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LETTERS TO THE EDITOR |
Department of Anesthesiology, University Medical Center, Würzburg, Germany
To the editor:
Tricuspid valve perforation associated with pulmonary artery catheter (PAC) placement has been reported (1). We describe a case in which guidance of catheter insertion by transesophageal echocardiography (TEE) may have prevented a similar complication. A 67-yr-old female patient was scheduled for replacement of the aortic and mitral valves as well as tricuspid annuloplasty resulting from severe tricuspid regurgitation.
After cannulation of the right radial artery and induction of general anesthesia, a triple-lumen central venous catheter and an 8F introducer sheath were inserted via the right internal jugular vein. Initial placement of a 7.5F PAC was immediately successful with the catheter being in a wedged position at a depth of 55 cm from the skin. Before skin incision, a monoplane TEE probe was introduced; this confirmed correct position of the PAC in the right pulmonary artery.
With initiation of cardiopulmonary bypass (CPB), the catheter was withdrawn into the superior vena cava, which is routine procedure at our institution for operations involving the tricuspid valve. After implantation of 27 mm and a 21 mm CarboMedics Bileaflet prostheses in the mitral and aortic positions, respectively, a tricuspid annuloplasty using a 34-mm Carpentier ring was performed. During weaning from CPB with a bypass flow rate of 50% of maximum calculated flow (2.4 L/min/m2), repositioning of the PAC was attempted with the TEE probe in a transgastric short-axis position to monitor volume load and regional wall motion abnormalities. Several attempts to redirect the catheter through the right heart were unsuccessful. Up to an insertion depth of 50 cm, no right ventricular pressure tracings could be obtained, without any perceptible resistance to catheter advancement. After withdrawing the TEE probe, the 4-chamber view revealed the tip of the PAC to impinge against the tricuspid annuloplasty ring. With catheter manipulation (rotation and using different volumes of balloon inflation) (2) under continuous TEE guidance, passage through the tricuspid valve and further into the pulmonary artery was achieved uneventfully. Even without noticeable resistance to catheter advancement, further "unguided" attempts might have resulted in damage to the Carpentier ring, the sutures, or the valve leaflets. We conclude that in the setting of tricuspid valvular surgery, PAC placement should be guided by TEE to prevent possible damage to valvular structures.
References
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