Ventricular fibrillation with intracoronary adenosine during fractional flow reserve assessment

Fractional flow reserve (FFR) measurement provides useful hemodynamic assessment of intermediate coronary stenoses affecting long term outcomes. While the gold standard remains intravenous adenosine, intracoronary (IC) bolus administration of adenosine is routinely used in clinical practice because of its ease of use and lower dose providing comparative hyperemia with the most common side effect being a transient atrioventricular block. A 62 year old male underwent left heart catheterization after ruling in for non-ST elevation myocardial infarction (NSTEMI). Presenting electrocardiogram (ECG) showed an old left bundle branch block and T-wave inversions in lateral leads (QTc 494 ms) with no significant electrolyte abnormalities. Coronary angiography revealed an intermediate lesion in mid left anterior descending coronary artery. FFR assessment with IC adenosine (24 μg/mL of normal saline) was performed inducing ventricular fibrillation (VF). He was successfully defibrillated with a single 200 J shock and no further arrhythmias were noticed during rest of his hospital stay.