Complications of right heart catheterization. A prospective autopsy study

The purpose of this study was to characterize the type and prevalence of abnormalities associated with right heart catheterization. We performed detailed post-mortem examinations of 32 consecutive patients brought to autopsy with a right heart catheter in the pulmonary artery. Thrombosis (17 patients, 53 percent), hemorrhagic lesions (25 patients, 78 percent), and intimal fibrin deposition (21 patients, 66 percent) were found at sites along the entire path of the catheter. Twenty-nine patients (91 percent) had either thrombosis, hemorrhage or both. While the superior vena cava was the most common site for all lesions, seven patients had thrombosis involving the chambers and valves of the heart and four had thrombosis involving the pulmonary artery. The incidence of thrombosis was significantly higher after 36 hours of catheterization (p less than 0.05). All five patients with thromboemboli in the more proximal pulmonary arteries had catheter-related thrombosis. We conclude that there is a high prevalence of thrombotic and hemorrhagic lesions in patients dying with pulmonary catheters in place; that the risk of thrombotic complications increases with duration of catheterization; and that patients with catheter-related thrombosis are at increased risk of thromboemboli to the proximal pulmonary arteries.     

Mural thromboses of the right heart. Clinico-pathological study]

39 instances of mural thrombosis of the right side of the heart were observed among 2000 cases of post-mortem examinations. The right atrium was the most frequent site of thrombosis; the right ventricle was involved in 8 cases. The relationships between right sided thrombosis and rhythm disturbances, myocardial or valvular disease, myocardial infarction, pulmonary disease, neoplasm, sepsis and disturbance of coagulation are discussed. The high incidence of pulmonary embolism and their relationship with thrombosis of the right side of the heart are emphasized.     

Post-infarction thrombosis of the right ventricle

Right ventricular mural thrombosis is not commonly detected and in most cases is related to the use of monitoring, infusion, or pacing catheters. We report right ventricular mural thrombosis, complicated by pulmonary embolism, in 2 cases of inferior wall myocardial infarction with right ventricular involvement. None of the patients had been monitored by means of right ventricular catheterization. Bidimensional echocardiography allowed visualization of the thrombi, and demonstrated their resolution after anticoagulant treatment.     

Postoperative nursing and prevention of complications in patients receiving coronary artery bypass grafting with the application of Swan-Ganz balloon floating catheter

Background The patients having received CABG are more likely to suffer from cardiac dysfunction and hemodynamic instability. Floating catheter provides a full set of hemodynamic parameters in an accurate manner.Methods From January 6,2018,to December 29,2018,101 patients receiving CABG in our department were selected. Among them,53 patients indwelt with Swan-Ganz balloon floating catheters. The correct application of indwelling Swan-Ganz balloon floating catheter was analyzed targeting 53 patients receiving CABG to standardize nursing and prevent complications. Results Of the 53 patients recruited,48 cases recovered,3 cases had clinical death,and 2 cases were automatically discharged. There are 16 cases subject to complications and adverse reactions. In 4 cases with catheter obstruction in SICU where CVP could be measured,floating catheters were removed in time within 24 hours after catheterization in 3 cases and 1 d22 h in 1 case. In 2 cases,catheter obstruction happened in SICU after CO measurement and before CVP measurement,where catheter obstruction was observed 1 d8 h after catheterization,and floating catheters were removed within 2 d22 h in all cases. There were 3 cases who had capillary hemorrhage at puncture sites,where compression hemostasis with cigarette coils and gauze blocks was performed in all cases,followed by 3 M TegadermTMtransparent film dressing for sterile covering at the puncture site. 4 cases suffered from transient premature ventricular contraction(PVC),which was alleviated without malignant arrhythmia after immediate suspension of operation. In addition,2 cases were subject to balloon catheters in the right ventricle and 1 case had balloon catheter in pulmonary artery,where CO,CI,SVR and other values except for the pulmonary capillary wedge pressure(PCWP)could be measured in all cases. Balloon rupture,pulmonary embolism,pulmonary hemorrhage,and pulmonary artery rupture,catheter knotting and catheter rupture or phlebitis and complications of catheter-related bloodstream infection(CRBI)were not found in the 53 patients. Conclusions The application of Swan-Ganz balloon floating catheter can provide hemodynamic monitoring data and guidance for monitoring the treatment of patients receiving CABG.Scientific application and management of pulmonary artery floating catheters and effective nursing can prevent complications and adverse reactions.[S Chin J Cardiol 2019;20(2):95-102]     

