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Retained left atrial catheter after coronary artery bypass operation
Retained Left Atrial Catheter after Coronary Artery Bypass Operation Ildiko Agoston, MD, Rakshak Sarda, MD, Antonio J. Chamoun, MD, Scott D. Lick, MD, and Masood Ahmad, MD, Galveston, Texas
We recently detected a retained left atrial (LA) pressure catheter 6 months after coronary artery bypass grafting with echocardiography.
CASE REPORT A 60-year-old woman underwent elective coronary artery bypass grafting. Weaning from bypass was marked by transient pulmonary hypertension, so a LA pressure catheter was placed by the right superior pulmonary vein to help with early postoperative treatment. This was removed apparently uneventfully at the bedside on the first postoperative day. The rest of her recovery was unremarkable. Discharge chest radiograph was normal, as was her follow-up radiograph 3 weeks later. Six months after operation, transthoracic echocardiography was performed to evaluate left ventricular function. A linear echodensity was seen in the LA (Figure 1). Transesophageal echocardiography was then performed and showed a mobile catheter in the LA originating outside the heart at the level of the right upper pulmonary vein (Figure 2). No clot was seen on the visible (intracardiac) portion of the catheter. Fluoroscopy confirmed the presence of the radiopaque-striped catheter curving around the right pericardium and stopping near the lower sternal wires (Figure 3), where it had apparently broken during removal. This could not be seen on a repeated chest radiograph. The patient underwent uneventful removal of the catheter under general anesthetic, using a subxiphoid approach with retraction of the lower right sternum.
Figure 1 Transthoracic parasternal long-axis view. Linear echogenic shadow (arrow) in left atrium (LA) represents retained catheter. AO, Aorta; LV, left ventricle.
Figure 2 Multiplane transesophageal echocardiography image. Catheter (arrow) in left atrium (LA) can be followed into right upper pulmonary vein (PV).
DISCUSSION From the Division of Cardiology, University of Texas Medical Branch at Galveston. Reprint requests: Masood Ahmad, MD, Division of Cardiology, University of Texas Medical Branch at Galveston, 301 University Blvd, Galveston, TX 77555-0553. J Am Soc Echocardiogr 2004;17:489-90. 0894-7317/$30.00 Copyright 2004 by the American Society of Echocardiography. doi:10.1016/j.echo.2004.02.009
Monitoring LA pressure in the postoperative period is a documented useful tool for optimizing hemodynamic parameters in patients undergoing open heart operation.1 Complications of LA monitoring catheter are rare and consist mainly of hemorrhage after catheter removal, systemic gaseous microembolization, and embolic stroke from retained catheter fragments.2 LA catheters are used frequently at our
489
Journal of the American Society of Echocardiography May 2004
490 Agoston et al
the catheter should be compared with an unused identical catheter to ensure that it has not broken. The catheter used was radiopaque, but was not large enough to show up on standard postoperative radiography. Hence, echocardiography or fluoroscopy was needed to demonstrate it. In this case, the catheter was a completely unsuspected transthoracic echocardiography finding remote from the operation. The catheter had no detectable clots by transesophageal echocardiography, but nonetheless was removed because of its potential to cause thrombosis and subsequent embolism. We chose not to try intravascular snaring to remove it because of the large portion of the catheter remaining outside the heart. Retained LA catheter should be entertained in the differential diagnosis of intra-atrial thin foreign body on postcardiacoperation echocardiogram. REFERENCES Figure 3 Fluoroscopy demonstrating retained left atrial catheter (arrows) in entire length extending beyond heart border into mediastinum.
hospital to aid in early postcardiac-operation treatment. They are usually removed on the first postoperative day. If resistance is encountered on removal,
1. Santini F, Gatti G, Borghetti V, Oppido G, Mazzucco A. Routine left atrial catheterization for the post-operative management of cardiac surgical patients: is the risk justified? Eur J Cardiothorac Surg 1999;16:218-21. 2. Yeo TC, Miller FA, Oh JK, Freeman WK. Retained left atrial catheter: an unusual cardiac source of embolism identified by transesophageal echocardiography. J Am Soc Echocardiogr 1998;11:66-70.
ELECTRONIC MANUSCRIPT SUBMISSION
Journal of the American Society of Echocardiography uses an online, electronic submission system. By accessing the Web site http://ees.elsevier.com/jase authors will be guided stepwise through the creation and uploading of the various files. When submitting a manuscript to Elsevier Editorial System, authors need to provide an electronic version of their manuscript. For this purpose original source files, not PDF files, are preferred. The author should specify a category designation for the manuscript (original investigation, review article, brief communication, etc) and choose a set of classifications from the prescribed list provided online. Authors may send queries concerning the submission process, manuscript status, or journal procedures to the Editorial Office ([email protected]). Once the submission files are uploaded, the system automatically generates an electronic (PDF) proof, which is then used for reviewing. All correspondence, including the Editor’s decision and request for revisions, will be by e-mail.
