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The Frequency of Cardiac Arrests in Patients with Congenital Heart Disease Undergoing Cardiac Catheterization

Odegard, Kirsten C. MD; Bergersen, Lisa MD, MPH; Thiagarajan, Ravi MD; Clark, Laura RA; Shukla, Avinash MBBS; Wypij, David PhD; Laussen, Peter C. MBBS

doi: 10.1213/ANE.0b013e3182908bcb
Pediatric Anesthesiology: Research Report
Continuing Medical Education

BACKGROUND: Cardiac catheterization for patients with congenital heart disease has shifted from diagnostic to predominantly interventional procedures because of advances in catheter-based technologies. Children undergoing therapeutic catheterization may be at higher risk of adverse events, and the purpose of our study was to determine the incidence of cardiac arrest (CA) in patients with congenital heart disease undergoing cardiac catheterization at a large pediatric tertiary referral center.

METHODS: All CAs from January 2004 through December 2009 occurring in the cardiac catheterization laboratory were reviewed. A CA was defined as an event in which cessation of circulation required chest compressions. Procedure, patient, practitioner, and system-related factors were examined.

RESULTS: Over the study period, during 7289 catheterization procedures, 70 procedures were associated with a CA (0.96 [99% confidence interval, 0.7–1.3] per 100 procedures); 48 events (69%) were successfully resuscitated to a perfusing rhythm, 18 events (26%) resulted in need for extracorporeal membrane oxygenation, and 4 events (6%) resulted in unsuccessful resuscitation. Sudden onset of cardiac arrhythmia led to CA during 38 events (54%). The duration of resuscitation after CA was ≤11 minutes in 71%. Occurrence of CA was associated with interventional procedures (P < 0.001) and younger age (P < 0.001). A change in systems for scheduling and communication of cases was associated with a significant reduction in the incidence of CA (1.5% vs 0.7%; P = 0.002).

CONCLUSIONS: The incidence of CA in children undergoing cardiac catheterization is high compared with pediatric noncardiac surgery. Procedural and system factors were associated with occurrence of CA in this cohort. These issues highlight the need for close communication, anticipation, and preparation.

Published ahead of print June 7, 2013

From the Department of Cardiac Anesthesia, Boston Children’s Hospital, Boston, Massachusetts.

Accepted for publication February 20, 2013

Published ahead of print June 7, 2013

Funding: Not applicable.

The authors declare no conflicts of interest.

This report was previously presented, in part, at the ASA.

Reprints will not be available from the authors.

Address correspondence to Kirsten C. Odegard, MD, Department of Cardiac Anesthesia, Boston Children’s Hospital, 300 Longwood Ave., Boston, MA 02115. Address e-mail to

While interventional cardiac catheterization has significantly increased the therapeutic options for patients with complex congenital heart disease (CHD), adverse events related to pediatric cardiac catheterization have been reported in 4% to 10% of procedures, although with low mortality.1–5 Many adverse events during catheterization are minor in nature; however, major events can also occur and may be unpredictable. These major events may be patient- and/or procedure-related, potentially life threatening, and may result from changes in hemodynamic stability and cardiac output, vessel or cardiac injury, or device embolization. The potential contribution of providers and the systems in place to facilitate care in the catheterization laboratory has not been evaluated.

Previously, we reported the risk for cardiac arrest during pediatric cardiac surgery as 0.8 per 100 procedures in our institution.6 Information regarding the frequency of cardiac arrest in children with CHD undergoing cardiac catheterization is limited. Given the increasing complexity of procedures, the risk may be higher than expected, and these issues should be appreciated when planning management. Many diagnostic cardiac catheterization procedures are performed using IV sedation directed by the physician performing cardiac catheterization without supervision from an anesthesiologist. High-risk populations have not been identified, and no specific guidelines have been formulated regarding the role for anesthesia personnel to identify, monitor, support, and manage these patients.6–10 In this study, we sought to determine the incidence of cardiac arrest in patients with CHD undergoing cardiac catheterization at a large pediatric tertiary referral center and describe potential patient-, procedure-, provider-, and system-related variables that could contribute.

