ventricular outflow tract obstruction, and in severe aortic stenosis where the steep catheter angle is preferred. In the latter two examples, the aortic valve is first crossed with either a J-tip guidewire or a straight hydrophilic guidewire with a soft tip to minimize the risk of LV injury.

It is unclear if a wire was used to cross the valve in this case, but contrast was injected through the MPA catheter leading to ventricular perforation and subsequent cardiac tamponade. This technique of contrast injection through end-hole catheters such as the MPA catheter is discouraged due to the very rare but possible risk of perforation as pressurized contrast exits the end of the catheter, especially when the tip is against the endocardial wall. Unfortunately, this technique is still commonly performed in practice for multiple reasons, including its greater efficiency (by avoiding an additional catheter exchange) and the presumed safety of catheters (such as that used in this case) that have both an end hole and two or more side holes, which theoretically reduce perforation risk as the hydraulic pressure of the contrast is dispersed through multiple exit points. Nevertheless, ventricular injury can still occur, as demonstrated in one recent case report.¹¹ In that instance, the operator was falsely reassured by the presence of a normal pressure reading, suggesting that the tip of the catheter was not against the wall, when in fact, the pressure sensor was likely affected by the side holes. Contrast injection was performed, which resulted in ventricular perforation, leading to rapid accumulation of blood into the pericardial space. Fortunately, early recognition of the iatrogenic injury allowed for rapid assessment with a right heart catheterization, demonstrating early tamponade physiology. A pericardial drain was emergently placed for stabilization, and the patient subsequently underwent successful surgical patch repair.¹¹

Contrary to the previously published case,¹¹ this instance of LV perforation was not recognized until 20 minutes after the conclusion of the procedure, when the patient complained of new and significant chest pain. Only upon secondary review of the imaging did the operator realize that a perforation had occurred. It would be another 40 minutes before surgical stabilization and repair were initiated. Given that the subtle finding of myocardial staining may be missed in real time, a final careful review at the conclusion of the case is recommended. During this review, the operator can assess whether additional angiograms are needed to evaluate a particular segment, branch, or lesion that might not have been projected well. More importantly, this final review allows for careful inspection of signs of complications that may not have been evident during the procedure. Had this complication been recognized when the patient was still on the catheterization table, a right heart catheterization could have been performed, and an arterial line placed, for better monitoring. If needed, a pericardial drain could have been placed as a bridge to definitive surgical repair.

Any discussion of a catastrophic complication of this type is incomplete without exploring how communication, or a breakdown in communication, affects outcomes. Every person in the catheterization lab has an important role in ensuring safety, including the radiology technologists documenting case progression while monitoring vital signs and the nursing staff circulating and providing support for the primary operator. Although the primary operator is ultimately responsible for the patient, each team member must be involved in ensuring that the case is proceeding safely. Radiology technologists and nurses, who should be reviewing images and pressures during the case, can be very helpful in cautioning the operator to avoid error.  If patient safety is jeopardized at any point, all team members should feel free to voice their concern. Ultimately, this case is an excellent example of what can happen when best practices are not followed, and resulting complications are missed due to inadequate or ineffective communication.  

Take Home Points

• Cardiac tamponade due to coronary dissection/perforation or left ventricular (LV) perforation is a rare but potentially catastrophic complication of cardiac catheterization and coronary angiography.
• Both patient-related and procedure-related factors are associated with increased risk of these complications; one example relevant to this case is the inappropriate use of a multipurpose A (MPA) catheter, in which contrast is pushed through an end hole that may be situated against the LV wall.
• Immediate recognition of iatrogenic injuries during cardiac catheterization enables more timely and effective interventions.
• As in any high-risk setting, effective communication is essential, and every team member must be empowered to voice their concerns to ensure that best practices are safely followed.

Tai Huu Pham, MD
Interventional Cardiology Fellow
Department of Internal Medicine, Division of Cardiovascular Medicine
UC Davis Health

Surabhi Atreja, MD
Clinical Professor, Interventional Cardiology
Department of Internal Medicine, Division of Cardiovascular Medicine
UC Davis Health

Editor’s Note: this case was adapted from Capozzola DD, Terrence J. Malpractice During Cardiac Catheterization Results in Death, $4.36 Million Verdict. Healthcare Risk Management (Relias Media). Published April 1, 2023. [Available at]

References

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