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Venous sheath to facilitate cardiac catheterization via the umbilical vein
November
1392
Brief Communications
American
Venous sheath to facilitate cardiac catheterization via the umbilical vein R. Scott Appleton, MD, Saadeh B. Jureidini, MB, ChB, Ian C. Balfour, MB, BS, and Soraya Nouri, MB, BS St. Louis, MO.
Cardiac catheterization remains an important diagnostic and therapeutic tool during the first week of life for many infants with congenital heart disease. Although the femoral veins are commonly used for catheter placement, the urnbilical vein continues to be an important portal for catheterization. The technique of umbilical venous catheterization has been described for over 25 years.le4 This technique entails placement of the angiographic or sept,ostomy catheter directly into the umbilical vein without a sheath. There are two disadvantages to this technique: (1) the ductus venosus could constrict during the process of catheter exchange, and (2) the kink in this venous route at the site of entry of the ductus venosus to the inferior vena cava reduces the torque of the catheter. We decided to use a venous sheath and dilator to overcome these limitat,ions. This is the first description in the literature in which a venous sheath was used to perform cardiac catheterization from the umbilical vein. A total of 16 infants with patent ductus venosus (group A) underwent successful venous catheterization with an umbilical venous sheath from February 1987 to July 1991. During the same period, there were 15 other neonates who were catheterized from the femoral vein because the ductus venosus was closed at the time that insertion of the original umbilical venous catheter was attempted igroup B). This group of 15 patients was used for comparison of ease of procedure and complications. The patients’ mean weight was of 3.1 kg (range, 2.1 to 3.8 kg), and mean age at the time of catheterization was 3.3 days (range, 6 hours to 9 days). The diagnoses were d-transposition of great vessels and ventricular septal defect (six), simple d-transposition of great vessels (two), tricuspid atresia (two), coarctation of aorta and ventricular septal defect (two), interrupted inferior vena cava and complex congenital heart disease (two), pulmonary atresia (one), and pulmonary stenosis (one). Placement of all umbilical venous lines was done in the neonatal intensive care unit, before patients reached the age of 6 days. Usually a 5F and a 3.5F umbilical catheter were placed in the vein and artery, respectively. In the cardiac catheterization laboratory, the umbilical stump and entire umbilical catheters were carefully scrubbed with Betadine and draped to maintain sterility. A clamp was
From the Division of Cardiology, Department non Children’s Hospital, St, Louis.
of Pediatrics,
Cardinal
Glen-
Reprint requests: R. Scott Appleton, MD, Pediatric Cardiology, Cardinal Glennon Children’s Hospital, 1465 South Grand Blvd., St. Louis, MO 63104.1095. 4/4/40564
1992
HearI Journal
placed on the catheter for hemostasis near the stump, and the catheter was cut about 1 cm from the clamp. A 0.0Y1 inch or smaller guide wire was placed into the catheter af”. ter the clamp was released and advanced under fluoroscopic or echocardiographic guidance into the right atrium. The catheter was then exchanged for a 5F, 6F, or SF rordis sheath and dilator (Cordis Corp., Miami Lakes, F1a.i. The sheath was carefully positioned to be above the diaphragm in the right atrium when t,he dilator was removed. With the sheath in place, it was possible to introduce end- or side-hole catheters into all heart chambers. In 11 patients, a balloon atria1 septostomy was performed with a 6F Septos catheter (Bard Corp., Tewksbury, Mass.) or a 5F Edwards catheter (American Edwards, Santa Ana, Calif.) and the appropriate size sheath. Before the septostomy catheter was pulled across the atria1 septum, the venous sheath was pulled back almost to the skin to avoid catching the balloon on the tip of the sheath. After the balloon was deflated, the sheath was readvanred to the right at,rium over the catheter. Two patients had interrupted inferior vena cava and azygos continuation. One had mitral stenosis, univentricular heart, and pulmonary stenosis and underwent transseptal puncture, blade atria1 septostomy, and balloon atria1 septostomy. The other patient had d-transposition of the great arteries and ventricular septal defect, and underwent balloon atria1 septostomy. This would not have been feasible had the femoral vein been used. At the completion of catheterization in 12 patients the umbilical vein sheath was exchanged over a wire for a 5F umbilical venous catheter to permit central venous access. When gentle circumferential pressure with umbilical tie on the umbilical stump was used, there was no bleeding even when an 8F sheath was exchanged for the smaller catheter. Two patienm had their catheterizations and balloon atria1 septostomies performed on an emergency basis in the neonatal intensive care units under echocardiographic guidance. The time needed to put the umbilical sheath and dilator in place was less than 5 minutes, compared with the time required to achieve femoral vein access, which ranged between 15 and 45 minutes. In group A there were no complications (e.g., bleeding, perforation, infection, stroke, liver disease, or venous thrombosis) from these procedures. This compared favorably with group B in which two of the 15 patients had iliac vein thrombosis, which limited the ability to repeat their catheterizations later in life.’ We successfully entered all accessible cardiac chambers and vessels in all 16 patients, and we believe that the sheath technique provided better torque control of the catheter than the technique without. a sheath. In two other patients in whom catheters were inserted directly into the umbilical vein without sheaths, the ductus venosus became constricted during catheter exchange. None of t.he 16 pat.ients with the sheath in the right atrium had ductus venosus constriction. It was previously considered that the ductus venosus could be dilated,s and our experience proves that this is feasible at least, to 3 mm (8F) in diameter without complications. The advantages of use of an umbilical win
Volume 124 Number 5
compared with use of the femoral vein are well described.le4 Our technique adds to these advantages the following: (1) improvement of torque control of the catheter; (2) ability to perform transseptal puncture and balloon and blade atria1 septostomy in patients with interrupted inferior vena cava and azygos continuation (to avoid surgical septostomy); and (3) avoidance of ductal venosus constriction during catheter exchange. REFERENCES 1.
2.
3. 4. 5. 6.
Linde L, Iligashiro SM, Bermen G, Sapia SO, Emmanouilides GC. Umbilical vessel cardiac catheterization and angiography. Circulation 1966;34:984-8. Abinader E, Zeltzer M, Riss E. Transumbilical atria1 septostomy in the newborn. Am J Dis Child 1970;119:354-6. Bullaboy CA, Jennings RB, Johnson DH, Kulcher CU. Bedside balloon atria1 septostomy using echocardiographic monitoring. Am J Cardiol 1984:53:971. Porter CJ, Gillette PC, Mullins CE, McNamera DG. Cardiac catheterization in the neonate. A comparison of three techniques. J Pediatr 197&93:97-101. Laurin S, Lundstrom NR. Venous thrombosis after cardiac catheterization in infants. Acta Radio1 1987;2&241-6. Lucas RV, Lock JE, Tandon R, Edwards J. Gross and histologic anatomy of total anomalous pulmonary venous connections. Am J Cardiol 198&62:292-300.
Use of laryngoscope and esophageal stethoscope to visually direct intraoperative insertion of pediatric transesophageal echocardiographic probe in infants and small children Barry Marcus, MD,a David J. Steward, MB, FRCPC,b Naguib R. Khan, MD: Edward B. Scott, MD,b Gary M. Scott, MD,b Audrey J. Gardner, RDMS, RVT, and Pierre C. Wang, MDa Los Angeles, Cc&f.
Transesophageal echocardiography is becoming established as an intraoperative monitor of surgical intervention for congenital heart disease.l-5 Pediatric transesophageal echocardiographic probes are available for use in the neonate through the adolescent. l-5 We report the use of an intraoperative technique for direct visual insertion of the pediatric transesophageal probe into the esophagus. Although various nonvisually directed techniques for intraoperative probe insertion in adults have been reported e 7 limited information regarding visually directed probe insertion technique in infants and small children is available. From %he Division of Pediatric Cardiology and bthe Department of Ariesthesiology, Childrem Hospital of Los Angeles, University of Southern California School of Medicine, Los Angeles. Reprint requests: Barry Marcus, MD, Division of Pediatric Cardiology, Box 34, Childrens Hospital of Los Angeles, 4650 Sunset Blvd., Los Angeles, CA 90027. 4l4i406lQ
Brief Communications
1393
A 10 mm tip 5 MHz 4%element pediatric transesophageal echocardiographic probe (Siemens) with two-dimensional imaging, color flow mapping, and continuous wave Doppler capability, connected to a Siemens SI-1200 ultrasound system, was used for intraoperative monitoring of congenital heart surgery in children who weighed less than 20 kg. Our technique for probe insertion is as follows. The probe is prepared in the slightly flexed unlocked position with contact jelly at its tip, and in children with teeth, a bite block is passed over the probe and positioned behind and away from the probe tip. After induction of general anesthesia and tracheal intubation with the patient supine with his or her head at midline, the endotracheal tube is taped to the left side of the mouth to facilitate planned introduction of the probe at the right side. A 9F esophageal stethoscope/thermometer is inserted in the esophagus for monitoring by the anesthesiologist. The anesthesiologist then