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Flailed tricuspid valve as a complication of retrieving fractured catheter
International Journal of Cardiology 119 (2007) 225 – 226 www.elsevier.com/locate/ijcard
Letter to the editor
Flailed tricuspid valve as a complication of retrieving fractured catheter Tsung-Neng Tsai, Kai-Min Chu, Bing-Hsiean Tzeng, Shih-Ping Yang, Wei-Shiang Lin ⁎ Division of Cardiology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, ROC Received 16 February 2006; received in revised form 20 July 2006; accepted 22 July 2006 Available online 25 October 2006
Abstract The implantable venous port system has gained popularity as venous access when prolonged chemotherapy is needed in cancer patients. Intravascular fracture and embolization of catheter fragments from port-catheter systems is rare. Here we report a 49-year-old lady who was found having a fractured port-catheter located over the right ventricular outflow tract (RVOT). Percutaneous transfemoral transcatheter retrieval of the fractured catheter was performed but complicated with flailed tricuspid valve. © 2006 Elsevier Ireland Ltd. All rights reserved. Keywords: Transcatheter retrieval of fractured catheter; Flailed tricuspid valve; Neoadjuvant chemotherapy
1. Case report A 49-year-old woman had a venous port-catheter (Mediport) implanted into the right subclavian vein for neoadjuvant chemotherapy for breast cancer. Intermittent palpitation and shortness of breath were noted over 2 weeks prior to admission especially when she lied down. On admission, a physical examination and an electrocardiogram revealed no abnormalities except a surgical scar over the left chest wall. A chest roentgenogram showed normal location of the port system, but the distal fragment of the catheter had migrated into the right ventricle and pulmonary trunk. (Fig. 1A) Subsequently, the percutaneous transcatheter retrieval of the fractured fragment was arranged with the Amplatz Nitinol gooseneck snare (Microvena, White Bear Lake, MN). The snare was put into the pulmonary artery smoothly but had difficulty in
⁎ Corresponding author. Division of Cardiology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center. No 325, Section 2, Cheng-Kung Road, Neihu 114, Taipei, Taiwan, ROC. Tel.: +886 2 87927160; fax: +886 2 87927161. E-mail address: [email protected] (W.-S. Lin). 0167-5273/$ - see front matter © 2006 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2006.07.178
grasping and holding the distal end of the fragment over RVOT. Then the loop snare slid back from the distal end to the middle portion of the fragment and held it tightly. (Fig. 1B) The fragment was retrieved slowly. Mild resistance was felt when it was pulled back from the tricuspid valves. At the same time, the patient complained of severe chest pain. After removal of the fractured fragment, a transthorathic echocardiography was performed and disclosed flailed tricuspid valves (TV) with severe regurgitation. (Fig. 2) Her chest pain subsided gradually and received regular follow up at the outpatient department without further complaint. 2. Discussion Since its first description in 1964 by Thomas et al. [1], the percutaneous transvenous removal of intravascular foreign bodies has become a frequently applied technique due to its feasibility and safety [2,3]. The reported success rate is higher than 95% with few complications [4]. The most procedure related complications were local hematoma over the puncture site or cardiac arrhythmia during manipulation of the snare in the heart chambers, flailed tricuspid valve has not been reported yet [5,6]. In our case, due to the specific location of
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T.-N. Tsai et al. / International Journal of Cardiology 119 (2007) 225–226
Fig. 1. (A) Chest X-ray shows fractured catheter has migrated to the right ventricle. (B) Because the catheter tip was located at the pulmonary valve, this will probably be difficult to grasp tightly with loop snare. Alternated loop snare hold at the middle portion of the fractured catheter.
Fig. 2. Transthorathic echocardiography under four chamber view disclosed a flailed tricuspid valve (arrows) with severe tricuspid regurgitation on colour Doppler.
the fragment over the pulmonary outflow tract, we had difficulty in holding the distal end of the fragment with snare and led us to grasp the middle portion of the fragment. Although the enfolded catheter had been pulled back through the TV, unfortunately it damaged the TV. It might be caused by increasing the contact dimension of the fragment with the TV when grasping the middle portion of the fragment. In this context, if the free end of the fragment is not easily held by the snare due to its specific location, two stage strategies might be required to reposite the fragment by a pigtail catheter to expose its free end, followed by grasping the distal end of the fragment by loop snare and pull back gently. In addition, an echocardiography should be followed routinely after the procedure especially when increased resistance happened during manipulation, in order to early detect the iatrogenic valvular damage.
References [1] Thomas J, Sinclair-Smith B, Bloomfield D, Davachi A. Nonsurgical retrieval of broken segment of steel spring guide from the right atrium and inferior vena cava. Circulation 1964;30:106–8. [2] Harikrishnan S, Rajeev E, Nair K, Tharakan J. Retrieval of friable catheter fragments. Int J Cardiol 2006;13:282–4. [3] Cioppa A, Ambrosini V, Battaglia S, et al. Endovascular foreign body retrieval from right side of the heart: a case series of six patients. Int J Cardiol 2005;10:143–4. [4] Cekirge S, Weiss JP, Foster RG, Neiman HL, McLean GK. Percutaneous retrieval of foreign bodies: experience with the Nitinol goose neck snare. J Vasc Interv Radiol 1993;4:805–10. [5] Gabelmann A, Kramer S, Gorich J. Percutaneous retrieval of lost or misplaced intravascular objects. Am J Roentgenol 2001;176:1509–13. [6] Koseoglu K, Parildar M, Oran I, Memis A. Retrieval of intravascular foreign bodies with goose neck snare. Eur J Radiol 2004;49:281–5.