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IRB approval was obtained to review all cardiac arrests occurring during pediatric cardiac catheterization at Boston Children’s Hospital, MA, between January 1, 2004 and December 31, 2009. The requirement for written informed consent was waived by the IRB. Data for cardiac arrests were obtained, and cases were verified and cross-referenced using 3 sources: (1) a registry maintained by the Cardiac Anesthesia Service (CAS) for anesthetics delivered in the cardiac operating rooms, cardiac catheterization laboratories, and other areas such as the cardiac magnetic resonance imaging suite; (2) a cardiac catheterization laboratory adverse event database; and (3) a cardiac arrest registry that contains patient demographic and event information for all cardiac arrests that occur across the entire Cardiovascular Program at Boston Children’s Hospital. As part of a regular systems review of all resuscitation events in our Cardiovascular Program, all cardiac arrest events were debriefed in detail at a monthly multidisciplinary Resuscitation Review Committee meeting.

All anesthetic procedures were staffed by cardiac anesthesiologists on the CAS. Data for the CAS registry were gathered prospectively by the staff who performed the anesthetic. All cases were cross-referenced with the daily schedule and billing records for completeness. The following data were collected in the database: patient demographic variables, diagnoses, ASA physical status classification, staff anesthesiologist and cardiologist, nature of the procedures, anesthetic technique, the disposition of the patient at completion of the procedure, and documentation of any events or complications that occurred during the procedure. The cardiac catheterization laboratory database prospectively collects information on catheterization, patients, and procedure-related complication. The following variables were abstracted for analysis: case type (diagnostic, interventional, or biopsy), age at procedure, weight, interventions performed such as angioplasty, or device placement, site of intervention, as well as adverse events including cardiac arrest.

A cardiac arrest was defined as an event where there was a sudden cessation of cardiopulmonary circulation or ventilation requiring external chest compressions for resuscitation. Each event was debriefed according to standard practice in our Cardiovascular Program, and we categorized the specific physiologic perturbation or change in clinical condition that was first apparent for each event that led to resuscitation. To evaluate the possible contribution of provider management to cardiac arrest, the etiology of the cardiac arrest events was categorized as (1) anesthesia-related according to the definition used by the Pediatric Perioperative Cardiac Arrest registry, or (2) not anesthesia-related. Cardiac arrests determined to be anesthesia-related were subclassified as likely related or possibly related using the definitions from a prior study on cardiac arrests in the cardiac operating room (Table 1).6 Events that were categorized as being not related to anesthesia were subclassified as either procedure-related or nurse-managed sedation-related. Patient medical information, anesthesia, and cardiac catheterization records were reviewed to verify all of the events, and subsequent clinic and admission notes were reviewed for longer term outcomes. Three of the authors (KCO, LB, PCL) categorized events according to etiology, and agreements were sought from the CAS faculty.

Our catheterization laboratory moved to a new building in July 2005, and the systems for patient screening and determining anesthetic care in our catheterization laboratory underwent systematic changes starting January 2006. This date was used as a cut point to evaluate whether the change in practice and systems may have impacted the frequency of cardiac arrest. Before July 2005, the cardiac catheterization laboratory consisted of 3 laboratories, 2 for diagnostic and interventional procedures, and 1 for electrophysiology (EP) procedures, and a 5-bed postprocedure and anesthesia care unit (PACU). The scheduling of cases and the decision as to whether a case should be performed by the CAS or by nurse-managed sedation was determined by the cardiologist performing the procedure. The technique for nurse-managed sedation was according to an approved protocol, with anesthesia back-up available when medication limits were reached, or when adverse events occurred. Two anesthesia faculty were scheduled to the catheterization laboratory each day, one assigned to the EP laboratory and the other to the diagnostic and intervention laboratories. After July 2005, the cardiac catheterization laboratory now included 2 biplane laboratories, a single plane laboratory, EP laboratory, dedicated cardiac magnetic resonance imaging, and a 10-bed PACU. A separate procedure room in the PACU was used for cases requiring anesthesia care, such as transesophageal echocardiography. With 6 locations for administering anesthesia, system changes were required; these included a new electronic scheduling method, rules for notification about changes in the case order and additions to the schedule, and daily morning huddles between the CAS staff assigned to the catheter laboratory, interventional cardiologists, technicians, and nursing staff before any cases being started. During the morning huddle, it was jointly confirmed by the cardiology and anesthesia teams as to whether a case would need general anesthesia or could be performed with nurse-managed sedation. Staff levels were increased to 3 anesthesia faculty, 2 pediatric anesthesia fellows, and 2 nurse anesthetists.

