Coronary Artery Air Embolism in the Non-operating room Anesthesia Setting.

Abstract

Coronary artery air embolism is a rare complication in the non–operating room anesthesia environment. In this setting, coronary artery air embolism is generally caused by communication between the atmosphere and the pulmonary venous system or by the creation of a bronchial-venous or alveolar-venous fistula during lung biopsy.1 Typical presentation is a result of the ensuing myocardial ischemia, and includes chest pain, arrhythmia, ST segment changes, bradycardia, hypotension, and cardiovascular collapse.2Figure 1 represents the intraprocedural computed tomography imaging of a 74-year-old woman who underwent percutaneous lung biopsy. Clearly visible is the air-fluid level in the ascending aorta, just distal to the right coronary artery ostia. Figure 2 shows air in the proximal right coronary artery. This patient’s procedural course was complicated by profound bradycardia, arrhythmia, and cardiogenic shock secondary to acute myocardial ischemia.Risk of coronary artery air embolism is underappreciated outside the cardiac operating room; thus, the anesthesiologist must maintain a high degree of suspicion and closely monitor the electrocardiogram for change. Risk factors include coughing, positive pressure ventilation, biopsy of cavitary lesions, and use of needle-within-needle biopsy systems.3 In supine patients, the right ventricle is particularly vulnerable to coronary artery air embolism secondary to the anterior takeoff of the right coronary. Treatment involves immediate Trendelenburg positioning to prevent cerebral air embolism, an inspiratory oxygen fraction of 1.0, central access, and catecholamine support of cardiac function and coronary perfusion pressure. Transcutaneous or transvenous pacing, as well as coronary angiography, aspiration, and localized vasodilator injection have also been trialed successfully in the catheterization laboratory.3 Finally, extracorporeal membrane oxygenation or cardiac bypass may be indicated if other measures fail.Support was provided solely from institutional and/or departmental sources.The authors declare no competing interests.