Ventricular Arrhythmias During Swan-Ganz Catheterization of the Critically III
1981; Elsevier BV; Volume: 79; Issue: 4 Linguagem: Inglês
10.1378/chest.79.4.413
ISSN1931-3543
AutoresCharles L. Sprung, Lawrence J. Jacobs, Panagiota Caralis, Michael Karpf,
Tópico(s)Non-Invasive Vital Sign Monitoring
ResumoThe incidence of ventricular arrhythmias in critically-ill patients during bedside right-sided heart catheterization with a flow-directed balloon-tipped catheter was determined. Twenty-nine of 60 catheterizations (48 percent) were associated with premature ventricular contractions and 20 (33 percent) were associated with ventricular tachycardia. Two patients required antiarrhythmic therapy or a precordial thump to convert ventricular tachycardia. One patient developed ventricular tachycardia and fibrillation and died. Serious catheter-induced arrhythmias, including sustained ventricular tachycardia, may occur during Swan-Ganz catheterization of the critically ill. The incidence of ventricular arrhythmias in critically-ill patients during bedside right-sided heart catheterization with a flow-directed balloon-tipped catheter was determined. Twenty-nine of 60 catheterizations (48 percent) were associated with premature ventricular contractions and 20 (33 percent) were associated with ventricular tachycardia. Two patients required antiarrhythmic therapy or a precordial thump to convert ventricular tachycardia. One patient developed ventricular tachycardia and fibrillation and died. Serious catheter-induced arrhythmias, including sustained ventricular tachycardia, may occur during Swan-Ganz catheterization of the critically ill. Since its first description in 1970, the flow-directed balloon-tipped catheter has been used routinely for the hemodynamic monitoring of critically-ill patients. Complications of catheterization are uncommon but include thrombosis,1Swan HJC Ganz W Forrester J Marcus H Diamond G Chonette D Catheterization of the heart in man with use of a flow-directed balloon-tipped catheter.N Engl J Med. 1970; 283: 447-451Crossref PubMed Scopus (1485) Google Scholar pulmonary infarction,2Foote GA Schabel SI Hodges M Pulmonary complications of the flow-directed balloon-tipped catheter.N Engl J Med. 1974; 290: 927-931Crossref PubMed Scopus (159) Google Scholar pulmonary artery rupture,3Pape LA Haffajee CI Markis JE et al.Fatal pulmonary hemorrhage after use of the flow-directed balloon-tipped catheter.Ann Intern Med. 1979; 90: 344-347Crossref PubMed Scopus (74) Google Scholar tricuspid valve rupture,4Smith WR Glauser FL Jemison P Ruptured chordae of the tricuspid valve: the consequence of flow-directed Swan-Ganz catheterization.Chest. 1976; 70: 790-792Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar intracardiac knotting of the catheter,5Lipp H O'Donoghue K Resnekov L Intracardiac knotting of a flow-directed balloon-tipped catheter.N Engl J Med. 1971; 284: 220PubMed Google Scholar and heart block.6Abernathy WS Complete heart block caused by the Swan-Ganz catheter.Chest. 1974; 65: 349Crossref PubMed Scopus (44) Google Scholar The introduction of the flow-directed catheter into the right ventricle has not been associated with ventricular arrhythmias in the cardiac catheterization laboratory7Steele P Davies H The Swan-Ganz catheter in the cardiac laboratory.Br Heart J. 1973; 35: 647-650Crossref PubMed Scopus (9) Google Scholar and has infrequently been associated with ectopy in the intensive care areas.1Swan HJC Ganz W Forrester J Marcus H Diamond G Chonette D Catheterization of the heart in man with use of a flow-directed balloon-tipped catheter.N Engl J Med. 1970; 283: 447-451Crossref PubMed Scopus (1485) Google Scholar, 8Voukydis PC Cohen SI Catheter-induced arrhythmias.Am Heart J. 1974; 88: 588-592Abstract Full Text PDF PubMed Scopus (20) Google Scholar In view of the large number of patients in intensive care units with multiple medical problems who are at risk for the development of premature ventricular contractions, the present study was instituted to evaluate the incidence of ventricular arrhythmias during bedside right-sided heart catheterization of the critically ill.Patients and MethodsSixty consecutive patients undergoing bedside right-sided heart catheterization in the medical intensive care unit and coronary care unit of the Miami Veterans Administration Medical Center were studied. A triple-lumen 7 F balloon-tipped flow-directed thermodilution catheter was inserted into the subclavian or internal jugular vein by a percutaneous Seldinger technic and advanced into the pulmonary artery with pressure monitoring. Second and third year residents, cardiology fellows, and attending staff with previous catheterization experience performed the right-sided heart catheterizations. All residents attended a review lecture and demonstration of the proper technique for the insertion of Swan-Ganz catheters before performing a catheterization. The balloon was inflated during catheter insertion, and the catheter was withdrawn from the heart if ectopy was observed. Fluoroscopy was used when physicians felt catheterization was difficult or prolonged. The ECG was visually monitored during catheterization while a permanent record was obtained