During the study period, 8 interventional cardiologists and 18 anesthesiologists provided clinical services in the catheterization laboratory. However, not all providers managed patients during the entire study period. Procedures were assigned to invasive cardiologists based on their scheduled day of service in the catheterization laboratory, as well as specific referral patterns to each interventional cardiologist and not according to specific complexity or type of procedure.

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All cases recorded in the catheterization database classified as diagnostic, interventional, or biopsy, regardless of age, were included in the analysis. The incidence of cardiac arrest was calculated for the entire cohort, and stratified by case type, age groups (<1 year, 1–10 years, 11–18 years, and >18 years), provider (CAS or nurse-administered sedation), and types of interventional procedures. As with many other pediatric centers performing congenital cardiac surgery and cardiac catheterization procedures, many adults with CHD were managed in our institution because of the need for specialized care. To be complete with our experience over the time frame, we included these procedures in our analysis of events. To be consistent with commonly used descriptions, the frequency of cardiac catheterization cardiac arrest over the time period was calculated per 10,000 anesthetics and per 100 cardiac catheterization procedures. All comparative analyses were conducted at a procedure level. Individual patients may have contributed >1 case to the cohort. However, risk of an event at each case was assumed to be independent.11 We tested serial correlations in the occurrence of cardiac arrest events using the run test and confirmed randomness of cardiac arrest events during the study period. Fisher exact test was used to test differences in proportions among groups. Confidence intervals (CIs) (99%) for point estimates were calculated using the Clapper Pearson method for proportions.12 Data analysis was conducted using SPSS (v 18.0, SPSS, Chicago, IL and STATA [v.11; 2 STATACORP, College Station, TX]) statistical software.

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Between January 1, 2004, and December 31, 2009, 7289 catheterization procedures were conducted, during which 70 procedures were associated with a cardiac arrest (5 procedures had 2 cardiac arrests during the same procedure; n = 70 patients), with an overall frequency of 0.96 (99% CI, 0.7–1.3) cardiac arrests per 100 catheterization procedures (Table 2). Details of the cardiac catheterization procedures are shown in Table 3; there were 4215 interventional catheterization procedures during which 5438 interventions were performed. The incidence of cardiac arrest was higher among interventional procedures compared with diagnostic or biopsy procedures (Table 2) (0.2 [99% CI, 0.01–4.00] per 100 procedures, P < 0.001). The incidence of cardiac arrests based on procedure type included ventricular device closure (n = 42, with 5 cardiac arrests, 11.9 per 100 procedures), intervention for intact atrial septum in patients with restricted atrial septal flow (n = 50, with 5 cardiac arrests, 10.0 per 100 procedures), mitral valve balloon dilation (n = 60, with 3 cardiac arrests, 5.0 per 100 procedures), pulmonary vein balloon dilations (n = 222, with 8 arrests, 3.6 per 100 procedures), and pulmonary artery balloon dilations (n = 1509, with 9 arrests, 0.6 per 100 procedures).

Cardiac arrests occurred more frequently in patients <1 year of age (Table 4). The median age for patients experiencing a cardiac arrest was 210 days (interquartile range 14–630 days), and median weight was 6.4 kg (interquartile range 3.6–12.1 kg); 19 patients (27%) were <30 days of age, and 37 were male. Patients had the following ASA class distribution: 21 (30%) in ASA class III, 47 (67%) class IV, and 2 (3%) in class V.

