Adenosine-induced Asystole Research Articles

Adenosine-induced Asystole during AVM Embolization

BackgroundAdenosine induced cardiac standstill has been used intraoperatively for both aneurysm and arteriovenous malformation (AVM) surgery and embolization. We sought to report the results of adenosine induced cardiac standstill as an adjunct to endovascular embolization of brain AVMs.Material and MethodsWe retrospectively identified patients in our prospectively maintained database to identify all patients since January 2007 in whom adenosine was used to induce cardiac standstill during the embolization of a brain AVM. We recorded demographic data, clinical presentation, Spetzler Martin grade, rupture status, therapeutic intervention and number of embolization sessions, angiographic and clinical results, clinical and radiological outcomes and follow-up information.ResultsWe identified 47 patients (22 female, 47%) with average age 42 ± 17 years (range 6–77 years) who had undergone AVM embolization procedures using adjunctive circulatory standstill with adenosine. In total there were 4 Spetzler Martin grade 1 (9%), 9 grade 2 (18%), 15 grade 3 (32%), 8 grade 4 (18%), and 11 grade 5 (23%) lesions. Of the AVMs six were ruptured or had previously ruptured. The average number of embolization procedures per patient was 5.7 ± 7.6 (range 1–37) with an average of 2.6 ± 2.2 (range 1–14) embolization procedures using adenosine. Overall morbidity was 17% (n = 8/47) and mortality 2.1% (n = 1/47), with permanent morbidity seen in 10.6% (n = 5/47) postembolization. Angiographic follow-up was available for 32 patients with no residual shunt seen in 26 (81%) and residual shunts seen in 6 patients (19%). The angiographic follow-up is still pending in 14 patients. At last follow-up 93.5% of patients were mRS ≤2 (n = 43/46).ConclusionAdenosine induced cardiac standstill represents a viable treatment strategy in high flow AVMs or AV shunts that carries a low risk of mortality and permanent neurological deficits.

What Is the Best Method to Achieve Safe and Precise Stent-Graft Deployment in Patients Undergoing TEVAR?

Thoracic endovascular aortic repair (TEVAR) for aortic pathologies requires sufficient landing zone of ideally more than 25 mm for safe anchoring of the stent-graft and prevention of endoleaks. In the aortic arch and at the thoracoabdominal transition, landing zone length is usually limited by the offspring of the major aortic side-branches. Exact deployment of the stent-graft to effectively use the whole length of the landing zone and to prevent occlusion of one of the side-branches is key to successful TEVAR. There are numerous techniques described to lower blood pressure and to reduce or eliminate aortic impulse to facilitate exact deployment of stent-grafts including pharmacologic blood pressure lowering, adenosine-induced asystole, inflow occlusion, and rapid pacing. Aim of this review was to assess the current literature to identify which of the techniques is best suited to prevent displacement and allow for precise placement of the stent-graft and safe balloon-molding.

Adenosine-Induced Cardiac Arrest for Transvenous Embolization of Midbrain Arteriovenous Malformation.

Few studies describe the use of adenosine-induced cardiac systole for treatment of cerebrovascular pathologies.We describe a midbrain arteriovenous malformation (AVM) treated with transvenous embolization using adenosine-induced asystole to achieve transient systemic hypotension with the purpose of furthering discussion on the technique and operative considerations for adenosine use in endovascular AVM treatments. A 29-yr-old man presented with sudden onset of severe bilateral headache, blurred vision, and numbness on the right side of his face and tongue. Noncontrast head computed tomography revealed fourth ventricle hemorrhage. Diagnostic cerebral angiography revealed a high-flow midbrain AVM with a posterior wall perforator from the basilar artery terminus and a draining vein into the straight sinus. Transarterial AVM embolization was successful. The patient was discharged with no residual neurological deficits but returned 1 wk later with slurred speech and left-sided dysmetria. Repeat angiography revealed partial AVM filling. Attempts at transarterial embolization were unsuccessful. Thus, transvenous AVM embolization with adenosine-induced cardiac asystole and systemic hypotension was performed. A total of 60 mg of adenosine was administered, followed by 2 additional doses of 60 and 40 mg; and complete cardiac asystole with a mean arterial pressure of 40 mmHg was maintained, resulting in successful embolization of the AVM. No residual filling was visualized on postembolization arterial angiography runs. The patient was neurologically stable and discharged on postoperative day 2. With appropriate and safe dosing, adenosine-induced asystole and systemic hypotension may be a feasible, safe option to reduce flow and assist endovascular transvenous embolization of high-flow AVMs.

