Safety of a guidewire technique for replacement of pulmonary artery catheters

The purpose of this study was to determine if a guidewire change from a pulmonary artery catheter (PAC) to a central venous catheter (CVC) poses a significant infection risk. A total of 128 consecutive cardiac surgical patients with PACs inserted in the operating room were entered into this study. Postoperatively, patients were randomly allocated to receive a double-lumen CVC, either at the initial introducer insertion site over a guidewire, or at a new site with de novo catheterization. The tips of all introducers, PACs, and CVCs were cut off, cultured, and semi-quantitatively analyzed. The results show that insertion of CVCs over a guidewire within 48 hours after initial venapuncture is no more likely to be associated with catheter colonization than is de novo percutaneous insertion at a different site. From 48 hours up to 72 hours following initial insertion of the PAC, an incidence of catheter-related infection of 35.3% was observed in the guidewire group, as opposed to 12.5% in the de novo group. It is recommended that the use of a guidewire technique for catheter replacement (PAC to CVC) is a safe alternative to de novo insertion of a CVC within 48 hours after initial insertion of the PAC. In order to minimize the potential risk of catheter-related infection and bacteremia in cardiac surgical patients, de novo catheterization beyond 48 hours after initial venapuncture is suggested.     

Temporary and permanent biventricular pacing via left ventricular epicardial leads implanted during primary cardiac surgery

OBJECTIVES: Biventricular pacing (BVP) is a new strategy for treating patients with severe congestive heart failure (CHF) and intraventricular conduction delay, but its full potential and technicalities of BVP require further evaluation. We evaluated BVP benefits in 4 patients in whom we implanted a left ventricular lead during primary cardiac surgery. METHODS: Four CHF patients treated surgically between October 2000 and August 2001 underwent, at primary surgery, the implantation of leads in the right atrium, right ventricle, and left ventricle (LV) for postsurgical BVP. All patients had severe LV dysfunction and dilatation with intraventricular conduction delay. Surgeries involved CABG alone (n = 1), CABG + Dor's operation (n = 2), and tricuspid valve replacement + Maze procedure (n = 1). BVP was begun immediately after surgery in all 4 patients. Hemodynamic variables with BVP were compared to those without BVP for each patient, and the utility and technical aspects of implantation were evaluated. RESULTS: BVP increased mean systemic blood pressure by 11% and mean LV stroke work index by 19% in the acute postsurgery period, and reduced mitral regurgitation. Two of the patients were implanted with a generator for permanent BVP, one at 1 month and the other at 6 months after surgery. The threshold of the LV epicardial lead of these 2 patients was below 2 V during follow-up, and BVP was successful. CONCLUSIONS: Temporary BVP during the short-term after cardiac surgery improved cardiac function and decreased mitral regurgitation in all 4 of our patients. Epicardial lead implantation may thus be a useful option during surgical treatment of patients with CHF and intraventricular conduction delay if long-term permanent BVP is indicated.     

激光血运重建术治疗冠心病的临床研究

目的:总结分析了99年9月至99年11月激光血运重建术治疗冠心病3例的临床经验。资料及方法:3例冠心病患者均为不稳定性心绞痛,有阵旧性心肌梗塞1例,3例均合并Ⅱ期高血压病。超声心动图左室射血分数在0.57～0.62之间,FS 0.28～0.30。经心肌核素扫描99~M(Ti—MiBi)及心电图检查均提示前壁及下壁缺血。在全麻下经左胸前外侧第5肋间进胸,显露左心室壁,采用高功率二氧化碳激光打孔器(梅曼公司HL-100型)在左室缺血区域打孔8～14个。结果:3例病人术后2周全部康复出院,术后无心律失常,无心衰及心肌梗塞,术后心绞痛症状均全部缓解,一般体力活动不受限制。结论:激光血运重建术治疗冠心病是安全、有效的,对于国人由于冠状动脉血管纤细,激光血远重建术适应证可适当放宽。     

