Skip to main content

Advertisement

SpringerLink
Log in

Incidence and outcomes of protamine reactions in patients undergoing catheter ablation of atrial fibrillation

  • Published:
Journal of Interventional Cardiac Electrophysiology Aims and scope Submit manuscript

Abstract

Background

Aggressive anticoagulation with heparin to maintain an activated clotting time (ACT) >300 s is required during catheter ablation of atrial fibrillation (AF) to reduce the risk of systemic thromboembolism. The purpose of this study is to describe the incidence and outcome of protamine reactions and analyze the risk factors in patients undergoing catheter ablation of AF.

Methods

The patient population included 242 consecutive patients (193 men, age 57.6 ± 10.8 years) with drug refractory AF who underwent catheter ablation and received protamine immediately following catheter ablation to reverse the effects of heparin. Fifty eight of these patients had prior exposure to protamine.

Results

Three of the 242 patients in our study developed an adverse reaction to protamine (1.2%). Although each of the three protamine reaction presented in a dramatic fashion with profound hypotension, all three patients responded to medical treatment and did not experience clinical sequelae. Age, gender, type of AF, number of ablations, prior exposure, diabetes mellitus, and ejection fraction did not predict the occurrence of these reactions.

Conclusion

This study reports, for the first time, the incidence and outcomes of protamine reaction in patients undergoing catheter ablation of AF. The results of this study reveal that protamine reactions present in a dramatic fashion often with profound hypotension. Although the incidence of protamine reactions in this setting is low (1.2%), they do occur. Electrophysiologists who use protamine need to be aware of this reaction and the appropriate therapeutic interventions.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Calkins, H., Brugada, J., Packer, D. L., Cappato, R., Chen, S. A., Crijns, H. J., et al. (2007). HRS/EHRA/ECAS expert consensus statement on catheter and surgical ablation of atrial fibrillation: recommendations for personnel, policy, procedures and follow-up. Heart Rhythm, 4, 816–861.

    Article  PubMed  Google Scholar 

  2. Cheema, A., Dong, J., Dalal, D., Marine, J. E., Henrikson, C. A., Spragg, D., et al. (2007). Incidence and time course of early recovery of pulmonary vein conduction after catheter ablation of atrial fibrillation. Journal of Cardiovascular Electrophysiology, 18(4), 387–391.

    Article  PubMed  Google Scholar 

  3. Patel, A. A., Clyne, C. A., Henyan, N. N., White, C. M., Zembrowski, B. F., Migeed, M., et al. (2007). The use of protamine after radiofrequency catheter ablation: a pilot study. Journal of Interventional Cardiac Electrophysiology, 18(2), 155–158.

    Article  PubMed  Google Scholar 

  4. Horrow, J. C. (1985). Protamine: a review of its toxicity. Anesthesia and Analgesia, 64(3), 348–361.

    Article  PubMed  CAS  Google Scholar 

  5. Shapira, N., Schaff, H. V., Piehler, J. M., White, R. D., Still, J. C., & Pluth, J. R. (1982). Cardiovascular effects of protamine sulfate in man. The Journal of Thoracic and Cardiovascular Surgery, 84(4), 505–514.

    PubMed  CAS  Google Scholar 

  6. Porsche, R., & Brenner, Z. R. (1999). Allergy to protamine sulfate. Heart & Lung, 28(6), 418–428.

    Article  CAS  Google Scholar 

  7. Levy, J. H., & Adkinson Jr., N. F. (2008). Anaphylaxis during cardiac surgery: implications for clinicians. Anesthesia and Analgesia, 106(2), 392–403.

    Article  PubMed  Google Scholar 

  8. Nordström, L., Fletcher, R., & Pavek, K. (1978). Shock of anaphylactoid type induced by protamine: a continuous cardiorespiratory record. Acta Anaesthesiologica Scandinavica, 22(3), 195–201.

    PubMed  Google Scholar 

  9. Panos, A., Orrit, X., Chevalley, C., & Kalangos, A. (2003). Dramatic post-cardiotomy outcome, due to severe anaphylactic reaction to protamine. European Journal of Cardio-Thoracic Surgery, 24(2), 325–327.

    Article  PubMed  CAS  Google Scholar 

  10. Weiler, J. M., Gellhaus, M. A., Carter, J. G., Meng, R. L., Benson, P. M., Hottel, R. A., et al. (1990). A prospective study of the risk of an immediate adverse reaction to protamine sulfate during cardiopulmonary bypass surgery. The Journal of Allergy and Clinical Immunology, 85(4), 713–719.