111例长期深静脉留置透析导管患者相关并发症的分析

目的 通过分析111例长期深静脉留置透析导管患者相关并发症的临床资料,探讨其防治措施。方法 选择我院2001年1月～2003年3月新留置长期深静脉双腔透析导管使用时间大于6个月的患者111例,导管留置总时间为1090个患者月,平均已留置时间为9．8个月。所有导管均选用Quinton Permcath带cuff长期留置透析导管,插管部位首选右颈内静脉,其次为左颈内静脉、髂外静脉。出现导管并发症(感染、血栓等)予对症处理。结果 局部血肿的发生率为8．1％。导管位置不良的发生率为4．5％。111例患者中有6例发生导管感染,感染率为5．4％,2例为细菌感染,抗生素治疗有效;4例为真菌感染,1例治愈,3例拔管并重新置管。导管血栓形成的发生率为18、9％,发生血栓时导管平均留置时间为36d;20例患者尿激酶溶栓后导管恢复通畅,成功率为95．2％,其中18例再次发生导管血栓,5例患者加服血小板抑制剂后能保持导管长期通畅,13例仍多次发生血栓,改服华法林后,9例有效,另4例改建内瘘或移植血管。溶栓及联合抗凝治疗使16例患者的导管使用寿命平均延长了6个月。结论 深静脉双腔透析导管的留置和长期应用是安全有效的,导管血栓形成是其最为常见的并发症,溶栓及联合抗凝治疗可显著延长导管的使用寿命。     

Cardiac thrombosis and thromboembolism in chronic chagas' heart disease

A retrospective study of Chagas' heart disease was carried out by a review of 1,345 autopsy reports, with special reference to cardiac thrombus and thromboembolic phenomena. The incidence of cardiac thrombus was higher in cases of heart failure (36%) than in cases of sudden death (15%), higher in heavier hearts, and unrelated to age or sex. The left- and right-sided cardiac chambers were equally affected by thrombus. Endocarditis and blood stasis were considered important factors in the pathogenesis of cardiac thrombus. Thromboembolic phenomena were more common in the systemic circulation but caused relatively more deaths by pulmonary embolism. Fourteen percent of patients with thromboembolic phenomena died from them. Patients with multiple thromboembolic phenomena had a higher risk of death from embolism. Cardiac thrombosis or thromboembolic phenomena, or both, were present in 44% of the cases studied. Prophylactic measures should be taken for these important complications of Chagas' heart disease.     

Thrombi in antrum atrii dextri of human heart as clinically important source for chronic microembolisation to lungs.

In many cases of chronic microembolic pulmonary hypertension the source of the emboli is unknown. Disease or injury to the sinus node is usually accompanied by thrombus formation within the antrum atrii dextri, and this region is not often inspected carefully during necropsy. In the present study the hearts of 14 patients with right ventricular hypertrophy or documented pulmonary hypertension showed disease or injury in the sinus node, and each had both old and recent thrombosis in the antrum atrii dextri. In all 14 cases both lungs were available for histological examination. The group included six cases of rheumatic heart disease with mitral stenosis, four cases of disseminated lupus erythematosus, and four cases of so-called primary pulmonary hypertension. Every lung contained both new and old microemboli, as well as a wide variety of other histological abnormalities narrowing the small pulmonary arteries. Many of these narrowing lesions were recognisable as the consequence of prior microembolisation. For future postmortem examination of cases of chronic microembolic pulmonary hypertension, mural thrombi within the antrum atrii dextri should be considered as one important potential source for recurring microembolisation to the lungs.     

