RESUMO
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.
Assuntos
Embolia Aérea , Embolia Intracraniana , Humanos , Embolia Aérea/etiologia , Embolia Aérea/diagnóstico , Embolia Intracraniana/etiologia , Embolia Intracraniana/diagnóstico , Remoção de Dispositivo/métodos , Remoção de Dispositivo/efeitos adversos , Pessoa de Meia-Idade , Masculino , Feminino , Doenças Pulmonares Intersticiais/etiologia , Doenças Pulmonares Intersticiais/diagnóstico , Doenças Pulmonares Intersticiais/terapia , Cateterismo de Swan-Ganz/efeitos adversos , Cateterismo de Swan-Ganz/instrumentaçãoAssuntos
Débito Cardíaco , Cateterismo de Swan-Ganz , Dispositivos Eletrônicos Vestíveis , Tecnologia sem Fio , Humanos , Tecnologia sem Fio/instrumentação , Cateterismo de Swan-Ganz/instrumentação , Desenho de Equipamento , Monitorização Fisiológica/instrumentação , Monitorização Fisiológica/métodos , Reprodutibilidade dos Testes , CatéteresRESUMO
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.
Assuntos
Encéfalo , Cateterismo de Swan-Ganz , Oxigenação por Membrana Extracorpórea , Imageamento por Ressonância Magnética , Imagens de Fantasmas , Sistemas Automatizados de Assistência Junto ao Leito , Humanos , Masculino , Pessoa de Meia-Idade , Imageamento por Ressonância Magnética/efeitos adversos , Imageamento por Ressonância Magnética/métodos , Feminino , Oxigenação por Membrana Extracorpórea/instrumentação , Oxigenação por Membrana Extracorpórea/efeitos adversos , Oxigenação por Membrana Extracorpórea/métodos , Idoso , Adulto , Encéfalo/diagnóstico por imagem , Cateterismo de Swan-Ganz/instrumentação , Cateterismo de Swan-Ganz/efeitos adversos , Estudos de ViabilidadeAssuntos
Cateterismo de Swan-Ganz , Veia Cava Superior , Humanos , Masculino , Cateterismo de Swan-Ganz/instrumentação , Cateterismo de Swan-Ganz/métodos , Ecocardiografia/métodos , Veia Cava Superior Esquerda Persistente/complicações , Veia Cava Superior Esquerda Persistente/diagnóstico por imagem , Artéria Pulmonar/diagnóstico por imagem , Artéria Pulmonar/anormalidades , Ultrassonografia de Intervenção/métodos , Veia Cava Superior/anormalidades , Veia Cava Superior/diagnóstico por imagem , AdultoRESUMO
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.
Assuntos
Cateterismo de Swan-Ganz/efeitos adversos , Cateterismo de Swan-Ganz/métodos , Dispositivos de Acesso Vascular , Adolescente , Cateterismo de Swan-Ganz/instrumentação , Humanos , Masculino , Artéria Pulmonar/diagnóstico por imagem , Radiografia/métodosRESUMO
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.
Assuntos
Cateterismo de Swan-Ganz/efeitos adversos , Traumatismos Cardíacos/etiologia , Ventrículos do Coração/lesões , Complicações Intraoperatórias/etiologia , Idoso , Aneurisma Aórtico/cirurgia , Cateterismo de Swan-Ganz/instrumentação , Ecocardiografia/métodos , Falha de Equipamento , Feminino , Septos Cardíacos/lesões , Humanos , Artéria Pulmonar/diagnóstico por imagemRESUMO
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.
Assuntos
Insuficiência Cardíaca/fisiopatologia , Insuficiência Cardíaca/cirurgia , Qualidade de Vida , Comportamento de Redução do Risco , Determinação da Pressão Arterial/instrumentação , Cateterismo de Swan-Ganz/instrumentação , Comportamentos Relacionados com a Saúde , Frequência Cardíaca , Hemodinâmica , Humanos , Estados UnidosRESUMO
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.
