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• W2588892956 abstract "The association between pulmonary artery catheters (PAC) and thrombus formation is not debated nor is it infrequent. In fact, the incidence of thrombosis associated with right heart catheterization in post-mortem evaluations was 53%.1Connors A.F. Castele R.J. Farhat N.Z. et al.Complications of right heart catheterization. A prospective autopsy study.Chest. 1985; 88: 567-572Abstract Full Text Full Text PDF PubMed Scopus (85) Google Scholar Assuming that a number of thrombi remain unidentified prior to PAC removal, this postmortem analysis could represent a conservative estimate. The 65% to 100% incidence of severe thrombosis reported by Hoar et al appeared to support that logic.2Hoar P.F. Stone J.G. Wicks A.E. et al.Thrombogenesis associated with Swan-Ganz catheters.Anesthesiology. 1978; 48: 445-447Crossref PubMed Scopus (49) Google Scholar Alternatively, one could conclude that the thrombosis observed by Hoar et al was partially the result of non-heparin-bonded catheters. Although the protection conferred by heparin coating was not observed by Mollenholt et al 48 hours after placement, its use makes intuitive sense, and our recent experience with non-heparin-bonded catheters in the operating room advocates for its utility in the immediate post-placement period.3Mollenholt P. Eriksson I. Andersson T. Thrombogenicity of pulmonary-artery catheters.Intensive Care Med. 1987; 13: 57-59Crossref PubMed Scopus (19) Google Scholar, 4Fontes M. Barash P.G. Pulmonary artery catheter under the microscope.Crit Care Med. 2000; 28: 891-892Crossref PubMed Scopus (3) Google Scholar Despite the published incidence of PAC-associated thrombi, this phenomenon at our institution was largely a non-entity until recently. As a matter of institutional protocol, we use PACs and transesophageal echocardiography (TEE) in all cardiac surgeries, including coronary artery bypass graft (CABG) and pulmonary thromboendarterectomy. All patients receive careful, complete TEE examinations intraoperatively. Furthermore, during pulmonary thromboendarterectomy, following pulmonary arteriotomy, the distal end of the PAC is temporarily withdrawn from the pulmonary artery by the surgeon and replaced into the pulmonary artery when the endarterectomy is complete. In our experience, the appearance of thrombus either on TEE or on direct inspection of the distal end of the catheter is exceedingly rare. Edwards Lifesciences (Irvine, CA) halted production of our preferred pulmonary artery catheter, VIP+ Model 834HF75 (Edwards Lifesciences, Irvine, CA). The company recently discontinued the production of heparinized pulmonary artery catheters, a product regulated under the Federal Drug Administration’s combination products category. The replacement of this heparin-bonded PAC with a non-heparin-bonded version, VIP+ Model 834F75 (Edwards Lifesciences, Irvine, CA), was almost immediately associated with an increase in PAC-associated thrombi. Within a 2-week period, thrombi attached to the non-heparin-bonded VIP+ model were identified by TEE in 5 patients intraoperatively. In all 5 cases (4 CABGs and 1 pulmonary thromboendarterectomy), the thrombus was located in the right atrium or superior vena cava attached to the PAC near the proximal injection (30 cm) or infusion (31 cm) ports (Fig 1, Fig 2). In 1 case of planned off-pump CABG, a PAC thrombus was identified in the right atrium adjacent to a newly diagnosed small atrial septal defect (ASD). Because of the presence of the nearby thrombus, the surgical plan was changed to an on-pump CABG to permit open surgical removal of the thrombus and ASD closure.Fig 2Transesophageal echocardiography, mid-esophageal bicaval still image demonstrating a thrombus (red arrow) attached to the pulmonary artery catheter in the superior vena cava.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Although the exact time of formation cannot be determined retrospectively, it was noted in 2 of the 5 cases that these thrombi were identified after the patient had been fully heparinized (ie, activated clotting time >400 seconds). Furthermore, all of these catheters were prepared according to our institutional protocol by flushing the lumens with heparinized saline (2 U of heparin/mL), placed through a 9-French introducer and proximal injection port maintained with a heparinized saline (2 U of heparin/mL) infusion. Therefore, the non-heparin-bound catheters were suspected to be the culprit. The manufacturer of the non-heparinized PACs was contacted, and a new lot of non-heparinized catheters was provided. Despite this change in inventory the problem persisted. A change to a heparin-bonded pulmonary artery catheter still in production, Criticath SP5507H TD Catheter (Argon Medical Devices, Plano, TX), has since resolved the issue at our institution. Although 17% (5 of 30 cases during that 2-week period) is well below the previously published incidence, the abrupt increase in our institution was alarming. Skeptics may attribute our history of thrombus-free years to a lack of investigation. However, more than 1,000 pulmonary thromboendarterectomies have been completed at our institution. Despite the thrombogenic patient population, detailed TEE right heart evaluation, and intraoperative surgical inspection of the distal PAC, catheter-associated thrombus previously was not an issue. Although other factors (eg, the use of introducers and protective sleeves, anti-fibrinolytic administration, and balloon manipulation) have been hypothesized to contribute to thrombus formation and the clinical significance of PAC thrombi remains unknown, our experience has led to a preference for heparin-bonded catheters.5Kaye A.D. Anwar M. Youngberg J.A. Introducers and protective sleeves may increase thrombogenicity of pulmonary artery catheters.J Cardiothorac Vasc Anesth. 1999; 13: 139-142Abstract Full Text PDF PubMed Scopus (4) Google Scholar, 6Dentz M.E. Slaughter T.F. Mark J.B. Early thrombus formation on heparin-bonded pulmonary artery catheters in patients receiving epsilon aminocaproic acid.Anesthesiology. 1995; 82: 583-586Crossref PubMed Scopus (41) Google Scholar, 7Bohrer H. Fleischer F. Lang J. et al.Early formation of thrombi on pulmonary artery catheters in cardiac surgical patients receiving high-dose aprotinin.J Cardiothorac Vasc Anesth. 1990; 4: 222-225Abstract Full Text PDF Scopus (64) Google Scholar Given that the thrombi were identified in the operating room within 2 hours of placement, our experience appeared to be consistent with the report by Whiffen et al, who determined that 65% of the heparin is released within the first 3 hours.8Whiffen J.D. Beeckler D.C. The fate of the surface heparin of GBH-coated plastics after exposure to the blood stream.J Thorac Cardiovasc Surg. 1966; 52: 121-125PubMed Google Scholar This early release of heparin may explain why PAC-associated thrombus was not noted previously after placement of heparin-bonded catheters in the operating room at our institution. While the jury is out on the long-term protective effect of heparin bonding on thrombus formation, our experience with early thrombus formation in non-heparin-coated pulmonary artery catheters has led to an institutional change. We are not advocating for a unilateral ban of non-heparin-bonded catheters but instead offer our experience as a reminder to remain vigilant for this potential complication and the management dilemma it poses in the cardiac operating room. Finally, early thrombus formation on pulmonary artery catheters may become more common in the future if other companies stop producing heparin-bonded catheters due to the regulatory pathways requirements for combination products." @default.
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• W2588892956 title "Early Thrombosis and Non-Heparin-Coated Pulmonary Artery Catheters" @default.
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