Mechanically-induced intraventricular block caused by a right-heart floating catheter--frequency and electrophysiologic findings

During the course of 2,434 right heart catheterizations with 2,019 floating 3F Grandjean catheters and 415 5F Swan-Ganz catheters we observed 7 patients (0.3%) with catheter-induced infranodal conduction impairment: right bundle branch block (RBBB) in 3 patients, left anterior fascicular block (LAFB) and subsequent RBBB in 1 patient, and complete heart block in 3 patients with pre-existing left bundle branch block (LBBB). There was no apparent difference regarding the incidence of blocks between the two types of catheters. Three patients (one with LAFB + RBBB and two with LBBB) underwent electrophysiologic studies. All three patients exhibited a prolongation of the HV-interval due to coexisting pathologic changes of the right bundle. LBBB patterns disappeared during distal His bundle pacing in two patients, indicating a proximal site of block and suggesting incomplete involvement of the right bundle. Additional mechanical trauma, probably in this region, produced the blocks. Thus, use of balloon tipped or flexible catheters does not provide complete protection against transient lesions of the conduction system.     

New technique for right heart catheterization using a mullins' sheath

A new technique for right heart catheterization using a Muilins' sheath is described. This device allows a Swan-Ganz catheter to reach pulmonary artery position easily and permits simultaneous pressure recordings in right heart chambers, thus avoiding a double venous puncture and two catheters. This new technique, its indications, and our experience in 29 patients are described. It is most useful in patients with severe pulmonary hypertension and in those conditions in which accurate right heart pressure measurements are needed.     

The hemodynamic changes in the course of the development from chronic obstructive pulmonary disease to cor pulmonale

Swan-Ganz catheterization was done in 36 cases of COPD (19 cases) and chronic cor pulmonale (17 cases) patients diagnosed clinically. The results showed that exercise might greatly increase the rate of early diagnosis of chronic cor pulmonale in 47.4%, which is significant in clinical practice, together with gamma-camera, echocardiography and vectorcardiography, it can further increase the early diagnostic rate of cor pulmonale. In these 36 cases, 13 cases had no pulmonary hypertension and in 7 cases of them pulmonary arterial mean pressure were still in normal range even after exercise. If only right heart catheterization was used to diagnose cor-pulmonale without above three noninvasive examinations mentioned above, a high rate of misdiagnosis cor pulmonale would be possible.     

Lack of correlation between P pulmonale and right atrial overload in chronic obstructive airways disease.

The correlation between P pulmonale and right atrial overload in chronic lung disease was studied. Right atrial pressure, pulmonary artery pressure, and cardiac output were measured with a Swan-Ganz catheter in nine patients with chronic lung disease and P pulmonale on the electrocardiogram (P wave amplitude of greater than or equal to 2.5 mm (0.25 mV) in leads II, III, and a VF. The results were compared with those in six patients with an atrial septal defect (left to right shunt greater than or equal to 50%) and six patients with pulmonary hypertension (mean pressure greater than or equal to 30 mm Hg without left sided heart disease). Right atrial volume and wall thickness were measured in 10 cases of P pulmonale among 1000 necropsy cases and compared with 141 normal hearts from the same series. The patients with P pulmonale did not show a significant increase in right atrial or pulmonary artery pressures. None of the patients with an atrial septal defect or pulmonary hypertension had P pulmonale on the electrocardiogram. In the necropsy cases of P pulmonale mean (1 SD) in right atrial volume (32 (12) ml) and wall thickness (1.5 (0.7) mm) were not significantly increased (40 (14) ml and 1.4 (0.5) mm in the normal hearts). There was a significant inverse relation between the presence of P pulmonale and the cardiothoracic ratio. In all the patients with P pulmonale chest x ray showed a low cardiothoracic ratio, a considerably depressed diaphragm, and a pendulous heart. This study showed no correlation between P pulmonale and right atrial overload in chronic lung disease. A more vertical anatomical position of the heart, particularly of the right atrium, seems to be the major factor responsible for generation of P pulmonale in chronic airways disease.     

