Coronary air embolism: Difference between revisions

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The introduction of an air bubble in the coronary microcirculation can be explained by Laplace's law and may result in development of an air lock. Laplace’s law  relates the pressure difference over a blood–air interface to the surface tension and the radius of the blood–air interface. The predominant mechanism is the air diffusion into the blood and surrounding tissues, leading to bubble shrinking, in wich, the severity of the cardiac impairment is related to the volume of air injected into the coronary arteries, the baseline cardiac function, and subsequent vascular responses such as vasospasm or distal air-lock.  However, the size and volume of the bubbles have the most important roles in blood flow speed restoration. Furthermore, this diffusion is significantly enhanced by an increase in the mean arterial pressure and the partial pressure of oxygen in the arterial system.<ref name="Van Blankenstein-1993">{{Cite journal  | last1 = Van Blankenstein | first1 = JH. | last2 = Slager | first2 = CJ. | last3 = Schuurbiers | first3 = JC. | last4 = Strikwerda | first4 = S. | last5 = Verdouw | first5 = PD. | title = Heart function after injection of small air bubbles in coronary artery of pigs. | journal = J Appl Physiol (1985) | volume = 75 | issue = 3 | pages = 1201-7 | month = Sep | year = 1993 | doi =  | PMID = 8226530 }}</ref> Both conditions and also vasoconstriction may cause a division of bubbles more proximal in the vascular bed leading to more rapid dispersion of bubbles which develop a deleterious effect on the microvasculature decreasing the capillary bed space and so leading to a decrease in distal coronary blood flow.<ref name="Dib-2006">{{Cite journal  | last1 = Dib | first1 = J. | last2 = Boyle | first2 = AJ. | last3 = Chan | first3 = M. | last4 = Resar | first4 = JR. | title = Coronary air embolism: a case report and review of the literature. | journal = Catheter Cardiovasc Interv | volume = 68 | issue = 6 | pages = 897-900 | month = Dec | year = 2006 | doi = 10.1002/ccd.20880 | PMID = 17086533 }}</ref>
The introduction of an air bubble in the coronary microcirculation can be explained by Laplace's law and may result in development of an air lock. Laplace’s law  relates the pressure difference over a blood–air interface to the surface tension and the radius of the blood–air interface. The predominant mechanism is the air diffusion into the blood and surrounding tissues, leading to bubble shrinking, in wich, the severity of the cardiac impairment is related to the volume of air injected into the coronary arteries, the baseline cardiac function, and subsequent vascular responses such as vasospasm or distal air-lock.  However, the size and volume of the bubbles have the most important roles in blood flow speed restoration. Furthermore, this diffusion is significantly enhanced by an increase in the mean arterial pressure and the partial pressure of oxygen in the arterial system.<ref name="Van Blankenstein-1993">{{Cite journal  | last1 = Van Blankenstein | first1 = JH. | last2 = Slager | first2 = CJ. | last3 = Schuurbiers | first3 = JC. | last4 = Strikwerda | first4 = S. | last5 = Verdouw | first5 = PD. | title = Heart function after injection of small air bubbles in coronary artery of pigs. | journal = J Appl Physiol (1985) | volume = 75 | issue = 3 | pages = 1201-7 | month = Sep | year = 1993 | doi =  | PMID = 8226530 }}</ref> Both conditions and also vasoconstriction may cause a division of bubbles more proximal in the vascular bed leading to more rapid dispersion of bubbles which develop a deleterious effect on the microvasculature decreasing the capillary bed space and so leading to a decrease in distal coronary blood flow.<ref name="Dib-2006">{{Cite journal  | last1 = Dib | first1 = J. | last2 = Boyle | first2 = AJ. | last3 = Chan | first3 = M. | last4 = Resar | first4 = JR. | title = Coronary air embolism: a case report and review of the literature. | journal = Catheter Cardiovasc Interv | volume = 68 | issue = 6 | pages = 897-900 | month = Dec | year = 2006 | doi = 10.1002/ccd.20880 | PMID = 17086533 }}</ref>


