Fractional flow reserve (FFR) measurement provides useful hemodynamic assessment of intermediate coronary stenoses affecting long term outcomes. While the gold standard remains intravenous adenosine, intracoronary (IC) bolus administration of adenosine is routinely used in clinical practice because of its ease of use and lower dose providing comparative hyperemia with the most common side effect being a transient atrioventricular block. A 62year old male underwent left heart catheterization after ruling in for non-ST elevation myocardial infarction (NSTEMI). Presenting electrocardiogram (ECG) showed an old left bundle branch block and T-wave inversions in lateral leads (QTc 494ms) with no significant electrolyte abnormalities. Coronary angiography revealed an intermediate lesion in mid left anterior descending coronary artery. FFR assessment with IC adenosine (24μg/mL of normal saline) was performed inducing ventricular fibrillation (VF). He was successfully defibrillated with a single 200J shock and no further arrhythmias were noticed during rest of his hospital stay

Akbar, Ghulam, MD

Khan, Fatima

Khan, Zubair A.

Malik, Sara

Saeed, Wajeeha

Sardar, Muhammad Rizwan

English

Lehigh Valley Health Network: LVHN Scholarly Works

Lehigh Valley Health Network LVHN Scholarly Works Department of Medicine Ventricular fibrillation with intracoronary adenosine during fractional flow reserve assessment. Zubair A. Khan Ghulam Akbar MD Lehigh Valley Health Network, ghulam.akbar@lvhn.org Wajeeha Saeed Sara Malik Fatima Khan See next page for additional authors Follow this and additional works at: https://scholarlyworks.lvhn.org/medicine  Part of the Medical Sciences Commons Published In/Presented At Khan, Z. A., Akbar, G., Saeed, W., Malik, S., Khan, F., & Sardar, M. R. (2016). Ventricular fibrillation with intracoronary adenosine during fractional flow reserve assessment. Cardiovascular Revascularization Medicine: Including Molecular Interventions, 17(7),487-489. doi:10.1016/j.carrev.2016.07.004. This Article is brought to you for free and open access by LVHN Scholarly Works. It has been accepted for inclusion in LVHN Scholarly Works by an authorized administrator. For more information, please contact LibraryServices@lvhn.org. Authors Zubair A. Khan, Ghulam Akbar MD, Wajeeha Saeed, Sara Malik, Fatima Khan, and Muhammad Rizwan Sardar This article is available at LVHN Scholarly Works: https://scholarlyworks.lvhn.org/medicine/975 Ventricular fibrillation with intracoronary adenosine during fractionalflow reserve assessment☆Zubair A. Khan a, Ghulam Akbar b,Wajeeha Saeed c, SaraMalik a, Fatima Khan d, Muhammad Rizwan Sardar a,e,⁎a Cooper University Hospital, Camden, NJ 08103, USAb Lehigh Valley Hospital, Allentown, PA 18103, USAc Albert Einstein College of Medicine, Bronx, NY 10457, USAd Abington Jefferson Health System, Philadelphia, PA 19001, USAe Rhode Island Hospital, Brown University, Warren, Alpert School of Medicine, RI 02903, USAa b s t r a c ta r t i c l e i n f oArticle history:Received 5 June 2016Accepted 6 July 2016Keywords:Fractional flow reservePercutaneous coronary interventionVentricular fibrillationFractional flow reserve (FFR) measurement provides useful hemodynamic assessment of intermediate coronarystenoses affecting long term outcomes. While the gold standard remains intravenous adenosine, intracoronary(IC) bolus administration of adenosine is routinely used in clinical practice because of its ease of use and lowerdose providing comparative hyperemia with the most common side effect being a transient atrioventricularblock. A 62 year oldmale underwent left heart catheterization after ruling in for non-ST elevation myocardial in-farction (NSTEMI). Presenting electrocardiogram (ECG) showed an old left bundle branch block and T-wave in-versions in lateral leads (QTc 494 ms) with no significant electrolyte abnormalities. Coronary angiographyrevealed an intermediate lesion in mid left anterior descending coronary artery. FFR assessment with IC adeno-sine (24 μg/mL of normal saline) was performed inducing ventricular fibrillation (VF). He was successfullydefibrillated with a single 200 J shock and no further arrhythmias were noticed during rest of his hospital stay.