Letter to the editor
Flailed tricuspid valve as a complication of retrieving fractured catheter Tsung-Neng Tsai, Kai-Min Chu, Bing-Hsiean Tzeng, Shih-Ping Yang, Wei-Shiang Lin ⁎ Division of Cardiology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, ROC Received 16 February 2006; received in revised form 20 July 2006; accepted 22 July 2006 Available online 25 October 2006
Abstract The implantable venous port system has gained popularity as venous access when prolonged chemotherapy is needed in cancer patients. Intravascular fracture and embolization of catheter fragments from port-catheter systems is rare. Here we report a 49-year-old lady who was found having a fractured port-catheter located over the right ventricular outflow tract (RVOT). Percutaneous transfemoral transcatheter retrieval of the fractured catheter was performed but complicated with flailed tricuspid valve. © 2006 Elsevier Ireland Ltd. All rights reserved. Keywords: Transcatheter retrieval of fractured catheter; Flailed tricuspid valve; Neoadjuvant chemotherapy
1. Case report A 49-year-old woman had a venous port-catheter (Mediport) implanted into the right subclavian vein for neoadjuvant chemotherapy for breast cancer. Intermittent palpitation and shortness of breath were noted over 2 weeks prior to admission especially when she lied down. On admission, a physical examination and an electrocardiogram revealed no abnormalities except a surgical scar over the left chest wall. A chest roentgenogram showed normal location of the port system, but the distal fragment of the catheter had migrated into the right ventricle and pulmonary trunk. (Fig. 1A) Subsequently, the percutaneous transcatheter retrieval of the fractured fragment was arranged with the Amplatz Nitinol gooseneck snare (Microvena, White Bear Lake, MN). The snare was put into the pulmonary artery smoothly but had difficulty in
⁎ Corresponding author. Division of Cardiology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center. No 325, Section 2, Cheng-Kung Road, Neihu 114, Taipei, Taiwan, ROC. Tel.: +886 2 87927160; fax: +886 2 87927161. E-mail address: [email protected] (W.-S. Lin). 0167-5273/$ - see front matter © 2006 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2006.07.178
grasping and holding the distal end of the fragment over RVOT. Then the loop snare slid back from the distal end to the middle portion of the fragment and held it tightly. (Fig. 1B) The fragment was retrieved slowly. Mild resistance was felt when it was pulled back from the tricuspid valves. At the same time, the patient complained of severe chest pain. After removal of the fractured fragment, a transthorathic echocardiography was performed and disclosed flailed tricuspid valves (TV) with severe regurgitation. (Fig. 2) Her chest pain subsided gradually and received regular follow up at the outpatient department without further complaint. 2. Discussion Since its first description in 1964 by Thomas et al. [1], the percutaneous transvenous removal of intravascular foreign bodies has become a frequently applied technique due to its feasibility and safety [2,3]. The reported success rate is higher than 95% with few complications [4]. The most procedure related complications were local hematoma over the puncture site or cardiac arrhythmia during manipulation of the snare in the heart chambers, flailed tricuspid valve has not been reported yet [5,6]. In our case, due to the specific location of
226
T.-N. Tsai et al. / International Journal of Cardiology 119 (2007) 225–226
Fig. 1. (A) Chest X-ray shows fractured catheter has migrated to the right ventricle. (B) Because the catheter tip was located at the pulmonary valve, this will probably be difficult to grasp tightly with loop snare. Alternated loop snare hold at the middle portion of the fractured catheter.
Fig. 2. Transthorathic echocardiography under four chamber view disclosed a flailed tricuspid valve (arrows) with severe tricuspid regurgitation on colour Doppler.
the fragment over the pulmonary outflow tract, we had difficulty in holding the distal end of the fragment with snare and led us to grasp the middle portion of the fragment. Although the enfolded catheter had been pulled back through the TV, unfortunately it damaged the TV. It might be caused by increasing the contact dimension of the fragment with the TV when grasping the middle portion of the fragment. In this context, if the free end of the fragment is not easily held by the snare due to its specific location, two stage strategies might be required to reposite the fragment by a pigtail catheter to expose its free end, followed by grasping the distal end of the fragment by loop snare and pull back gently. In addition, an echocardiography should be followed routinely after the procedure especially when increased resistance happened during manipulation, in order to early detect the iatrogenic valvular damage.
References [1] Thomas J, Sinclair-Smith B, Bloomfield D, Davachi A. Nonsurgical retrieval of broken segment of steel spring guide from the right atrium and inferior vena cava. Circulation 1964;30:106–8. [2] Harikrishnan S, Rajeev E, Nair K, Tharakan J. Retrieval of friable catheter fragments. Int J Cardiol 2006;13:282–4. [3] Cioppa A, Ambrosini V, Battaglia S, et al. Endovascular foreign body retrieval from right side of the heart: a case series of six patients. Int J Cardiol 2005;10:143–4. [4] Cekirge S, Weiss JP, Foster RG, Neiman HL, McLean GK. Percutaneous retrieval of foreign bodies: experience with the Nitinol goose neck snare. J Vasc Interv Radiol 1993;4:805–10. [5] Gabelmann A, Kramer S, Gorich J. Percutaneous retrieval of lost or misplaced intravascular objects. Am J Roentgenol 2001;176:1509–13. [6] Koseoglu K, Parildar M, Oran I, Memis A. Retrieval of intravascular foreign bodies with goose neck snare. Eur J Radiol 2004;49:281–5.