with a recording system.Catheter-induced ventricular tachycardia was defined as three or more consecutive ventricular premature beats. Patients were considered to have catheter-related arrhythmias only if they had a marked increase in ectopic activity and either bigeminy, trigeminy, two consecutive or two of three ventricular beats being premature ventricular contractions, or ventricular tachycardia. Catheterization time was defined as the time from entry into a central vein until the proper catheter position for pulmonary artery wedge pressure recordings was obtained. Arterial blood gas determinations were performed on an acid base laboratory. Cardiac enzyme and serum electrolyte levels were determined on a column chromatograph and an autoanalyzer, respectively. The data are expressed as the mean of the group ± SEM and were analyzed by the Chi Square test. Statistical significance was defined as p < 0.05.ResultsTabled 1IndicationNo. PatientsSeptic Shock16Volume Resuscitation16Respiratory Failure8Cardiogenic Shock6Hypovolemic Shock5Congestive Heart Failure vs. Pneumonia4Refractory Pulmonary Edema3Obstructive Shock1Vasodilation1Total60 Open table in a new tab Twenty nine of the sixty catheterizations (48 percent) were associated with premature ventricular contractions and twenty (33 percent) were associated with ventricular tachycardia. Of the patients with permanent records, 27 of 40 (68 percent) had evidence of ventricular ectopic beats, and 19 (48 percent) had ventricular tachycardia. Ventricular ectopy typically occurred when the catheter was advanced through the right ventricle; combinations of multiple ventricular premature beats usually preceded ventricular tachycardia. Ventricular tachycardia was usually self-limited and lasted one to two seconds in ten patients, three seconds in two patients, and five to six seconds in five patients. In two patients, ventricular tachycardia intermixed with other ventricular arrhythmias and/or sustained ventricular tachycardia persisted for 15 and 30 seconds, respectively, and required antiarrhythmic agents or a precordial thump in addition to removal of the catheter for conversion. In one patient, the insertion of a guide wire through a central venous catheter into the right ventricle precipitated ventricular tachycardia, ventricular fibrillation, and death. This was the only catheter-related mortality. This patient was included despite the fact that a guide wire and not a balloon-tipped catheter caused ventricular tachycardia because guide wires are required to introduce Swan-Ganz catheters and are an integral part of the catheterization process. In addition to the ventricular arrhythmias observed on the visual monitor system during catheterization, nine patients exhibited ventricular ectopy on the permanent ECG record that had not been previously noted. Five had evidence of ventricular tachycardia, two had two consecutive premature ventricular contractions, and two had bigeminy or trigeminy.Patients had evidence of shock (28), acidosis (pH ≤ 7.2) (4), hypoxia (P02 60 mm Hg) (6), electrolyte imbalance (k < 3.5 mEq/L and Ca ≤ 8.0 mg/dl [albumin corrected]) (22), and myocardial infarction or ischemia (10). Twenty-one patients had one risk factor, 17 had two, and five had three predisposing factors for the development of arrhythmias. Seventeen patients had no risk factors. The mean catheterization time was 40 ± 5 minutes (range 8 to 180 minutes). There was no difference in catheterization time between the patients with and without predisposing conditions. The relationship between ventricular arrhythmias and predisposing factors and duration of catheterization is shown in Table 1. The incidence of arrhythmias could not be correlated with either predisposing factors or duration of catheterization (p < 0.1). However, a significantly increased incidence of arrhythmias was found in patients with both risk factors for ectopy and increased catheterization times compared to patients with only one or neither of these factors (p < 0.01). The mortality rate of the 60 patients was 55 percent.Table 1Frequency of Ventricular Arrhythmias During Catheterization Based on Predisposing Factors and Duration of Catheterization*Increased catheterization time was defined as greater than 20 minutes.PVC†PVC—bigeminy, trigeminy, two consecutive or two of three ventricular beats being premature ventricular contractions, and ventricular tachycardia.No PVCRisk factor, ↑ cath time141Risk factor, no ↑ cath time57No risk factor, ↑ cath time44No risk factor, no ↑ cath time22* Increased catheterization time was defined as greater than 20 minutes.† PVC—bigeminy, trigeminy, two consecutive or two of three ventricular beats being premature ventricular contractions, and ventricular tachycardia. Open table in a new tab DiscussionPacemaker wires and central venous and pulmonary artery catheters are known to cause ventricular arrhythmias.7Steele P Davies H The Swan-Ganz catheter in the cardiac laboratory.Br Heart J. 1973; 35: 647-650Crossref PubMed Scopus (9) Google Scholar, 8Voukydis PC Cohen SI Catheter-induced arrhythmias.Am Heart J. 1974; 88: 588-592Abstract Full Text PDF PubMed Scopus (20) Google Scholar, 9Grossman W Cardiac catheterization and angiography. Lea & Febiger, Philadelphia1976: 19-20Google Scholar, 10Lown B Temte JV Arter WJ Ventricular tachyarrhythmias: clinical aspects.Circulation. 