==Causes==
==Types==
=====Direct Coronary Embolism=====
* Infective [[endocarditis]]<ref name="BRUNSON-">{{Cite journal  | last1 = BRUNSON | first1 = JG. | title = Coronary embolism in bacterial endocarditis. | journal = Am J Pathol | volume = 29 | issue = 4 | pages = 689-701 | month =  | year =  | doi =  | PMID = 13065415 }}</ref><ref name="Loire-1985">{{Cite journal  | last1 = Loire | first1 = R. | last2 = Tabib | first2 = A. | title = [Coronary embolism. Apropos of 61 anatomo-clinical cases]. | journal = Arch Mal Coeur Vaiss | volume = 78 | issue = 6 | pages = 821-7 | month = Jun | year = 1985 | doi =  | PMID = 3929712 }}</ref><ref name="Loire-1977">{{Cite journal  | last1 = Loire | first1 = R. | last2 = Dubreuil | first2 = C. | last3 = Perrin | first3 = A. | title = [Coronary emboli. Study of a series of 30 anatomo-clinical cases]. | journal = Arch Mal Coeur Vaiss | volume = 70 | issue = 1 | pages = 1-7 | month = Jan | year = 1977 | doi =  | PMID = 403875 }}</ref><ref name="Roxas-2011">{{Cite journal  | last1 = Roxas | first1 = CJ. | last2 = Weekes | first2 = AJ. | title = Acute myocardial infarction caused by coronary embolism from infective endocarditis. | journal = J Emerg Med | volume = 40 | issue = 5 | pages = 509-14 | month = May | year = 2011 | doi = 10.1016/j.jemermed.2007.12.041 | PMID = 18947962 }}</ref>
* [[Coronary Artery Thrombus|Thrombotic]] material on diseased or prosthetic aortic or mitral valves<ref>{{Cite book  | last1 = Libby | first1 = Peter. | last2 = Braunwald | first2 = Eugene | title = Braunwald's heart disease : a textbook of cardiovascular medicin | date = 2008 | publisher = Saunders/Elsevier | location = Philadelphia | isbn = 1-4160-4106-0 | pages =  }}</ref><ref name="Loire-1985">{{Cite journal  | last1 = Loire | first1 = R. | last2 = Tabib | first2 = A. | title = [Coronary embolism. Apropos of 61 anatomo-clinical cases]. | journal = Arch Mal Coeur Vaiss | volume = 78 | issue = 6 | pages = 821-7 | month = Jun | year = 1985 | doi =  | PMID = 3929712 }}</ref>
* [[Valve stenosis]] and [[atrial fibrillation]]<ref name="CHENG-1953">{{Cite journal  | last1 = CHENG | first1 = JT. | last2 = CAHILL | first2 = WJ. | last3 = FOLEY | first3 = EF. | title = Coronary embolism. | journal = J Am Med Assoc | volume = 153 | issue = 3 | pages = 211-3 | month = Sep | year = 1953 | doi =  | PMID = 13069294 }}</ref>
* [[Cardiac myxoma]]<ref name="Panos-1997">{{Cite journal  | last1 = Panos | first1 = A. | last2 = Kalangos | first2 = A. | last3 = Sztajzel | first3 = J. | title = Left atrial myxoma presenting with myocardial infarction. Case report and review of the literature. | journal = Int J Cardiol | volume = 62 | issue = 1 | pages = 73-5 | month = Oct | year = 1997 | doi =  | PMID = 9363506 }}</ref><ref name="Soejima-1997">{{Cite journal  | last1 = Soejima | first1 = Y. | last2 = Niwa | first2 = A. | last3 = Tanaka | first3 = M. | last4 = Doi | first4 = M. | last5 = Nitta | first5 = M. | last6 = Takamoto | first6 = T. | last7 = Hiroe | first7 = M. | last8 = Marumo | first8 = F. | last9 = Kusumoto | first9 = M. | title = A left atrial myxoma complicated with acute myocardial infarction. | journal = Intern Med | volume = 36 | issue = 1 | pages = 31-4 | month = Jan | year = 1997 | doi =  | PMID = 9058097 }}</ref><ref name="Milicevic-2008">{{Cite journal  | last1 = Milicevic | first1 = G. | last2 = Gavranovic | first2 = Z. | last3 = Cupic | first3 = H. | last4 = Cerovec | first4 = D. | last5 = Stipic | first5 = H. | last6 = Jukic | first6 = M. | last7 = Letica | first7 = D. | last8 = Predrijevac | first8 = M. | title = Unremitting embolus from cardiac myxoma at circumflex artery trifurcation. | journal = Int J Cardiol | volume = 126 | issue = 3 | pages = 424-6 | month = Jun | year = 2008 | doi = 10.1016/j.ijcard.2007.01.091 | PMID = 17462763 }}</ref>
 
=====Paradoxical Coronary Embolism=====
*
 
 
=====Iatrogenic Coronary Embolism=====


==Epidemiology and Demographics==
==Epidemiology and Demographics==

Revision as of 16:58, 22 November 2013

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Vanessa Cherniauskas, M.D. [2]

Synonyms and keywords: Coronary artery air embolism; coronary air embolization

Overview

Coronary air embolism is a complication of coronary angiograpghy, in which there is an iatrogenic introduction of gas bubbles into the blood stream, that can be associated with high morbidity and even mortality. In this case, the signs and symptoms result from the cessation of the blood flow within the arterial segment, caused by even a small amount of bubbles, which lead to tissue ischemia from oxygen starvation and may cause cellular damage and irreversible injury. The most dangerous consequences occur in brain and heart due to their vulnerability to short periods of ischemia.[1]

Definition

The coronary air embolism is a result from the iatrogenic introduction of gas bubbles into the blood stream, an uncommon complication in the cardiac catheterization.[1]

