RESUMEN
Cerebral air embolism after removal of central venous catheter (CVC) is a rare complication but can lead to fatal outcomes. We report a rare case of both cerebral venous and arterial embolism occurring in a patient with underlying scleroderma-related interstitial lung disease (SSc-ILD) and pulmonary hypertension following removal of percutaneous introducer sheath for pulmonary artery catheterization. We discuss the mechanisms, pathophysiology, management and prevention of cerebral air embolism.
Asunto(s)
Embolia Aérea , Embolia Intracraneal , Humanos , Embolia Aérea/etiología , Embolia Aérea/diagnóstico , Embolia Intracraneal/etiología , Embolia Intracraneal/diagnóstico , Remoción de Dispositivos/métodos , Remoción de Dispositivos/efectos adversos , Persona de Mediana Edad , Masculino , Femenino , Enfermedades Pulmonares Intersticiales/etiología , Enfermedades Pulmonares Intersticiales/diagnóstico , Enfermedades Pulmonares Intersticiales/terapia , Cateterismo de Swan-Ganz/efectos adversos , Cateterismo de Swan-Ganz/instrumentaciónRESUMEN
INTRODUCTION: More than 1.2 million pulmonary artery catheters (PACs) are used in cardiac patients per annum within the United States. However, it is contraindicated in traditional 1.5 and 3T magnetic resonance imaging (MRI) scans. We aimed to test preclinical and clinical safety of using this imaging modality given the potential utility of needing it in the clinical setting. METHODS: We conducted two phantom experiments to ensure that the electromagnetic field power deposition associated with bare and jacketed PACs was safe and within the acceptable limit established by the Food and Drug Administration. The primary end points were the safety and feasibility of performing Point-of-Care (POC) MRI without imaging-related adverse events. We performed a preclinical computational electromagnetic simulation and evaluated these findings in nine patients with PACs on veno-arterial extracorporeal membrane oxygenation. RESULTS: The phantom experiments showed that the baseline point specific absorption rate through the head averaged 0.4 W/kg. In both the bare and jacketed catheters, the highest net specific absorption rates were at the neck entry point and tip but were negligible and unlikely to cause any heat-related tissue or catheter damage. In nine patients (median age 66, interquartile range 42-72 y) with veno-arterial extracorporeal membrane oxygenation due to cardiogenic shock and PACs placed for close hemodynamic monitoring, POC MRI was safe and feasible with good diagnostic imaging quality. CONCLUSIONS: Adult ECMO patients with PACs can safely undergo point-of-care low-field (64 mT) brain MRI within a reasonable timeframe in an intensive care unit setting to assess for acute brain injury that might otherwise be missed with conventional head computed tomography.
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Encéfalo , Cateterismo de Swan-Ganz , Oxigenación por Membrana Extracorpórea , Imagen por Resonancia Magnética , Fantasmas de Imagen , Sistemas de Atención de Punto , Humanos , Masculino , Persona de Mediana Edad , Imagen por Resonancia Magnética/efectos adversos , Imagen por Resonancia Magnética/métodos , Femenino , Oxigenación por Membrana Extracorpórea/instrumentación , Oxigenación por Membrana Extracorpórea/efectos adversos , Oxigenación por Membrana Extracorpórea/métodos , Anciano , Adulto , Encéfalo/diagnóstico por imagen , Cateterismo de Swan-Ganz/instrumentación , Cateterismo de Swan-Ganz/efectos adversos , Estudios de FactibilidadAsunto(s)
Gasto Cardíaco , Cateterismo de Swan-Ganz , Dispositivos Electrónicos Vestibles , Tecnología Inalámbrica , Humanos , Tecnología Inalámbrica/instrumentación , Cateterismo de Swan-Ganz/instrumentación , Diseño de Equipo , Monitoreo Fisiológico/instrumentación , Monitoreo Fisiológico/métodos , Reproducibilidad de los Resultados , CatéteresAsunto(s)
Cateterismo de Swan-Ganz , Vena Cava Superior , Humanos , Masculino , Cateterismo de Swan-Ganz/instrumentación , Cateterismo de Swan-Ganz/métodos , Ecocardiografía/métodos , Vena Cava Superior Izquierda Persistente/complicaciones , Vena Cava Superior Izquierda Persistente/diagnóstico por imagen , Arteria Pulmonar/diagnóstico por imagen , Arteria Pulmonar/anomalías , Ultrasonografía Intervencional/métodos , Vena Cava Superior/anomalías , Vena Cava Superior/diagnóstico por imagen , AdultoRESUMEN