1973; 47: 1364-1381Crossref PubMed Scopus (41) Google Scholar The insertion of conventional stiff catheters or electrodes into the right ventricle is usually associated with ventricular ectopic activity, whereas the introduction of flexible flow-directed balloon-tipped catheters is only rarely associated with arrhythmias.7Steele P Davies H The Swan-Ganz catheter in the cardiac laboratory.Br Heart J. 1973; 35: 647-650Crossref PubMed Scopus (9) Google Scholar, 8Voukydis PC Cohen SI Catheter-induced arrhythmias.Am Heart J. 1974; 88: 588-592Abstract Full Text PDF PubMed Scopus (20) Google Scholar, 9Grossman W Cardiac catheterization and angiography. Lea & Febiger, Philadelphia1976: 19-20Google Scholar The original reported incidence of ventricular arrhythmias in acutely-ill patients undergoing Swan-Ganz catheterization was 11 percent.1Swan HJC Ganz W Forrester J Marcus H Diamond G Chonette D Catheterization of the heart in man with use of a flow-directed balloon-tipped catheter.N Engl J Med. 1970; 283: 447-451Crossref PubMed Scopus (1485) Google Scholar Recently, Elliott et al11Elliott CG Zimmerman GA Clemmer TP Complications of pulmonary artery catheterization in the care of critically ill patients.Chest. 1979; 76: 647-652Abstract Full Text Full Text PDF PubMed Scopus (188) Google Scholar reported a higher incidence of ventricular ectopy. Premature ventricular contractions occurred, but sustained ventricular tachycardia was not noted.1Swan HJC Ganz W Forrester J Marcus H Diamond G Chonette D Catheterization of the heart in man with use of a flow-directed balloon-tipped catheter.N Engl J Med. 1970; 283: 447-451Crossref PubMed Scopus (1485) Google Scholar, 11Elliott CG Zimmerman GA Clemmer TP Complications of pulmonary artery catheterization in the care of critically ill patients.Chest. 1979; 76: 647-652Abstract Full Text Full Text PDF PubMed Scopus (188) Google Scholar The present study demonstrates a high incidence of ventricular arrhythmias during balloon-tipped catheterization of the critically ill. In fact, three of the 60 patients (5 percent) developed sustained ventricular tachycardia that did not resolve upon withdrawal of the catheter or wire.The high incidence of arrhythmias found in this study may be related to several factors. All patients underwent catheterization with triple-lumen Swan-Ganz thermodilution catheters. The triple-lumen flotation catheter is associated with a higher incidence of ventricular premature beats than the double-lumen catheter.12Forrester JS Diamond GA Swan HJC Bedside diagnosis of latent cardiac complications in acutely ill patients.JAMA. 1972; 222: 59-63Crossref PubMed Scopus (27) Google Scholar Secondly, myocardial infarction or ischemia, shock, acidosis, electrolyte disturbances, increased sympathetic tone, and various drugs are predisposing factors for the development of ventricular arrhythmias.13Hurst JW Logue RB Schlant RC Wenger NK The heart. McGraw-Hill Book Co, New York1978: 651-687Google Scholar These conditions are common in patients requiring catheterization in an intensive care unit. Most of the present patients had evidence of at least one risk factor for the development of ectopy. Thirdly, the majority of the patients were difficult to catheterize because of the severe shock, large right ventricles, dilated pulmonary arteries, or marked pulmonary hypertension. Therefore, the duration of catheterization was longer than previous reports.1Swan HJC Ganz W Forrester J Marcus H Diamond G Chonette D Catheterization of the heart in man with use of a flow-directed balloon-tipped catheter.N Engl J Med. 1970; 283: 447-451Crossref PubMed Scopus (1485) Google Scholar The present critically-ill patients with predisposing conditions for arrhythmias and increased catheterization times manifested an increased incidence of ectopy. Finally, all arrhythmias occurring during catheterization may not be documented. Nine of the present patients had ventricular arrhythmias that were not observed during catheterization but were documented after examination of the simultaneous electrocardiographic records.Past recommendations have stated that antiarrhythmic therapy and a defibrillator should always be available at the bedside during catheterization. In addition, guide wires and CVP catheters used for the insertion of Swan-Ganz catheters should be cautiously introduced, and special care should be taken so they are not advanced into the right ventricle.This report is not intended to minimize the importance of the Swan-Ganz catheter in the intensive care area. The present study does document a high frequency of ventricular arrhythmias during catheterization with a flow-directed catheter. These patients may represent a more critically-ill population than those reported previously, as reflected by the high mortality. However, it is precisely this group of acutely ill patients in whom Swan-Ganz catheterization has become a standard procedure and in whom the predisposition for ventricular ectopy is particularly marked. The Swan-Ganz catheter is an essential