Cardiac anesthesia staff were directly responsible for the management in 4485 procedures (62%), of these 3843 (86%) were under general anesthesia and 642 (14%) under deep sedation. The remaining 2804 (38%) procedures were performed using sedation protocols administered by catheterization laboratory nursing staff and directed by the interventional cardiologist (Table 4). Of the 70 procedures associated with cardiac arrests, 55 (79%) occurred in procedures managed by the CAS, compared with 15 (21%) cardiac arrests with nurse-managed sedation (Table 4). However, a higher proportion of interventional cases were performed with general anesthesia by the CAS, and the median age and weight of patients receiving general anesthesia by CAS were lower than patients receiving nursing-managed sedation (2.6 years and 12 kg compared with 13.6 years and 45 kg) (Table 4).

The majority of the cardiac arrests, 63 of 70 (90%), were classified as procedure-related, but in 7 procedures, the cardiac arrest was classified as either possibly or likely related to anesthesia (n = 4) or to nurse-managed sedation (n = 3). Details of these cases are shown in Table 5 and stratified by age group in Table 6.

The primary etiology of the cardiac arrests determined from debriefing after each event is shown in Table 7. An arrhythmia occurred at the onset of a cardiac arrest in 54% of the procedures, of which 79% were resuscitated to a spontaneous circulation at the time of the event. An anesthesiologist assigned to the catheterization laboratory was present and assisted during all resuscitations. The documented duration of chest compressions was <2 minutes in 37 events (53%), 2 to 11 minutes in 13 events (19%), and in 20 (29%) events, chest compressions lasted >11 minutes with a maximum duration of 49 minutes. Forty-eight cardiac arrest events (69%) were successfully resuscitated to a perfusing rhythm, 18 cardiac arrest events (26%) required resuscitation with extracorporeal membrane oxygenation (ECMO) in the catheterization laboratory, and in 4 (6%) cardiac arrest events resuscitation was unsuccessful. Five (7%) cardiac arrest events required emergent procedures in the operating room after resuscitation in the cardiac catheterization laboratory. There were 9 later deaths after resuscitation and transfer from the catheterization laboratory, but before discharge from hospital, for a total mortality of 19% among all patients sustaining a cardiac arrest in the catheterization laboratory. There was no mortality in the 7 patients with events attributed to anesthesia or nursing sedation.

After opening of the new catheterization laboratory and changes to the scheduling, staffing, and the communication of cases, the frequency of cardiac arrests decreased significantly from 1.5% (99% CI, 0.9–2.2; events in 2300 procedures in 2004 and 2005) to 0.7% (99% CI, 0.5–1.1; events in 4989 procedures between 2006 and 2009, P = 0.002) (Table 8). Over the study period, there were an increasing proportion of procedures managed by the CAS (Table 8).

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In this single-center review of patients with CHD undergoing cardiac catheterization, the frequency of cardiac arrest was 0.96 events/100 cardiac catheterizations, with an overall survival to discharge of 81%. While 72% of the events were relatively brief with the duration of resuscitation <11 minutes, ECMO was required in 26% of events when return of a circulation could not be attained. A cardiac arrest was more common during interventional procedures under anesthesia and was more frequent in infants. A decrease in the frequency of cardiac arrest over the time frame of the study was associated with systematic changes in the organization of care in the catheterization laboratory.

The frequency of cardiac arrest during cardiac catheterization reported in this study is higher than that reported from multi-institutional and single-center reports of the risk for perioperative cardiac arrest in pediatric patients undergoing general anesthesia.8,13,14 It is, however, comparable with the frequency of cardiac arrest occurring in the operating room in children undergoing cardiac surgery previously reported from our institution (0.8 per 100 surgical procedures).6 Factors contributing to cardiac arrest are multifactorial in origin and may be patient-, practitioner-, or procedure-related. The resuscitation from cardiac arrest may also be related to the systems for providing care in a particular environment, because this may have an impact on the anticipation and preparation for an event, as well as the effectiveness of responses when a sudden or unexpected event occurs.