Assuntos
Cateterismo de Swan-Ganz/métodos , Intervenção Médica Precoce/métodos , Contração Miocárdica , Artéria Pulmonar/crescimento & desenvolvimento , Estenose de Artéria Pulmonar/terapia , Função Ventricular Direita , Animais , Animais Recém-Nascidos , Cateterismo de Swan-Ganz/instrumentação , Modelos Animais de Doenças , Hemodinâmica , Desenho de Prótese , Falha de Prótese , Artéria Pulmonar/patologia , Estenose de Artéria Pulmonar/diagnóstico por imagem , Estenose de Artéria Pulmonar/patologia , Estenose de Artéria Pulmonar/fisiopatologia , Stents , Sus scrofa , Fatores de TempoAssuntos
Malformações Arteriovenosas/terapia , Cateterismo de Swan-Ganz , Hipertensão Pulmonar/terapia , Artéria Pulmonar/anormalidades , Veias Pulmonares/anormalidades , Pressão Arterial , Malformações Arteriovenosas/complicações , Malformações Arteriovenosas/diagnóstico por imagem , Malformações Arteriovenosas/fisiopatologia , Cateterismo de Swan-Ganz/instrumentação , Angiografia por Tomografia Computadorizada , Ecocardiografia , Feminino , Humanos , Hipertensão Pulmonar/diagnóstico , Hipertensão Pulmonar/etiologia , Hipertensão Pulmonar/fisiopatologia , Pessoa de Meia-Idade , Artéria Pulmonar/diagnóstico por imagem , Artéria Pulmonar/fisiopatologia , Circulação Pulmonar , Veias Pulmonares/diagnóstico por imagem , Veias Pulmonares/fisiopatologia , Resultado do TratamentoRESUMO
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.
Assuntos
Cateterismo de Swan-Ganz , Fibrinolíticos/administração & dosagem , Embolia Pulmonar/terapia , Terapia Trombolítica/métodos , Ativador de Plasminogênio Tipo Uroquinase/administração & dosagem , Doença Aguda , Adulto , Idoso , Idoso de 80 Anos ou mais , Cateterismo de Swan-Ganz/efeitos adversos , Cateterismo de Swan-Ganz/instrumentação , Cateteres de Demora , Angiografia por Tomografia Computadorizada , Feminino , Fibrinolíticos/efeitos adversos , Humanos , Infusões Intra-Arteriais , Masculino , Pessoa de Meia-Idade , Flebografia/métodos , Embolia Pulmonar/diagnóstico por imagem , Embolia Pulmonar/fisiopatologia , Estudos Retrospectivos , Terapia Trombolítica/efeitos adversos , Terapia Trombolítica/instrumentação , Fatores de Tempo , Resultado do Tratamento , Ativador de Plasminogênio Tipo Uroquinase/efeitos adversos , Dispositivos de Acesso Vascular , Adulto JovemRESUMO
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.
Assuntos
Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Cateterismo de Swan-Ganz/instrumentação , Implante de Prótese de Valva Cardíaca/instrumentação , Próteses Valvulares Cardíacas , Insuficiência da Valva Pulmonar/cirurgia , Valva Pulmonar/cirurgia , Stents , Tetralogia de Fallot/cirurgia , Adolescente , Adulto , Idoso , Angiografia , Cateterismo de Swan-Ganz/efeitos adversos , Cateterismo de Swan-Ganz/métodos , Ecocardiografia , Feminino , Implante de Prótese de Valva Cardíaca/efeitos adversos , Implante de Prótese de Valva Cardíaca/métodos , Hemodinâmica , Humanos , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Desenho de Prótese , Valva Pulmonar/diagnóstico por imagem , Valva Pulmonar/fisiopatologia , Insuficiência da Valva Pulmonar/diagnóstico por imagem , Insuficiência da Valva Pulmonar/etiologia , Insuficiência da Valva Pulmonar/fisiopatologia , Recuperação de Função Fisiológica , Estudos Retrospectivos , Índice de Gravidade de Doença , Tetralogia de Fallot/fisiopatologia , Fatores de Tempo , Resultado do Tratamento , Adulto JovemRESUMO
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.