tool for the care of the acutely ill. However, physicians must be aware that ventricular arrhythmias during catheterization of the critically ill are common, are usually self-limited, but may require therapeutic intervention. The true incidence of ventricular arrhythmias during catheterization can be ascertained only with continuous permanent electrocardiographic monitoring. Since its first description in 1970, the flow-directed balloon-tipped catheter has been used routinely for the hemodynamic monitoring of critically-ill patients. Complications of catheterization are uncommon but include thrombosis,1Swan HJC Ganz W Forrester J Marcus H Diamond G Chonette D Catheterization of the heart in man with use of a flow-directed balloon-tipped catheter.N Engl J Med. 1970; 283: 447-451Crossref PubMed Scopus (1485) Google Scholar pulmonary infarction,2Foote GA Schabel SI Hodges M Pulmonary complications of the flow-directed balloon-tipped catheter.N Engl J Med. 1974; 290: 927-931Crossref PubMed Scopus (159) Google Scholar pulmonary artery rupture,3Pape LA Haffajee CI Markis JE et al.Fatal pulmonary hemorrhage after use of the flow-directed balloon-tipped catheter.Ann Intern Med. 1979; 90: 344-347Crossref PubMed Scopus (74) Google Scholar tricuspid valve rupture,4Smith WR Glauser FL Jemison P Ruptured chordae of the tricuspid valve: the consequence of flow-directed Swan-Ganz catheterization.Chest. 1976; 70: 790-792Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar intracardiac knotting of the catheter,5Lipp H O'Donoghue K Resnekov L Intracardiac knotting of a flow-directed balloon-tipped catheter.N Engl J Med. 1971; 284: 220PubMed Google Scholar and heart block.6Abernathy WS Complete heart block caused by the Swan-Ganz catheter.Chest. 1974; 65: 349Crossref PubMed Scopus (44) Google Scholar The introduction of the flow-directed catheter into the right ventricle has not been associated with ventricular arrhythmias in the cardiac catheterization laboratory7Steele P Davies H The Swan-Ganz catheter in the cardiac laboratory.Br Heart J. 1973; 35: 647-650Crossref PubMed Scopus (9) Google Scholar and has infrequently been associated with ectopy in the intensive care areas.1Swan HJC Ganz W Forrester J Marcus H Diamond G Chonette D Catheterization of the heart in man with use of a flow-directed balloon-tipped catheter.N Engl J Med. 1970; 283: 447-451Crossref PubMed Scopus (1485) Google Scholar, 8Voukydis PC Cohen SI Catheter-induced arrhythmias.Am Heart J. 1974; 88: 588-592Abstract Full Text PDF PubMed Scopus (20) Google Scholar In view of the large number of patients in intensive care units with multiple medical problems who are at risk for the development of premature ventricular contractions, the present study was instituted to evaluate the incidence of ventricular arrhythmias during bedside right-sided heart catheterization of the critically ill. Patients and MethodsSixty consecutive patients undergoing bedside right-sided heart catheterization in the medical intensive care unit and coronary care unit of the Miami Veterans Administration Medical Center were studied. A triple-lumen 7 F balloon-tipped flow-directed thermodilution catheter was inserted into the subclavian or internal jugular vein by a percutaneous Seldinger technic and advanced into the pulmonary artery with pressure monitoring. Second and third year residents, cardiology fellows, and attending staff with previous catheterization experience performed the right-sided heart catheterizations. All residents attended a review lecture and demonstration of the proper technique for the insertion of Swan-Ganz catheters before performing a catheterization. The balloon was inflated during catheter insertion, and the catheter was withdrawn from the heart if ectopy was observed. Fluoroscopy was used when physicians felt catheterization was difficult or prolonged. The ECG was visually monitored during catheterization while a permanent record was obtained with a recording system.Catheter-induced ventricular tachycardia was defined as three or more consecutive ventricular premature beats. Patients were considered to have catheter-related arrhythmias only if they had a marked increase in ectopic activity and either bigeminy, trigeminy, two consecutive or two of three ventricular beats being premature ventricular contractions, or ventricular tachycardia. Catheterization time was defined as the time from entry into a central vein until the proper catheter position for pulmonary artery wedge pressure recordings was obtained. Arterial blood gas determinations were performed on an acid base laboratory. Cardiac enzyme and serum electrolyte levels were determined on a column chromatograph and an autoanalyzer, respectively. The data are expressed as the mean of the group ± SEM and were analyzed by the Chi Square test. Statistical significance was defined as p < 0.05. Sixty consecutive patients undergoing bedside right-sided heart catheterization in the medical intensive care unit and coronary care unit of the Miami Veterans Administration Medical Center were studied. A triple-lumen 7 F balloon-tipped flow-directed thermodilution catheter was inserted into the subclavian or internal jugular vein by a