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Direct right atrial catheter insertion with video-assisted thoracic surgery
Ann Thorac Surg 1996;62:1197
CASE REPORT BIRNBAUMET AL VATS RIGHT ATRIALCATHETERINSERTION
erative cases that have severe fibrotic a d h e s i o n s b e t w e e n the heart and the pericardium, and can be especially harmful in patients who have u n d e r g o n e coronary artery b y p a s s grafting b e c a u s e forceful dissection of the a d h e sions m a y j e o p a r d i z e p a t e n t bypass grafts. The transdiaphragmatic a p p r o a c h m a k e s it possible to reach the pericardial cavity in patients who have such severe a d h e s i o n s that it is risky to use the conventional subxip h o i d approach. T r a n s e s o p h a g e a l e c h o c a r d i o g r a p h y is a r e m a r k a b l y simple and helpful m e t h o d to reliably localize the pericardial effusion a n d confirm its complete drainage by this a p p r o a c h [31, There have been several other a p p r o a c h e s r e p o r t e d for pericardial drainage, including a thoracoscopic a p p r o a c h t h r o u g h an intercostal space a n d a laparoscopic a p p r o a c h without an a b d o m i n a l incision [4, 5]. However, we think t r a n s d i a p h r a g m a t i c a p p r o a c h with l a p a r o t o m y g u i d e d by transesophageal e c h o c a r d i o g r a p h y is the safest a n d the most secure choice in patients who have localized pericardial effusion in the posterior region of the heart, especially patients who have u n d e r g o n e coronary artery bypass grafting, to protect the b y p a s s grafts and achieve complete drainage. References 1. Moores DW, Dziuban SW Jr. Pericardial drainage procedures [Reviewl. Chest Surg Clin North Am 1995;5:359-73. 2. Temeck BK, Pass HI. A method to facilitate subxiphoid pericardiotomy. Ann Thorac Surg 1994;57:1015-7. 3. Golub RJ, McNulty CM, McClellan JR, St. Laurent L. Prior MW. Usefulness of transesophageal Doppler echocardiography in the surgical drainage of a loculated purulent pericardial effusion. Am Heart J 1993;126:724-7. 4. Hurley JP, Subarreddy K, McCarthy J, Wood AE. Videoassisted thoracic surgery for delayed pericardial effusion post-CABG [Review]. Chest 1994;106:1617-9. 5. Mayer HJ. Transdiaphragmatic pericardial window: a new approach. J Cardiovasc Surg 1993;34:173-5.
Direct Right Atrial Catheter Insertion With Video-Assisted Thoracic Surgery Peter L. Birnbaum, MD, Constantine Michas, MD, a n d Sheldon E. Cohen, MD Departments of Cardiac and General Surgery,, Fresno Community Hospital and Medical Center, Fresno, California Chronic gastrointestinal disorders may require support with long-term total parenteral nutrition via a central venous catheter. Central venous access may be problematic because of infection or thrombosis of previous catheters. We report a case where video-assisted thoracic surgical catheter insertion directly into the right atrium provided a successful and safe method of long-term central venous access for parenteral nutrition.
(Ann Thorac Surg 1996;62:1197) Accepted tor publication April 23, 1996. Address reprint requests to Dr Birnbaum, 110 N Valeria, Suite 204, Fresno, CA 93701. © 1996 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
1197
hronic total p a r e n t e r a l nutrition via central venous access has p r o v e d lifesaving for m a n y patients suffering from a wide range of severe gastrointestinal disorders. Indwelling catheters are p r o n e to infection a n d thrombosis. The surgeon m a y be faced with a d i l e m m a to provide reliable v e n o u s access for a group of patients critically d e p e n d e n t on long-term total p a r e n t e r a l nutrition. Video-assisted thoracic surgery has p r o v i d e d the surgeon with a less invasive rnodality capable of p r o v i d ing reliable a n d safe catheter insertion directly into the right atrium.