Commentary: Adenosine-Induced Cardiac Arrest for Transvenous Embolization of Midbrain Arteriovenous Malformation.

Commentary: Adenosine-Induced Cardiac Arrest for Transvenous Embolization of Midbrain Arteriovenous Malformation.

What are the options for cardiac standstill during aneurysm surgery? A systematic review.

To perform a systematic review of the techniques for transient circulatory arrest during intracerebral aneurysm surgery according to the PRISMA guidelines. Search of PubMed and Google Scholar using the following: ("heart arrest" OR "cardiac standstill"[All Fields]) AND ("intracranial aneurysm" OR "intracranial"[All Fields] AND "aneurysm"[All Fields]). A total of 41 original articles were retrieved, of which 17 were excluded (review articles, editorials and single-case reports). A total of 24 separate articles published between 1984 and 2018 were included in the final analysis, where the majority of patients harbored anterior circulation giant or large aneurysms. Adenosine-induced cardiac arrest gave a short, temporary asystole. The method had benefits in aneurysm with a broad neck, a thin wall, in specific localizations with narrow surgical corridors or in case of intraoperative rupture. Rapid ventricular pacing (RVP) allows a longer and more easily controlled hypotension. Its use is largely limited to elective cases. Deep hypothermic circulatory arrest required a complex infrastructure, and fatal procedure complications lead to a 11.5-30% 30-day mortality rate, limiting its application to giant or complex aneurysm of the basilar artery or to residual posterior circulation aneurysm after endovascular treatment. Adenosine and RVP are both effective options to facilitate clipping of complex aneurysms. However, their use in patient with ischemic heart disease and cardiac arrhythmias should be avoided, and their safety in the context of subarachnoid hemorrhage is yet to be determined. Today, deep hypothermic circulatory arrest is almost obsolete due to endovascular alternatives.

Atrial fibrillation with hemodynamic instability after the use of the third dose of adenosine during surgery for 7 intracranial aneurysms

Adenosine-induced asystole is a technique that prevents and controls the intraoperative rupture of cerebral aneurysm, facilitating temporary, and/or definitive clipping of the aneurysm. This is the case of a 58-year-old woman who underwent clipping of 7 intracranial aneurysms, who was induced asystole with adeno-sine 3 times and developed atrial fibrillation with hemodynamic instability after the last dose. Adenosine has been shown to be useful and safe, however, its use should be planned and possible cardiological complications should be considered.

Adenosine-Assisted Clipping of Intracranial Aneurysms.

Temporary parent vessel clip occlusion in aneurysm surgery is not always practical or feasible. Adenosine-induced transient cardiac arrest may serve as an alternative. All patients who underwent microsurgical clipping of intracranial aneurysms under adenosine-induced asystole performed by the author between September 2011 and July 2014 were retrospectively reviewed. A total of 16 craniotomies were performed and 16 aneurysms were clipped under adenosine-induced asystole (in 8 basilar arteries, 7 internal carotid arteries, and 1 middle cerebral artery) in 14 patients (8 females, 6 males). Seven cases were elective and 7 were performed after subarachnoid hemorrhage. The patients' mean age was 54 years (range, 39-70 years). The indications for adenosine use were proximal control in narrow surgical corridors in 11 cases, aneurysm softening in 4 cases, and aneurysm rupture in 1 case. A single dose was used in 12 patients; 2 patients had multiple boluses. The median (range) total dose was 30 (18-60)mg. Adenosine induced bradycardia with concomitant arterial hypotension in all patients and the majority also had asystole for 5-15s. Transient cardiac arrhythmias were noted in 1 patient (atrial fibrillation in need of electroconversion after two boluses). Nine clinical scenarios were identified in which adenosine-induced temporary cardiac arrest and deep hypotension was an effective adjunct to temporary clipping during the microsurgical clipping of intracranial aneurysms.