percutaneous Seldinger technic and advanced into the pulmonary artery with pressure monitoring. Second and third year residents, cardiology fellows, and attending staff with previous catheterization experience performed the right-sided heart catheterizations. All residents attended a review lecture and demonstration of the proper technique for the insertion of Swan-Ganz catheters before performing a catheterization. The balloon was inflated during catheter insertion, and the catheter was withdrawn from the heart if ectopy was observed. Fluoroscopy was used when physicians felt catheterization was difficult or prolonged. The ECG was visually monitored during catheterization while a permanent record was obtained with a recording system. Catheter-induced ventricular tachycardia was defined as three or more consecutive ventricular premature beats. Patients were considered to have catheter-related arrhythmias only if they had a marked increase in ectopic activity and either bigeminy, trigeminy, two consecutive or two of three ventricular beats being premature ventricular contractions, or ventricular tachycardia. Catheterization time was defined as the time from entry into a central vein until the proper catheter position for pulmonary artery wedge pressure recordings was obtained. Arterial blood gas determinations were performed on an acid base laboratory. Cardiac enzyme and serum electrolyte levels were determined on a column chromatograph and an autoanalyzer, respectively. The data are expressed as the mean of the group ± SEM and were analyzed by the Chi Square test. Statistical significance was defined as p < 0.05. ResultsTabled 1IndicationNo. PatientsSeptic Shock16Volume Resuscitation16Respiratory Failure8Cardiogenic Shock6Hypovolemic Shock5Congestive Heart Failure vs. Pneumonia4Refractory Pulmonary Edema3Obstructive Shock1Vasodilation1Total60 Open table in a new tab Twenty nine of the sixty catheterizations (48 percent) were associated with premature ventricular contractions and twenty (33 percent) were associated with ventricular tachycardia. Of the patients with permanent records, 27 of 40 (68 percent) had evidence of ventricular ectopic beats, and 19 (48 percent) had ventricular tachycardia. Ventricular ectopy typically occurred when the catheter was advanced through the right ventricle; combinations of multiple ventricular premature beats usually preceded ventricular tachycardia. Ventricular tachycardia was usually self-limited and lasted one to two seconds in ten patients, three seconds in two patients, and five to six seconds in five patients. In two patients, ventricular tachycardia intermixed with other ventricular arrhythmias and/or sustained ventricular tachycardia persisted for 15 and 30 seconds, respectively, and required antiarrhythmic agents or a precordial thump in addition to removal of the catheter for conversion. In one patient, the insertion of a guide wire through a central venous catheter into the right ventricle precipitated ventricular tachycardia, ventricular fibrillation, and death. This was the only catheter-related mortality. This patient was included despite the fact that a guide wire and not a balloon-tipped catheter caused ventricular tachycardia because guide wires are required to introduce Swan-Ganz catheters and are an integral part of the catheterization process. In addition to the ventricular arrhythmias observed on the visual monitor system during catheterization, nine patients exhibited ventricular ectopy on the permanent ECG record that had not been previously noted. Five had evidence of ventricular tachycardia, two had two consecutive premature ventricular contractions, and two had bigeminy or trigeminy.Patients had evidence of shock (28), acidosis (pH ≤ 7.2) (4), hypoxia (P02 60 mm Hg) (6), electrolyte imbalance (k < 3.5 mEq/L and Ca ≤ 8.0 mg/dl [albumin corrected]) (22), and myocardial infarction or ischemia (10). Twenty-one patients had one risk factor, 17 had two, and five had three predisposing factors for the development of arrhythmias. Seventeen patients had no risk factors. The mean catheterization time was 40 ± 5 minutes (range 8 to 180 minutes). There was no difference in catheterization time between the patients with and without predisposing conditions. The relationship between ventricular arrhythmias and predisposing factors and duration of catheterization is shown in Table 1. The incidence of arrhythmias could not be correlated with either predisposing factors or duration of catheterization (p < 0.1). However, a significantly increased incidence of arrhythmias was found in patients with both risk factors for ectopy and increased catheterization times compared to patients with only one or neither of these factors (p < 0.01). The mortality rate of the 60 patients was 55 percent.Table 1Frequency of Ventricular Arrhythmias During Catheterization Based on Predisposing Factors and Duration of Catheterization*Increased catheterization time was defined as greater than 20 minutes.PVC†PVC—bigeminy, trigeminy, two consecutive or two of three ventricular beats being premature ventricular contractions, and ventricular tachycardia.No PVCRisk factor, ↑ cath time141Risk factor, no ↑ cath time57No risk factor, ↑ cath time44No risk factor, no ↑ cath time22* Increased catheterization time was defined as greater than 20 minutes.