C
A 45-year-old w o m a n with l o n g - s t a n d i n g s c l e r o d e r m a a n d severe malnutrition h a d been d e p e n d e n t on total p a r e n t e r a l nutrition for all her nutritional needs for the past 3 years. Recurrent venous t h r o m b o s i s h a d complicated seven prior central venous catheters placed through internal/external jugular veins a n d both groin sites. Video-assisted thoracic surgical techniques were applied with d o u b l e - l u m e n intubation a n d the patient in the left lateral decubitus position. A t h r e e - p o r t intercostal access t e c h n i q u e was e m p l o y e d . The thoracoscope was used t h r o u g h the seventh intercostal space in the posterior axillary line. The thoracoscopic needle driver was e m p l o y e d via the midaxillary line in the fifth intercostal space. An atraumatic thoracoscopic g r a s p e r was inserted via the m i d s c a p u l a r line in the fifth intercostal space. The s u p e r i o r p e r i c a r d i u m was o p e n e d 5 cm longitudinally, anterior to the phrenic nerve, p r o v i d i n g excellent exposure to the free wall of the right atrium. A 4-0 Prolene (Ethicon, Somerville, NJ) p u r s e s t r i n g suture was placed in the right atrium using a v i d e o - a s s i s t e d thoracic surgical needle driver. A s t a n d a r d n e e d l e / g u i d e w i r e introducer set, via the midaxillary trocar site, was then u s e d for the insertion of a n u m b e r 9.5 G r o s h o n g catheter directly into the right atrium. The p u r s e s t r i n g suture was tied down and a second 4-0 Prolene suture was u s e d to fix the catheter in position to the pericardial edge. All knots were tied intracorporeally. The proximal catheter end was b r o u g h t out of the chest and t u n n e l e d u n d e r the s u b c u t a n e o u s tissues of the anterior chest wall. Care was taken to ensure slack r e m a i n e d on the catheter within the chest to p r e v e n t tension d u r i n g lung inflation. Blood loss was minimal. A n u m b e r 32 chest tube was positioned in the apex of the right pleural cavity. A p o s t o p e r a t i v e chest r o e n t g e n o g r a m confirmed excellent positioning of the catheter within the right atrium. The patient is p r e s e n t l y 7 m o n t h s postoperative without any catheter problems.
Comment Video-assisted thoracic surgery, m a y provide a safe a n d reliable t e c h n i q u e for establishing direct right atrial catheter insertion for patients whose central venous system is otherwise inaccessible. 0003-49751961515.00 PII S0003-4975(96)00382-7
CASE REPORT BIRNBAUMET AL VATS RIGHT ATRIALCATHETERINSERTION
erative cases that have severe fibrotic a d h e s i o n s b e t w e e n the heart and the pericardium, and can be especially harmful in patients who have u n d e r g o n e coronary artery b y p a s s grafting b e c a u s e forceful dissection of the a d h e sions m a y j e o p a r d i z e p a t e n t bypass grafts. The transdiaphragmatic a p p r o a c h m a k e s it possible to reach the pericardial cavity in patients who have such severe a d h e s i o n s that it is risky to use the conventional subxip h o i d approach. T r a n s e s o p h a g e a l e c h o c a r d i o g r a p h y is a r e m a r k a b l y simple and helpful m e t h o d to reliably localize the pericardial effusion a n d confirm its complete drainage by this a p p r o a c h [31, There have been several other a p p r o a c h e s r e p o r t e d for pericardial drainage, including a thoracoscopic a p p r o a c h t h r o u g h an intercostal space a n d a laparoscopic a p p r o a c h without an a b d o m i n a l incision [4, 5]. However, we think t r a n s d i a p h r a g m a t i c a p p r o a c h with l a p a r o t o m y g u i d e d by transesophageal e c h o c a r d i o g r a p h y is the safest a n d the most secure choice in patients who have localized pericardial effusion in the posterior region of the heart, especially patients who have u n d e r g o n e coronary artery bypass grafting, to protect the b y p a s s grafts and achieve complete drainage. References 1. Moores DW, Dziuban SW Jr. Pericardial drainage procedures [Reviewl. Chest Surg Clin North Am 1995;5:359-73. 2. Temeck BK, Pass HI. A method to facilitate subxiphoid pericardiotomy. Ann Thorac Surg 1994;57:1015-7. 3. Golub RJ, McNulty CM, McClellan JR, St. Laurent L. Prior MW. Usefulness of transesophageal Doppler echocardiography in the surgical drainage of a loculated purulent pericardial effusion. Am Heart J 1993;126:724-7. 4. Hurley JP, Subarreddy K, McCarthy J, Wood AE. Videoassisted thoracic surgery for delayed pericardial effusion post-CABG [Review]. Chest 1994;106:1617-9. 5. Mayer HJ. Transdiaphragmatic pericardial window: a new approach. J Cardiovasc Surg 1993;34:173-5.