Pathophysiology

The introduction of an air bubble in the coronary microcirculation can be explained by Laplace's law and may result in development of an air lock. Laplace’s law relates the pressure difference over a blood–air interface to the surface tension and the radius of the blood–air interface. The predominant mechanism is the air diffusion into the blood and surrounding tissues, leading to bubble shrinking, in wich, the severity of the cardiac impairment is related to the volume of air injected into the coronary arteries, the baseline cardiac function, and subsequent vascular responses such as vasospasm or distal air-lock. However, the size and volume of the bubbles have the most important roles in blood flow speed restoration. Furthermore, this diffusion is significantly enhanced by an increase in the mean arterial pressure and the partial pressure of oxygen in the arterial system.[2] Both conditions and also vasoconstriction may cause a division of bubbles more proximal in the vascular bed leading to more rapid dispersion of bubbles which develop a deleterious effect on the microvasculature decreasing the capillary bed space and so leading to a decrease in distal coronary blood flow.[1]

Types

Direct Coronary Embolism
Paradoxical Coronary Embolism


Iatrogenic Coronary Embolism

Epidemiology and Demographics

Risk Factors

Signs and Symptoms

Rare Signs and Symptoms

Diagnosis

Clinical Significance

Treatment

  • 100% oxygen by face mask
  • Analgesics
  • Monitorand treat arrhythmias
  • Circulatory support with pressors and intra-aortic balloon pump counter pulsation as necessary[12]
  • Intracoronary thrombus aspiration catheter systems which are the best options to resolve intracoronary air embolisms safely and harmlessly.[13]

Example

Coronary Air Embolism
(Left Anterior Descending Artery; RAO Caudal)

References

  1. ↑ 1.0 1.1 1.2 Dib, J.; Boyle, AJ.; Chan, M.; Resar, JR. (2006). "Coronary air embolism: a case report and review of the literature". Catheter Cardiovasc Interv. 68 (6): 897–900. doi:10.1002/ccd.20880. PMID 17086533. Unknown parameter |month= ignored (help)
  2. ↑ Van Blankenstein, JH.; Slager, CJ.; Schuurbiers, JC.; Strikwerda, S.; Verdouw, PD. (1993). "Heart function after injection of small air bubbles in coronary artery of pigs". J Appl Physiol (1985). 75 (3): 1201–7. PMID 8226530. Unknown parameter |month= ignored (help)
  3. ↑ BRUNSON, JG. "Coronary embolism in bacterial endocarditis". Am J Pathol. 29 (4): 689–701. PMID 13065415.
  4. ↑ 4.0 4.1 Loire, R.; Tabib, A. (1985). "[Coronary embolism. Apropos of 61 anatomo-clinical cases]". Arch Mal Coeur Vaiss. 78 (6): 821–7. PMID 3929712. Unknown parameter |month= ignored (help)
  5. ↑ Loire, R.; Dubreuil, C.; Perrin, A. (1977). "[Coronary emboli. Study of a series of 30 anatomo-clinical cases]". Arch Mal Coeur Vaiss. 70 (1): 1–7. PMID 403875. Unknown parameter |month= ignored (help)
  6. ↑ Roxas, CJ.; Weekes, AJ. (2011). "Acute myocardial infarction caused by coronary embolism from infective endocarditis". J Emerg Med. 40 (5): 509–14. doi:10.1016/j.jemermed.2007.12.041. PMID 18947962. Unknown parameter |month= ignored (help)
  7. ↑ Libby, Peter.; Braunwald, Eugene (2008). Braunwald's heart disease : a textbook of cardiovascular medicin. Philadelphia: Saunders/Elsevier. ISBN 1-4160-4106-0.
  8. ↑ CHENG, JT.; CAHILL, WJ.; FOLEY, EF. (1953). "Coronary embolism". J Am Med Assoc. 153 (3): 211–3. PMID 13069294. Unknown parameter |month= ignored (help)
  9. ↑ Panos, A.; Kalangos, A.; Sztajzel, J. (1997). "Left atrial myxoma presenting with myocardial infarction. Case report and review of the literature". Int J Cardiol. 62 (1): 73–5. PMID 9363506. Unknown parameter |month= ignored (help)
  10. ↑ Soejima, Y.; Niwa, A.; Tanaka, M.; Doi, M.; Nitta, M.; Takamoto, T.; Hiroe, M.; Marumo, F.; Kusumoto, M. (1997). "A left atrial myxoma complicated with acute myocardial infarction". Intern Med. 36 (1): 31–4. PMID 9058097. Unknown parameter |month= ignored (help)
  11. ↑ Milicevic, G.; Gavranovic, Z.; Cupic, H.; Cerovec, D.; Stipic, H.; Jukic, M.; Letica, D.; Predrijevac, M. (2008). "Unremitting embolus from cardiac myxoma at circumflex artery trifurcation". Int J Cardiol. 126 (3): 424–6. doi:10.1016/j.ijcard.2007.01.091. PMID 17462763. Unknown parameter |month= ignored (help)
  12. ↑ 12.0 12.1 Kahn, JK.; Hartzler, GO. (1990). "The spectrum of symptomatic coronary air embolism during balloon angioplasty: causes, consequences, and management". Am Heart J. 119 (6): 1374–7. PMID 2353622. Unknown parameter |month= ignored (help)
  13. ↑ Celik, A.; Ozeke, O. (2010). "Management of coronary air embolism during coronary stenting". Kardiol Pol. 68 (6): 716–8, discussion 719. PMID 20806212. Unknown parameter |month= ignored (help)


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