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Education  |   September 2015
Ventricular Asystole during Pulmonary Artery Catheter Insertion
Author Notes
  • From the Department of Anesthesiology, Mayo Clinic College of Medicine, Rochester, Minnesota.
  • Address correspondence to Dr. Barbara: barbara.david@mayo.edu
Article Information
Education / Images in Anesthesiology
Education   |   September 2015
Ventricular Asystole during Pulmonary Artery Catheter Insertion
Anesthesiology 9 2015, Vol.123, 669. doi:10.1097/ALN.0000000000000563
Anesthesiology 9 2015, Vol.123, 669. doi:10.1097/ALN.0000000000000563
Although the overall pulmonary artery catheter (PAC) use has decreased, it remains a valuable tool in select patients. PAC insertion may result in ventricular or supraventricular dysrhythmias due to contact of the catheter with the cardiac chamber walls. The use of balloon-tipped catheters during insertion serves to increase the catheter tip surface area, thereby mitigating applied pressure (and potential injury) should the catheter tip contact endocardium.1  The right bundle branch is located superficially in the endocardium of the right ventricle and is susceptible to trauma. Transient right bundle branch block may result and has been reported in 0 to 12% of patients undergoing right heart catheterization.2,3  In patients with preexisting left bundle branch block, iatrogenic right bundle branch block with PAC placement results in complete heart block. As noted in figure A and B, complete heart block may present as regular p waves with ventricular asystole and cardiac arrest (fig. A).
Although typically transient, complete heart block occurring during PAC placement can cause hemodynamic instability warranting immediate treatment. Prompt removal of the PAC may result in resolution of the complete heart block and hemodynamic stability (fig. B, total duration of ventricular asystole 10 s). Advanced cardiac life support and pacing should be provided as indicated. Previously, prophylactic temporary transvenous pacemaker placement was recommended in left bundle branch block patients undergoing PAC placement, but concerns of risks outweighing benefits of this approach have caused it to fall out of favor.2,3 
Competing Interests
The authors declare no competing interests.
References
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Morris, D, Mulvihill, D, Lew, WY Risk of developing complete heart block during bedside pulmonary artery catheterization in patients with left bundle-branch block.. Arch Intern Med. (1987). 147 2005–10 [Article] [PubMed]
Sprung, CL, Elser, B, Schein, RM, Marcial, EH, Schrager, BR Risk of right bundle-branch block and complete heart block during pulmonary artery catheterization.. Crit Care Med. (1989). 17 1–3 [Article] [PubMed]