Direct Right Atrial Catheter Insertion With Video-Assisted Thoracic Surgery Peter L. Birnbaum, MD, Constantine Michas, MD, a n d Sheldon E. Cohen, MD Departments of Cardiac and General Surgery,, Fresno Community Hospital and Medical Center, Fresno, California Chronic gastrointestinal disorders may require support with long-term total parenteral nutrition via a central venous catheter. Central venous access may be problematic because of infection or thrombosis of previous catheters. We report a case where video-assisted thoracic surgical catheter insertion directly into the right atrium provided a successful and safe method of long-term central venous access for parenteral nutrition.
(Ann Thorac Surg 1996;62:1197) Accepted tor publication April 23, 1996. Address reprint requests to Dr Birnbaum, 110 N Valeria, Suite 204, Fresno, CA 93701. © 1996 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
1197
hronic total p a r e n t e r a l nutrition via central venous access has p r o v e d lifesaving for m a n y patients suffering from a wide range of severe gastrointestinal disorders. Indwelling catheters are p r o n e to infection a n d thrombosis. The surgeon m a y be faced with a d i l e m m a to provide reliable v e n o u s access for a group of patients critically d e p e n d e n t on long-term total p a r e n t e r a l nutrition. Video-assisted thoracic surgery has p r o v i d e d the surgeon with a less invasive rnodality capable of p r o v i d ing reliable a n d safe catheter insertion directly into the right atrium.
C
A 45-year-old w o m a n with l o n g - s t a n d i n g s c l e r o d e r m a a n d severe malnutrition h a d been d e p e n d e n t on total p a r e n t e r a l nutrition for all her nutritional needs for the past 3 years. Recurrent venous t h r o m b o s i s h a d complicated seven prior central venous catheters placed through internal/external jugular veins a n d both groin sites. Video-assisted thoracic surgical techniques were applied with d o u b l e - l u m e n intubation a n d the patient in the left lateral decubitus position. A t h r e e - p o r t intercostal access t e c h n i q u e was e m p l o y e d . The thoracoscope was used t h r o u g h the seventh intercostal space in the posterior axillary line. The thoracoscopic needle driver was e m p l o y e d via the midaxillary line in the fifth intercostal space. An atraumatic thoracoscopic g r a s p e r was inserted via the m i d s c a p u l a r line in the fifth intercostal space. The s u p e r i o r p e r i c a r d i u m was o p e n e d 5 cm longitudinally, anterior to the phrenic nerve, p r o v i d i n g excellent exposure to the free wall of the right atrium. A 4-0 Prolene (Ethicon, Somerville, NJ) p u r s e s t r i n g suture was placed in the right atrium using a v i d e o - a s s i s t e d thoracic surgical needle driver. A s t a n d a r d n e e d l e / g u i d e w i r e introducer set, via the midaxillary trocar site, was then u s e d for the insertion of a n u m b e r 9.5 G r o s h o n g catheter directly into the right atrium. The p u r s e s t r i n g suture was tied down and a second 4-0 Prolene suture was u s e d to fix the catheter in position to the pericardial edge. All knots were tied intracorporeally. The proximal catheter end was b r o u g h t out of the chest and t u n n e l e d u n d e r the s u b c u t a n e o u s tissues of the anterior chest wall. Care was taken to ensure slack r e m a i n e d on the catheter within the chest to p r e v e n t tension d u r i n g lung inflation. Blood loss was minimal. A n u m b e r 32 chest tube was positioned in the apex of the right pleural cavity. A p o s t o p e r a t i v e chest r o e n t g e n o g r a m confirmed excellent positioning of the catheter within the right atrium. The patient is p r e s e n t l y 7 m o n t h s postoperative without any catheter problems.
Comment Video-assisted thoracic surgery, m a y provide a safe a n d reliable t e c h n i q u e for establishing direct right atrial catheter insertion for patients whose central venous system is otherwise inaccessible. 0003-49751961515.00 PII S0003-4975(96)00382-7