Lack of correlation between P pulmonale and right atrial overload in chronic obstructive airways disease

The correlation between P pulmonale and right atrial overload in chronic lung disease was studied. Right atrial pressure, pulmonary artery pressure, and cardiac output were measured with a Swan-Ganz catheter in nine patients with chronic lung disease and P pulmonale on the electrocardiogram (P wave amplitude of greater than or equal to 2.5 mm (0.25 mV) in leads II, III, and a VF. The results were compared with those in six patients with an atrial septal defect (left to right shunt greater than or equal to 50%) and six patients with pulmonary hypertension (mean pressure greater than or equal to 30 mm Hg without left sided heart disease). Right atrial volume and wall thickness were measured in 10 cases of P pulmonale among 1000 necropsy cases and compared with 141 normal hearts from the same series. The patients with P pulmonale did not show a significant increase in right atrial or pulmonary artery pressures. None of the patients with an atrial septal defect or pulmonary hypertension had P pulmonale on the electrocardiogram. In the necropsy cases of P pulmonale mean (1 SD) in right atrial volume (32 (12) ml) and wall thickness (1.5 (0.7) mm) were not significantly increased (40 (14) ml and 1.4 (0.5) mm in the normal hearts). There was a significant inverse relation between the presence of P pulmonale and the cardiothoracic ratio. In all the patients with P pulmonale chest x ray showed a low cardiothoracic ratio, a considerably depressed diaphragm, and a pendulous heart. This study showed no correlation between P pulmonale and right atrial overload in chronic lung disease. A more vertical anatomical position of the heart, particularly of the right atrium, seems to be the major factor responsible for generation of P pulmonale in chronic airways disease.     

心肌梗死后室壁瘤并附壁血栓抗栓治疗随访

目的通过对心肌梗死后室壁瘤内附壁血栓形成的患者进行随访,评价抗血小板药物及抗凝药物对室壁瘤附壁血栓患者预后的影响。方法回顾性分析2002年3月-2009年2月,确诊为心肌梗死后室壁瘤内附壁血栓形成的66例内科治疗患者,其中单服阿斯匹林25例,阿斯匹林＋波立维（1年）27例,长期单纯华法林口服4例,阿斯匹林＋华法林6例,阿斯匹林＋华法林＋波立维（1年）3例。服用华法林者INR维持在1．8—3．0。出院后均继续规律服药,进行电话和门诊随访,并行Kaplan-Meier生存分析。结果66例中8例死亡：其中脑血栓、室间隔穿孔、脑出血及咯血各1例;猝死2例;心衰2例;存活58例中脑栓塞者2例;1例下肢血管栓塞及肺柃塞;1例下肢动脉栓塞,服用阿司匹林或华法林发生栓塞事件比率无差别,而联合抗栓治疗出血事件多,左心室射血分数〈35％事件发生率高。结论室壁瘤心功能差患者栓塞事件发生率高,阿斯匹林和华法林在预防心肌梗死后室壁瘤血栓栓塞脱落效果相似,但需更大样本和更长时间随访进一步证实。     

Nonobstructive coronary thrombosis in sudden cardiac death

Careful histologic studies were performed on the coronary arteries, myocardium and conduction system of the hearts of six men aged 32 to 44 years who died suddenly with no history of heart disease. All six hearts demonstrated coronary atherosclerosis without evidence of complete obstruction or myocardial Infarction. A nonobstructing mural coronary thrombus was found in all six hearts; in four, the thrombus was located in the left anterior descending coronary artery. Distal microthrombi were found in four hearts.In these six men, the terminal event, often a ventricular arrhythmia, may have been related to the mural coronary thrombus. Small fragments originating from such lesions can obstruct the microcirculation producing sudden lethal arrhythmias. Nonobstructing mural coronary thrombosis may be more prevalent and more significant than previously suspected and should be considered In cases of sudden cardiac death.     

