Entrapment of pulmonary artery catheter in a suture at the inferior vena cava cannulation site

Entrapment of a pulmonary artery catheter (Swan-Ganz catheter) in the heart, vena cava, or pulmonary artery is a very rare and serious complication that may lead to life-threatening complications such as cardiac rupture, pulmonary artery rupture, cardiac tamponade, among others, if not recognized and treated early. We report entrapment of a Swan-Ganz catheter in the purse-string suture at the inferior vena cava cannulation site for a patient undergoing aortic valve replacement. This situation required a repeat sternotomy to release the pulmonary artery catheter.     

Modified semicircular constricting annuloplasty (Sagban's annuloplasty) in severe functional tricuspid regurgitation: alternative surgical technique and its mid-term results

OBJECTIVE: De Vega annuloplasty is one of the most effective methods used in surgical correction of functional tricuspid regurgitation (FTR). Physiologic annular motions are protected by De Vega annuloplasty. However, recurrent tricuspid regurgitation secondary to Bowstring (Guitar string) phenomenon may be seen after De Vega annuloplasty as a result of gliding (jiggle) effect. The aim of this new annuloplasty was to prevent Bowstring phenomenon seen in De Vega annuloplasty. METHODS: Twenty-five patients with severe FTR secondary to the left-sided valvular heart disease were included in this study. Modified semicircular constricting annuloplasty (Sagban's annuloplasty): The procedure is performed utilizing 0 and 2-0 polypropylene sutures. At first, 0 and 2-0 polypropylene sutures are fixed and knotted at anteroseptal and posteroseptal comissural regions (named as anchoring points). 2-0 Polypropylene sutures which come from anchoring points in clockwise and counterclockwise direction are used to encircle the free wall annulus as well as 0 polypropylene sutures in spiral fashion (spiral annulary suture technique). When both sutures get to the anteroposterior comissural region (tying point), they are passed through plastic snares. After the annuloplasty is completed, with the heart beating and the pulmonary artery clamped, competency of the valve is tested by injecting saline into the right ventricular chamber before the adjusting suture is tied. In this annuloplasty, 0 polypropylene sutures are used for reduction and constriction, 2-0 polypropylene sutures are used for the fixation of 0 polypropylene sutures in annular level. RESULTS: FTR improved totally in 16 patients (66.7%), 4 patients (16.7%) had first degree, 3 patients (12.5%) had second degree, and only 1 patient (4.2%) had third degree residual tricuspid regurgitation in an average follow-up period of 17.8 months. One patient died from low cardiac output in early postoperative period. CONCLUSION: There is no risk of recurrent regurgitation secondary to Bowstring phenomenon in this alternative annuloplasty technique and this annuloplasty is cost-effective and performed easily.     

A new approach to left heart decompression.

A simple, safe, indirect technique for decompression of the left heart is described. Pulmonary artery venting produces immediate and total decompression of the left heart through spontaneous retrograde pulmonary flow across the open mitral valve in the hypothermic (29 degrees C) electrically fibrillated heart. This allows free retrograde flow of left heart blood across the pulmonary valve into the right ventricle, where it is taken up by the usual caval cannulas. In 25 of 66 consecutive patients undergoing elective ventricular fibrillation and anoxic arrest, left heart venting was necessary as indicated by rising left heart pressures. Total cardiac decompression was immediately and completely achieved by this simple indirect technique. Direct left heart venting, with its associated risks and disadvantages, was never necessary, and we now consider it obsolete.     

Feasibility of mitral valve repair using the loop technique.

PURPOSE: The most difficult aspect of chordal replacement in a mitral valve repair using expanded polytetrafluoroethylene (ePTFE) sutures, is determining the appropriate length of artificial chorda and ligation of the ePTFE sutures without the knot sliding. PATIENTS AND METHODS: We adopted a loop technique reported by Mohr et al. in 12 consecutive cases from October 2005. Nine cases were comparative broad-range prolapses of the posterior leaflet, 2 cases were anterior and the posterior leaflet and 1 case was vegetation of the anterior leaflet. Chordal replacement was done by 4 loops in 11 cases and by 8 loops in 1 case. RESULTS: Postoperative echocardiography showed more physiological movement of the posterior leaflet than by the resection suture method. When comparing of the peak pressure gradient across the mitral valve on echocardiography between the loop technique group and the non-loop technique group, the gradient in the loop technique group (n=11) was 1.8+/-0.7 mmHg and in the non-loop technique group (n=18) was 3.2+/-1.0 mm Hg. There was a significant statistical difference between 2 groups. The loop technique also seemed to be superior procedure hemodynamically. CONCLUSION: This technique may be useful through both port-access minimally invasive cardiac surgery (MICS) and a conventional approach to the mitral valve, and simplifying chordal replacement. We report on the feasibility of the loop technique based on our experience.     

