Complications- How to Avoid and Rescue

1. Complications- How to Avoid and Rescue PROF. DR. ALPAY ÇELIKER

5. Complication is destiny of the every pediatric cardiologist who is working at interventional area.

6. Causes • Patient related • Intervention related • Operator related • Catheter & device related • Miscellaneous

7. Patient Related • Age and BW • Severity of underlying heart disease • Previous intervention and operation • General status of the patient • Heart Failure • Hypoxia • Acidosis • Electrolyte imbalance • Bleeding diathesis • Neurologic status • Other conditions related with syndromic patients

8. Causes Related to Intervention Type of Intervention Duration of intervention Difficulty of procedure Supply of Needed Devices Enough number and type Appropriate alternatives Beware of “reuse” catheters and devices

9. Operator(s) Related Causes First and second operator Experince level Competence at alternative methods Anesthesia Intervention familiar Echocardiographist Competent associated personal: Nurse, technician Surgical back-up when needed

10. Problems with Catheter and Devices • Not appropriate • “Reuse” • Not indicated • Very stiff or floopy; short-long, small internal diameter • Newer catheter and devices

11. Complication of VSD Closure • Relatively safe; but carries risk at small ages/body weight; and bad hemodynamic condition • May occur any phase from the beginning to a few weeks

12. Complication Rate is increased when: • Small age and body weight • Complex procedures • Severe underlying heart disease • Large VSD in an infant • Hybrid procedures • Patients at CICU

13. Operator Related Causes • Beginners may have more complications • Personal first interventions • Beginning of a new method More experience may lead less complications.

14. Specific Problems of VSD Closure • High degree difficulty regarding the • Manipulation • Imaging • Alternative routes • Unique complications • Rhythm problems • Semilunar (aortic valve) regurgitation • Av valve (Tricuspid>mitral) • LV perforations

15. Prevention of Complications • Preoperative planning • Previous operations & interventions • Latest clinical&echocardiographic evaluation (>1 week) • Indivudialized planning for each patient • Continuous monitoring for the complications • Do not lean any body (including nurses and anesthesia team) • Intervene before the final phase of the complication • Prepare to solve for the possible complications at the cath lab.

17. Periheral Nerve Injury • Brachial plexsus injury • Usually temporary • Treatment: Time and physical rehabilitation • May occur direct puncture, local anesthesic infiltration

18. Central Artery Injury • Specifically in small kids • Stiff and large catheters and sheaths • Vigorous and uncontrolled manipulation • Close follow-up during manipulation • Correct equipment/technique and meticulous work

19. Coronary artery injury • Inadvertent catheterization of coronary arteries • Emboli (air, clot) at coronary circulation

20. Temporary/Benign Arrhythmias • Sinus bradicardia: May occur secondary to catheter manipulation, anesthesia >>> controlled respiration, atropine IV • Bundle branch blocks: Catheter or wire travma to the conduction system • Tachycardia (VT>SVT) Stop the catheter movement or pull back Pullback or reposition the catheter Kardiyoversiyon 0.5 joule/kg

21. Major Arrhytmias • Catheter/wire/ sheath/ device trauma to the conduction system • It is very important since it may be related with the early or late permanent AV block Pull-back or reposition the catheter. If it recurs with unforced and appropriate catheter manipulation consider to abandone the procedure Complete AV block

22. Systemic Complications • Blood loss, anemia, shock • Hemolysis • Hypotermia • Hypoxia, acidosis • Allergic reactions • Malign hypertermia • Infection

23. Device Embolization • The most common reasons are incorrect device size/type selection and imaging problems • May cause hemodynamic problems • LV, RV, ascending aorta • Percutaneous extraction tolls should be on the shelf • Surgical backup may be needed

25. Av Block

28. Extraction of Embolized Device • General Measures: • Hemodynamic status • Cardiac rhythm • Blood and blood products • Surgical backup • Another cardiologist (if needed) • Equipment • Sheaths • Snares • Bioptome • Various catheters

29. Endomyocardial Biopsy Forceps Gooseneck Snare

30. Methods • Embolization site is very important • Echocardiographic imaging is very important ıf embolizations would occur to the ventricles. • Generally, there is no rhythm problems, and hemodynamic deterioriation at aortic and pulmonary embolization • Planning of device capture and extraction route • Always monitor the arterial pressure

31. Selection of Extraction Sheath • > 2F form the delivery sheath • Braided sheaths should be used

32. Selection of Catheter • Must have appropriate inner lumen diameter/lenght for the capture device/snare • High torque capability. • Longer than the sheath • Usually Judkins right coronary artery catheter

33. Capture of the device • Devices embolized to the ventricles should be expelled to the great vessels to prevent AV valve chordae or semilunar valve damage. • Device should be catched from the delivery hub • One may try to capture the delivery hub as proximal as possible to facilitate to extraction • Pullback of the device inside the sheath • Do not move the device before the pullback of the device inside the sheath • If there would be a diffculty for pulbback one can move the catheter very cautiously.

34. Prevention of Complications • Detailed history, clinical, laboratory, ECHO, , catheter and surgical data of the patient • Anticipate the possible complications • Usage of appropriate equipment • Do not force the catheter, test injections • Continuous monitoring for the complications • Working careful and patience • Knowing how do you solve the complication.

35. Conclusion • Every effort should be instituted to prevent complications • This measures may be paramount importance in sick/small children • Prepare for unexpected complications in every patients. • Appropriate equipment and surgical back-up is very important to manage the complications.

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