Abstract 4139704: Coronary Artery Air Embolism During Left Heart Catheterization: A Rare Yet Potentially Fatal Complication

Coronary artery air embolism is a rare yet potentially fatal complication of interventional cardiac procedures, presenting from asymptomatic to cardiac arrest. There are no established guidelines for its management, and the focus is on primary prevention. Here, we present a case of iatrogenic coronary artery air embolism during an elective left heart catheterization (LHC). A 61-year-old male with mitral valve prolapse underwent preoperative LHC which showed a stenotic left anterior descending artery and normal right coronary artery (RCA). On the following left ventriculogram, significant inferior wall hypokinesis was observed, and the patient developed acute chest pain, ST elevations, and complete heart block (Figure 1a). Suspecting new RCA pathology, reevaluation revealed multiple air emboli and Thrombolysis In Myocardial Infarction (TIMI) grade 1 flow (Figure 1b). The RCA was flushed multiple times with heparinized saline, resolving the air emboli and restoring TIMI grade 3 flow (Figure 1c). At the procedure's end, the patient was pain-free and in sinus rhythm. A repeat transthoracic echocardiogram showed normal ventricular function without regional wall motion abnormalities. The patient was discharged without further complications. Coronary air embolism can occur iatrogenically and is inversely correlated with operator experience. Prevention through proper technique is crucial: catheters should be adequately aspirated, all connections tightened, and the catheter should be tested distal to the aortic cusp to prevent emboli occurrence. Although there are no established guidelines, management includes administering 100% oxygen, intracoronary saline boluses, or breaking down emboli with a guidewire. In our case, the sudden onset hypokinesis of the inferior wall with complete heart block in a confirmed normal RCA raised suspicion for new RCA pathology. Immediate heparinized saline allowed for air emboli dissociation as a more immediate intervention than 100% oxygen and did not involve intravascular manipulation which could result in dissection. Our case highlights the importance of early detection of rapidly changing pathology and stresses meticulous technique for testing equipment as a prevention method.