By John Stathopoulos
Since my interventional cardiology fellowship I realized that – except hating to have a patient develop a complication – in order to provide efficient and beneficial to the patient therapy we need to minimize the complications occurrence and also to understand as better as we can each complication, so that we minimize its harmful effect and prevent major morbid events. After the advent of stents and the easily now treated coronary dissections after angioplasty, maybe the most frightening and devastating complication of interventional cardiology is coronary perforation with tamponade.
Because of the rarity of the complication, few studies have specifically addressed outcomes associated with cardiac tamponade during PCI. Several questions arose in our minds like: What is the effect of a coronary perforation without tamponade? What is the short and long term effect of tamponade after coronary perforation on the patient? Does successful treatment of coronary perforation and tamponade mitigates any future adverse sequelae? What is the effect of ventricular tachycardia during tamponade? What is the role of emergent surgical repair for treatment of coronary perforation in the current era?
In our study all patients with tamponade were treated with pericardiocentesis. Tamponade increased the risk of death by more than 3 fold relative to patients with coronary perforation but no tamponade. Death during the follow-up period occurred in 30.8% of the patients who experienced tamponade. Additionally, coronary perforation with tamponade during non-elective PCI carried a significantly worse long-term prognosis than the same complication during elective PCI. Also, although the rate of tamponade after PCI has remained grossly unchanged from earlier reports, the related in-hospital mortality and referral for emergent surgical treatment have decreased.
Despite the limitations of this retrospective study our understanding of this fortunately rare complication after PCI has improved. Early diagnosis and immediate implementation of therapy to restore hemodynamic stability and seal the perforation are keys to successful outcome. Complex PCI procedures (eg attempts to reopen chronic total occlusions) that have greater perforation risk should be undertaken among higher-risk patients only after consideration of the short and long term risk from tamponade and patients with tamponade that are discharged successfully from the hospital, need to be monitored closely for development of cardiac and non cardiac related morbidity.
When one day we unexpectedly experience coronary perforation and tamponade development during PCI, we will hopefully be well prepared to deal with it for the benefit of our patient. We hope that increasing operator experience and improving technology, along with the ever-increasing number of cardiac interventions, will likely offset in the future the risk from associated complications during PCI.
- Stathopoulos I, Kossidas K, Panagopoulos G, Garratt K. Cardiac Tamponade Complicating Coronary Perforation During Angioplasty: Short-Term Outcomes and Long-Term Survival. J INVASIVE CARDIOL 2013;25(10):486-491.
A selection of High-Risk PCI articles:
- Cavender MA, Rajeswaran J, DiPaola L, Houghtaling P, Kiernan MS, Rassi AN, Menon V, Whitlow PW, Ellis SG, Shishehbor MH. Outcomes of culprit versus multivessel PCI in patients with multivessel coronary artery disease presenting with ST-elevation myocardial infarction complicated by shock. J Invasive Cardiol. 2013 May;25(5):218-24.
- Spini V, Cecchi E, Chiostri M, Landi D, Romano SM, Mattesini A, Gensini GF, Giglioli C. Effects of two different treatments with continuous renal replacement therapy in patients with chronic renal dysfunction submitted to coronary invasive procedures. J Invasive Cardiol. 2013 Feb;25(2):80-4.
- Cook J, Uretsky BF, Sachdeva R. Intervention in the occluded vein graft: with high risk can come great reward. Review of techniques with case examples. J Invasive Cardiol. 2012 Nov;24(11):612-7.
- Jones HA, Kalisetti DR, Gaba M, McCormick DJ, Goldberg S. Left ventricular assist for high-risk percutaneous coronary intervention. J Invasive Cardiol. 2012 Oct;24(10):544-50. Review.
- Hendler A, Katz M, Gurevich Y, Reicher M, Blatt A, Gabara Z, Zyssman I, Vered Z, Krakover R. 30-day outcome after percutaneous coronary angioplasty in nonagenarians: feasibility and specific considerations in different clinical settings. J Invasive Cardiol. 2011 Dec;23(12):521-4.
- Hermanides RS, Ottervanger JP, ten Berg JM, Gosselink AT, van Houwelingen G, Dambrink JH, Stella PR, Hamm C, van ‘t Hof AW; On-TIME 2 Trial Investigators. Net clinical benefit of prehospital glycoprotein IIb/IIIa inhibitors in patients with ST-elevation myocardial infarction and high risk of bleeding: effect of tirofiban in patients at high risk of bleeding using CRUSADE bleeding score. J Invasive Cardiol. 2012 Mar;24(3):84-9.