Assuntos
Cateterismo de Swan-Ganz/instrumentação , Cateterismo de Swan-Ganz/métodos , Ecocardiografia Transesofagiana/métodos , Artéria Pulmonar/diagnóstico por imagem , Ultrassonografia de Intervenção/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos ProspectivosRESUMO
We compared the similarity of cardiac-output (CO) estimates between available bolus thermodilution pulmonary-artery catheters (PAC), arterial pulse-contour analysis (LiDCOplus™, FloTrac™ and PiCCOplus™), and bioreactance (NICOM™). Repetitive simultaneous estimates of CO obtained from the above devices were compared in 21 cardiac-surgery patients during the first 2 h post-surgery. Mean and absolute values for CO across the devices were compared by ANOVA, Bland-Altman, Pearson moment, and linear-regression analyses. Twenty-one simultaneous CO measurements were made before and after therapeutic interventions. Mean PAC CO (5.7 ± 1.5 L min) was similar to LiDCO™, FloTrac™, PiCCO™, and NICOM™ CO (6.0 ± 1.9, 5.9 ± 1.0, 5.7 ± 1.8, 5.3 ± 1.0 L min, respectively). Mean CO bias between each paired method was -0.10 (PAC-LiDCO), 0.18 (PAC-PiCCO), -0.40 (PAC-FloTrac), -0.71 (PAC-NICOM), 0.28 (LiDCO-PiCCO), 0.39 (LiDCO-FloTrac), -0.97 (NICOM-LiDCO), 0.61 (PiCCO-FloTrac), -1.0 (NICOM-FloTrac), -0.73 (NICOM-PiCCO) L/min, with limits of agreement (1.96 SD, ±95% CI) of ± 2.01, ±2.35, ±2.27, ±2.70, ±1.97, ±2.17, ±3.51, ±2.87, ±2.40, and ± 3.14 L min, respectively, and the percentage error for each of the paired devices was 35, 41, 40, 47, 33, 36, 59, 50, 42, and 55%, respectively. From Pearson moment analysis, dynamic changes in CO, estimated by each device, showed good cross-correlations. Although all devices studied recorded similar mean CO values, which dynamically changed in similar directions, they have markedly different bias and precision values relative to each other. Thus, results from prior studies that have used one device to estimate CO cannot be used to validate others devices.
Assuntos
Débito Cardíaco , Procedimentos Cirúrgicos Cardíacos/instrumentação , Cateterismo de Swan-Ganz/instrumentação , Cateterismo de Swan-Ganz/métodos , Frequência Cardíaca , Artéria Pulmonar , Termodiluição/métodos , Idoso , Algoritmos , Análise de Variância , Feminino , Humanos , Modelos Lineares , Masculino , Pessoa de Meia-Idade , Monitorização Fisiológica , Período Pós-Operatório , Reprodutibilidade dos Testes , Fatores de TempoAssuntos
Cateterismo de Swan-Ganz/instrumentação , Contraindicações de Procedimentos , Trombólise Mecânica/métodos , Artéria Pulmonar/diagnóstico por imagem , Embolia Pulmonar/terapia , Terapia Trombolítica/efeitos adversos , Adulto , Angiografia por Tomografia Computadorizada , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Embolia Pulmonar/diagnósticoRESUMO
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.
Assuntos
Cateterismo de Swan-Ganz/instrumentação , Embolectomia/instrumentação , Embolia Pulmonar/cirurgia , Doença Aguda , Desenho de Equipamento , Humanos , Fatores de Risco , Falha de TratamentoRESUMO
Treatment of acute submassive pulmonary embolism (PE) with thrombolytic therapy remains an area of controversy. For patients who fail or who have contraindications to systemic thrombolysis, catheter-directed therapy (CDT) may be offered depending on the patient's condition and the available institutional resources to perform CDT. Although various CDT techniques and protocols exist, the most studied method is low-dose catheter-directed thrombolytic infusion without mechanical thrombectomy. This article reviews current protocols and data on the use of CDT for acute submassive pulmonary embolism.
Assuntos
Cateterismo de Swan-Ganz/instrumentação , Catéteres , Protocolos Clínicos , Medicina Baseada em Evidências , Fibrinolíticos/administração & dosagem , Embolia Pulmonar/tratamento farmacológico , Terapia Trombolítica/instrumentação , Doença Aguda , Cateterismo de Swan-Ganz/efeitos adversos , Desenho de Equipamento , Fibrinolíticos/efeitos adversos , Humanos , Infusões Intra-Arteriais , Embolia Pulmonar/diagnóstico por imagem , Embolia Pulmonar/fisiopatologia , Fatores de Risco , Terapia Trombolítica/efeitos adversos , Resultado do TratamentoRESUMO
This article will focus on 3 avenues for future research: (1) addressing the lack of short- and long-term clinical outcome research on catheter-directed therapy; (2) determining the safety and efficacy of novel thrombus removal devices; and (3) translating our knowledge of the pathobiology and pathophysiology of pulmonary embolism into novel diagnostic and therapeutic strategies.