The frequency for cardiac arrests was higher during interventional procedures compared with diagnostic catheterizations, being most frequent in our study for patients undergoing device closure of a ventricular septal defect, neonates undergoing an intervention for a restrictive atrial septum and mitral valve balloon dilation. The higher incidence for cardiac arrest in these patient populations is not surprising and should be anticipated. The risk of cardiac arrest and adverse events in patients undergoing device closure of ventricular septal defects in the catheterization laboratory has been previously described.15 The risk is primarily related to the procedure itself because of stiff wires and catheters passing across the muscular septum which may induce arrhythmias, and from stenting open semilunar and atrioventricular valves which in turn can lead to a low cardiac output state. Newborns with single ventricle physiology and a restrictive atrial communication can have a small left atrium and severe left atrial hypertension, and be in a low cardiac output state with severe hypoxemia at the time of intervention. The risk for inadvertent perforation of the small left atrium during atrial septostomy and balloon dilation is increased and was the cause of cardiac arrest in 2 of the 5 patients in our study who had a cardiac arrest during this procedure. Patients undergoing balloon dilation of the mitral valve to treat stenosis also have left atrial hypertension and are at risk for arrhythmias and a severe decrease in cardiac output during balloon inflation.

This study provides information on incidence and outcome for cardiac arrest in a large volume and intervention-based pediatric catheterization laboratory. The rate of cardiac arrest we report may be a reflection of the complexity of cases and intensity of interventions performed in our institution. While the incidence of cardiac arrest is high during certain catheter-based interventional procedures as described above, it is not possible to compare this risk to what it might be if the same procedures were performed under cardiopulmonary bypass in the cardiac operating room. The indications for these procedures are different between the catheterization laboratory and the operating room, and we have not attempted to compare these separate patient populations.

The reported mortality directly related to pediatric cardiac catheterization is low,1,3–5,16 and during the study period, the mortality for any procedure performed in our catheterization laboratory was 0.2%, with no mortality attributed to anesthesia or nurse sedation. However, in patients who suffered a cardiac arrest, the mortality before discharge was considerably higher at 19%. Procedure-type risk groups have recently been developed for patients undergoing cardiac catheterization.17 We were unable to determine whether there were potentially preventable events related to the procedure or catheterization technique that contributed to a cardiac arrest, and while an event may be unpredictable, it may be possible to eventually assess risk based on diagnostic categories, procedural categories, and hemodynamic vulnerability. Further work is needed to determine whether diagnosis- or procedure-risk categorization provides a robust framework for assessment before the catheter procedure, or can form the basis for preprocedure discussions regarding management, including whether the procedure should be performed under sedation or general anesthesia. A physiologic assessment of the risk for an adverse event during cardiac catheterization based on hemodynamic vulnerability has also been recently described.11 We did not include this information in our analysis because data were incomplete, and the risk of hemodynamic vulnerability has only been prospectively collected for patients undergoing cardiac catheterization since mid-2007. Nevertheless, using these indicators of hemodynamic vulnerability prospectively may allow for the development of predictors for cardiac arrest during cardiac catheterization.

As noted, the cardiac arrest was brief and usually related to a sudden change in rhythm, with return of a perfusing rhythm after administration of resuscitation drugs and manipulation of catheters or wires in the heart by the physician performing catheterization. However, it is important to appreciate that these events can be unpredictable and procedure-related; staff should anticipate potential events according to procedure type and underlying pathophysiology and have resuscitation medications and equipment immediately available. Air embolism was identified as the cause of 1 cardiac arrest in our study. The potential for air embolism is increased when catheters are frequently changed through large sheaths, and entrainment of air may occur during spontaneous ventilation and during contrast injection. Six cardiac arrests were directly attributed to coronary angiography resulting in sudden onset of myocardial ischemia, manifest as ventricular fibrillation in 3 patients, and bradycardia with hypotension in the other 3 patients; 4 patients survived to discharge, 3 after achieving return of the circulation, and 1 after ECMO cardiopulmonary resuscitation.