† PVC—bigeminy, trigeminy, two consecutive or two of three ventricular beats being premature ventricular contractions, and ventricular tachycardia. Open table in a new tab Twenty nine of the sixty catheterizations (48 percent) were associated with premature ventricular contractions and twenty (33 percent) were associated with ventricular tachycardia. Of the patients with permanent records, 27 of 40 (68 percent) had evidence of ventricular ectopic beats, and 19 (48 percent) had ventricular tachycardia. Ventricular ectopy typically occurred when the catheter was advanced through the right ventricle; combinations of multiple ventricular premature beats usually preceded ventricular tachycardia. Ventricular tachycardia was usually self-limited and lasted one to two seconds in ten patients, three seconds in two patients, and five to six seconds in five patients. In two patients, ventricular tachycardia intermixed with other ventricular arrhythmias and/or sustained ventricular tachycardia persisted for 15 and 30 seconds, respectively, and required antiarrhythmic agents or a precordial thump in addition to removal of the catheter for conversion. In one patient, the insertion of a guide wire through a central venous catheter into the right ventricle precipitated ventricular tachycardia, ventricular fibrillation, and death. This was the only catheter-related mortality. This patient was included despite the fact that a guide wire and not a balloon-tipped catheter caused ventricular tachycardia because guide wires are required to introduce Swan-Ganz catheters and are an integral part of the catheterization process. In addition to the ventricular arrhythmias observed on the visual monitor system during catheterization, nine patients exhibited ventricular ectopy on the permanent ECG record that had not been previously noted. Five had evidence of ventricular tachycardia, two had two consecutive premature ventricular contractions, and two had bigeminy or trigeminy. Patients had evidence of shock (28), acidosis (pH ≤ 7.2) (4), hypoxia (P02 60 mm Hg) (6), electrolyte imbalance (k < 3.5 mEq/L and Ca ≤ 8.0 mg/dl [albumin corrected]) (22), and myocardial infarction or ischemia (10). Twenty-one patients had one risk factor, 17 had two, and five had three predisposing factors for the development of arrhythmias. Seventeen patients had no risk factors. The mean catheterization time was 40 ± 5 minutes (range 8 to 180 minutes). There was no difference in catheterization time between the patients with and without predisposing conditions. The relationship between ventricular arrhythmias and predisposing factors and duration of catheterization is shown in Table 1. The incidence of arrhythmias could not be correlated with either predisposing factors or duration of catheterization (p < 0.1). However, a significantly increased incidence of arrhythmias was found in patients with both risk factors for ectopy and increased catheterization times compared to patients with only one or neither of these factors (p < 0.01). The mortality rate of the 60 patients was 55 percent. DiscussionPacemaker wires and central venous and pulmonary artery catheters are known to cause ventricular arrhythmias.7Steele P Davies H The Swan-Ganz catheter in the cardiac laboratory.Br Heart J. 1973; 35: 647-650Crossref PubMed Scopus (9) Google Scholar, 8Voukydis PC Cohen SI Catheter-induced arrhythmias.Am Heart J. 1974; 88: 588-592Abstract Full Text PDF PubMed Scopus (20) Google Scholar, 9Grossman W Cardiac catheterization and angiography. Lea & Febiger, Philadelphia1976: 19-20Google Scholar, 10Lown B Temte JV Arter WJ Ventricular tachyarrhythmias: clinical aspects.Circulation. 1973; 47: 1364-1381Crossref PubMed Scopus (41) Google Scholar The insertion of conventional stiff catheters or electrodes into the right ventricle is usually associated with ventricular ectopic activity, whereas the introduction of flexible flow-directed balloon-tipped catheters is only rarely associated with arrhythmias.7Steele P Davies H The Swan-Ganz catheter in the cardiac laboratory.Br Heart J. 1973; 35: 647-650Crossref PubMed Scopus (9) Google Scholar, 8Voukydis PC Cohen SI Catheter-induced arrhythmias.Am Heart J. 1974; 88: 588-592Abstract Full Text PDF PubMed Scopus (20) Google Scholar, 9Grossman W Cardiac catheterization and angiography. Lea & Febiger, Philadelphia1976: 19-20Google Scholar The original reported incidence of ventricular arrhythmias in acutely-ill patients undergoing Swan-Ganz catheterization was 11 percent.1Swan HJC Ganz W Forrester J Marcus H Diamond G Chonette D Catheterization of the heart in man with use of a flow-directed balloon-tipped catheter.N Engl J Med. 1970; 283: 447-451Crossref PubMed Scopus (1485) Google Scholar Recently, Elliott et al11Elliott CG Zimmerman GA Clemmer TP Complications of pulmonary artery catheterization in the care of critically ill patients.Chest. 