ATP-induced ventricular asystole and hypotension during endovascular stenting surgery

To describe four cases of endoluminal stenting surgery in which adenosine 5'-triphosphate (ATP) was used to arrest the heart for accurate placement of the stent-graft.

Four patients with descending thoracic aortic aneurysm were anaesthetized for deployment of a self-expanding stent-graft. Maintenance of general anaesthesia was performed with isoflurane and nitrous oxide in three patients, and with fentanyl and propofol in another. An initial trial of 20 mg ATP was administered via a central venous catheter as rapidly as possible, and produced third degree AV block of 8 +/- 1.7 sec and 59.7 +/- 17.5 sec hypotension, mean blood pressure < 60 mmHg, in three patients. The time to onset of AV block was 15.7 +/- 6.7 sec. In these patients, deployment of the stent-graft was performed during ventricular asystole produced by 30 mg ATP, which produced 16.3 +/- 2.1 sec third and second degree AV block. In one patient anaesthetized with fentanyl and propofol, 20 mg ATP did not change AV conduction. However, after 10 mg edrophonium, 20 mg ATP produced 9 sec third degree AV block. In all cases, heart rate and PQ interval were restored to the pre-drug control level within 50 sec after the commencement of AV block. There were no clinical complications related to this procedure in any patient.

ATP is a convenient and suitable agent to produce transient ventricular asystole for the precise deployment of a self-expanding stent-graft. Co-administration of a parasympathomimetic agent might potentiate the inhibitory effect of ATP on AV conduction.