Stitched To the Heart – Till Intervention Do Us Part

ABSTRACT: The case report describes the situation where a venous infusion catheter was inadvertently stitched to the lateral wall of the right atrium during valve replacement. A dual percutaneous approach was used to first sever the catheter at the suture and then remove both ends safely. The risk of tearing the suture which would have resulted in tamponade had to be avoided. J INVASIVE CARDIOL 2010;22:E42–E43 Entrapment of a central venous catheter to an intracardiac structure in open heart surgery is a rare but serious complication. We report a case wherein a central venous catheter was inadvertently sutured to the right atrium in a patient who underwent aortic valve replacement. Percutaneous retrieval of the entrapped catheter in such cases reduces the need for surgery and its associated complications. Case Report. A 42-year-old female intravenous drug user with chronic hepatitis B and HIV co-infection presented with infective endocarditis of the native aortic and mitral valves. The patient underwent aortic valve replacement through a median sternotomy with a 21 mm Edwards Lifesciences Perimount Magna Ease bioprosthetic valve (Irvine, California). Mitral valve repair was done with a 28 mm Edwards Lifesciences mitral ring and the tricuspid valve received a 34 mm Edwards Lifesciences tricuspid ring. A 7 French (Fr) triple lumen central venous catheter inserted preoperatively through the right subclavian vein was inadvertently sutured to the right atrial wall after cannulation of the superior vena cava for extracorporeal bypass. This was detected in the intensive care unit on the second postoperative day when attempts to withdraw the catheter were met with firm resistance. Chest radiography was performed which ruled out any knot or kink that could account for the catheter being stuck. Procedure. The catheter was successfully retrieved percutaneously using a combination of techniques in the catheterization laboratory under local anesthesia. The distal free tip of the catheter in the right atrium was caught with a nitinol Goose Neck snare (Plymouth, Minnesota) introduced from the right femoral vein. The snare was moved up around the catheter about 15 mm when resistance was met revealing the site of fixation of the catheter to the right atrial wall by the surgical suture. Attempts to pull the catheter with the snare failed. A second self fabricated snare (doubled-over 0.014 inch coronary guidewire) was pushed over the first snare completely up to the suture. The initial snare was then retracted towards the distal end of the entrapped catheter in the idea to secure it after cutting the catheter with the self-fabricated snare right at the suture. Maximal retraction was then applied to the self-fabricated snare (Figure 1) but it proved impossible to sever the entrapped catheter which resisted being cut by the wire. We then tried in vain to sever the catheter at the attachment site with a biotome. Finally it was hoped that the catheter was sufficiently weakened just caudal to the inadvertent suture to be torn by simultaneous traction from below using the Goose Neck snare and above pulling at the catheter itself close to its subclavian entry. Applying near maximal strength of 2 people, the catheter first elastically stretched and then finally snapped. Both fragments could be easily removed through the subclavian venous puncture and the femoral venous puncture respectively (Figure 2). The patient had no discomfort during the procedure. She was surveyed for possible pericardial effusion considering the fact that the suture in the free right atrial wall would loosen somewhat by removal of the entrapped catheter. Her electrocardiogram and echocardiogram the next day were normal and so was the remainder of her hospital stay. Discussion. Entrapment of a catheter to an intracardiac structure after an open heart surgery is a rare occurrence with potentially serious consequences. The overall prevalence of a Swan Ganz catheter entrapment is 0.065%.1 Early detection is essential and should be suspected when resistance is encountered while withdrawing the catheter. Diagnostic confirmation is made by chest radiography, fluoroscopy and echocardiography. Blind forceful extraction should not be done as it may result in atrial laceration and resultant hemorrhagic tamponade.2 Various percutaneous techniques have been described for the removal of intravascular foreign bodies. The most frequently identified foreign bodies are fragments of venous catheters. Kanazawa et al3 reported the successful percutaneous retrieval of an entrapped catheter using a combination of loop-snare wire and myocardial biopsy forceps. The catheter was cut into two pieces with the forceps and the suture loosened by repeated push and pull manipulation. Neuerburg et al4 reported the successful retrieval of an entrapped catheter by tearing the catheter into two pieces by simultaneously pulling both ends of it using two nitinol Goose Neck snares placed as close to the point of suture fixation as possible. We used a combination of these methods to loosen the suture, weaken the catheter at its entrapped site, and finally sever it without loosing control of the pieces. The above procedure carried a definite risk and surgical option was kept ready in case of an emergency.

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From the Swiss Cardiovascular Center Bern, University Hospital, Bern, Switzerland. The authors report no conflict of interest regarding the content herein. Manuscript submitted August 14, 2009, provisional acceptance given August 31, 2009, final version September 22, 2009. Address for correspondence: Bernhard Meier, M.D., FACC, FESC, Professor of Cardiology, Cardiovascular Department, University Hospital Bern, 3010 Bern, Switzerland. Email: bernhard.meier@insel.ch

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References

1. Kaplan M, Demirtas M, Cimen S. Swan-Ganz catheter entrapment in open heart surgery. J Card Surg 2000;15:313–315. 2. Huang GS, Wang HJ, Chen CH, et al. Pulmonary artery rupture after attempted removal of a pulmonary artery catheter. Anesth Analg 2002;95:299–301. 3. Kanazawa S, Yasui K, Hiraki Y. Percutaneous retrieval of a central venous catheter sutured to the wall of the inferior vena cava. Cardiovasc Intervent Radiol 1994;17:347–349. 4. Neuerberg JM, Gunther RW, Chalabi K, Hunter D. Percutaneous retrieval of a central venous catheter sutured to the wall of the right atrium. Cardiovasc Intervent Radiol 1999;22:79–80.