1979; 76: 647-652Abstract Full Text Full Text PDF PubMed Scopus (188) Google Scholar reported a higher incidence of ventricular ectopy. Premature ventricular contractions occurred, but sustained ventricular tachycardia was not noted.1Swan HJC Ganz W Forrester J Marcus H Diamond G Chonette D Catheterization of the heart in man with use of a flow-directed balloon-tipped catheter.N Engl J Med. 1970; 283: 447-451Crossref PubMed Scopus (1485) Google Scholar, 11Elliott CG Zimmerman GA Clemmer TP Complications of pulmonary artery catheterization in the care of critically ill patients.Chest. 1979; 76: 647-652Abstract Full Text Full Text PDF PubMed Scopus (188) Google Scholar The present study demonstrates a high incidence of ventricular arrhythmias during balloon-tipped catheterization of the critically ill. In fact, three of the 60 patients (5 percent) developed sustained ventricular tachycardia that did not resolve upon withdrawal of the catheter or wire.The high incidence of arrhythmias found in this study may be related to several factors. All patients underwent catheterization with triple-lumen Swan-Ganz thermodilution catheters. The triple-lumen flotation catheter is associated with a higher incidence of ventricular premature beats than the double-lumen catheter.12Forrester JS Diamond GA Swan HJC Bedside diagnosis of latent cardiac complications in acutely ill patients.JAMA. 1972; 222: 59-63Crossref PubMed Scopus (27) Google Scholar Secondly, myocardial infarction or ischemia, shock, acidosis, electrolyte disturbances, increased sympathetic tone, and various drugs are predisposing factors for the development of ventricular arrhythmias.13Hurst JW Logue RB Schlant RC Wenger NK The heart. McGraw-Hill Book Co, New York1978: 651-687Google Scholar These conditions are common in patients requiring catheterization in an intensive care unit. Most of the present patients had evidence of at least one risk factor for the development of ectopy. Thirdly, the majority of the patients were difficult to catheterize because of the severe shock, large right ventricles, dilated pulmonary arteries, or marked pulmonary hypertension. Therefore, the duration of catheterization was longer than previous reports.1Swan HJC Ganz W Forrester J Marcus H Diamond G Chonette D Catheterization of the heart in man with use of a flow-directed balloon-tipped catheter.N Engl J Med. 1970; 283: 447-451Crossref PubMed Scopus (1485) Google Scholar The present critically-ill patients with predisposing conditions for arrhythmias and increased catheterization times manifested an increased incidence of ectopy. Finally, all arrhythmias occurring during catheterization may not be documented. Nine of the present patients had ventricular arrhythmias that were not observed during catheterization but were documented after examination of the simultaneous electrocardiographic records.Past recommendations have stated that antiarrhythmic therapy and a defibrillator should always be available at the bedside during catheterization. In addition, guide wires and CVP catheters used for the insertion of Swan-Ganz catheters should be cautiously introduced, and special care should be taken so they are not advanced into the right ventricle.This report is not intended to minimize the importance of the Swan-Ganz catheter in the intensive care area. The present study does document a high frequency of ventricular arrhythmias during catheterization with a flow-directed catheter. These patients may represent a more critically-ill population than those reported previously, as reflected by the high mortality. However, it is precisely this group of acutely ill patients in whom Swan-Ganz catheterization has become a standard procedure and in whom the predisposition for ventricular ectopy is particularly marked. The Swan-Ganz catheter is an essential tool for the care of the acutely ill. However, physicians must be aware that ventricular arrhythmias during catheterization of the critically ill are common, are usually self-limited, but may require therapeutic intervention. The true incidence of ventricular arrhythmias during catheterization can be ascertained only with continuous permanent electrocardiographic monitoring. Pacemaker wires and central venous and pulmonary artery catheters are known to cause ventricular arrhythmias.7Steele P Davies H The Swan-Ganz catheter in the cardiac laboratory.Br Heart J. 1973; 35: 647-650Crossref PubMed Scopus (9) Google Scholar, 8Voukydis PC Cohen SI Catheter-induced arrhythmias.Am Heart J. 1974; 88: 588-592Abstract Full Text PDF PubMed Scopus (20) Google Scholar, 9Grossman W Cardiac catheterization and angiography. Lea & Febiger, Philadelphia1976: 19-20Google Scholar, 10Lown B Temte JV Arter WJ Ventricular tachyarrhythmias: clinical aspects.Circulation. 1973; 47: 1364-1381Crossref PubMed Scopus (41) Google Scholar The insertion of conventional stiff catheters or electrodes into the right ventricle is usually associated with ventricular ectopic activity, whereas the introduction of flexible flow-directed balloon-tipped catheters is only rarely associated with arrhythmias.7Steele P Davies H The Swan-Ganz catheter in the cardiac laboratory.Br Heart J. 1973; 35: 647-650Crossref PubMed Scopus (9) Google Scholar, 8Voukydis PC Cohen SI Catheter-induced arrhythmias.Am Heart J. 1974; 88: 588-592Abstract Full Text PDF PubMed Scopus (20) Google Scholar, 9Grossman W Cardiac catheterization and angiography. Lea & Febiger, Philadelphia1976: 19-20Google Scholar The original reported incidence of ventricular arrhythmias in acutely-ill patients undergoing Swan-Ganz catheterization was 11 percent.1Swan HJC Ganz W Forrester J Marcus H Diamond G Chonette D Catheterization of the heart in man with use of a flow-directed balloon-tipped catheter.N Engl J Med. 1970; 283: 447-451Crossref PubMed Scopus (1485) Google Scholar Recently, Elliott et al11Elliott CG Zimmerman GA Clemmer TP Complications of pulmonary artery catheterization in the care of critically ill patients.Chest. 