简易肺动脉导管在心脏直视术后的临床应用

目的通过术中置放简易肺动脉导管（PACs,硬膜外留置管）进行肺动脉压和混合静脉压氧饱和度（SvO2）监测,观察其在术后监测的作用。方法对52例心脏直视术后,并行简易肺动脉导管监测的病人临床资料进行回顾性分析。结果21例病人有不同程度的肺动脉高压（PAP）,12例患者肺动脉舒张压（DPAP）偏低,13例患者DPAP升高,9例患者SvO2低于50％。予以相应处理后．上述参数有所改善。结论心脏直视术后简易肺动脉导管监测可以有效指导临床处理,提高心脏直视术后的监测处理水平。     

A simple method to pass a pulmonary artery flotation catheter rapidly into the pulmonary artery in anaesthetized patients

Background. In some patients passage of a pulmonary artery flotationcatheter (PAFC) into the pulmonary artery may be difficult andtime consuming and the prolonged manipulation can cause ventriculararrhythmias. A simple clinical method used during general anaesthesiais presented to allow rapid passage of a PAFC into the pulmonaryartery. Methods. The operating table is positioned head up and slightlyright side down to position the pulmonary valve at the highestlevel possible. When the balloon catheter is in the right ventricularoutflow tract (indicated by premature ventricular contractions)the ventilator is paused in inspiration and the balloon cathetersimultaneously passed into the pulmonary artery. Results. The manoeuvre shortens the time necessary to pass thecatheter into the pulmonary artery and may reduce ventriculararrhythmias. Over 5 yr, 105 PAFCs were inserted with this methodwithout major complications. Conclusion. This method may reduce the risk of ventricular arrhythmias,and could be particularly useful in high-risk critically illpatients. Br J Anaesth 2003; 90: 794–6     

Length of insertion for pulmonary artery catheters to locate different cardiac chambers in patients undergoing cardiac surgery

Background. Although, guidelines related to length of insertionof a pulmonary artery catheter to reach a particular cardiacchamber are available, these are not backed by clinical studies.We measured the length of insertion of pulmonary artery cathetersto locate the right ventricle, pulmonary artery and pulmonarycapillary wedge positions in 300 adult patients undergoing electivecardiac surgery. Methods. The pulmonary artery catheters were inserted usinga standard technique through the right internal jugular vein.The right ventricle, pulmonary artery and wedge position ofthe catheter were confirmed by the characteristic waveforms,and the length of insertion to these points was measured. Results. The right ventricle was reached at 24.6 (3) cm (95%CI 24.2–24.9 cm), pulmonary artery at 36 (4) cm (95% CI35.6–36.5 cm) and wedge position at 42.8 (5.7) cm (95%CI 42.2–43.5 cm). The length of catheter to reach theright ventricle, pulmonary artery and wedge position was significantlymore in patients undergoing valve surgery as compared with thoseundergoing coronary artery bypass grafting [26 (3.8) and 24(2.5) cm; 38.5 (4.6) and 35 (3.2) cm; and 47.8 (6.9) and 41.2(4.1) cm, respectively, P<0.001]. The length of insertionto reach pulmonary artery and pulmonary capillary wedge positionwas directly related to height of the patient (Pearson’scorrelation 0.157 and 0.15, respectively). Conclusions. We have provided the norms related to length ofinsertion of pulmonary artery catheter, which should be usefulin accurate placement of the catheter and minimize complicationsrelated to coiling of the catheter.     

Novel arterioplasty of severe left pulmonary artery stenosis using native main pulmonary artery

There are multiple approaches described for the repair of stenosed branch pulmonary arteries. Regardless of the technique used, restenosis is common. We describe a case of severe left pulmonary artery stenosis repaired with a novel technique using the native main pulmonary artery which was transected and turned down to create a direct anastomosis with the left pulmonary artery. This tension‐free tissue to tissue anastomosis resulted in hemodynamically gratifying results with the potential for growth.     

Central venous pressure and pulmonary artery pressure monitoring

Central venous pressure and pulmonary artery pressure are used as measures of cardiovascular filling. While pressure–volume relationships are not constant, trends in central venous pressure give an indication of increasing or decreasing right ventricular filling, while pulmonary artery pressure gives an indirect indication of left ventricular filling pressure. Cardiac output can be estimated by use of thermodilution.     