© 2016 Elsevier Inc. All rights reserved.1. IntroductionFFR assessment is an increasingly utilized tool in cardiac catheteriza-tion laboratorieswhich provides useful hemodynamic assessment of in-termediate coronary stenoses affecting long term outcomes [1]. Whilethe gold standard remains intravenous adenosine administration, ICbolus administration of adenosine is routinely used in clinical practicebecause of its ease of use, lower dose, and hence, overall cost. Recentdata suggest that higher doses of IC adenosine could be as efficient as in-travenous adenosine in obtainingmaximumhyperemia and are consid-ered to be relatively safe and well tolerated. We present a case of VFinduced by IC adenosine during FFR assessment.2. Case reportA 62-year-old male with significant history of active smoking over25 years, peripheral arterial disease, cerebrovascular accident, hyper-tension and hyperlipidemia presented to emergency department withan acute worsening of intermittent exertional chest pressure radiatingto left arm for a month and associated shortness of breath. His chestpain resolved upon arrival after chewable aspirin 324 mg and a singledose of 0.4 mg sublingual nitroglycerine. Blood pressure on presenta-tion was 140/73 mmHg with a pulse of 70 bpm. He was euvolemic onphysical examination and presenting ECG showed an old LBBB and T-wave inversions in lateral leads with a QTc interval of 494 ms and QRSduration of 136ms (Fig. 1). Pertinent admission laboratory data includea K+ of 3.6 mmol/L (3.6 mEq/L), Mg of 0.78 mmol/L (1.9 mg/dL), NT-proBNP of 3254 ng/L and initial Troponin-I of b0.01 μg/L. He ruled infor a NSTEMI with a repeat Troponin-I of 0.7 μg/L andwas started on in-travenous heparin infusion alongwith a high intensity statin and a beta-blocker. Coronary angiography revealed a normal left main with mildnon-obstructive disease in left circumflex and right coronary arteries.There were two lesions in themid segment of the LAD, up to maximum50% stenosis inmultiple views (Fig. 2). To assess their physiologic signif-icance, FFR measurement was performed. Baseline FFR assessment de-creased from 0.99 to 0.92 following administration of 72 μg (24 μg/mLof normal saline) of IC adenosine. In order to ensuremaximal hyperemicresponse of the coronary bed, an additional 96 μg of IC adenosine wasadministered after two minutes, followed by fast normal saline flush.Cardiovascular Revascularization Medicine 17 (2016) 487–489Abbreviations: ECG, Electrocardiogram; FFR, Fractional Flow Reserve; IC, Intracoronary;LAD, Left Anterior Descending Coronary Artery; LBBB, left bundle branch block; NSTEMI,Non ST-segment ElevationMyocardial Infarction; VF, Ventricular Fibrillation; VT, VentricularTachycardia.☆ Disclosures: The authors report no financial relationships or conflicts of interest re-garding the content herein. Dr. Sardar reports funding support from the American HeartAssociation, the Kitchen and Kelly Research Fund, and the North American Center for Con-tinuingMedical Education. Themanuscript has been read and approved by all the authors,requirements for authorship have beenmet, and each author believes that themanuscriptrepresents honest work.⁎ Corresponding author at: Structural Heart Disease/Interventional Cardiology, BrownUniversity, Warren Alpert School of Medicine, Providence, RI 02903, USA. Tel.: +1 347327 2734.E-mail address: rizwansardar@hotmail.com (M.R. Sardar).http://dx.doi.org/10.1016/j.carrev.2016.07.0041553-8389/© 2016 Elsevier Inc. All rights reserved.Contents lists available at ScienceDirectCardiovascular Revascularization MedicineDownloaded for library services (libraryservices@lvhn.org) at Lehigh Valley Health Network from ClinicalKey.com by Elsevier on August 26, 2022. For personal use only. No other uses without permission. Copyright ©2022. Elsevier Inc. All rights reserved.The patient went into polymorphic VT, degenerating into coarse VF im-mediately following the saline flush (Fig. 3). He was successfullydefibrillated with a single 200 J shock and remained