Adenosine-assisted clipping of intracranial aneurysms.

Temporary parent vessel clip occlusion in aneurysm surgery is not always practical or feasible. Adenosine-induced transient cardiac arrest may serve as an alternative. We retrospectively reviewed our clinical database between September 2011 and July 2014. All patients who underwent microsurgical clipping of intracranial aneurysms under adenosine-induced asystole were included. A total of 18 craniotomies were performed, and 18 aneurysms were clipped under adenosine-induced asystole (7 basilar arteries, 8 internal carotid arteries, 1 middle cerebral artery, and 1 anterior communicating artery) in 16 patients (10 females, 6 males). Nine cases were elective and seven after subarachnoid hemorrhage. Mean age was 54years (range 39-70). The indications for adenosine use were proximal control in narrow surgical corridors in 13 cases and "aneurysm softening" in 4 cases. A single dose was used in 14 patients; 3 patients had multiple boluses. The median (range) total dose was 30 (18-135) mg. Adenosine induced a bradycardia with concomitant arterial hypotension in all patients, and the majority also had asystole for 5-15 sec. Transient cardiac arrhythmias were noted in one patient (AFib in need of electroconversion after two boluses). Nine clinical scenarios where adenosine-induced temporary cardiac arrest and deep hypotension was an effective adjunct to temporary clipping during microsurgical clipping of intracranial aneurysms were identified.

Adenosine-assisted neurovascular surgery: initial case series and review of literature.

Cerebral aneurysms in complex anatomical locations and intraoperative rupture of aneurysms are challenging for neurosurgeons and anaesthetists alike. Mechanical and non-mechanical methods to reduce blood flow into aneurysms are well-recognised techniques to facilitate aneurysm exclusion from the circulation. Mechanical methods like temporary clipping of parent arteries, carotid artery ligation and endovascular balloon occlusion are commonly used in clinical practice. However, non-mechanical techniques such as rapid ventricular pacing and adenosine-induced cardiac standstill with hypotension are still emerging strategies. The aim of this study is to report our units' experience in the use of adenosine in aneurysm clipping and arteriovenous malformation (AVM) resection and review the literature. The records of all patients who had adenosine-assisted clipping of intracranial aneurysms and AVM resections in our institute between November 2015 and December 2016 were extracted from prospectively maintained database. The following data were collected: patient demographics, comorbidities, size and location of the aneurysms or AVM, number of boluses and total dose of adenosine administered, duration of cardiac standstill and hypotension (systolic blood pressure<60mmHg), intraoperative and postoperative complications and outcome scores at discharge. Literature search on Embase and PubMed for the terms "adenosine and clipping", "adenosine and aneurysm" and "adenosine and AVM" was performed. Eight aneurysms and two AVMs were identified. While both AVMs were elective procedures, half of the aneurysm clippings were on urgent basis. We used adenosine safely with spontaneous return of rhythm in all cases. Temporary clips to the parent artery were applied for brief periods in 2 patients who had pre-adenosine intraoperative rupture. We did not observe any immediate or late adverse events related to administration of adenosine. From our literature review, a total of ten case series and four case reports were identified. There were no reports on the use of adenosine in AVM resection. Transient adenosine-induced asystole is a safe and effective technique in facilitating surgical treatment of complex aneurysms and AVMs. In addition, adenosine use reduces the need, duration, and associated complications of temporary clip applications to parent arteries.