El catéter de Swan-Ganz es un dispositivo ampliamente utilizado para la monitorización del paciente crítico, así como durante lasintervenciones de cirugía cardiovascular. Sin embargo, su implantación y uso no están exentos del desarrollo de complicaciones.Presentamos un caso de atrapamiento del catéter con la sutura de cierre de la atriotomía izquierda durante una intervención de sustitución valvular mitral. (AU)
The Swan-Ganz catheter is a widely used device for monitoring critical patients, as well as during cardiovascular surgery. However,its implantation and use are not exempt from the development of complications. We present a case of catheter entrapment with theclosing suture of the left atriotomy during a mitral valve replacement procedure. (AU)
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Humanos , Persona de Mediana Edad , Cirugía Torácica/instrumentación , Cateterismo de Swan-Ganz/instrumentación , Válvula Mitral/cirugíaRESUMEN
BACKGROUND: Pulmonary artery catheter insertion is a routine practice in high-risk patients undergoing cardiac surgery. However, pulmonary artery catheter insertion is associated with numerous complications that can be devastating to the patient. Incorrect placement is an overlooked complication with few case reports to date. CASE PRESENTATION: An 18-year-old male patient underwent elective mitral valve replacement due to severe mitral valve regurgitation. The patient had a history of synovial sarcoma, and Hickman catheter had been inserted in the right internal jugular vein for systemic chemotherapy. We made multiple attempts to position the pulmonary artery catheter in the correct position but failed. A chest radiography revealed that the pulmonary artery catheter was bent and pointed in the cephalad direction. Removal of the pulmonary artery catheter was successful, and the patient was discharged 10 days after the surgery without complications. CONCLUSIONS: To prevent misplacement of the PAC, clinicians should be aware of multiple risk factors in difficult PAC placement, and be prepared to utilize adjunctive methods, such as TEE and fluoroscopy.
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Cateterismo de Swan-Ganz/efectos adversos , Cateterismo de Swan-Ganz/métodos , Dispositivos de Acceso Vascular , Adolescente , Cateterismo de Swan-Ganz/instrumentación , Humanos , Masculino , Arteria Pulmonar/diagnóstico por imagen , Radiografía/métodosRESUMEN
No disponible
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Humanos , Femenino , Persona de Mediana Edad , Hemoptisis/etiología , Cateterismo de Swan-Ganz/efectos adversos , Embolización Terapéutica/métodos , Cateterismo de Swan-Ganz/instrumentación , Arteria Pulmonar/lesiones , Ecocardiografía , Hemoptisis/diagnóstico por imagen , Angiografía/instrumentaciónRESUMEN
A pesar de la extendida y frecuente utilización del catéter de arteria pulmonar en nuestro medio para el manejo hemodinámico en pacientes críticos y particularmente en pacientes tras cirugía cardiaca, en la actualidad siguen planteándose dudas sobre la necesidad de su uso. Es preciso valorar el riesgo/beneficio de su colocación y tener en cuenta sus posibles complicaciones, que aun siendo poco frecuentes, pueden llegar a ser potencialmente graves. En este artículo exponemos una complicación muy poco frecuente ocurrida en nuestro centro sobre el uso del catéter de arteria pulmonar de la que no teníamos constancia hasta ahora. Se trata de una perforación del tabique interventricular y de la pared libre del ventrículo izquierdo debido a una acodadura firme del catéter de arteria pulmonar, que no fue sospechada ni diagnosticada salvo por la visión directa del corazón, tras la esternotomía, durante la cirugía cardiaca. La mejora de la seguridad del paciente implica reflexionar sobre el valor de los eventos adversos, de manera que al aumentar la conciencia de la situación y del mecanismo por el que se producen, pueda reducirse la probabilidad de repetición
