Cardiovascular
Medicine
Complete Heart Block without Ventricular Escape Rhythm during Left Ventriculography
Further Education Cardiology
Asystole of 7 Seconds during a Diagnostic Coronary Angiogram
Peer-review

Complete Heart Block without Ventricular Escape Rhythm during Left Ventriculography

Case Report
Further Education Cardiology
Peter Laurenz Dietrich
Additional authors
Silvan Meier, Raban Jeger
Issue
2024/02
DOI:
https://doi.org/10.4414/cvm.2024.1338832878
Cardiovasc Med. 2024;27(02):55-57
Data Supplement
Supplementary-video1.mp4
Affiliations
Division of Cardiology, Triemli Hospital Zurich, Switzerland

Published on 27.03.2024

Abstract

Complete heart block (CHB) is a rare complication during left ventriculography. We present a case of transient CHB without ventricular escape rhythm in a patient with an incomplete trifascicular block.
Keywords: AV block; complete heart block; left ventriculography

Case Description

A 80-year-old male patient with known severe triple vessel disease and a history of multiple percutaneous coronary interventions of all three major coronary arteries including the left main coronary artery, was admitted with a hypertensive crisis and elevated troponin levels (high-sensitive troponin 53 ng/l, normal <14 ng/l). Baseline 12-lead surface electrocardiogram (ECG) showed a preexisting asymptomatic incomplete trifascicular block, namely a first degree AV block with a PR interval of 206 ms, a complete right bundle branch block (RBBB) and a left anterior fascicular block with a QRS duration of 160 ms (fig. 1). The ECG showed no signs of ischemia. Baseline medication included 5 mg of nebivolol twice daily.
Figure 1: Baseline ECG showing first degree AV block (PR interval: 206 ms), complete right bundle branch block and left anterior fascicular block (QRS duration: 160 ms).
Coronary angiography showed diffuse coronary artery disease unchanged to a previous exam two years earlier with patent stents. There was no significant stenosis in a major coronary vessel. For assessment of the left ventricular function, volume and filling pressures, left ventriculography was performed in a standard fashion using a 5F pigtail catheter. 40 ml of contrast dye at a rate of 15 ml/s and a pressure of 963 pound per square inch were injected with an ACIST CVi™ power injector (ACIST CVi™ Contrast Delivery System, ACIST Medical Systems, Bracco Group, Eden Prairie, MN). Due to a ventricular couplet with abrupt movement of the catheter towards the left ventricular outflow tract (LVOT), the patient developed a complete heart block (CHB) with preserved atrial but no ventricular contractions (fig. 2, video). Atrioventricular conduction resumed after seven seconds. Briefly, the patient was hypotensive, but never unconscious. The ECG after the procedure showed a slightly longer PR-interval of 230ms, but remained otherwise unchanged compared to the baseline ECG (fig 3). The beta blocker was stopped. Rhythm monitoring over the next 24h was unremarkable. The patient was discharged the next day. A three-day Holter monitor and a treadmill exercise test one month later were unremarkable and the patient was free from cardiac complaints.
Figure 2: Still frame of left ventriculography. Please note the ECG with complete heart block after a ventricular couplet with persistent P-waves (white arrows).
Figure 3: ECG after the coronary angiography with a slightly prolonged PR interval of 230 ms but otherwise unchanged findings compared to the baseline ECG.

Discussion

Left ventriculography is a standard method to evaluate left ventricular volume and function with a low complication rate [1]. Iatrogenic conduction system injury during left ventriculography has been reported in the context of unintentional contact of the catheter with the LVOT and/or preexisting RBBB [2–4]. Anatomical studies have shown the proximity of the atrioventricular bundle and the left bundle branch to the aortic root [5]. In the present case, the combination of only one remaining conducting fascicle (the left posterior fascicle), contact of the catheter with the LVOT during a ventricular couplet, and preexisting beta blocker therapy may have contributed to a transient CHB.
We recommend to consider transthoracic echocardiography as an alternative to measure left ventricular function in patients with conduction abnormalities, especially if a RBBB is present. Besides giving more detailed information about regional wall motion abnormality and valvular function, performing transthoracic echocardiography instead of left ventriculography also reduces contrast dye exposure.
Dr. Peter Dietrich
Triemli Hospital Zurich
Division of Cardiology
Birmensdorferstrasse 497
CH-8063 Zurich
PeterLaurenz.Dietrich[at]stadtspital.ch
1 Santos CCL, Oliveira RP, Sena J, Oliveira AD, Ferreira MG, Santos Filho A, et al. Fatores que Impactam a Decisão de Realizar Ventriculografia Esquerda em Doença Arterial Coronariana [Factors That Impact the Decision to Perform Left Ventriculography in Coronary Artery Disease]. Arq Bras Cardiol. 2022 Mar;118(3):607–13. English, Portuguese. doi: 10.36660/abc.20200217. PMID: 35319611.
2 Marine JE, Smith TW, Monahan KM. High-grade atrioventricular block caused by his-purkinje injury during contrast left ventriculography. Circulation. 2001 Oct;104(14):E77-8. PMID: 11581153.
3 Gaglani RD, Turk AA, Mehra MR, Lach RD. Ventricular standstill complicating left heart catheterization in the presence of uncomplicated right bundle branch block. Cathet Cardiovasc Diagn. 1992 Nov;27(3):212–4. PMID: 1306060.
4 Shammas NW, Lee JK, Daubert JP, Pomerantz RM. Complete heart block complicating retrograde left ventricular catheterization: case report and review. Cathet Cardiovasc Diagn. 1994 Feb;31(2):122–6. PMID: 8149423.
5 Kawashima T, Sato F. Visualizing anatomical evidences on atrioventricular conduction system for TAVI. Int J Cardiol. 2014 Jun;174(1):1–6. Epub 2014 Apr 12. PMID: 24750717.
Ethics Statement
Written Informed consent was obtained.
Conflict of Interest Statement
PLD and SM have no potential conflicts of interest to declare.
RJ has received grants from Abbott, Amgen, AstraZeneca, Bayer, Biosense Webster, B. Braun-Melsungen Ag, Biotronik, Boston Scientific, Bristol-Myers Squibb, Carionovum, Cordis, Daiichi Sankyo, Edwards Lifesciences, GE Medical Systems, MCM Medsys, Medtronic, Novartis, Pfizer, Terumo and Vascular Medical GmbH, all directly to the institution.
Author Contributions
All authors contributed in the writing and reviewing process of the manuscript. All authors gave final approval of the version to be published.

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