Morphological risk factors of stroke during thoracic endovascular aortic repair

This study aims to identify independent factors correlating to an increased risk of perioperative stroke during thoracic endovascular aortic repair (TEVAR). A prospective maintained TEVAR database, medical records, and imaging studies of 300 patients (205 men; median age of all, 66 years, range 21-89), who underwent TEVAR between March 1997 and February 2011, were reviewed. Preoperative CT data sets were reviewed by two experienced radiologists with focus on the atheroma burden in the aortic arch (grade I, normal, to grade V, ulcerated or pedunculated atheroma). Aortic arch geometry (arch types I-III) was documented. Further parameters included in the univariate analysis were age, gender, urgency of repair, duration of procedure, adenosine-induced cardiac arrest or rapid pacing, proximal landing zone, left subclavian artery (LSA) coverage, and number of stent grafts. Multivariate logistic regression analysis was performed to assess the independent correlations of potential risk factors. Atherosclerotic aneurysm was the most common pathology (44%). One hundred and fifty-four of our patients (51%) were treated under urgent or emergent conditions. Seventeen percent of all patients had significant arch atheroma (grade IV or V), and 43% had a steep type III aortic arch. The perioperative stroke was 4% (12 patients; median age, 73 years, range 31-78). Two strokes were lethal (0.7%). All strokes were classified as embolic based on imaging characteristics. In eight patients, strokes were located in the left cerebral hemisphere (seven of them in the anterior and one in the posterior circulation). Four stroke patients (one in the left posterior circulation) underwent LSA coverage without revascularization. Three stroke patients had severe arch atheroma grade V. Five patients suffering stroke were recognized to have a type III aortic arch. Strokes were equally distributed between zones 0-2 vs. 3-4 (n = 6 each, 5 vs. 3.3%). The highest incidence was found in zone 1 (11.4%). In univariate analysis, grade V arch atheroma (odds ratios (OR), 5.35; 95% confidence intervals (CI), 1.00-25.87; P = 0.035) and zone 1 deployment (OR, 5.03; 95% CI, 1.19-20.03; P = 0.021) were significantly associated with perioperative stroke. In multivariate analysis, both parameters were confirmed as independent significant risk factors for stroke during TEVAR. Stroke risk during TEVAR is directly associated with the atheroma burden of the aortic arch and the proximal landing zone. These factors should be considered during patient selection, planning, and implantation strategies of TEVAR.

Transient Adenosine-Induced Asystole for the Management of Complex Aneurysms at the Skull Base

Background: Transient adenosine-induced asystole is a reliable method for producing a short period of relative hypotension during surgical and endovascular procedures. Although the technique has been described in the surgical treatment of aneurysms, little description of its use in large and giant aneurysms has been described.

Transient Adenosine-Induced Asystole during Surgical Removal of a Giant Cerebellopontine Angle Hemangioblastoma

Transient Adenosine-Induced Asystole during Surgical Removal of a Giant Cerebellopontine Angle Hemangioblastoma

Adenosine for Temporary Flow Arrest During Intracranial Aneurysm Surgery: A Single-Center Retrospective Review

Clip application for temporary occlusion is not always practical or feasible. Adenosine is an alternative that provides brief periods of flow arrest that can be used to advantage in aneurysm surgery, but little has been published on its utility for this indication. To report our 2-year consecutive experience with 40 aneurysms in 40 patients for whom we used adenosine to achieve temporary arterial occlusion during aneurysm surgery. We retrospectively reviewed our clinical database between May 2007 and December 2009. All patients who underwent microsurgical clipping of intracranial aneurysms under adenosine-induced asystole were included. Aneurysm characteristics, reasons for adenosine use, postoperative angiographic and clinical outcome, cardiac complications, and long-term neurological follow-up with the modified Rankin Scale were noted. Adenosine was used for 40 aneurysms (10 ruptured, 30 unruptured). The most common indications for adenosine were aneurysm softening in 17 cases and paraclinoid location in 14 cases, followed by broad neck in 12 cases and intraoperative rupture in 6 cases. Troponins were elevated postoperatively in 2 patients. Echocardiography did not show acute changes in either. Clinically insignificant cardiac arrhythmias were noted in 5 patients. Thirty-six patients were available for follow-up. Mean follow-up was 12.8 months. The modified Rankin Scale score was 0 for 29 patients at the time of the last follow-up. Four patients had an modified Rankin Scale score of 1, and scores of 2 and 3 were found in 2 and 1 patients, respectively. Adenosine appears to allow safe flow arrest during intracranial aneurysm surgery. This can enhance the feasibility and safety of clipping in select circumstances.

