Arrhythmia prevention protocol during papaverine administration for invasive coronary functional assessment
Abstract Background A comprehensive invasive functional assessment in the catheterization laboratory is an important part of the guideline-directed management of patients with chronic coronary syndromes. The induction of maximal coronary hyperemia is a mandatory step during the measurement of hyperemic indexes such as fractional flow reserve (FFR), coronary flow reserve (CFR), and index of microcirculatory reserve (IMR). Papaverine is one of the hyperemic agents that allows for the induction of stable and prolonged hyperemia. However, this drug has been reported to increase the risk of ventricular arrhythmias with reported rates of events between 1.7-5% Purpose To evaluate the feasibility and safety of hyperemic protocol using initial intravenous administration of lidocaine followed by intracoronary papaverine for hyperemia induction in patients undergoing invasive coronary functional assessment. Methods This is a single-center prospective study that included patients with chronic coronary syndrome referred for invasive coronary angiography. Patients underwent a comprehensive functional assessment with measurement of FFR, CFR, and IMR. Initially, all patients received 100 mg of lidocaine i.v.,followed by intracoronary papaverine administration (20 mg into the left and 10 mg into the right coronary arteries). The rate of arrhythmic events was recorded. Results A total of 363 patients with chronic coronary syndrome were included in the study. The mean age was 67 ± 9 years, 69% males, 96% with dyslipidemia, 64% smokers, 29% diabetics, 18% with previous myocardial infarction, 31% with previous PCI, 6% with peripheral artery disease, 12% with previous stroke, 6% with COPD. The mean left ventricular ejection fraction was 55 ± 9%. In 36% of the patients (n=130) a functional significant stenosis with an FFR ≤0.80 was found and those patients with obstructive CAD underwent PCI. In 48% of the patients (n = 174) a microvascular dysfunction was registered with an abnormal result of CFR and/or IMR. In the rest 16.3% of the patients no abnormality was registered. A total of 6 (1.6%) ventricular arrhythmic events were registered after papaverine administration. Those episodes of ventricular tachycardia and fibrillation required 200J biphasic defibrillation. Additionally, one episode of atrial fibrillation was registered and was self-terminated. All patients restored sinus rhythm and were hemodynamically stable at the end of the procedure. Conclusion A protocol of initial administration of lidocaine before intracoronary papaverine injection may reduce the arrhythmic events during invasive coronary functional assessment.
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