David's procedure for pulmonary artery aneurysm

Pulmonary artery aneurysm (PAA) is a rare entity with fatal complications. Its silent course contributes to large aneurysms with compression symptoms. We present a 39-year-old female idiopathic pulmonary arterial hypertension patient with a giant PAA causing severe pulmonary regurgitation (PR) and symptomatic left main coronary artery compression (LMCA). Since she had a failed LMCA stenting attempt, she underwent surgery. A valve-sparing David-like pulmonary trunk reconstruction and coronary artery bypass were performed. This case illustrates that David-like reconstruction procedure can be applied to the PAA with severe PR.     

Impact of systolic pulmonary artery pressure on all-cause mortality in elderly cardiac patients

Objective. Elevated systolic pulmonary artery pressure (sPAP) is common among elderly patients with cardiac and pulmonary diseases. The lowest level of sPAP associated with increased mortality rate in octogenarians with cardiac diseases is however not sufficiently studied. Therefore, the present study aimed to identify the lowest level of sPAP associated with increased 5-year all-cause mortality in this patient group. Design. Of 538 octogenarians presented at the three Sahlgrenska University Hospitals (Sahlgrenska, Östra and Mölndal) with either congestive heart failure (CHF) or acute coronary syndrome (ACS), only 302 patients who had undergone echocardiography with data on sPAP were included in the present study. In order to identify the lowest level of sPAP associated with increased mortality rate, Cox proportional-hazard regression multivariable models were built for sPAP levels as low as 30?mmHg and upward with 5?mmHg intervals. Results. sPAP?>35?mmHg was identified as the lowest level associated with increased 5-year all-cause mortality (HR?=?1.7, 95% of CI?=?1.1–2.6 and p?=?.013). Every increase of 5?mmHg in sPAP was associated with a 10% increased relative risk for all-cause mortality. Conclusions. In octogenarians with cardiac diseases the lowest level of sPAP associated with increased all-cause mortality was >35?mmHg and the mortality rate increased with increasing sPAP.     

肺动脉高压幼犬肺动脉压力与肺动脉结构的关系

目的 探讨肺动脉高压（ＰＨ）时肺动脉压力（ＰＡＰ）与结构的关系。方法 实验幼犬１５条,分２组：分流组（ｎ＝１２）,正常对照组（ｎ＝３）。分流术后９０ｄ两组行血流动力学检测后,放血处死,肺组织切片行病理学检测。结果 （１）分流组左下肺动脉压（ＰＬＬＰＡ）由１．３６ｋＰａ（１ｋＰａ＝０．７５ｍｍＨｇ）升至１１．１３ｋＰａ,左下肺血管阻力（ＬＬＰＶＲ）由５．６５Ｗｏｏｄ’ｓ单位升至１４．３１Ｗｏｏｄ’ｓ     

Left superior pulmonary artery sling

A pulmonary artery sling is formed when the left pulmonary artery originates from the right pulmonary artery and encircles the distal trachea, coursing between the trachea and esophagus to reach the hilum of the left lung. Pulmonary artery slings are often associated with distal tracheal narrowing, due to either intrinsic stenosis or secondary compression by the anomaly itself. We report a very rare case in which the left superior pulmonary artery originated from the right pulmonary artery and then acted as a sling, the left inferior pulmonary artery originated from the pulmonary trunk.     

In vitro reappraisal of the pulmonary artery catheter balloon volume-pressure relationship: comparison of four different catheters

The most serious risk of the use of the flow-directed pulmonary artery (PA) catheter is PA rupture due to high balloon inflation pressure of the catheter. Previously reported measurements of PA catheter intra-balloon pressure and volume during balloon inflation were performed mostly in a static fashion, that is, measurements were performed after a certain volume of air had been injected into the balloon. In this study, simultaneous measurements of pressure and volume, in addition to a static study, were performed in vitro using four PA catheters (Abbott Opticath, Arrow Hands-Off, Baxter Edwards and Spectramed). The peak intra-balloon pressure was recorded immediately before loss of resistance was felt in the inflating syringe. Contrary to previously reported studies, the peak intra-balloon pressure was not the pressure exerted on the pulmonary artery wall unless the tip of the catheter was already in the peripheral pulmonary artery. The loss of resistance volume which was constant for each catheter could be used reliably as an indicator of instantaneous balloon inflation. The slower the rate of injection, the lower were the peak pressure and the injection volume at the peak pressure. The Abbott, Edwards and Spectramed catheters had similar characteristics of inflation volume and intra-balloon pressure. The Arrow catheter had higher balloon opening and plateau pressures, and a smaller balloon volume compared with the other three catheters.     