Despite the widespread and frequent use in our setting of pulmonary artery catheters for haemodynamic management in critically ill patients, particularly after heart surgery, some experts continue to question the need for these devices. Clinicians need to weigh up the risks and benefits of pulmonary artery catheters placement and bear in mind the potential complications which, though rare, can be potentially fatal. We present a pulmonary artery catheters-related complication not hitherto described in the literature, involving perforation of the interventricular septum and left ventricular free wall caused by a kink in the pulmonary artery catheters that was not suspected, and only diagnosed by direct vision of the heart after pericardial opening. In the interest of patient safety, we must consider the impact of adverse events; improving our situational awareness and our understanding of the mechanisms behind such events can help reduce the likelihood of repetitions in the future
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Humanos , Femenino , Anciano , Cateterismo de Swan-Ganz/efectos adversos , Lesiones Cardíacas/etiología , Ventrículos Cardíacos/lesiones , Complicaciones Intraoperatorias/etiología , Aneurisma de la Aorta/cirugía , Cateterismo de Swan-Ganz/instrumentación , Ecocardiografía/métodos , Falla de Equipo , Tabiques Cardíacos/lesiones , Arteria Pulmonar/diagnóstico por imagenRESUMEN
Despite the widespread and frequent use in our setting of pulmonary artery catheters for haemodynamic management in critically ill patients, particularly after heart surgery, some experts continue to question the need for these devices. Clinicians need to weigh up the risks and benefits of pulmonary artery catheters placement and bear in mind the potential complications which, though rare, can be potentially fatal. We present a pulmonary artery catheters-related complication not hitherto described in the literature, involving perforation of the interventricular septum and left ventricular free wall caused by a kink in the pulmonary artery catheters that was not suspected, and only diagnosed by direct vision of the heart after pericardial opening. In the interest of patient safety, we must consider the impact of adverse events; improving our situational awareness and our understanding of the mechanisms behind such events can help reduce the likelihood of repetitions in the future.
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Cateterismo de Swan-Ganz/efectos adversos , Lesiones Cardíacas/etiología , Ventrículos Cardíacos/lesiones , Complicaciones Intraoperatorias/etiología , Anciano , Aneurisma de la Aorta/cirugía , Cateterismo de Swan-Ganz/instrumentación , Ecocardiografía/métodos , Falla de Equipo , Femenino , Tabiques Cardíacos/lesiones , Humanos , Arteria Pulmonar/diagnóstico por imagenRESUMEN
Introduction Congestive heart failure is a leading cause of cardiovascular mortality and morbidity in the United States and places a significant economic burden on the health care system. The CHAMPION trial showed significant reductions in heart failure hospitalizations and length of stay as well as improvements in quality of life among patients who underwent implantation of the CardioMEMS device (CardioMEMS Inc., Atlanta, GA, USA). While the benefits of the device have been well demonstrated, we explored the "pseudo-placebo" effect of device placement on patients' lifestyle modifications. Methods Thirty patients with the CardioMEMS device were contacted for a follow-up survey that included questions about lifestyle modifications, symptomatic and dietary improvement, increased physical activity, and changes in their cardiac medication regimen. Results Dyspnea improved in 57% of patients, 70% of patients improved their diet, and 43% increased their physical activity. Only 7% of patients found it difficult to transmit the data. Discussion The CHAMPION trial showed numerous benefits for patients who underwent CardioMEMS device placement. In our study, we found that device placement also resulted in a "pseudo-placebo" effect with most patients making positive lifestyle modifications.