    Article  PubMed  CAS  Google Scholar 

  11. Kimmel, S. E., Sekers, M. A., Berlin, J. A., Ellison, N., DiSesa, V. J., & Strom, B. L. (1998). Risk factors for clinically important adverse events after protamine administration following cardiopulmonary bypass. Journal of the American College of Cardiology, 32(7), 1916–1922.

    Article  PubMed  CAS  Google Scholar 

  12. Weiler, J. M., Gellhaus, M. A., Carter, J. G., Meng, R. L., Benson, P. M., Hottel, R. A., et al. (1990). A prospective study of the risk of an immediate adverse reaction to protamine sulfate during cardiopulmonary bypass surgery. The Journal of Allergy and Clinical Immunology, 85(4), 713–719.

    Article  PubMed  CAS  Google Scholar 

  13. Gottschlich, G. M., Gravlee, G. P., & Georgitis, J. W. (1988). Adverse reactions to protamine sulfate during cardiac surgery in diabetic and non-diabetic patients. Annals of Allergy, 61(4), 277–281.

    PubMed  CAS  Google Scholar 

  14. Levy, J. H., Schwieger, I. M., Zaidan, J. R., Faraj, B. A., & Weintraub, W. S. (1989). Evaluation of patients at risk for protamine reactions. The Journal of Thoracic and Cardiovascular Surgery, 98(2), 200–204.

    PubMed  CAS  Google Scholar 

  15. Just-Viera, J. O., Fischer, C. R., Gago, O., & Morris, J. D. (1984). Acute reaction to protamine. Its importance to surgeons. The American Surgeon, 50(1), 52–60.

    PubMed  CAS  Google Scholar 

  16. Stewart, W. J., McSweeney, S. M., Kellett, M. A., Faxon, D. P., & Ryan, T. J. (1984). Increased risk of severe protamine reactions in NPH insulin-dependent diabetics undergoing cardiac catheterization. Circulation, 70(5), 788–792.

    PubMed  CAS  Google Scholar 

  17. Reed, D. C., & Gascho, J. A. (1988). The safety of protamine sulfate in diabetics undergoing cardiac catheterization. Catheterization and Cardiovascular Diagnosis, 14(1), 19–23.

    Article  PubMed  CAS  Google Scholar 

  18. Vincent, G. M., Janowski, M., & Menlove, R. (1991). Protamine allergy reactions during cardiac catheterization and cardiac surgery: risk in patients taking protamine-insulin preparations. Catheterization and Cardiovascular Diagnosis, 23(3), 164–168.

    Article  PubMed  CAS  Google Scholar 

  19. Joint Task Force on Practice Parameters; American Academy of Allergy, Asthma and Immunology American College of Allergy, Asthma and Immunology; Joint Council of Allergy, Asthma (2005). The diagnosis and management of anaphylaxis: an updated practice parameter. The Journal of Allergy and Clinical Immunology, 115(3, supplement 2), S483–S523.

    Article  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Medicine, Division of Cardiology, School of Medicine, Johns Hopkins University, Baltimore, MD, USA

    Karuna Chilukuri, Charles A. Henrikson, Darshan Dalal, Daniel Scherr, Edwin C MacPherson, Alan Cheng, David Spragg, Saman Nazarian, Sunil Sinha, Ronald Berger, Joseph E. Marine & Hugh Calkins

  2. From Department of Medicine, Division of Cardiology, Medical University of Graz, Graz, Austria

    Daniel Scherr

  3. The Johns Hopkins Hospital, 600 North Wolfe Street, Carnegie 530, Baltimore, MD, 21287-0409, USA

    Hugh Calkins

Authors
  1. Karuna Chilukuri
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Charles A. Henrikson
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Darshan Dalal
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Daniel Scherr
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Edwin C MacPherson
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Alan Cheng
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. David Spragg
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Saman Nazarian
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Sunil Sinha
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Ronald Berger
    View author publications

    You can also search for this author in PubMed Google Scholar

  11. Joseph E. Marine
    View author publications

    You can also search for this author in PubMed Google Scholar

  12. Hugh Calkins
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Hugh Calkins.

Additional information

Disclosures

No potential conflicts of interest arise from the publication of this manuscript.

Dr. Chilukuri was supported by The Norbert and Louise Grunwald Cardiac Arrhythmia Research Fund. Dr. Scherr was supported by the FWF—Austrian Science Fund.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Chilukuri, K., Henrikson, C.A., Dalal, D. et al. Incidence and outcomes of protamine reactions in patients undergoing catheter ablation of atrial fibrillation. J Interv Card Electrophysiol 25, 175–181 (2009). https://doi.org/10.1007/s10840-009-9364-0

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10840-009-9364-0

Keywords

Search

Navigation