Adenosine-induced Transient Asystole for Intracranial Aneurysm Surgery

BRIEF SUMMARY: We describe the use of adenosine-induced cardiac arrest to facilitate intracranial aneurysm clip ligation. Cerebral aneurysms are highly variable which may result in difficult surgical exposure for clip ligation in select cases. Secure clip placement is often not feasible without temporarily decompressing the aneurysm. This can be accomplished with temporary clip ligation of proximal vessels, or with deep hypothermic circulatory arrest on cardiopulmonary bypass, although these methods have their own inherent risks. Here we describe an alternate method of decompressing the aneurysm via adenosine-induced transient asystole. We examined the records of 27 patients who underwent craniotomy for cerebral aneurysm clipping in which adenosine was used to induce transient asystole to facilitate clip ligation. Duration of adenosine-induced bradycardia (heart rate <40) and hypotension (SBP < 60) recorded on the electronic anesthesia record and outcome data including incidence of successful clipping, intraoperative and postoperative complications, and mortality were recorded. Satisfactory aneurysm decompression was achieved in all cases, and all aneurysms were clipped successfully. The median dose of intravenous adenosine resulting in bradycardia greater than 30 seconds was 30 mg. The median dose of adenosine resulting in hypotension greater than 30 seconds was 15 mg, and greater than 60 seconds was 30 mg. One case of prolonged hypotension after rapid redosing of adenosine required brief closed chest compressions before circulation was spontaneously restored. No other adverse events were observed. Adenosine cardiac arrest is a relatively novel method for decompression of intracranial aneurysms to facilitate clip application. With appropriate safety precautions, it is a reasonable alternative method when temporary clipping of proximal vessels is not desirable or not possible.

Transient Adenosine-Induced Asystole During the Surgical Treatment of Anterior Circulation Cerebral Aneurysms: Technical Note

Transient adenosine-induced asystole is a reliable method for producing a short period of relative hypotension during surgical and endovascular procedures. Although the technique has been described in the endovascular treatment of brain arteriovenous malformations, aortic aneurysms, and posterior circulation cerebral aneurysms, little description of its use in anterior circulation aneurysms is available. To assess the benefits of adenosine-induced transient asystole in complex anterior circulation aneurysms, to describe our experience in selected cases, and to provide the first experience of the use of adenosine in anterior circulation aneurysms. The adenosine-induced cardiac arrest protocol allows us to titrate the duration of cardiac arrest on the basis of individual patient responses. The operative setup is the same as with all aneurysm clippings, with the addition of the placement of transcutaneous pacemakers as a precaution for prolonged bradycardia or asystole. Escalating doses of adenosine are given to determine the approximate dose that results in 30 seconds of asystole. When requested by the surgeon, the dose of adenosine is administered for definitive dissection and clipping. We present 6 cases in which this technique was used. The use of transient adenosine-induced asystole provided excellent circumferential visualization of the aneurysm neck and safe clip application. All patients did well neurologically and suffered no evidence of perioperative cerebral ischemia or delayed complication from the use of adenosine itself. Transient adenosine-induced asystole is a safe and effective technique in select circumstances that may aid in safe and effective aneurysm clipping. Along with the traditional techniques of brain relaxation, skull base approaches, and temporary clipping, adenosine-induced asystole facilitates circumferential visualization of the aneurysm neck and is another technique available to cerebrovascular surgeons.