Pathological studies in experimental Candida endocarditis.

Mycotic endocarditis was produced in rabbits by indwelling intracardiac catheters filled with a suspension of Candida albicans. Grossly, cardiac lesions consisted of massive fungoid valvular vegetations and/or "sleeve thrombi" surrounding the catheter. Microscopically, platelet-fibrin aggregates were observed to be loosely attached to the valvular cusps. With time, the vegetations became organized and more firmly attached against the endocardium. Also observed was a heavy neutrophylic collar often containing Candida cells which infiltrate the subendothelial tissues of the valvular cusps. Sterile endocardial lesions were produced by retained catheters. The lesions consisted of discrete, glistening, hemispherical nodules in the right heart; and similar elevated plaques on the mural endocardium of the left ventricle. Microscopically, these lesions consisted of fibrous connective tissues devoid of inflammatory cells. The lesions in the left ventricle were more extensive, extending into the myocardium.     

Complications of indwelling catheters in cystic fibrosis: a 10-year review

STUDY OBJECTIVE: Patients with cystic fibrosis (CF) frequently require recurrent courses of IV antibiotics to treat acute exacerbations of their pulmonary disease. Over time, CF patients often lose peripheral access, and indwelling central venous catheters are placed. We attempted to determine the type and incidence of catheter complications so that CF patients could be fully informed of the risks prior to placement of these catheters. DESIGN: The charts of all CF patients who attended the Adult Cystic Fibrosis Clinic of the University of Washington Medical Center from January 1989 through December 1998 were reviewed. Demographic information was obtained along with the type and duration of catheter, type and number of complications, and the use of anticoagulant medication. MEASUREMENTS AND RESULTS: Of the 218 CF patients who attended the clinic, 65 patients (30%) had indwelling catheters in place at some time during the study period. A total of 87 catheters were placed into these 65 patients. The total number of catheter-days for first indwelling catheters was 68,220. The total number of catheter-days for all catheters was 75,660 (210 catheter-years). Thirty-five catheter-related complications were identified, occurring in 26 patients. Complications included thrombosis (n = 14), infections (n = 9), mechanical problems (n = 6), pneumothorax (n = 3), superior vena cava syndrome/stenosis (n = 2), and air embolism (n = 1), for an overall complication rate of 0. 463/1,000 catheter-days. CONCLUSION: We conclude that indwelling catheters are relatively safe in patients with CF. Good infection control policies appear to prevent most infectious complications. The most common complication is that of thrombosis, which may be recurrent in some patients. Consideration should be given to prophylactic warfarin therapy despite the potential risk of significant hemoptysis in this patient population.     

漂浮导管和猪尾导管测量肺血管血流动力学参数的比较

目的 比较漂浮导管和猪尾导管测量肺血管血流动力学参数的差异及一致性.方法 入选2018年9月21日至2018年11月30日中国医学科学院阜外医院肺血管病中心疑诊"肺动脉高压"的患者64例,比较漂浮导管和猪尾导管先后测量肺血管血流动力学参数的差异,并进行相关性分析和Bland-Altman一致性分析.结果 漂浮导管测量的...     

Morphologic features of an intact ventricular septum susceptible to subpulmonary obstruction in complete transposition