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Insuficiencia Cardíaca/fisiopatología , Insuficiencia Cardíaca/cirugía , Calidad de Vida , Conducta de Reducción del Riesgo , Determinación de la Presión Sanguínea/instrumentación , Cateterismo de Swan-Ganz/instrumentación , Conductas Relacionadas con la Salud , Frecuencia Cardíaca , Hemodinámica , Humanos , Estados UnidosAsunto(s)
Malformaciones Arteriovenosas/terapia , Cateterismo de Swan-Ganz , Hipertensión Pulmonar/terapia , Arteria Pulmonar/anomalías , Venas Pulmonares/anomalías , Presión Arterial , Malformaciones Arteriovenosas/complicaciones , Malformaciones Arteriovenosas/diagnóstico por imagen , Malformaciones Arteriovenosas/fisiopatología , Cateterismo de Swan-Ganz/instrumentación , Angiografía por Tomografía Computarizada , Ecocardiografía , Femenino , Humanos , Hipertensión Pulmonar/diagnóstico , Hipertensión Pulmonar/etiología , Hipertensión Pulmonar/fisiopatología , Persona de Mediana Edad , Arteria Pulmonar/diagnóstico por imagen , Arteria Pulmonar/fisiopatología , Circulación Pulmonar , Venas Pulmonares/diagnóstico por imagen , Venas Pulmonares/fisiopatología , Resultado del TratamientoRESUMEN
OBJECTIVE: To determine the consequences of an early catheter-based intervention on pulmonary artery (PA) growth and right ventricular (RV) myocardial function in an animal model of branch PA stenosis. BACKGROUND: Acute results and safety profiles of deliberate stent fracture within the pulmonary vasculature have been demonstrated. The long-term impact of early stent intervention and deliberate stent fracture on PA growth and myocardial function is not understood. METHODS: Implantation of small diameter stents was performed in a pig model of left PA stenosis at 6 weeks (10 kg) followed by dilations at 10 (35 kg) and 18 weeks (65 kg) with intent to fracture and implant large diameter stents. Hemodynamics, RV contractility, and 2D/3D angiography were performed with each intervention. The heart and pulmonary vasculature were histologically assessed. RESULTS: Stent fracture occurred in 9/12 and implantation of large diameter stents was successful in 10/12 animals with no PA aneurysms or dissections. The final stented PA segment and distal left PA branch origins equaled the corresponding PA diameters of sham controls. Growth of left PA immediately beyond the stent was limited and there was diffuse fibro-intimal proliferation within the distal left and right PA. RV contractility was diminished in the intervention group and the response to dobutamine occurred uniquely via increases in heart rate. CONCLUSIONS: Early stent intervention in this surgically created PA stenosis model was associated with improved growth of the distal PA vasculature but additional investigation of PA vessel physiology and impact on the developing heart are needed.
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Cateterismo de Swan-Ganz/métodos , Intervención Médica Temprana/métodos , Contracción Miocárdica , Arteria Pulmonar/crecimiento & desarrollo , Estenosis de Arteria Pulmonar/terapia , Función Ventricular Derecha , Animales , Animales Recién Nacidos , Cateterismo de Swan-Ganz/instrumentación , Modelos Animales de Enfermedad , Hemodinámica , Diseño de Prótesis , Falla de Prótesis , Arteria Pulmonar/patología , Estenosis de Arteria Pulmonar/diagnóstico por imagen , Estenosis de Arteria Pulmonar/patología , Estenosis de Arteria Pulmonar/fisiopatología , Stents , Sus scrofa , Factores de TiempoRESUMEN
BACKGROUND: To evaluate the safety and efficacy of selective catheter-directed thrombolysis (SCDT) in treating acute massive pulmonary thromboembolism (AMPTE). METHODS: Twenty-six AMPTE patients were enrolled between March 2010 and March 2013. A Uni*Fuse infusion system was inserted into the main pulmonary artery thrombus. The thrombolytic regimen included an intraoperative bolus injection of 250,000 IU urokinase, followed by continuous thrombolytic infusion of 5,000 IU/kg per (every) 24 hr urokinase for 72 hr postoperatively. Clinical symptoms, shock index (SI), systolic pulmonary artery pressure (sPAP), peripheral arterial partial pressure of oxygen (PaO2), and Miller index (MI) were assessed before and after treatment. RESULTS: The patients included 16 men and 10 women (49.9 ± 18.8 years old; time to onset of 50.2 ± 28.5 hr). After thrombolysis, dyspnea and cough were relieved to varying degrees; chest pain, hemoptysis, and syncope disappeared. Importantly, a clinical success rate of 100% was achieved. All objective indices were improved: SI decreased from 1.74 ± 0.38 before operation to 0.71 ± 0.09 postoperatively (P = 0.00); PaO2 increased from 52.78 ± 6.92 mm Hg to 85.98 ± 5.91 mm Hg (P = 0.00); sPAP was reduced from 65.19 ± 8.22 mm Hg to 34.42 ± 4.05 mm Hg (P = 0.00); MI dropped from 0.69 ± 0.09 to 0.33 ± 0.06 (P = 0.00). Mean total urokinase amounts were 1,298,000 IU for each patient. Postoperative complications included 2 cases of puncture-site hematoma (cured by pressure bandage) and 1 case of gastrointestinal hemorrhage (healed by conservative treatment without blood transfusion). CONCLUSIONS: SCDT may be considered a safe and efficacious treatment for AMPTE.