Intraprocedural Imaging of Left Atrium and Pulmonary Veins: A Comparison Study between Rotational Angiography and Cardiac Computed Tomography

Atrial fibrillation (AF) ablation is facilitated by anatomical visualization of the left atrium (LA) and the pulmonary veins (PVs). The purpose of this study was to compare accuracy, radiation exposure, and costs between three-dimensional atriography (3D-ATG) and cardiac computed tomography (CCT). Seventy patients with an indication for AF ablation were included. Contrast-enhanced CCT was performed preoperatively for all patients. In addition, intraoperative 3D-ATG was performed with contrast medium injection either indirectly into the pulmonary arteries during a breath-hold (Ind.-RTA, n = 25) or directly into the LA, during adenosine-induced asystole (Ad.-RTA, n = 23), or rapid ventricular pacing (VP-RTA, n = 22). We evaluated vertical ostial PV diameters and LA volume, time needed to perform, radiation exposure, and procedural cost for each imaging method. The correlation coefficient between 3D-ATG and CCT for the ostial PV diameters was r = 0.83 for Ind.-RTA, 0.91 for Ad.-RTA, and 0.88 for the VP-RTA method (P > 0.05). The volume correlations were r = 0.87 for Ind.-RTA, 0.82 for Ad.-RTA, and 0.8 for VP-RTA (P > 0.05). Time to perform was 13 ± 5 minutes for ATG and 46 ± 9 minutes for CCT (P < 0.05). Effective radiation dose was 2.2 ± 0.2 mSv for ATG and 20.4 ± 7.4 mSv for CCT (P < 0.05). The procedural cost was estimated at 91-95 € for ATG and at 126-151 € for CCT. 3D-ATG is an intraprocedural imaging modality that provides anatomical accuracy comparable to that of CCT with significantly lower radiation dose, in less time and at less financial expense (PACE 2011; 34:315-322).

Adenosine-induced cardiac arrest during intraoperative cerebral aneurysm rupture

Background Rupture of an intracranial aneurysm during surgical clipping may have devastating consequences. Should this happen all methods ought to be considered to stop the bleeding. A short-term cardiac arrest induced by adenosine could be a feasible method to help the surgeon. We present our experiences in the administration of adenosine during an intraoperative aneurysm rupture. Methods Medical records of patients who underwent surgical clipping of a cerebral arterial aneurysm were reviewed from 2 university hospitals' operative database in the years 2003 to 2008. Patients were included in this study if adenosine had been administered during intraoperative rupture of an aneurysm. Results Altogether, 16 of 1014 patients were identified with the use of adenosine during an intraoperative rupture of an aneurysm. All of the patients had sinus rhythm and normotension before the rupture of the aneurysm. Twelve patients were administered a single dose of adenosine and 4 multiple boluses for induction of cardiac arrest; the median (range) total dose was 12 (6-18) mg and 27 (18-87) mg, respectively. The clipping of the aneurysm and the recovery of circulation were uneventful in all cases. In a subgroup analysis according to patient outcome as alive/dead, the pre- and postoperative neurologic condition correlated with the outcome, whereas adenosine did not have any effect on the patient outcome. Conclusion In a case of a sudden aneurysm rupture, adenosine-induced circulatory arrest could be a safe option to facilitate clipping of an aneurysm. However, if adenosine is used, a very close collaboration between the surgeon and the anesthesiologist is required.

A review of the management of posterior communicating artery aneurysms in the modern era

