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• W2172000988 abstract "Transesophageal echocardiography (TEE) is increasingly used as a diagnostic tool and an intraoperative monitoring device. The left atrial (LA) catheter is used to better quantify left ventricular filling pressures after cardiac surgery, especially after complex cardiac cases, in which a pulmonary artery catheter may be contraindicated or its readings potentially unreliable (chronically raised pulmonary arterial or venous pressures). We describe our experience in the use of TEE to help in the location and removal of a recognized retained fragment of an LA catheter. A 29-year-old man, who had previously undergone multiple surgical procedures for management and correction of Fallot's tetralogy, was scheduled for orthotopic cardiac transplantation. His original diagnosis was tetralogy of Fallot with an azygous continuation of the superior vena cava draining to a left superior vena cava and coronary sinus. At the age of 2 years, he had a classic right Blalock-Taussig shunt, then 5 years later underwent a radical repair (Lennox), including a Dacron patch ventricular septal defect closure and a homograft right ventricular outflow tract replacement. Two years later, the pulmonary valve was replaced with a homograft. Because of worsening symptoms of heart failure (chest pain and shortness of breath), the patient was listed on the cardiac transplant waiting list. The transplant procedure did not proceed uneventfully; the superior vena cava needed to be reconstructed from a leg vein because there was a large degree of anatomic distortion from previous repairs. A radiopaque LA catheter was inserted through the LA appendage at the end of the procedure because a pulmonary artery catheter was thought to be relatively contraindicated owing to the various anastomoses in the venocaval system. After completion of the surgery, the patient was transferred to the intensive care unit for continuing support. During the next 5 days, a persistent low cardiac output syndrome requiring inotrope support and the development of acute renal failure hampered the patient's progress. On day 7 post-transplant, the LA catheter was removed because it was giving no significant additional clinical information. At the time of removal, some resistance was felt while pulling the catheter. This was overcome with minimal extra force; however, when the tip was inspected after removal, it was noted that there were approximately 4 cm of the distal end missing. The patient at this point was still sedated, intubated, and ventilated. The decision to reopen the chest to find and remove the catheter fragment depended on knowing that it still remained in the heart and had not migrated either to the pericardial cavity or further into the systemic circulation. Plain chest radiography and transthoracic echocardiography were unsuccessful in identifying the fragment. Using a Hewlett Packard omniplane TEE probe and a Hewlett Packard Sonos 1500 console, good-quality images were obtained. The catheter tip was easily located in the oblique short-axis view of the base of the heart, being visible as 2 parallel echodense lines (Fig 1).Approximately 3 cm of catheter were seen extending into the atrial cavity from the region where the right upper pulmonary vein drains into the left atrium. No evidence of extension outside the atrial cavity was obtained, although an increased echodensity consistent with a hematoma was identified external to the left atrium. The hematoma was thought to be secondary to the operative procedure and not the retained fragment. It was clear that the LA catheter fragment was still in the left atrium, tethered to its wall. In view of the risk of embolization or thrombus formation, it was decided to reopen the chest and remove the fragment. The patient was scheduled for a resternotomy. During surgery, intraoperative TEE confirmed the position of the fragment before the chest was opened. Additionally, because of the surrounding hematoma and distortion of anatomy, intraoperative TEE helped to guide the surgeon to the location of the fragment and after the procedure confirmed that no residual fragments were left in the heart. The indications for and the complications of LA catheters are well described.1Santini F Gatti G Borghetti V et al.Routine left atrial catheterization for the postoperative management of cardiac surgical patients: Is the risk justified?.Eur J Cardiothorac Surg. 1999; 16: 218-221Crossref PubMed Scopus (20) Google Scholar It is accepted that fragments from incomplete removal of a catheter should be removed if possible because of the risk of embolic events.2Yeo TC Miller Jr, FA Oh JK Freeman WK Retained left atrial catheter: An unusual cardiac source of embolism identified by transoesophageal echocardiography.J Am Soc Echocardiogr. 1998; 11: 66-70Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar, 3Drummond-Webb JJ Bokesch PM Ebied MR et al.Branch retinal artery occlusion from a retained left atrial catheter 21 years after operation.Ann Thorac Surg. 1998; 65: 254-255Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar Previous investigators have used echocardiography to locate such fragments. In the previously described reports,4Win A Pastore JO Coletta D Junda RJ Echocardiographic detection of a retained left atrial catheter.Am Heart J. 1980; 99: 93-95Abstract Full Text PDF PubMed Scopus (13) Google Scholar the patient presented with evidence of embolization from a presumed intracardiac source. TEE was used in the routine investigation, and the retained atrial fragment unexpectedly found. We describe a case in which a catheter fragment was known to be retained and was identified before any adverse embolic events related to the fragment occurred. The line tip was not visible on plain chest radiography or transthoracic echocardiography. Computed tomography scanning has been tried unsuccessfully.4Win A Pastore JO Coletta D Junda RJ Echocardiographic detection of a retained left atrial catheter.Am Heart J. 1980; 99: 93-95Abstract Full Text PDF PubMed Scopus (13) Google Scholar Because the left atrium is close to the TEE probe transducer, high-frequency ultrasound can be used, and superior resolution of intracardiac structures can be obtained when compared with the transthoracic approaches. The unique ability of TEE to be performed during the surgical procedure for removal was an invaluable tool." @default.
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• W2172000988 title "Utility of transesophageal echocardiography in the management of retained left atrial catheter" @default.
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• W2172000988 doi "https://doi.org/10.1053/jcan.2001.22023" @default.
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