uses a laryngoscope to directly visualize the posterior pharynx, hypopharynx, and esophageal stethoscope. While the anesthesiologist holds the laryngoscope, the echocardiographer stands to the right of the anesthesiologist and directly visualizes the esophageal stethoscope via the laryngoscope and then passes the transesophageal probe along the track of the esophageal stethoscope into the esophagus. Once the probe is in the esophagus and cardiac images are being obtained, the laryngoscope is removed and standard transesophageal echocardiographic examination proceeds.l-T In children with teeth, the bite block is moved forward to lie between the teeth and the probe. We have attemped intraoperative pediatric probe insertion with this direct visualization technique in 30 consecutive patients, and successfu1uncomplicated insertion was achieved in 28 patients who weighed 5.1 to 19.6 kg (mean, 10.9 k 3.9 kg) and who were between the ages of 6 months and 7.5 years (mean, 2.4 & 1.7 years). In two patients, a child with Down syndrome and duodenal atresia who weighed 3.6 kg and a child with no obvious maxillofacial abnormalities who weighed 3.4 kg, the size of the proximal esophagus was visualized to be too small in relation to the probe tip to allow probe passage even after removal of the esophageal stethoscope. Probe placement therefore was not pursued. Direct esophageal visualization in these two patients avoided attempts at nonvisually directed probe passage, which would have failed and might have caused trauma to the pharyngeal and hypopharyngeal tissues. Before our use of this visually directed technique, a patient who weighed 3.9 kg underwent nonvisually directed probe insertion without obvious difficulty or trauma, but after echocardiographic study and probe removal, airway management was difficult; subsequent laryngoscopy suggested posterior pharyngeal and laryngeal inflammation. We use this direct visualization technique for intraoperative pediatric probe insertion to: (1) assure that the probe is being passed directly into the esophagus and not toward neighboring soft tissues; (2) assessprobe size in relation to esophageal size in the small infant so that probe passage is not pursued when a particularly small esophagus would not
1392
Brief Communications
American
Venous sheath to facilitate cardiac catheterization via the umbilical vein R. Scott Appleton, MD, Saadeh B. Jureidini, MB, ChB, Ian C. Balfour, MB, BS, and Soraya Nouri, MB, BS St. Louis, MO.
Cardiac catheterization remains an important diagnostic and therapeutic tool during the first week of life for many infants with congenital heart disease. Although the femoral veins are commonly used for catheter placement, the urnbilical vein continues to be an important portal for catheterization. The technique of umbilical venous catheterization has been described for over 25 years.le4 This technique entails placement of the angiographic or sept,ostomy catheter directly into the umbilical vein without a sheath. There are two disadvantages to this technique: (1) the ductus venosus could constrict during the process of catheter exchange, and (2) the kink in this venous route at the site of entry of the ductus venosus to the inferior vena cava reduces the torque of the catheter. We decided to use a venous sheath and dilator to overcome these limitat,ions. This is the first description in the literature in which a venous sheath was used to perform cardiac catheterization from the umbilical vein. A total of 16 infants with patent ductus venosus (group A) underwent successful venous catheterization with an umbilical venous sheath from February 1987 to July 1991. During the same period, there were 15 other neonates who were catheterized from the femoral vein because the ductus venosus was closed at the time that insertion of the original umbilical venous catheter was attempted igroup B). This group of 15 patients was used for comparison of ease of procedure and complications. The patients’ mean weight was of 3.1 kg (range, 2.1 to 3.8 kg), and mean age at the time of catheterization was 3.3 days (range, 6 hours to 9 days). The diagnoses were d-transposition of great vessels and ventricular septal defect (six), simple d-transposition of great vessels (two), tricuspid atresia (two), coarctation of aorta and ventricular septal defect (two), interrupted inferior vena cava and complex congenital heart disease (two), pulmonary atresia (one), and pulmonary stenosis (one). Placement of all umbilical venous lines was done in the neonatal intensive care unit, before patients reached the age of 6 days. Usually a 5F and a 3.5F umbilical catheter were placed in the vein and artery, respectively. In the cardiac catheterization laboratory, the umbilical stump and entire umbilical catheters were carefully scrubbed with Betadine and draped to maintain sterility. A clamp was
From the Division of Cardiology, Department non Children’s Hospital, St, Louis.
