waleed y. kadro, md - salamhospital.com · waleed y. kadro, md american board certified in:...
TRANSCRIPT
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Aspiration of Blood From The LV Cavity to
Treat Refractory Ventricular Arrhythmias
during Complex Coronary Interventions.
WALEED Y. KADRO, MD
American Board Certified in:
Interventional Cardiology, Heart Rhythm, Cardiovascular Medicine
and internal Medicine
Director: The Golden Center For Advanced Cardiovascular Interventions
and Clinical Research.
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I Have Nothing to Disclose.
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• Maya Turkmani.
• Yaman Rai Balha.
• Tarek Alsaied
• Hussam Rahim.
• Ali Dbs.
• Reda Shehadat.
• Ismael Eid.
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BACKGROUND
• Ventricular fibrillation (VF) may occur during coronary angiogram or during complex coronary intervention.
• It can happen during wire or catheter manipulation, balloon inflation or stent deployment.
• The reason for that is mainly due to ischemia induced by these maneuvers.
• Ventricular fibrillation occurs frequently in the cath lab when the ischemic substrate is already present as in the setting of acute myocardial infarction or unstable angina.
• VF may also occur as a reaction to the contrast material used during angiogram.
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• VF is usually treated easily in the cath lab with prompt cardioversion.
• VF may become refractory for cardioversion, especially in the setting of severe ischemic burden.
• Reduced left ventricular (LV) function and LV cavity dilatation increase the incidence of VF during ischemia and may make it refractory for cardioversion.
• Ischemia and LV dilation result in elevation of left ventricular filling pressure (LVEDP).
• Elevated LVEDP by itself causes subendocardial ischemia and predispose for VF.
BACKGROUND
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BACKGROUND
• When VF doesn’t respond to cardioversion, myocardial ischemia continue to be present, more LVEDP elevation, more LV dilation, more refractory VF.
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•V Fib Begets V Vib
BACKGROUND
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• After prolonged V fib cardioversion may sometimes results into an electrical sinus rhythm with QRS complex on the monitor but without any mechanical (contractile) activity on the hemodynamic monitor or fluoroscopy i.e. Electro- mechanical dissociation (EMD).
BACKGROUND
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BACKGROUND
• Insertion of intra aortic balloon pump (IABP) reduces ischemia, LVEDP and LV dilation by unloading the LV only when the contractile activity is present.
• IABP will not be able to unload the LV unless there is a mechanical and an electrical activity with whom the device should be synchronized.
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•IABP doesn’t work in V fib or EMD.
BACKGROUND
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METHOD
• We report a new and a quick simple method to unload the LV cavity and reduce LVEDP.
• A pigtail or a JR catheter is inserted inside the LV cavity.
• A manual aspiration of 80 –100cc of blood from the LV cavity is done through the catheter using a 20ml syringe.
• The aspirated blood is thrown away.
• This maneuver will quickly reduce the LVEDP.
• It may make the refractory VF more responsive to cardioversion.
• It can also provide a simple decompression of the overfilled LV cavity after prolonged circulatory arrest.
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METHOD
•It is as simple as this.
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RESULTS
• This method was used in 5 cases of refractory VF in the cath lab in the setting of AMI or severe unstable angina.
• Three of these case failed 3 attempts of DC cardio version.
• After doing this maneuver, those three cases responded immediately to the next attempt of cardioversion.
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METHOD
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RESULTS
• The 2 other cases of VF responded to cardioversion with electrical sinus rhythm however the 2 patients remained pulseless in electromechanical dissociation (EMD).
• No arterial BP on hemodynamic monitor and no cardiac movement on fluoroscopy were seen.
• Despite ruling out tamponade and mechanically treating cardiac ischemia the two patients remained in EMD.
• After doing the pigtail maneuver EMD resolved and active cardiac movement were seen on fluoroscopy with acceptable arterial pressure recovery.
• One of those two patients required further insertion of IABP to support his BP, IABP was removed after 24h.
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RESULTS
•All of these 5 patients
survived till hospital
discharge.
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RESULTS
• This method was used in 3 elderly patients who entered the cath lab on IABP due to cardiogenic shock.
• The maneuver was helpful in in restoring SR and getting the patients outside the cath lab in a stable hemodynamic condition on IABP.
• None of those 3 patient survived due to other co morbid conditions: massive stoke, acute renal failure and sepsis.
• No recurrence of V fib or ventricular arrhythmias were noted in those patient outside the cath lab.
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RESULTS
• The maneuver was used in one patient who developed a refractory V fib after the first injection of contrast during diagnostic coronary angiogram.
• The patient failed multiple attempts of cardioversion and was put on CPS.
• After the maneuver successful cardioversion was obtained from the first attempt.
• Coronary angiogram after that showed no obvious stenosis.
• She was took off CPS without any further problem.
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My Worst Nightmare
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My Worst Nightmare
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My Worst Nightmare
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My Worst Nightmare
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• The maneuver was used in one patient who developed standstill during unprotected LM stenting in the setting of occluded RCA.
• After a chest thumb the patient showed electrical activity on the monitor but the were no mechanical contraction on fluoroscopy.
• After the maneuver mechanical contraction started back and acceptable BP was restored.
RESULTS
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RESULTS
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RESULTS
• The maneuver was used as a prophylactic method before LM stenting in 4 patients.
• No malignant arrhythmia was noted during or after LM stenting.
• No significant prolonged drop in BP was noted after stenting.
• None of those cases required insertion of an IABP.
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CONCLUSION
• Quick insertion of a catheter in the LV with quick blood aspiration facilitates response to cardioversion.
• It may relieve EMD not related to tamponade during coronary intervention.
• The catheter can be used to give intracardiac emergency medication during the code.
• This maneuver may reduce the need of inserting IABP during complex coronary interventions.
• This maneuver can be used as a prophylactic measure before and during complex coronary interventions.
• It looks that the interventional cardiologists need this simple way of LV venting in the cath lab.
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• To Use this maneuver in the EP lab.
• To Use this maneuver during V fib threshold testing with ICD implants.
• To add the maneuver of direct aspiration of blood from the LV Cavity using a large needle through the chest wall to the algorithm of cardiac resuscitation for a coding victim.
FUTURE DIRECTIONS
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• When you use this maneuver in the future please send me an e-mail with the details.
• Waleed Y. Kadro, MD
The Golden Cardiovascular Center
P.O. Box 6891 Mouhajreen
Damascus, SYRIA.
Tel: 963 933 567962
Fax: 963 11 3326646
E-mail: [email protected]
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• The Golden Cardiovascular Center is proud to be the only Syrian canter who presents at Euorp PCR, ESC, TCT and ACC.