Related Experiment Video
Updated: Jan 13, 2026
Post-Myocardial Infarction Heart Failure in Closed-chest Coronary Occlusion/Reperfusion Model in Göttingen Minipigs and Landrace Pigs
Published on: April 17, 2021
Protamine Utilization and Clinical Outcomes for Coronary Artery Perforation in Chronic Total Occlusion Percutaneous
Akash Kataruka1, Kanwar Parhar2, David Daniels3
1Division of Cardiology, University of Washington, Seattle, Washington.
Insights
Protamine use after coronary artery perforation during chronic total occlusion percutaneous coronary intervention significantly reduced in-hospital mortality and cardiac tamponade. This finding suggests a potential benefit for managing this complication in PCI procedures.
Area of Science:
- Cardiology
- Interventional Cardiology
- Vascular Medicine
Background:
- Coronary artery perforation is a rare but serious complication during percutaneous coronary intervention (PCI).
- Limited evidence exists for optimal management strategies for coronary artery perforation, particularly following chronic total occlusion (CTO) PCI.
- Protamine sulfate is sometimes used to reverse heparin anticoagulation, but its role in managing coronary perforation is not well-defined.
Purpose of the Study:
- To evaluate the temporal trends and clinical outcomes associated with protamine use in patients experiencing coronary artery perforation during CTO PCI.
- To assess the impact of protamine administration on in-hospital mortality and cardiac tamponade in this patient population.
Main Methods:
- A single-center retrospective analysis of patients undergoing CTO PCI between September 2014 and December 2018.
- Data collection included patient demographics, procedural details, and clinical outcomes, focusing on coronary perforations.
- Multivariate logistic regression was employed to analyze the association between protamine use and primary outcomes (in-hospital mortality and cardiac tamponade).
Main Results:
- Coronary perforation occurred in 11.0% of 1454 CTO PCI patients; 42.5% received protamine.
- The primary outcome (in-hospital mortality or cardiac tamponade) was significantly lower in the protamine group (11.8%) compared to the non-protamine group (40.2%; P < .01).
- Protamine use was independently associated with improved outcomes (OR, 0.27; 95% CI, 0.10-0.65; P < .01), with reduced in-hospital mortality and cardiac tamponade rates.
Conclusions:
- Protamine administration following coronary artery perforation during CTO PCI was associated with a significant reduction in death and cardiac tamponade.
- No increased risk of stent thrombosis was observed with protamine use in this cohort.
- Further research is needed to establish definitive guidelines for protamine use in managing coronary artery perforation.
Background:
Limited evidence exists for the management of coronary artery perforation. We evaluated temporal trends and clinical outcomes associated with protamine use following coronary artery perforation in patients undergoing percutaneous coronary intervention (PCI) for chronic total occlusions (CTOs).
Methods:
A single-center retrospective analysis was performed on coronary perforations in patients undergoing CTO PCI procedures between September 10, 2014, and December 31, 2018, encompassing a change in institutional practice regarding use of protamine at case conclusion. The primary outcome was a composite of in-hospital mortality and cardiac tamponade. Multivariate logistic regression analyses were used to assess the association between protamine use and clinical outcomes.
Results:
In total, 1454 patients undergoing CTO PCI, coronary perforation occurred in 160 (11.0%), of which 68 (42.5%) received protamine. Ellis perforation classification was similar in the protamine and non-protamine groups (P = .148). The primary outcome of in-hospital mortality or cardiac tamponade occurred less frequently in the protamine group compared with the nonprotamine group (11.8% vs 40.2%; P < .01). In-hospital mortality (1.5% vs 14.1%; P = .01) and cardiac tamponade (10.3% vs 26.1%; P = .02) occurred less frequently in the protamine group. In a multivariate logistic regression, protamine was independently associated with an improved primary outcome (OR, 0.27; 95% CI, 0.10-0.65; P < .01).
Conclusions:
In this retrospective analysis, use of protamine in patients with coronary artery perforation complicating CTO PCI was associated with a reduction in death and cardiac tamponade without evidence of increased stent thrombosis. Additional studies are warranted to establish optimal strategies for protamine use.
