A potential hazard of the transseptal left atrial catheterization technic∗

New Method A Potential Hazard of the Transseptal Left Atrial Catheterization Technic* HENRY D . MCINTOSH, M .D ., ROBERT E . WHALEN, M .D ., RAFAEL R . HERNANDEZ, M .D ., JAMES J . MORRTS, M .D . and D . EDMOND MILLER, M .D .

Durham, North Carolina

in this clinic with over 100 patients has demonstrated that the transseptal technic' for left atrial catheterization is relatively easy and free of major complication .? a Utilization of percutaneous methods for introducing the catheter' through which to pass the needle and the ease with which the catheter may subsequently be passed over the needle into the left atrium 2.' make this method extremely useful . However, passing a 59 cm . needle into the venous system and atria through a guiding catheter or "sleeve" is fraught with potential hazard . The point of the needle must be sharp or it will not easily penetrate the interatrial septum . If the point is sharp enough it can also be forced through the wall of the guiding catheter . The present report discusses this potential hazard and describes certain undesirable characteristics of the radiopaque Nylon catheter which is generally used as the "sleeve" for the needle .

E

determine if the penetration could have been recognized with conventional fluoroscopy, the same catheter and needle were placed in a phantom with a density similar to a 70 kg . man . Despite accommodating for 10 minutes, we could not recognize the needle tip extending through the catheter with conventional fluoroscopy . Unexpected penetration of the catheter by the needle may be avoided by using a leading stylus (Fig . 2, bottom)? It is possible with force, however, for the stylus to penetrate the catheter . The internal wall of the Nylon catheter tends to become rough and obstruct the free passage of the needle . If resistance is encountered, the needle should he withdrawn several centimeters and the catheter rotated . If resistance is again encountered, the needle should be removed and a new catheter introduced . It is apparent that monitoring the passage of the needle with an image intensifier is an added precaution in preventing this complication .

XPERIENCE

Penetration

of Catheter

"Sleeve"

by

Needle :

Elongation of Nylon Catheter by Heat and Fluid :

We know of four such instances when the needle It became apparent on several occasions, inadvertently perforated the guiding catheter . while monitoring the transseptal catheterizaFortunately there were no serious sequelae . tion with the image amplifier, that the tip of the Figures 1 and 2 (top) show an x-ray film and needle did not protrude beyond the end of the photograph of such a penetration that occurred catheter as far as would be expected from prein our laboratory . It was immediately reccatheterization measurements . This observaognized that the needle had penetrated the tion prompted an investigation of the effect of catheter wall in this instance, as the study was fluid and heat on the No . 8 Lehman Nylon being done with an image intensifier . f To catheters+ used as a "sleeve" for the transf Eight inch, Picker X-ray Corp ., White Plains, New t. U . S . Catheter and Instrument Corp ., Glens Falls, York. New York . * From the Department of Medicine, Duke Medical Center, Durham, North Carolina . This work was supported by Research Grants H-4807 and H-TS 5369 from the National Heart institute and H-3582 and M-2109 from the Duke Medical Center for Aging, both of the National Institutes of Health, U. S . Public Health Service, and Grants-in-Aid from the American and North Carolina Heart Associations and the Life Insurance Medical Research Fund . DECEMBER

1961

835



836

McIntosh et . al .

Top : Photograph of the same catheter and needle seen in Figure 1 . Bottom : Leading rounded stylus for introduction of Ross-Braunwald transseptal needle (left insert) . The screw stop was made locally (right insert), FIG .2 .

"Spot" x-ray film showing the No . 8 Nylon Lehman catheter penetrated by the Ross-Braunwald trausseptal needle (left) ; retrograde aortic catheter (right) . FIG . 1 .

septal needle . Table I demonstrates that the Lehman catheter actually increases in length when placed in a 37 degree water bath . There was no change in length when the catheter was placed in water at room temperature . Thus, careful measurement, prior to catheterization, of the length of protrusion of the needle past the catheter may not be accurate after the catheter has been in the body for more than a few minutes . The catheter may also be stretched by the needle if the tip meets resistance while passing through the catheter and pressure is exerted . The elongation of the Lehman Nylon catheter

TABLE I

Changes in Catheter Length (mm .) in a 37 °c . Water Bath Type of Catheter

30

60

Minutes

Minutes

is thought to be due to the hydrophilic and thermoplastic properties of the Nylon threads . 6 Teflon" catheters* do not appear to elongate (Table I) . The material is said to be essentially void of hydrophilic properties . 6 The internal lumen is smoother than the Nylon catheter and the point of the needle is less likely to meet resistance and penetrate the wall . OdmanLedin and polyethylene tubing are also frequently used as a "sleeve" for the needle . The former is radiopaque, the latter is not . Table I indicates that the Swedish tubing may elongate 2 to 3 mm . We have had no experience with radiopaque polyethylene tubing . In retrospect, we believe that some of our "difficult" transseptal catheterizations were due to elongation of the catheter . The tip of the needle was probably not extending sufficiently beyond the catheter tip to penetrate the septum . When the septum is not crossed easily as expected, there is a natural tendency to "push harder" or try another site . Both acts are potentially hazardous . SUMMARY AND CONCLUSIONS

No. 8 Lehman'

A B C

No . 8 Ross fC-10 Teflon` PE-205 Polyethylene Tubingt Yellow (dman-Ledint

+2

+11

+4 +7 -1

+10 +13 - 1

0 +2

+ 1

+ 3

* U .S. Catheter and Instrument Corp ., Glens Falls, New York . t Clay Adams, New York, New York . t Picker X-Ray Corp ., White Plains, New York .

1 . A potential hazard of the transseptal technic of left heart catheterization is penetration of the wall of the guiding catheter with possible laceration of the great veins or right atrium . Suggestions for preventing this potential complication are offered . 2 . Radiopaque Nylon catheters, commonly * U .S. Catheter and Instrument Corp ., Glens Falls, New York . THE AMERICAN JOURNAL OF CARDIOLOGY



Transseptal Left Atrial Catheterization used as the "sleeve" for the transseptal needle, elongate when placed in an environment of 37'c . Radiopaque Teflon catheters are free of this disadvantage . Use of such catheters is recommended for this procedure .

niques for catheter insertions.

4.

DECEMBER 1961

177 :76,

and ScHERLIS, L . Transscptal catheterization of the left heart : observations in 56 patients . Am . Heart J., 60 : 879, 1960 . BROCKENBROUGH, E . C . and BRAUNWALD, E . A new technic for left ventricular angiocardiography and transseptat left heart catheterization . Am . J.

Cardiol ., 6 : 1062, 1960. 5 . GGRLSN, R ., KRASNGW, N., LEVINE, H . J ., NEILL, W . A ., 1VACMAN, R . J . and MESSER, J . V. A

Am . J. Cordial., 3 : 653, 1959 .

2 . MCIr osu, H. D ., SLEEPER, J . C ., THOMPSGN, H . K., JR, and WHALEN, R . E . Simplification of left heart catheterization utilizing percutaneous tech-

J.A .M.A .,

1961 . 3 . SINGLETON, R . T.

REFERENCES

1 . Ross, J ., JR., BRAUNWALD, E . and MORROW, A. G. 'l'ransseptal left atrial puncture : New technic for the measurement of left atrial pressure in man .

837

6.

modification of the technic of transseptal left heart catheterization . Am, J. Cordial ., 7 : 580, 1961 . Duke University, Durham, North Carolina . Personal communication .