of Pediatrics,
Cardinal
Glen-
Reprint requests: R. Scott Appleton, MD, Pediatric Cardiology, Cardinal Glennon Children’s Hospital, 1465 South Grand Blvd., St. Louis, MO 63104.1095. 4/4/40564
1992
HearI Journal
placed on the catheter for hemostasis near the stump, and the catheter was cut about 1 cm from the clamp. A 0.0Y1 inch or smaller guide wire was placed into the catheter af”. ter the clamp was released and advanced under fluoroscopic or echocardiographic guidance into the right atrium. The catheter was then exchanged for a 5F, 6F, or SF rordis sheath and dilator (Cordis Corp., Miami Lakes, F1a.i. The sheath was carefully positioned to be above the diaphragm in the right atrium when t,he dilator was removed. With the sheath in place, it was possible to introduce end- or side-hole catheters into all heart chambers. In 11 patients, a balloon atria1 septostomy was performed with a 6F Septos catheter (Bard Corp., Tewksbury, Mass.) or a 5F Edwards catheter (American Edwards, Santa Ana, Calif.) and the appropriate size sheath. Before the septostomy catheter was pulled across the atria1 septum, the venous sheath was pulled back almost to the skin to avoid catching the balloon on the tip of the sheath. After the balloon was deflated, the sheath was readvanred to the right at,rium over the catheter. Two patients had interrupted inferior vena cava and azygos continuation. One had mitral stenosis, univentricular heart, and pulmonary stenosis and underwent transseptal puncture, blade atria1 septostomy, and balloon atria1 septostomy. The other patient had d-transposition of the great arteries and ventricular septal defect, and underwent balloon atria1 septostomy. This would not have been feasible had the femoral vein been used. At the completion of catheterization in 12 patients the umbilical vein sheath was exchanged over a wire for a 5F umbilical venous catheter to permit central venous access. When gentle circumferential pressure with umbilical tie on the umbilical stump was used, there was no bleeding even when an 8F sheath was exchanged for the smaller catheter. Two patienm had their catheterizations and balloon atria1 septostomies performed on an emergency basis in the neonatal intensive care units under echocardiographic guidance. The time needed to put the umbilical sheath and dilator in place was less than 5 minutes, compared with the time required to achieve femoral vein access, which ranged between 15 and 45 minutes. In group A there were no complications (e.g., bleeding, perforation, infection, stroke, liver disease, or venous thrombosis) from these procedures. This compared favorably with group B in which two of the 15 patients had iliac vein thrombosis, which limited the ability to repeat their catheterizations later in life.’ We successfully entered all accessible cardiac chambers and vessels in all 16 patients, and we believe that the sheath technique provided better torque control of the catheter than the technique without. a sheath. In two other patients in whom catheters were inserted directly into the umbilical vein without sheaths, the ductus venosus became constricted during catheter exchange. None of t.he 16 pat.ients with the sheath in the right atrium had ductus venosus constriction. It was previously considered that the ductus venosus could be dilated,s and our experience proves that this is feasible at least, to 3 mm (8F) in diameter without complications. The advantages of use of an umbilical win
Volume 124 Number 5
compared with use of the femoral vein are well described.le4 Our technique adds to these advantages the following: (1) improvement of torque control of the catheter; (2) ability to perform transseptal puncture and balloon and blade atria1 septostomy in patients with interrupted inferior vena cava and azygos continuation (to avoid surgical septostomy); and (3) avoidance of ductal venosus constriction during catheter exchange. REFERENCES 1.
2.
3. 4. 5. 6.
Linde L, Iligashiro SM, Bermen G, Sapia SO, Emmanouilides GC. Umbilical vessel cardiac catheterization and angiography. Circulation 1966;34:984-8. Abinader E, Zeltzer M, Riss E. Transumbilical atria1 septostomy in the newborn. Am J Dis Child 1970;119:354-6. Bullaboy CA, Jennings RB, Johnson DH, Kulcher CU. Bedside balloon atria1 septostomy using echocardiographic monitoring. Am J Cardiol 1984:53:971. Porter CJ, Gillette PC, Mullins CE, McNamera DG. Cardiac catheterization in the neonate. A comparison of three techniques. J Pediatr 197&93:97-101. Laurin S, Lundstrom NR. Venous thrombosis after cardiac catheterization in infants. Acta Radio1 1987;2&241-6. Lucas RV, Lock JE, Tandon R, Edwards J. Gross and histologic anatomy of total anomalous pulmonary venous connections. Am J Cardiol 198&62:292-300.