A case report of ross operation and ventricular septal defect closure following correction of type A interruption by modified Blalock-Park, pulmonary artery banding and patent ductus arteriosus division

A 2-year-old boy who had undergone a correction of a type A interruption using a modified Blalock-Park operation, pulmonary artery banding and the division of a patent ductus arteriosus, underwent a Ross operation and closure of ventricular septal defect (VSD). Although a pre-operative echo cardiogram revealed a bicuspid aortic valve, and a Doppler echocardiogram showed only 10 mmHg of pressure gradient across the aortic valve, Ross procedure was performed as a procedure accompanying the closure of a total conus VSD. The total conus VSD was closed with a Dacron patch using pledget mattress sutures. In addition, a running suture was applied over the denuded aortic root and the cranial margin to achieve water tight closure. An aortic root replacement procedure was our first choice for the Ross operation. After both coronary buttons were re-implanted into pulmonary sinuses, a pulmonary artery autograft was wrapped around by the remaining aortic wall for reinforcement to prevent future dilatation. The main pulmonary artery was reconstructed using a bicuspid pericardial valve conduit with a diameter of 24 mm. A post-operative echocardiogram showed no neoaortic valve regurgitation, good coaptation of tri-leaflets, mild regurgitation of pericardial valve and good cardiac performance.     

Use of the pulmonary artery for left ventricular venting during cardiac operations

Data relating to the hemodynamic efficaciousness and mechanism of action of a pulmonary artery catheter or vent used for left ventricular venting during cardiac operations are presented. The pulmonary artery vent is a plastic sump catheter that is introduced into the main pulmonary artery through a purse-string suture and connected via a roller pump to the venous reservoir of the heart-lung perfusion machine. Placement and removal require only a few minutes. The pulmonary artery vent retrieved 85% of a 99mtechnetium-labeled solution placed in the left atrium during aortic cross-clamping, and there was no detectable radioactivity in peripheral or aortic root blood samples. Pulmonary artery vent return during cardiopulmonary bypass in 10 patients undergoing coronary artery bypass averaged 12.5 L. The effectiveness of left ventricular decompression was evaluated in 20 patients also undergoing bypass grafting. Use of the pulmonary artery vent consistently and significantly decreased left heart pressures, compared to the control situation with the vent off, with the aortic cross-clamp applied, and in both the fibrillating and beating heart in the early postischemic reperfusion period. We reached the following conclusions: (1) The pulmonary artery vent withdraws left heart blood via the pulmonary vasculature, in addition to returning right heart spillover and retrieving bronchial flow. (2) Left heart pressures are reduced to levels which reduce oxygen demands and preserve endocardial perfusion, therefore protecting myocardium, during fibrillation and during coronary reperfusion of the beating heart. (3) Because of its effectiveness and safety, especially the impossibility of introducing air into the left ventricle, the pulmonary artery vent is recommended for routine left ventricular venting.     

Novel suture device for beating-heart mitral leaflet approximation

BACKGROUND: This investigation evaluates the potential of using a novel suturing device to achieve mitral valve repair (Alfieri type) on a beating heart without cardiopulmonary bypass. METHODS: Eight healthy adult sheep were anesthetized and the chest was opened via a left thoracotomy. The suture device was directly inserted into the appendage of the left atrium. Suction ports on the distal tip of the device grasped and approximated the mitral leaflets while the heart was beating. Two-dimensional echocardiography and intracardiac pressure monitoring at the tip of the device were utilized to guide the procedure. The device was used to place two single sutures across the two leaflets at the center of the mitral valve. A knot pusher with integrated cutter was used to tie the sutures and cut the suture ends. RESULTS: In all animals, the free margins of the mitral leaflets were successfully grasped and approximated by this device. Echocardiography confirmed successful deployment of the sutures in all cases, with a figure-of-eight appearance of the valve and normal valve hemodynamic function after placement of the sutures. Mid-leaflet approximation was verified at autopsy immediately after the procedure. No tissue damage was observed. CONCLUSIONS: This study demonstrates that mitral valve repair (Alfieri type) can be performed safely and consistently on a beating heart without cardiopulmonary bypass using this new tissue approximation suture device. This technique may be applicable to the treatment of ischemic mitral regurgitation in conjunction with revascularization procedures or to mitral regurgitation in heart failure patients.     