Background:Technical advancements have significantly improved surgical and endovascular treatment of cerebral aneurysms. In this paper, we review the literature with regard to treatment of one of the most common intra-cranial aneurysms encountered by neurosurgeons and interventional radiologists.Conclusions:Anterior clinoidectomy, temporary clipping, adenosine-induced cardiac arrest, and intraoperative angiography are useful adjuncts during surgical clipping of these aneurysms. Coil embolization is also an effective treatment alternative particularly in the elderly population. However, coiled posterior communicating artery aneurysms have a particularly high risk of recurrence and must be followed closely. Posterior communicating artery aneurysms with an elongated fundus, true posterior communicating artery aneurysms, and aneurysms associated with a fetal posterior communicating artery may have better outcome with surgical clipping in terms of completeness of occlusion and preservation of the posterior communicating artery. However, as endovascular technology improves, endovascular treatment of posterior communicating artery aneurysms may become equivalent or preferable in the near future. One in five patients with a posterior communicating artery aneurysm present with occulomotor nerve palsy with or without subarachnoid hemorrhage. Factors associated with a higher likelihood of recovery include time to treatment, partial third nerve deficit, and presence of subarachnoid hemorrhage. Both surgical and endovascular therapy offer a reasonable chance of recovery. Based on level 2 evidence, clipping appears to offer a higher chance of occulomotor nerve palsy recovery; however, coiling will remain as an option particularly in elderly patients or patients with significant comorbidity.

A new approach for contrast-enhanced X-ray imaging of the left atrium and pulmonary veins for atrial fibrillation ablation: rotational angiography during adenosine-induced asystole

Atrial fibrillation ablation is a complex procedure that requires detailed anatomic information about left atrium (LA) and pulmonary veins (PVs). The goal of this study was to test rotational angiography of the LA during adenosine-induced asystole as an imaging tool in patients undergoing atrial fibrillation ablation. Seventy patients with paroxysmal or persistent atrial fibrillation undergoing PV isolation were included. After transseptal puncture, adenosine (30 mg) was given intravenously, and during atrioventricular block, contrast medium was directly injected in the LA; a rotational angiography was performed (right anterior oblique 55 degrees to left anterior oblique 55 degrees). Rotational angiography images were assessed qualitatively in all patients and quantitatively in 45 patients in comparison with computed tomography (CT) images. The majority of rotational angiography imaging data (94%) were deemed at least 'useful' in delineating the LA-PV anatomy. The so-called 'ridge' between left superior PV and left atrial appendage was delineated in 90% of the patients. All accessory PVs were independently identified by rotational angiography and CT. A blinded quantitative comparison of PV ostial diameters showed an excellent correlation between rotational angiography and CT measurements (r > 0.90 for all PVs). No serious adverse effects occurred in association with adenosine. Intra-procedural contrast-enhanced rotational angiography of the LA-PV during adenosine-induced asystole is feasible and provides anatomical information of high diagnostic value for atrial fibrillation ablation.

High-Dose Adenosine-Induced Asystole Assisting Accurate Deployment of Thoracic Stent Grafts in Conscious Patients

Adenosine has been used to induce asystole and assist deployment of endoluminal grafts. However, application of high-dose adenosine in conscious patients has not been described. In this prospective study, we administered high-dose adenosine in patients undergoing thoracic stent grafting. Asystole duration in relationship to the dosage of adenosine, safety, and side effect profiles was investigated. All patients who underwent thoracic stent grafting between 1998 and 2006 were the potential study subjects. They received monitored anesthesia care and local anesthesia unless contraindicated. Adenosine was given via rapid intravenous bolus immediately prior to the deployment of the stent graft. Every patient received a dose of 36 mg. If needed, a second dose of 18 mg was given. Duration of asystole was recorded after each administration. Patients' vital signs before and after administration were also documented. Side effect profiles were collected intra- and postoperatively. A total of 46 patients received adenosine (34 men, 12 women). Mean age was 60.4 +/- 17.5 years. American Society of Anesthesiologists scores were II in one patient (2%), III in six patients (13%), and IV in 39 patients (85%). Eighteen patients received a single dose of 36 mg adenosine, 15 were given a second dose of 18 mg, and 13 received nonstandard dosages. Asystole durations were 18.8 +/- 8.8 and 11.6 +/- 5.5 sec for 36 and 18 mg, respectively. Technical success was achieved in all cases. The differences achieved statistical significance (p = 0.0009). There were no severe cardiac or pulmonary complications. High-dose adenosine can be given safely in conscious patients. The dose-response was predictable and reproducible. The dosages used in our study induce sufficient duration of asystole, which ensured accurate deployment of thoracic stent grafts.