The resuscitation of patients in the catheterization laboratory may be difficult, particularly if ECMO is required when there has been no return of a perfusing rhythm or circulation with initial resuscitation efforts. Support with ECMO and emergent surgical interventions may alter the outcomes after serious adverse events during cardiac catheterization for CHD.18,19 There are competing processes during resuscitation in the catheterization laboratory, from providing effective resuscitation, to determining and treating the underlying cause, to cannulation for ECMO. The laboratory can become crowded, noisy, and dangerous with the potential for radiation exposure if fluoroscopy is performed during resuscitation. Our resuscitation review and debriefing after events in the catheterization laboratory over the years have focused specifically on improving teamwork and communication, identifying leadership for coordinating resuscitation efforts and role clarity during events. We have used a rapid ECMO deployment system in the Cardiovascular Program at our institution since 1996, and therefore readily call for ECMO support early during resuscitation. In this series, ECMO was used during 18 cardiac arrests, with 10 (55%) patients surviving to discharge; on 4 occasions, ECMO was used to facilitate resuscitation and bridge to the operating room (n = 3, 2 survived) or heart transplantation (n = 1, survived).

The incidence of anesthesia- or nurse-managed sedation-related cardiac arrest in our study is 1.2 to 8.7 times higher than that reported for general pediatric anesthesia–related cardiac arrests, although lower than the incidence of anesthesia-related cardiac arrest in children undergoing cardiac surgery.4,5,8–10,13,14,20 There was no anesthesia-related morbidity or mortality in our study, compared with 6% to 35% in other studies. Younger age, higher ASA status, and emergency procedures have been identified as risk factors for cardiac arrest during pediatric procedures.1,4–6,8–10,13,14,20 This increased risk for anesthesia-related events in neonates and infants is also identified in our series for patients undergoing cardiac catheterization. It was not possible to determine the risk for cardiac arrest based on the ASA status, because the majority of patients were classified as either status III or IV. The incidence of anesthesia-related cardiac arrest was 8.9 per 10,000 anesthetics and was similar to the frequency under nurse-managed sedation of 10.7 per 10,000. Because of the low frequency of events, it was not possible to determine the risk related to practitioner experience. The standard practice at our institution and Cardiovascular Program is for pediatric cardiac anesthesiologists to provide all anesthesia services in the catheterization laboratory. We are not advocating that this is the preferred staffing model, and we could not compare the outcomes between cardiac versus noncardiac anesthesiologists. However, the complexity of cases and higher risk for sudden cardiac arrest does indicate that staff providing anesthesia for pediatric cardiac catheter–based interventions need to be familiar with the environment and challenges of these cases present.

In our study, 62% of the catheterizations were performed under anesthesia care; of these, 86% were performed under general anesthesia, and 14% spontaneously breathing (monitored anesthesia care) either with a natural airway or a laryngeal mask airway. The number of cases performed under anesthesia has steadily increased since January 2006 after reevaluation of the system for scheduling and communication about cases, with a concerted effort to increase the involvement of the CAS faculty assigned to the catheterization laboratory in the day-to-day operations and planning. This was particularly necessary with the expansion of the catheterization footprint and potential anesthesia locations after the opening of a new facility in July 2005. A reduction in the frequency of cardiac arrests from 1.5 to 0.7 per 100 procedures has occurred since these systems changes were introduced. We speculate that the involvement of cardiac anesthesia staff during all phases of management, from scheduling to anesthesia technique and anticipation of potential adverse events, is a contributing factor to the reduction in cardiac arrests over the recent era. While patient volume has increased, we are unable to determine whether a change in case complexity or the experience of the cardiac catheterizers is also a contributing factor.

The increasing demand of anesthetic support for diagnostic and interventional procedures for children outside the operating room creates additional hazards and risks for adverse events.21 The cardiac catheterization laboratory is one such location, often remote from the operating room, and it may not be well configured to accommodate anesthetic personnel. Relative to patient size, the lateral and anterior–posterior cameras used for imaging are in close proximity to the patient’s head and neck, limiting access to the patient and the airway. The environment is dark and convective heat loss occurs and may be particularly problematic for newborns and infants. However, we were not able to identify any event in our series that was directly related to these environmental hazards.

