Myocardial Staining during Left Ventriculography with a Pigtail Catheter

The pigtail is the preferred catheter for left ventriculography. Because of its end-hole, which allows its manipulation with a guidewire, it can be advanced to the left ventricle both by the femoral and brachial approaches. The design of the catheter with multiple holes virtually eliminates the possibility of myocardial staining and the occurrence of ectopic ventricular beats is small.^1,2 The intramyocardial injection of contrast (myocardial staining) is caused by the improper positioning of the ventriculography catheter and can lead to refractory ventricular tachyarrythmias and occasionally cardiac death. In this report, we describe the case of an 81-year-old man referred for cardiac catheterization due to severe aortic stenosis. The procedure was performed via the femoral approach using a Judkins right coronary catheter and a straight guidewire to cross the stenotic aortic valve. Once the guidewire was inside the left ventricle, a 6 Fr pigtail catheter was advanced deeply in the ventricle, and the catheter could not adopt its regular “pigtail” shape, so the tip remained against the left ventricular wall. When ventriculography was performed, a considerable amount of contrast was infiltrated in the myocardium (see Figure) with severe chest pain, but no clinical consequences were observed. Small injections of contrast are rarely associated with clinical implications, but it can be a life-threatening complication with the development, as it has been mentioned, of ventricular tachycardia or fibrillation. In addition, the powerful injection of contrast may cause myocardial perforation and cardiac tamponade. Thus, during the procedure, proper and careful manipulation and positioning of the catheter, even using a pigtail, is important in order to avoid severe complications, particularly when a guidewire is used to cross the aortic valve. The course of our patient was uneventful and he was alive two years after the procedure. Aortic valve replacement was not needed due to the confirmation of moderate-grade aortic stenosis.

1. Folland ED, Oprian C, Giacomini J, et al. Complications of cardiac catheterization and angiography in patients with vascular heart disease. VA Cooperative Study on Valvular Heart Disease. Cathet Cardiovasc Diagn 1989;17:15–21. 2. Hilton TC, Deligonul U, Aguirre F, Kern MJ. “End-hole” pigtail catheter: An unusual complication of left ventriculography. Cathet Cardiovasc Diagn 1991;23:139–140.