Intracardiac knotting of a Swan-Ganz catheter. Detection using intraoperative trans-esophageal echocardiography]

Transoesophageal echocardiography is a new technique that allows continuous and noninvasive assessment of cardiac function during surgery. More recently this technique is being used to detect the presence of external objects into the cardiac cavities. We report a case of Swan-Ganz catheter knotting confirmed by this echocardiography technique. He was a 57 year old male with previous history of arterial hypertension and ischemic heart disease who was scheduled for surgery because poor response to medical therapy. After anesthetic induction a thermodilution catheter was introduced percutaneously into the right internal jugular vein under continuous pressure monitoring from the distal catheter hole. In view of the difficulties in introducing the catheter into the pulmonary artery an intravascular catheter knotting was suspected and a bidimensional transesophageal echocardiogram confirmed the diagnosis. During extracorporeal circulation the catheter was withdrawn through a right auriculotomy. Monitoring with a Swan-Ganz catheter, as other invasive monitoring techniques, is followed by a certain degree of complications which should be avoided by a careful manipulation. Echocardiography is a valuable diagnostic procedure to identify the position of monitoring catheters into the cardiac cavities.     

Coronary artery surgery with induced temporary asystole and intermittent ventricular pacing: an experimental study

Coronary artery bypass grafting performed without cardiopulmonary bypass points a difficulty in performing coronary anastomoses on a beating heart. A non-cardiopulmonary bypass technique in sheep by which individual sutures can be placed on a still heart is described. Epicardial pacing wires were placed and a curved needle passed between the aorta and pulmonary artery into the muscular interventricular septum and directed caudally and to the right. The tip of the needle now lay in the vicinity of the outflow of the bundle of His. No cardiac chamber or vital structures were traversed. Injection of lignocaine here resulted in immediate ventricular asystole. Ventricular pacing restored cardiac output. After establishing local control of the vessel coronary anastomosis was performed stopping ventricular pacing for the few seconds required to place a single suture and reinstating it between the passage of sutures. Reversion to sinus rhythm occurred spontaneously.     

Port-access minimally invasive cardiac surgery increases surgical complexity, increases operating room time, and facilitates early postoperative hospital discharge

BACKGROUND: Proposed advantages of port-access cardiac surgery have yet to be substantiated. The authors retrospectively compared patients undergoing port-access cardiac surgery with a matched group undergoing conventional cardiac surgery. METHODS: Forty-six patients who underwent port-access cardiac surgery were matched with 46 who underwent conventional cardiac surgery. Absolute criteria for matching included morning-of-surgery admission, procedure undergone, and care being delivered by one of two surgeons. If possible, matching included care delivered by one of two anesthesiologists. Patients were matched as closely as possible for preoperative demographic and clinical characteristics. RESULTS: All 46 pairs of patients were matched for procedure and admitted the morning of surgery. All 92 operations were performed by one of two surgeons, and 89% were performed by one of two anesthesiologists. Preoperative demographic and clinical characteristics were equivalent between groups. Compared with conventional cardiac surgery, port-access cardiac surgery increased surgical complexity (it almost tripled cardiopulmonary bypass time during coronary artery bypass grafting and increased it almost 40% during mitral valve procedures) and increased total operating room time (P < 0.0001). Port-access cardiac surgery had no beneficial effect on earlier postoperative extubation, decreased incidence of atrial fibrillation, or intensive care unit time, yet it decreased postoperative duration of stay (P = 0.029, all patients), a benefit observed primarily in patients undergoing coronary artery bypass grafting (P = 0.002). CONCLUSIONS: This retrospective analysis revealed that port-access cardiac surgery increases surgical complexity, increases operating room time, has no effect on earlier postoperative extubation or decreased incidence of atrial fibrillation or intensive care unit time, and may facilitate postoperative hospital discharge (primarily in patients undergoing coronary artery bypass grafting). Properly designed prospective investigation is necessary to ascertain whether port-access cardiac surgery truly offers any benefits over conventional cardiac surgery.     

Port-access Minimally Invasive Cardiac Surgery Increases Surgical Complexity, Increases Operating Room Time, and Facilitates Early Postoperative Hospital Discharge

Background: Proposed advantages of port-access cardiac surgery have yet to be substantiated. The authors retrospectively compared patients undergoing port-access cardiac surgery with a matched group undergoing conventional cardiac surgery.

Methods: Forty-six patients who underwent port-access cardiac surgery were matched with 46 who underwent conventional cardiac surgery. Absolute criteria for matching included morning-of-surgery admission, procedure undergone, and care being delivered by one of two surgeons. If possible, matching included care delivered by one of two anesthesiologists. Patients were matched as closely as possible for preoperative demographic and clinical characteristics.