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Cateterismo de Swan-Ganz , Fibrinolíticos/administración & dosificación , Embolia Pulmonar/terapia , Terapia Trombolítica/métodos , Activador de Plasminógeno de Tipo Uroquinasa/administración & dosificación , Enfermedad Aguda , Adulto , Anciano , Anciano de 80 o más Años , Cateterismo de Swan-Ganz/efectos adversos , Cateterismo de Swan-Ganz/instrumentación , Catéteres de Permanencia , Angiografía por Tomografía Computarizada , Femenino , Fibrinolíticos/efectos adversos , Humanos , Infusiones Intraarteriales , Masculino , Persona de Mediana Edad , Flebografía/métodos , Embolia Pulmonar/diagnóstico por imagen , Embolia Pulmonar/fisiopatología , Estudios Retrospectivos , Terapia Trombolítica/efectos adversos , Terapia Trombolítica/instrumentación , Factores de Tiempo , Resultado del Tratamiento , Activador de Plasminógeno de Tipo Uroquinasa/efectos adversos , Dispositivos de Acceso Vascular , Adulto JovenRESUMEN
BACKGROUND: Transcatheter, bilateral branch pulmonary artery (PA) valve implantation is a novel treatment for patients with severe pulmonary insufficiency and oversized right ventricle (RV) outflow tract. There is scarce data on efficacy and safety of this approach. METHODS: This was a retrospective study of 8 patients with repaired tetralogy of fallot (TOF) who underwent bilateral branch PA valve implantation. Demographics, echocardiography, cardiac catheterization, and axial imaging data were reviewed. Variables were compared by a paired sample t-test. RESULTS: All patients were adult sized (weight 43-99 kg) with oversized RV outflow tract not suitable for conventional transcatheter pulmonary valve implantation. Staged bare metal PA stenting followed by valve implantation (interval 3-5 months) was technically successful in 7 patients with one stent embolization. In another patient, proximal stent migration prevented placement of bilateral pulmonary valve stents. There were a total of 14 valved branch PA stents placed (Melody valve n = 9, Sapien XT n = 2, Sapien 3 n = 3). In the 7 patients undergoing successful branch pulmonary valve placement, at median follow up of 10 months (range 3 months to 6 years), 13 (93%) valves had none/trivial insufficiency on echocardiography. Prevalve and postvalve implantation cardiac magnetic resonance imaging in five patients showed significant reduction of indexed RV end-diastolic volume (152 ± 27 to 105 ± 15 mL/m2 , P < .001). CONCLUSIONS: Transcatheter, bilateral branch PA valve implantation was technically feasible with satisfactory efficacy and safety in patients with repaired TOF, severe pulmonary insufficiency, and oversized RV outflow tracts. Elimination of pulmonary insufficiency with this method resulted in reduced RV end-diastolic volume. This approach can be offered as an alternative to surgery, particularly in patients considered high risk for standard surgical placement and who are not candidates for the newer self-expanding valve prosthesis for placement in RV outflow tracts larger than 30 mm diameter.