1979; 76: 647-652Abstract Full Text Full Text PDF PubMed Scopus (188) Google Scholar reported a higher incidence of ventricular ectopy. Premature ventricular contractions occurred, but sustained ventricular tachycardia was not noted.1Swan HJC Ganz W Forrester J Marcus H Diamond G Chonette D Catheterization of the heart in man with use of a flow-directed balloon-tipped catheter.N Engl J Med. 1970; 283: 447-451Crossref PubMed Scopus (1485) Google Scholar, 11Elliott CG Zimmerman GA Clemmer TP Complications of pulmonary artery catheterization in the care of critically ill patients.Chest. 1979; 76: 647-652Abstract Full Text Full Text PDF PubMed Scopus (188) Google Scholar The present study demonstrates a high incidence of ventricular arrhythmias during balloon-tipped catheterization of the critically ill. In fact, three of the 60 patients (5 percent) developed sustained ventricular tachycardia that did not resolve upon withdrawal of the catheter or wire. The high incidence of arrhythmias found in this study may be related to several factors. All patients underwent catheterization with triple-lumen Swan-Ganz thermodilution catheters. The triple-lumen flotation catheter is associated with a higher incidence of ventricular premature beats than the double-lumen catheter.12Forrester JS Diamond GA Swan HJC Bedside diagnosis of latent cardiac complications in acutely ill patients.JAMA. 1972; 222: 59-63Crossref PubMed Scopus (27) Google Scholar Secondly, myocardial infarction or ischemia, shock, acidosis, electrolyte disturbances, increased sympathetic tone, and various drugs are predisposing factors for the development of ventricular arrhythmias.13Hurst JW Logue RB Schlant RC Wenger NK The heart. McGraw-Hill Book Co, New York1978: 651-687Google Scholar These conditions are common in patients requiring catheterization in an intensive care unit. Most of the present patients had evidence of at least one risk factor for the development of ectopy. Thirdly, the majority of the patients were difficult to catheterize because of the severe shock, large right ventricles, dilated pulmonary arteries, or marked pulmonary hypertension. Therefore, the duration of catheterization was longer than previous reports.1Swan HJC Ganz W Forrester J Marcus H Diamond G Chonette D Catheterization of the heart in man with use of a flow-directed balloon-tipped catheter.N Engl J Med. 1970; 283: 447-451Crossref PubMed Scopus (1485) Google Scholar The present critically-ill patients with predisposing conditions for arrhythmias and increased catheterization times manifested an increased incidence of ectopy. Finally, all arrhythmias occurring during catheterization may not be documented. Nine of the present patients had ventricular arrhythmias that were not observed during catheterization but were documented after examination of the simultaneous electrocardiographic records. Past recommendations have stated that antiarrhythmic therapy and a defibrillator should always be available at the bedside during catheterization. In addition, guide wires and CVP catheters used for the insertion of Swan-Ganz catheters should be cautiously introduced, and special care should be taken so they are not advanced into the right ventricle. This report is not intended to minimize the importance of the Swan-Ganz catheter in the intensive care area. The present study does document a high frequency of ventricular arrhythmias during catheterization with a flow-directed catheter. These patients may represent a more critically-ill population than those reported previously, as reflected by the high mortality. However, it is precisely this group of acutely ill patients in whom Swan-Ganz catheterization has become a standard procedure and in whom the predisposition for ventricular ectopy is particularly marked. The Swan-Ganz catheter is an essential tool for the care of the acutely ill. However, physicians must be aware that ventricular arrhythmias during catheterization of the critically ill are common, are usually self-limited, but may require therapeutic intervention. The true incidence of ventricular arrhythmias during catheterization can be ascertained only with continuous permanent electrocardiographic monitoring. The authors thank the nursing, respiratory therapy, and house staff of the Veterans Administration Medical Center's Medical Intensive Care Unit and Coronary Care Unit, and Drs. M. Goldstein, J. Pinero, H. Sobin, Mr. B. Eisler, Mrs. B. Gold, R. Sprung, A. Sepe, and the Miami Veterans Administration Medical Center's Medical Library staff for their technical assistance.
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