Results: All 46 pairs of patients were matched for procedure and admitted the morning of surgery. All 92 operations were performed by one of two surgeons, and 89% were performed by one of two anesthesiologists. Preoperative demographic and clinical characteristics were equivalent between groups. Compared with conventional cardiac surgery, port-access cardiac surgery increased surgical complexity (it almost tripled cardiopulmonary bypass time during coronary artery bypass grafting and increased it almost 40% during mitral valve procedures) and increased total operating room time (P < 0.0001). Port-access cardiac surgery had no beneficial effect on earlier postoperative extubation, decreased incidence of atrial fibrillation, or intensive care unit time, yet it decreased postoperative duration of stay (P = 0.029, all patients), a benefit observed primarily in patients undergoing coronary artery bypass grafting (P = 0.002).     

Treatment of severe pulmonary hemorrhage after cardiopulmonary bypass by selective, temporary balloon occlusion

Severe pulmonary bleeding causes frequent mortality, particularly if this event occurs during separation from extracorporeal circulation during cardiac surgery. We present a new approach to treat this life-threatening complication: temporary balloon occlusion of the pulmonary artery feeding the involved lobe. On attempting to wean a 71-yr-old female patient from cardiopulmonary bypass after aortic valve replacement, she lost more than 2 L of blood through her trachea over approximately 15 min and severe gas embolism into the left atrium was visualized on transesophageal echocardiography. As the bleeding was too vigorous to be localized by fiberoptic bronchoscopy, an interventional cardiologist was consulted. After localizing the affected lobe using fluoroscopy, he inflated a balloon dilating catheter in the lower lobe artery. This effectively stopped the bleeding. Separation from extracorporeal circulation was uneventful using one-lung ventilation to prevent further gas embolism. Sixteen hours after the end of surgery the catheter could be deflated and removed without any further intervention. The patient made an excellent recovery.     

Transoesophageal echocardiography: a useful tool to diagnose entrapment of pulmonary artery catheter

Placement of a pulmonary artery catheter during cardiac surgery is associated with various complications, one of which is entrapment. On the day following surgery unusual resistance was encountered while attempting to remove a pulmonary artery catheter from a patient who had undergone coronary artery bypass grafting. Entrapment of the catheter was confirmed by transoesophageal echocardiography, which demonstrated invagination of the free wall of the pulmonary trunk on gentle traction on the pulmonary artery catheter. Surgical exploration revealed that the catheter was transfixed by the suture used to close the pulmonary artery vent site. Surgical re-exploration and other potential complications related to catheter retrieval can be avoided if catheter entrapment is diagnosed intra-operatively. We suggest that a high index of clinical suspicion along with the use of intra-operative transoesophageal echocardiography is considered in situations where catheter entrapment is a possibility.     

Port-access mitral valve replacement after surgical correction for Bland-White-Garland syndrome

A 79-year-old woman with Bland-White-Garland syndrome was admitted to our institution for surgical treatment of severe mitral regurgitation (MR). She had previously undergone mitral valve repair and coronary artery bypass grafting for both mitral insufficiency and a coronary artery anomaly 14 years earlier. However, the degree of residual MR had gradually worsened, and redo mitral valve surgery was scheduled. Multidetector row computed tomography revealed that the right coronary artery (RCA) was dilated and located just behind the sternum, and saphenous vein graft bypassed to the left anterior descending artery was occluded. This meant that the RCA was the only vessel supplying coronary blood flow. We successfully performed port-access mitral valve replacement under mild hypothermia with fibrillatory arrest to prevent damage to the RCA. We propose that port-access surgery is a safe and effective treatment for redo cardiac surgery after initial surgical correction of a congenital heart anomaly.     

Hemostatic technique for internal mammary artery anastomotic bleeding

When internal mammary artery is used for myocardial revascularization, a not uncommon occurrence is intraoperative bleeding from the internal mammary artery to coronary artery anastomosis. The conventional method of hemostasis of placing additional sutures across the suture line may produce anastomotic stenosis or may aggravate the bleeding by producing tears, especially as these additional sutures are placed on a beating heart. We describe a simple technique by which hemostasis can be achieved without the risk of anastomotic stenosis or aggravation of the bleeding, as it avoids placing sutures over the anastomotic suture line.     