Cardiac output--pulse contour analysis vs. pulmonary artery thermodilution

BACKGROUND: The aims of this study were to determine the agreement between pulmonary artery thermodilution (PA-TD), transpulmonary thermodilution (TP-TD) and the pulse contour method, and to test the ability of the pulse contour method to track changes in cardiac output. METHODS: Cardiac output was determined twice before cardiac surgery with both PA-TD and TP-TD. The precision (two standard deviations of the difference between repeated measurements) and agreement of the two methods were calculated. Post-operatively, cardiac output was determined with the PA-TD and pulse contour methods, and the bias and limits of agreement were again calculated. Finally, in patients with heart rates below 60 beats/min or a cardiac index of less than 2.5 l/min/m2, atrial pacing was started and the haemodynamic consequences were monitored with the PA-TD and pulse contour methods. RESULTS: Twenty-five patients were included. The precisions of PA-TD and TP-TD were 0.41 l/min [95% confidence interval (CI), +/- 0.07] and 0.48 l/min (95% CI, +/- 0.08), respectively. The bias and limits of agreement between PA-TD and TP-TD were - 0.46 l/min (95% CI, +/- 0.11) and +/- 1.10 l/min (95% CI, +/- 0.19), respectively. Post-operatively, the bias and limits of agreement between the PA-TD and pulse contour methods were 0.07 l/min and +/- 2.20 l/min, respectively. The changes in cardiac output with atrial pacing were in the same direction and of the same magnitude in 15 of the 16 patients. CONCLUSION: The precision of cardiac output measurements with PA-TD and TP-TD was very similar. The transpulmonary method, however, overestimated the cardiac output by 0.46 l/min. Post-operatively, cardiac output measurements with the PA-TD and pulse contour methods did not agree, but the pulse contour method reliably tracked pacing-induced changes in cardiac output.     

Pericardial placement of a pulmonary artery catheter

Extravascular placement of a pulmonary artery catheter occurred when it was passed down an in situ sheath, the side arm of which had already been used for administration of fluids without any problems. The case emphasises that complications occur with the use of invasive monitoring and a correctly placed line may become extravascular even in a short time.     

Swan-Ganz catheter-induced pseudoaneurysm of the pulmonary artery

Pseudoaneurysm of the pulmonary artery (PA) induced by Swan-Ganz catheter injury is an important complication with high mortality. We report a case of PA pseudoaneurysm treated by PA repair. A 52-year-old woman developing infiltrate in the right lung field in chest radiography after a second mitral valve replacement was diagnosed with PA pseudoaneurysm confirmed by contrast-enhanced computed tomography and pulmonary angiography. The cause was considered Swan-Ganz catheter injury. The patient was carefully observed because there was no evidence of bronchial hemorrhage. The perforation was closed and the cavity plicated under extracorporeal circulation to avoid delayed rupture of the pseudoaneurysm when she underwent a third mitral valve replacement.     

Survival following cardiac tamponade and arrest in a paediatric patient with penetrating trauma to pulmonary artery

A seven-year-old child with an airgun pellet injury to the upper part of the anterior chest wall was transported in a state of shock from a nearby hospital to this trauma centre. The nature and site of injury associated with engorged neck veins, hypotension, pulsus paradoxus and an enlarged liver suggested the possibility of acute pericardial tamponade. On arrival in the emergency room the child had a brief period of cardiac arrest revived by basic resuscitation procedures. Pericardiocentesis was negative in the emergency room. Emergency median sternotomy with pericardiotomy was done to relieve the tamponade which was peroperatively diagnosed to be due to a tear in the pulmonary artery close to its origin. Early clinical diagnosis, rapid surgical intervention in the operating room and efficient anaesthetic management within the ‘Golden Hour’ saved life. It is believed that this is the first report of survival of a paediatric patient with a gunshot penetrating trauma to the pulmonary artery leading to cardiac tamponade and a brief period of cardiac arrest.