Use of laryngoscope and esophageal stethoscope to visually direct intraoperative insertion of pediatric transesophageal echocardiographic probe in infants and small children Barry Marcus, MD,a David J. Steward, MB, FRCPC,b Naguib R. Khan, MD: Edward B. Scott, MD,b Gary M. Scott, MD,b Audrey J. Gardner, RDMS, RVT, and Pierre C. Wang, MDa Los Angeles, Cc&f.
Transesophageal echocardiography is becoming established as an intraoperative monitor of surgical intervention for congenital heart disease.l-5 Pediatric transesophageal echocardiographic probes are available for use in the neonate through the adolescent. l-5 We report the use of an intraoperative technique for direct visual insertion of the pediatric transesophageal probe into the esophagus. Although various nonvisually directed techniques for intraoperative probe insertion in adults have been reported e 7 limited information regarding visually directed probe insertion technique in infants and small children is available. From %he Division of Pediatric Cardiology and bthe Department of Ariesthesiology, Childrem Hospital of Los Angeles, University of Southern California School of Medicine, Los Angeles. Reprint requests: Barry Marcus, MD, Division of Pediatric Cardiology, Box 34, Childrens Hospital of Los Angeles, 4650 Sunset Blvd., Los Angeles, CA 90027. 4l4i406lQ
Brief Communications
1393
A 10 mm tip 5 MHz 4%element pediatric transesophageal echocardiographic probe (Siemens) with two-dimensional imaging, color flow mapping, and continuous wave Doppler capability, connected to a Siemens SI-1200 ultrasound system, was used for intraoperative monitoring of congenital heart surgery in children who weighed less than 20 kg. Our technique for probe insertion is as follows. The probe is prepared in the slightly flexed unlocked position with contact jelly at its tip, and in children with teeth, a bite block is passed over the probe and positioned behind and away from the probe tip. After induction of general anesthesia and tracheal intubation with the patient supine with his or her head at midline, the endotracheal tube is taped to the left side of the mouth to facilitate planned introduction of the probe at the right side. A 9F esophageal stethoscope/thermometer is inserted in the esophagus for monitoring by the anesthesiologist. The anesthesiologist then uses a laryngoscope to directly visualize the posterior pharynx, hypopharynx, and esophageal stethoscope. While the anesthesiologist holds the laryngoscope, the echocardiographer stands to the right of the anesthesiologist and directly visualizes the esophageal stethoscope via the laryngoscope and then passes the transesophageal probe along the track of the esophageal stethoscope into the esophagus. Once the probe is in the esophagus and cardiac images are being obtained, the laryngoscope is removed and standard transesophageal echocardiographic examination proceeds.l-T In children with teeth, the bite block is moved forward to lie between the teeth and the probe. We have attemped intraoperative pediatric probe insertion with this direct visualization technique in 30 consecutive patients, and successfu1uncomplicated insertion was achieved in 28 patients who weighed 5.1 to 19.6 kg (mean, 10.9 k 3.9 kg) and who were between the ages of 6 months and 7.5 years (mean, 2.4 & 1.7 years). In two patients, a child with Down syndrome and duodenal atresia who weighed 3.6 kg and a child with no obvious maxillofacial abnormalities who weighed 3.4 kg, the size of the proximal esophagus was visualized to be too small in relation to the probe tip to allow probe passage even after removal of the esophageal stethoscope. Probe placement therefore was not pursued. Direct esophageal visualization in these two patients avoided attempts at nonvisually directed probe passage, which would have failed and might have caused trauma to the pharyngeal and hypopharyngeal tissues. Before our use of this visually directed technique, a patient who weighed 3.9 kg underwent nonvisually directed probe insertion without obvious difficulty or trauma, but after echocardiographic study and probe removal, airway management was difficult; subsequent laryngoscopy suggested posterior pharyngeal and laryngeal inflammation. We use this direct visualization technique for intraoperative pediatric probe insertion to: (1) assure that the probe is being passed directly into the esophagus and not toward neighboring soft tissues; (2) assessprobe size in relation to esophageal size in the small infant so that probe passage is not pursued when a particularly small esophagus would not