Off-pump myocardial revascularization. The single-suture technique: how to avoid any complication

INTRODUCTION: Coronary artery bypass grafting without cardiopulmonary bypass (CPB) is now an accepted technique of complete myocardial revascularization. The technique was originally described by Kolesov [Kolesov 1967] and later abandoned when the CPB became the gold standard for cardiac operations on the arrested heart. In the late 1980s off-pump coronary grafting was reintroduced by Benetti and Buffolo with very encouraging results, especially for high-risk patients [Benetti 1985, Buffolo 1996]. This technique was limited to the grafting of left anterior descending (LAD) coronary artery and sometimes to the right coronary artery (RCA) [Benetti 1985, Buffolo 1996]. In recent years, technical advantages in coronary exposure and mechanical stabilization have come from the industry, leading to the possibility of a complete off-pump myocardial revascularization. The exposure of coronary arteries in the circumflex territory has been described by Ricardo Lima from Brazil. He described a series of four sutures on the pericardium, which allowed a good exposure of such surgically difficult territory. Tomas Salerno simplified the "Lima sutures" with a technique using a single suture placed in the oblique sinus of the posterior pericardium, which allowed a good exposure of the circumflex territory and less heart manipulation. [Bergsland 1997, Salerno 1999, Ricci 2000]. This deep pericardial suture may injure the organs situated just behind the pericardium, such as the esophagus and thoracic aorta [Ricci 2000], and several complications have been reported in literature: injury of the left lower pulmonary vein has resulted in post-operative bleeding and dangerous hematoma behind the left atrium [Fukui 2002]; and subcutaneous emphasema has been detected in several cases in our experience. We report a different way to pose the single lima suture in order to avoid any damage to the structures behind the posterior pericardium.     

Pulmonary artery rupture caused by a Swan-Ganz catheter during heart surgery. A successful therapeutic procedure

A patient with mitral valve stenosis (NYHA IV) suffered a pulmonary artery rupture after valve replacement and weaning from bypass. This event coincided with the measurement of pulmonary capillary wedge pressure. Anticoagulation aggravated the endobronchial bleeding to a near fatal outcome. By intubating with a double-lumen endobronchial tube and clamping the right pulmonary artery, the pulmonary hemorrhage and its complications could be controlled. After antagonizing the heparin dose and supporting the right heart with epinephrine bleeding was reduced substantially, following which the right pulmonary artery was declamped. In older patients or patients with pulmonary hypertension the following procedures for preventing pulmonary artery rupture should be taken: before inflating the balloon the catheter should be withdrawn into a large vessel; after inflation the balloon the catheter can be advanced to the wedge position.     

Comparison of direct aortic and femoral cannulation for port-access cardiac operations.

BACKGROUND: Differences in outcome after direct aortic cannulation (AORT) in the chest versus standard femoral arterial cannulation (FEM) have not been defined for minimally invasive cardiac operations utilizing the port-access approach. METHODS: A retrospective study was performed of 165 patients undergoing port-access cardiac mitral valve operation (n = 126) or coronary artery bypass grafting (n = 39). In 113 patients, FEM was used, while in 52 patients, AORT was accomplished through a port in the first intercostal space. RESULTS: AORT eliminated endoaortic balloon clamp migration (0/36 [0%] vs. 17/95 [18%]), and groin wound or femoral arterial complications (0/52 [0%] vs. 11/113 [10%]) without changing procedure times (363+/-55 vs. 355+/-70 minutes). Complications attributable to AORT were injury to the right internal mammary artery and aortic cannulation site bleeding in 1 patient each. CONCLUSIONS: Direct aortic cannulation is technically easy, allows use of an endoaortic clamp, and avoids aorto-iliac arterial disease, the groin incision, and possible femoral arterial injury associated with femoral arterial cannulation. Direct arterial cannulation should expand the pool of patients eligible for port-access operation, and may become the standard for port-access procedures.     

硝普钠经肺动脉直接输注对肺动脉高压的疗效观察

目的　观察硝普钠对二尖瓣置换术后肺动脉高压的疗效。方法　对二尖瓣置换术后具有肺动脉高压的患者 ,由颈内静脉或锁骨下静脉放置Swan -Ganz导管监测其血液动力学指标 ,采用硝普钠经肺动脉端直接输注进行治疗 ,观察硝普钠治疗前后上述血液动力学指标的变化情况。结果　采用硝普钠进行治疗后 ,患者的平均动脉血压 (MAP)、平均肺动脉压 (MPAP)、外周血管阻力指数 (SVRI)及肺血管阻力指数 (PVRI)较用药前明显下降 (P <0 0 5 ) ,而每搏输出量 (SV)、心输出量(CO)及心脏指数 (CI)较用药前明显增高 (P <0 0 5 )。结论　由肺动脉直接输注硝普钠可有效降低二尖瓣置换术后的肺动脉高压 ,并可提高患者的心输出量