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Possible methodological weaknesses associated with our study include its representation of the experience from only a single institution. Although we tried to maintain a complete registry with mandatory completion of a data form for each case, we relied on self-reporting of adverse events. As a result, some events may have been missed and the true incidence of adverse events underestimated. In addition, our report does not quantify “near misses” during cardiac anesthesia, such as hypotension or rhythm changes that require immediate intervention to prevent circulatory collapse and arrest. Assignment of whether a case would need general anesthesia or could be performed with nurse-managed sedation was not random. Differences in patients’ characteristics and severity of CHD were not adjusted for when evaluating differences in event rates between anesthesia- or nurse-managed sedation groups. This should be considered in the interpretation of our results. Cardiac arrests events occurred with all providers, both interventional cardiologists and anesthesiologists. The small number of cardiac arrest events, large number of providers (8 interventional cardiologists and 18 anesthesiologists), and lack of information on case complexity data precluded the meaningful assessment of the influence of provider on the occurrence of cardiac arrest events. This major limitation should be considered when interpreting the information from these analyses. We report the frequency of cardiac arrests over a defined period and evaluated the contributing factors based on the best available information. Debriefing and thorough review of every event by our Resuscitation Oversight Committee did allow for some evaluation of the root cause for events but did not assign blame or responsibility. While we can describe a “failure to rescue” rate, it was not possible to assign preventability from the available information. While we did describe and evaluate key changes in the systems of care introduced in our catheterization laboratory over the time course of the study, it was not possible to undertake a detailed systems analysis to determine which changes were most important and why.

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Our study demonstrates the increased frequency of cardiac arrest in children undergoing cardiac catheterization and is higher than that published for cardiac arrest during pediatric noncardiac and cardiac surgery. Specific procedures have a higher risk, and infants appear to be at the highest risk. This increased risk further supports the notion that these patients ought to be managed by an experienced team of anesthesiologists working closely with the interventional cardiologists, nursing staff, and catheterization technicians to ensure a robust system for care is in place for direct communication and anticipation, and to promptly manage critical events when they occur.

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Name: Kirsten C. Odegard, MD.

Contribution: This author helped design and conduct the study, analyze the data, and write the manuscript.

Attestation: Kirsten C. Odegard has seen the original study data, reviewed the analysis of the data, approved the final manuscript, and is the author responsible for archiving the study files.

Name: Lisa Bergersen, MD, MPH.

Contribution: This author helped design and conduct the study, analyze the data, and write the manuscript.

Attestation: Lisa Bergersen has seen the original study data, reviewed the analysis of the data, and approved the final manuscript.

Name: Ravi Thiagarajan, MD.

Contribution: This author helped design and conduct the study, analyze the data, and write the manuscript.

Attestation: Ravi Thiagarajan has seen the original study data, reviewed the analysis of the data, and approved the final manuscript.

Name: Laura Clark, RA.

Contribution: This author helped conduct the study, analyze the data, and write the manuscript.

Attestation: Laura Clark has seen the original study data, reviewed the analysis of the data, and approved the final manuscript.

Name: Avinash Shukla, MBBS.

Contribution: This author helped design and conduct the study, analyze the data, and write the manuscript.

Attestation: Avinash Shukla has seen the original study data, reviewed the analysis of the data, and approved the final manuscript.

Name: David Wypij, PhD.

Contribution: This author helped analyze the data and write the manuscript.

Attestation: David Wypij has seen the original study data, reviewed the analysis of the data, and approved the final manuscript.

Name: Peter C. Laussen, MBBS.

Contribution: This author helped design and conduct the study, analyze the data, and write the manuscript.

Attestation: Peter C. Laussen has seen the original study data, reviewed the analysis of the data, and approved the final manuscript.

This manuscript was handled by: Peter J. Davis, MD.

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