We recently detected a retained left atrial (LA) pressure catheter 6 months after coronary artery bypass grafting with echocardiography.
CASE REPORT A 60-year-old woman underwent elective coronary artery bypass grafting. Weaning from bypass was marked by transient pulmonary hypertension, so a LA pressure catheter was placed by the right superior pulmonary vein to help with early postoperative treatment. This was removed apparently uneventfully at the bedside on the first postoperative day. The rest of her recovery was unremarkable. Discharge chest radiograph was normal, as was her follow-up radiograph 3 weeks later. Six months after operation, transthoracic echocardiography was performed to evaluate left ventricular function. A linear echodensity was seen in the LA (Figure 1). Transesophageal echocardiography was then performed and showed a mobile catheter in the LA originating outside the heart at the level of the right upper pulmonary vein (Figure 2). No clot was seen on the visible (intracardiac) portion of the catheter. Fluoroscopy confirmed the presence of the radiopaque-striped catheter curving around the right pericardium and stopping near the lower sternal wires (Figure 3), where it had apparently broken during removal. This could not be seen on a repeated chest radiograph. The patient underwent uneventful removal of the catheter under general anesthetic, using a subxiphoid approach with retraction of the lower right sternum.
Figure 1 Transthoracic parasternal long-axis view. Linear echogenic shadow (arrow) in left atrium (LA) represents retained catheter. AO, Aorta; LV, left ventricle.
Figure 2 Multiplane transesophageal echocardiography image. Catheter (arrow) in left atrium (LA) can be followed into right upper pulmonary vein (PV).
DISCUSSION From the Division of Cardiology, University of Texas Medical Branch at Galveston. Reprint requests: Masood Ahmad, MD, Division of Cardiology, University of Texas Medical Branch at Galveston, 301 University Blvd, Galveston, TX 77555-0553. J Am Soc Echocardiogr 2004;17:489-90. 0894-7317/$30.00 Copyright 2004 by the American Society of Echocardiography. doi:10.1016/j.echo.2004.02.009
Monitoring LA pressure in the postoperative period is a documented useful tool for optimizing hemodynamic parameters in patients undergoing open heart operation.1 Complications of LA monitoring catheter are rare and consist mainly of hemorrhage after catheter removal, systemic gaseous microembolization, and embolic stroke from retained catheter fragments.2 LA catheters are used frequently at our
489
Journal of the American Society of Echocardiography May 2004
490 Agoston et al
the catheter should be compared with an unused identical catheter to ensure that it has not broken. The catheter used was radiopaque, but was not large enough to show up on standard postoperative radiography. Hence, echocardiography or fluoroscopy was needed to demonstrate it. In this case, the catheter was a completely unsuspected transthoracic echocardiography finding remote from the operation. The catheter had no detectable clots by transesophageal echocardiography, but nonetheless was removed because of its potential to cause thrombosis and subsequent embolism. We chose not to try intravascular snaring to remove it because of the large portion of the catheter remaining outside the heart. Retained LA catheter should be entertained in the differential diagnosis of intra-atrial thin foreign body on postcardiacoperation echocardiogram. REFERENCES Figure 3 Fluoroscopy demonstrating retained left atrial catheter (arrows) in entire length extending beyond heart border into mediastinum.
hospital to aid in early postcardiac-operation treatment. They are usually removed on the first postoperative day. If resistance is encountered on removal,
1. Santini F, Gatti G, Borghetti V, Oppido G, Mazzucco A. Routine left atrial catheterization for the post-operative management of cardiac surgical patients: is the risk justified? Eur J Cardiothorac Surg 1999;16:218-21. 2. Yeo TC, Miller FA, Oh JK, Freeman WK. Retained left atrial catheter: an unusual cardiac source of embolism identified by transesophageal echocardiography. J Am Soc Echocardiogr 1998;11:66-70.
ELECTRONIC MANUSCRIPT SUBMISSION
Journal of the American Society of Echocardiography uses an online, electronic submission system. By accessing the Web site http://ees.elsevier.com/jase authors will be guided stepwise through the creation and uploading of the various files. When submitting a manuscript to Elsevier Editorial System, authors need to provide an electronic version of their manuscript. For this purpose original source files, not PDF files, are preferred. The author should specify a category designation for the manuscript (original investigation, review article, brief communication, etc) and choose a set of classifications from the prescribed list provided online. Authors may send queries concerning the submission process, manuscript status, or journal procedures to the Editorial Office ([email protected]). Once the submission files are uploaded, the system automatically generates an electronic (PDF) proof, which is then used for reviewing. All correspondence, including the Editor’s decision and request for revisions, will be by e-mail.