Twenty-five autopsy specimens of complete transposition of the great arteries with intact ventricular septum (VS) were categorized as “bulging” (11 cases) or “nonbulging” (14 cases) according to the curvature of the VS. A fibrous ridge was observed on the VS, especially at the site of mitral apposition in 82% of the bulging group. No fibrous ridge was seen in the nonbulging group. An objective index of anteroposteriorness was then designed to measure the distance between the midpoint of the nonfacing aortic cusp line and the left anterior descending coronary artery. In the bulging group, the aorta lay more anterior to the pulmonary trunk, whereas in the hearts with a straight VS, the aorta tended to lie side by side and to the right of the pulmonary trunk. The midmitral line is an imaginary line in the middle of the anterior mitral leaflet. The more the pulmonary valve is wedged toward the right atrioventricular junction, the more the midmitral line will pass through the nonfacing pulmonary cusp rather than right pulmonary cusp or the nonfacing/right commissure. This was so in 100% of the bulging group, but in only 36% of the nonbulging group. These differences between the groups in terms of antero-posterior index and extent of wedging were statistically significant. In conclusion, if the aorta lies more anterior and to the left of pulmonary trunk rather than side by side and to the right, the “wedged” subpulmonary area will be more susceptible to obstruction caused by septal bulging. Cross-sectional echocardiography is the best means of diagnosing these features.     

Thrombotic complications of silicone rubber catheters during autologous marrow and peripheral stem cell transplantation: prospective comparison of Hickman and Groshong catheters.

Thrombosis is common after placement of silicone rubber subclavian vein catheters in patients with malignancy receiving conventional doses of chemotherapy. To determine the incidence of this complication in marrow transplant patients and the effect of different catheter designs on thrombosis rates, patients were randomized to receive either open-ended Hickman catheters or valve-ended Groshong catheters for venous access during the transplantation procedure. A total of 35 catheters were placed, of which 23 were double-lumen (11 Groshong and 12 Hickman) and 12 were single-lumen (six Groshong and six Hickman). Arm venograms were performed on all patients at the time of hematopoietic recovery or occurrence of symptoms of subclavian vein thrombosis. There were 10 cases of total subclavian vein thrombosis (three were symptomatic) and 12 cases of asymptomatic non-occlusive mural thrombi. Only 13 normal veins were found. There was no difference in thrombosis rate between the Hickman and Groshong catheters. Double lumen catheters tended to be more likely to cause total venous occlusion (nine of 23) than single lumen catheters (one of 12) (p = 0.06, Fisher's exact test). We conclude that subclavian vein thrombosis is a common occurrence after placement of silicone rubber catheters for venous access during marrow transplantation. Most cases are asymptomatic. Groshong catheters are just as likely to cause this complication as Hickman catheters.     

Clinical, echocardiographic and evolutive aspects of right atrial thrombosis

The clinical and echocardiographic features of right atrial thrombi were examined in 9 patients, 5 men and 4 women aged 16 to 86 years. The 2D echocardiographic diagnosis was confirmed at autopsy (4 cases) or by the association of severe recurrent pulmonary embolism (5 cases). Three patients had associated ischaemic heart disease and on patient had dilated cardiomyopathy. The clinical presentation was: acute cor pulmonale (5 cases including 2 patients which biventricular myocardial infarction), chronic post-embolic cor pulmonale (1 case), tricuspid valve obstruction (1 case), general ill health with pyrexia (1 case) and heparin-induced thrombocytopenia (1 case). Predisposing factors included: absence of anticoagulent therapy (7 cases), previous supraventricular arrhythmias (2 cases) and right ventricular failure (6 cases, including 2 of right ventricular infarction). In 2 patients the thrombi were relatively immobile and had a wide base of implantation on the interatrial septum; in 1 patient, multiple thrombi were observed lining the right heart cavities from the inferior vena cava to the pulmonary infundibulum. In the other 6 patients, the thrombi were very mobile with a visible pedicule of implantation (2 cases) or totally free (4 cases). The variable polylobulated appearances, completely irregular whirling motion and intermittent prolapse into the tricuspid valve were characteristic features of the latter 4 cases. They disappeared spontaneously (2 cases) or after fibrinolytic therapy (2 cases) in under 36 hours. Three patients were operated with one postoperative death. The global hospital mortality was 22%. The present occasional detection of right atrial thrombosis will certainly become more common if patients with pulmonary embolism, right ventricular infarction or deep venous thrombosis are systematically examined by 2D echocardiography in the acute phase of their illness.