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(Circulation. 2001;104:e77.)
© 2001 American Heart Association, Inc.

Images in Cardiovascular Medicine

High-Grade Atrioventricular Block Caused by His-Purkinje Injury During Contrast Left Ventriculography

Joseph E. Marine, MD; Timothy W. Smith, MD, PhD; Kevin M. Monahan, MD

From the Section of Cardiology, Boston Medical Center and Boston University School of Medicine, Boston, Mass.

Correspondence to Kevin M. Monahan, MD, Section of Cardiology, Boston Medical Center, 88 East Newton Street, Boston, MA 02118. E-mail kevin.monahan@bmc.org

A 68-year-old woman with exertional chest discomfort was referred for cardiac catheterization. Her medications did not include atrioventricular (AV) nodal blocking agents, and she had no prior history of dizziness or syncope. Her admission ECG was normal, including a normal axis, PR interval, and QRS morphology and duration (Figure 1). Right heart catheterization and coronary angiography demonstrated normal right heart pressures, mild luminal irregularities in the left anterior descending coronary artery, a discrete 50% stenosis in the left circumflex coronary artery, and normal right coronary artery. A 6-French, 145-degree, angled pigtail catheter with end holes and multiple side holes was introduced into the left ventricle through a retrograde transaortic approach, and contrast ventriculography was performed using 45 cc of ionic contrast delivered at 15 cc/s using a standard power injector.

View larger version (41K): [in this window] [in a new window]   Figure 1. Admission 12-lead ECG. Except for motion artifact, the tracing is normal.

During the initial phase of injection, the pigtail catheter withdrew into the left ventricular outflow tract for several seconds before being advanced back into the midventricle (Figure 2A). Ventricular tachycardia was observed throughout the injection, followed by complete AV block with a wide complex escape rhythm (Figure 3). Cineangiography at the end of the ventriculogram showed persistent dye staining of the high interventricular septum, 5 to 10 mm beneath the aortic valve (Figures 2B and 2C).

View larger version (78K): [in this window] [in a new window]   Figure 2. A, Left ventriculogram in the 30-degree right anterior oblique view at the start of contrast injection. B, Left ventriculogram after completion . . . [Full Text of this Article]