hemodynamicallystable for the rest of the procedure. Transthoracic echocardiogram ob-tained after the procedure showed moderately depressed left ventricu-lar ejection fraction with global hypokinesis and no significant valvularabnormalities. No further arrhythmias were noticed for the remainderof his hospital stay.3. DiscussionAdenosine has long been utilized for treatment and identification ofsupraventricular tachycardias and during electrophysiology studies toinduce ectopy. It is generally considered a safe drug owing to its shorthalf-life. Adenosine has variable mechanisms of action on peripheraland coronary circulation and myocardium. It results in shortening ofatrial action potentials, reducing the effective refractory period resultingin a temporary atrioventricular block [2]. In addition, adenosine causes areflex increase in circulating catecholamine levels which occasionallyresults in rebound sinus tachycardia and atrial or ventricular ectopythat may provoke re-initiation of reentrant tachyarrhythmias [3].However, transient bradyarrhythmias remain the more commonproaarhythmic effects of intravenous adenosine and the data regardingsustained ventricular dysrhythmias remain scarce [4].FFR assessment utilizes adenosine's endothelium dependentvasodilatory effects onperipheral and coronary circulation. Although in-travenous and intracoronary injections are thought to be comparable[5], there is still no clear consensus on a minimum effective, safe ICadenosine dose and concentration required for FFR assessment [6]. ICadenosine is generally well tolerated with themost common side effectbeing a transient atrioventricular block seen with high doses [7]. Shahet al. for thefirst time reported a case series of three patientswhodevel-oped VF following administration of IC adenosine [8]. Unlike our casewhere VF was precipitated by much smaller and more concentrateddose of IC adenosine, all three patients in their case series received atleast 360 μg (12 μg/mL of normal saline) boluses of IC adenosine duringFFR assessment of LAD or left circumflex arteries. Although baseline ECGcharacteristicswere not reported by Shah et al., to our knowledge, this isthe first case of IC adenosine induced VF with a more routinely usedconcentration with a much smaller dose concentration and in the pres-ence of existing LBBB.Considering sustained VT/VF to be a life threatening arrhythmia, it isimportant to recognize risk factors like electrolyte derangements thatmay predispose patients to this during routine FFR assessments. Pres-ence of prolongedQT interval on ECG should also prompt careful reviewof patient's prior history and medications which may interact withadenosine. Bundle branch blocks prolong QT interval and pose a com-mon clinical problem in assessing the intrinsic QTc interval [9]. Baselinebundle branch block or prolonged QT interval did not predict develop-ment of malignant arrhythmias during FFR assessment through IC pa-paverine in a cohort reported by Nakayama et al [10]. Shah et al. haveproposed that volume of intracoronary injection (adenosine plus salinemix), may displace coronary blood for a few seconds contributing to de-velopment of VF and report no new cases of IC adenosine induced VFFig. 1. Presenting ECG showing normal sinus rhythm with LBBB.Fig. 2.Mid LAD lesion (arrow)which was assessed by intracoronary FFR.488 Z.A. Khan et al. / Cardiovascular Revascularization Medicine 17 (2016) 487–489Downloaded for library services (libraryservices@lvhn.org) at Lehigh Valley Health Network from ClinicalKey.com by Elsevier on August 26, 2022. For personal use only. No other uses without permission. Copyright ©2022. Elsevier Inc. All rights reserved.since doubling of dilution concentration in their practice [8]. This hy-pothesis may partially be responsible, considering old experience of op-tical coherence tomography (OCT)where 5/468 (1.1%) patients sufferedVF with a mean volume of intracoronary contrast injected of 36.6 ±9.4 ml [11]. Similarly, in our case, although IC adenosine injection wasmore concentrated (24 μg/mL of saline), it was immediately followedby 15 cm3 of normal saline