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Procedimientos Quirúrgicos Cardíacos/efectos adversos , Cateterismo de Swan-Ganz/instrumentación , Implantación de Prótesis de Válvulas Cardíacas/instrumentación , Prótesis Valvulares Cardíacas , Insuficiencia de la Válvula Pulmonar/cirugía , Válvula Pulmonar/cirugía , Stents , Tetralogía de Fallot/cirugía , Adolescente , Adulto , Anciano , Angiografía , Cateterismo de Swan-Ganz/efectos adversos , Cateterismo de Swan-Ganz/métodos , Ecocardiografía , Femenino , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Implantación de Prótesis de Válvulas Cardíacas/métodos , Hemodinámica , Humanos , Imagen por Resonancia Magnética , Masculino , Persona de Mediana Edad , Diseño de Prótesis , Válvula Pulmonar/diagnóstico por imagen , Válvula Pulmonar/fisiopatología , Insuficiencia de la Válvula Pulmonar/diagnóstico por imagen , Insuficiencia de la Válvula Pulmonar/etiología , Insuficiencia de la Válvula Pulmonar/fisiopatología , Recuperación de la Función , Estudios Retrospectivos , Índice de Severidad de la Enfermedad , Tetralogía de Fallot/fisiopatología , Factores de Tiempo , Resultado del Tratamiento , Adulto JovenRESUMEN
OBJECTIVE: Pulmonary artery catheters (PACs) have routinely been positioned by wedging into the pulmonary artery before pulling back 1-2 centimeters or advancing the PAC several centimeters after achieving a pulmonary artery waveform. A rare, major complication is pulmonary artery rupture. This study presents transesophageal echocardiography (TEE) for PAC placement by leaving the catheter tip at the one o'clock position, upper window short-axis view of the ascending aorta at the bifurcation of the pulmonary artery (TEE distance). DESIGN: Prospective observational cohort study. SETTING: Large urban academic medical center. PARTICIPANTS: 30 males and 30 females undergoing cardiac surgery requiring cardiopulmonary bypass. INTERVENTION: TEE was utilized to obtain an upper esophageal short-axis view of the aorta with long-axis view of the main and right pulmonary arteries. MEASUREMENTS AND RESULTS: The distance between TEE position and wedge position was recorded along with patients' gender, height, and weight. A correlation was found between TEE and wedge distances (P < .0001). There were significant gender differences in TEE distance, with a mean of 43.6 cm in females and 46.5 cm in males (P = .0004). The mean wedge distance was 47.5 cm in females and 51.9 cm in males (P < .0001). The differences between distances of wedge and TEE positions (5.39 cm, males; 3.93 cm, females) were also significant (P < .0001). CONCLUSIONS: By securing the PAC at the one o'clock TEE position, physicians are assured of a safety margin of several centimeters. This direct visualization method for PAC placement may decrease the risk for accidental wedging intraoperatively.
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Cateterismo de Swan-Ganz/instrumentación , Cateterismo de Swan-Ganz/métodos , Ecocardiografía Transesofágica/métodos , Arteria Pulmonar/diagnóstico por imagen , Ultrasonografía Intervencional/métodos , Adulto , Anciano , Anciano de 80 o más Años , Estudios de Cohortes , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios ProspectivosAsunto(s)
Cateterismo de Swan-Ganz/instrumentación , Contraindicaciones de los Procedimientos , Trombolisis Mecánica/métodos , Arteria Pulmonar/diagnóstico por imagen , Embolia Pulmonar/terapia , Terapia Trombolítica/efectos adversos , Adulto , Angiografía por Tomografía Computarizada , Femenino , Humanos , Masculino , Persona de Mediana Edad , Embolia Pulmonar/diagnósticoRESUMEN
A significant number of patients with high-risk pulmonary embolism have contraindications to thrombolytic therapy. Catheter-based therapy may be helpful and consists of a multitude of catheters and techniques, some old and some new. Although there are few data supporting the use of any of these techniques, there has been a recent rise in interest and use of catheter-based pulmonary embolectomy. This text describes the contemporary devices used in pulmonary embolism treatment, discusses their challenges, and proposes some future directions.