Abstract 10721: Pharmacologic Management of Bradycardia During Rotational Atherectomy: A 10-Year Veterans Affairs Experience

Abstract

Introduction: Rotational atherectomy (RA) is frequently used for plaque modification in patients with calcified coronary lesions. RA use in dominant artery lesions is often associated with transient bradyarrhythmias, thought to be due to adenosine release from injured erythrocytes. As such, prophylactic transvenous pacemakers (TVP) are often placed, increasing risk of bleeding and tamponade. We hypothesize that patients undergoing RA at risk for bradyarrhythmias can be safely managed with non-selective adenosine receptor antagonists without routine prophylactic TVP use. Methods: We retrospectively identified 384 consecutive patients who underwent RA at the Ralph H. Johnson VA Medical Center between January 2011 and September 2020. Patients were divided into those pretreated with aminophylline or theophylline (n=147) and those who were not. Primary and secondary endpoints were breakthrough bradyarrhythmia requiring acute pharmacologic or TVP rescue and a composite of 30-day cardiovascular mortality, readmission, and permanent pacemaker implantation. Results: A total of 319 patients who underwent 358 RA procedures met our inclusion criteria. None of the patients had a prophylactic TVP. Overall, 25 patients (6.9%) developed bradycardia, all successfully managed pharmacologically without TVP rescue. Of those pretreated, significantly more patients (12.2%) developed breakthrough bradycardia compared to the 3.3% that did not receive pretreatment (P value 0.001). RA on a dominant vessel was the only significant risk factor among those who developed bradycardia. There was no difference in the secondary endpoint between those pretreated with a non-selective adenosine receptor antagonist compared to those that were not (P value 0.09). Conclusion: Plaque modification with RA can be safely done without routine prophylactic TVP use with favorable acute procedural and short-term outcomes with aminophylline or theophylline pretreatment. There is a significant risk of breakthrough bradycardia with RA on a dominant vessel that can be easily managed medically.