Vaiyani D, Kelleman M, Downey LA, Kanaan U, Petit CJ, Bauser-Heaton H.Pediatr Cardiol. 2021 Jan 29. doi: 10.1007/s00246-020-02535-4. Online ahead of print.PMID: 33512547
Take Home Points:
- Longer procedure duration and female gender is correlated with increased risk of adverse events in the cardiac catheterization laboratory.
- Patients with higher pulmonary artery pressure and PVR with certain levels of pulmonary vasoreactivity testing are more likely to have adverse events.
Commentary from Dr. Arash Salavitabar (Ann Arbor, MI, USA), section editor of Congenital
Heart Disease Interventions Journal Watch: The authors sought to describe risk factors for adverse events in children with pulmonary arterial hypertension during cardiac catheterization. This was a 5-year single-center, retrospective study that included patients with indexed pulmonary vascular resistance (PVRi) >3 WU*m2, pulmonary artery (PA) pressure 20 mmHg, and PA wedge pressure 15 mmHg. This institution’s protocol for pulmonary vasoreactivity testing was to perform baseline hemodynamics on room air, followed by 100% FiO2, followed by 100% FiO2 and 40ppm inhaled nitric oxide; however, this was not performed in all children. Adverse events were defined as unplanned events related to anesthesia induction or catheterization from which patient harm could have resulted and occurred within 24 hours of cardiac catheterization.
The authors report 198 cardiac catheterizations in 191 patients that met inclusion criteria. There were 33 patients who received transcatheter interventions. There were 28 (14.1%) adverse events (Table 1). There were 6 deaths, with 4 patients developing PH crisis several days following cardiac catheterization.
There were no significant associations between adverse events and patient age, prematurity, Trisomy 21, congenital heart disease, need for baseline respiratory support or history of bronchopulmonary dysplasia, chronic lung disease, use of pulmonary vasodilators, diuretics, vasoactive medications, or use of iNO. Females were more likely to experience an adverse event than males. Risk factors for adverse events are shown in Table 5, notably showing associations between adverse events and procedure duration, PA pressures and PVR on oxygen, as well as PA pressures on oxygen and iNO. These values were not significantly associated at baseline. There was also a more significant change in PA pressures (but not PVR) in response to oxygen and iNO in those patients who had adverse events. The odds of an adverse event increased by 22% for every 15 minutes increase in procedure times. Odds for an adverse event were also increased for every 10 mmHg increase in mPAP while on oxygen (OR 1.58, CI 1.11-2.26) and 61% while on oxygen and iNO (OR 1.61, CI 1.18-2.21). Controlling for procedure time, females had a 388% increase in the odds of experiencing an adverse event when compared to males (OR 3.88, 95% CI; [1.44–10.40], p = 0.007). The patients with adverse events were more likely to have undergone an intervention.
The authors speculated that the association between adverse events and longer procedure times was due to additional opportunities to develop hypoxia and acidosis, thus predisposing to increased PVR. The procedure duration was rightfully identified in this paper as a potentially modifiable risk factor. This paper also is the first to point to female gender as a risk factor, however there were no additional comments made regarding this statistic and its potential cause. This study nicely adds to the existing literature on risk factors for adverse events in this particularly challenging patient population and will allow for better pre-procedural stratification and counseling.