bolus, which would have led to higherbolus volume injection at one time. Thismay not be the sole reason; un-derlying LBBB with pseudo prolongation of QTc may have played a roleas well, especially in the presence of deranged electrolytes.4. ConclusionFFR assessment has become the benchmark of guiding revasculari-zation therapy for intermediate coronary lesions and more routinelyused than before. It is important to recognize potential complicationsand side effects associated with IC adenosine. Furthermore, cardiaccatheterization labs should be equipped and have protocols delineatedto handle such life threatening emergencies.References[1] Zhang D, Lv S, Song X, Yuan F, Xu F, Zhang M, et al. Fractional flow reserve versusangiography for guiding percutaneous coronary intervention: a meta-analysis.Heart 2015;101:455–62. http://dx.doi.org/10.1136/heartjnl-2014-306578.[2] Böhm M. Cardiac effects of adenosine. Mechanism of action, pathophysiologic andclinical significance. Klin Wochenschr 1987;65:487–99.[3] Watt AH, Routledge PA. Transient bradycardia and subsequent sinus tachycardiaproduced by intravenous adenosine in healthy adult subjects. Br J Clin Pharmacol1986;21:533–6.[4] Mallet ML. Proarrhythmic effects of adenosine: a review of the literature. EmergMed J 2004;21:408–10. http://dx.doi.org/10.1136/emj.2004.016048.[5] López-Palop R, Carrillo P, Frutos A, Cordero A, Agudo P, Mashlab S, et al. Comparisonof effectiveness of high-dose intracoronary adenosine versus intravenous adminis-tration on the assessment of fractional flow reserve in patients with coronaryheart disease. Am J Cardiol 2013;111:1277–83. http://dx.doi.org/10.1016/j.amjcard.2013.01.270.[6] Schlundt C, Bietau C, Klinghammer L, Wiedemann R, Rittger H, Ludwig J, et al. Com-parison of intracoronary versus intravenous administration of adenosine for mea-surement of coronary fractional flow reserve. Circ Cardiovasc Interv 2015;8. http://dx.doi.org/10.1161/CIRCINTERVENTIONS.114.001781.[7] De Luca G, Venegoni L, Iorio S, Giuliani L, Marino P. Effects of increasing doses ofintracoronary adenosine on the assessment of fractional flow reserve. JACCCardiovasc Interv 2011;4:1079–84. http://dx.doi.org/10.1016/j.jcin.2011.08.004.[8] Shah AH, Chan W, Seidelin PH. Ventricular fibrillation precipitated by intracoronaryadenosine during fractional flow reserve assessment— a cautionary tale. Heart LungCirc 2015;1–3. http://dx.doi.org/10.1016/j.hlc.2015.05.012.[9] Bogossian H, Frommeyer G, Ninios I, Hasan F, Nguyen QS, Karosiene Z, et al. New for-mula for evaluation of the QT interval in patients with left bundle branch block.Heart Rhythm 2014;11:2273–7. http://dx.doi.org/10.1016/j.hrthm.2014.08.026.[10] Nakayama M, Tanaka N, Sakoda K, Hokama Y, Hoshino K, Kimura Y, et al.Papaverine-induced polymorphic ventricular tachycardia during coronary flow re-serve study of patients with moderate coronary artery disease. Circ J 2015;79:530–6. http://dx.doi.org/10.1253/circj.CJ-14-1118.[11] Barlis P, Gonzalo N, Di Mario C, Prati F, Buellesfeld L, Rieber J, et al. A multicentreevaluation of the safety of intracoronary optical coherence tomography.EuroIntervention 2009;5:90–5.Fig. 3. Degeneration of normal sinus rhythm to polymorphic VT (Panel A) and later ventricular fibrillation (Panel B) following 96 μg (concentration, 24 μg/mL of normal saline) ofintracoronary adenosine and successful defibrillation with 200 J ×1 (Panels C & D).489Z.A. Khan et al. / Cardiovascular Revascularization Medicine 17 (2016) 487–489Downloaded for library services (libraryservices@lvhn.org) at Lehigh Valley Health Network from ClinicalKey.com by Elsevier on August 26, 2022. For personal use only. No other uses without permission. Copyright ©2022. Elsevier Inc. All rights reserved.

Ventricular fibrillation with intracoronary adenosine during fractional flow reserve assessment.

https://scholarlyworks.lvhn.org/cgi/viewcontent.cgi?article=1991&context=medicine

Ventricular fibrillation with intracoronary adenosine during fractional flow reserve assessment.

Abstract

Similar works

Full text

Available Versions

Lehigh Valley Health Network: LVHN Scholarly Works