The
Left
Atrial
Barry David
S. Leitman, P. Naidich,
MD MD
Georgeann
Catheter:
McGuinness,
Dorothy
MD
I. McCauley,
Its
subsequently replacement
chest
sis
wall,
Index
terms:
565.122 cations,
#{149} Catheters 565.447
Radiology
T
Catheters
1992;
and catheterization,
and Heart,
catheterization, foreign bodies,
#{149}
compli565.447
connected
and saline
(Fig
of this report
to monitor
tam blood
left
samples,
atrial
and
of
pressure,
ob-
to deliver
pharthat freto
our knowledge, no recent publication within the radiobogie literature has detheir
use.
Because
use
of this
catheter is not without complications, familiarity with its typical radiographic appearance should be of value in the interpretation of postoperative radiographs, tensive
especially care units.
Catheter
poor
vascular
usually
in
access,
two
simultaneously are
removed
be-
drains
orrhage resulting can be detected. usually retained as most mediastinal
from LAC removal The LAC is therefore for only a short period, tubes are removed
within
following
24 hours
unstable patients, may be retained sary.
are, so that
hem-
surgery.
however, for as long
Jude,
which
was
lion
valve
disk
prosthe-
St Paul).
The postoperative cated by sternal with Staphylococcus bridement
aortic 25
course was compliosteomyelitis associated aurcus septieemia,
successfully
and
treated
intravenous
of antibiotics
d#{233}-
with
administra-
for 6 weeks.
At this
time, radiography revealed a previously unsuspected catheter in the region of
the left atrium. mitted
for
The
evaluation
patient and
was
read-
potential
In
the catheter as neces-
those
obtained
Report
A 66-year-old
catheter (LAC). LACs have been
maceuticals (1-4). Despite the fact these devices are well known and quently used by cardiac surgeons,
seribed
at a
fore mediastinal
is to de-
and highlight awareness used intracardiac device
known as the left atrial For more than 30 years, used
typically
(St
underwent with a size
185:611-612
purpose
scribe a commonly
of 5% dextrose
(5,6) (Fig 1). Rarely,
be placed
2). LACs
to
The
to a pressure
is infused,
with
may
is used
to the skin.
a solution
of 50 mL/h
patients
LACs
suture
is then
in 0.25N
rate
a single
relative
monitor,
Case HE
and
its position
catheter
The authors describe the radiographic appearance of the left atrial catheter, a widely used postsurgical intracardiac device. Recognition of the characteristic appearance of this catheter should be of value in detection of potential complications, including line fracture with resultant retention and/or embolization, infection, prosthetic valve dysfunction, and even cardiac tamponade.
Complications’
and
when appropriate. The proximal end of the catheter is then brought through the hold
MD
Uses
aortie
valve
man
was admitted
replacement.
Eleven
for years
prior to admission, he had undergone uncomplicated triple coronary artery bypass graft surgery. Six years prior to admission, he started to experience lightheadedness; subsequent cardiac catheterization revealed patency of all
three across
grafts but a gradient of 45 mm Hg the aortic valve. Conservative
therapy
was
continued
before admission, gan experiencing lightheadedness
until
3 months
when the patient beincreasingly severe associated
with
the
new onset of angina. Cardiac catheterization at this time showed a transaortic gradient of 100 mm Hg. The patient
Figure
1. Normal position of LAC. Collimated view of a digital anteroposterior chest radiograph obtained after aortic valve replacement demonstrates the LAC (arrowheads) projecting over the right side of the mediastinum and within the left atrium.
in in-
Placement
The LAC (ITE Iubing Zens Industrial Products, Raritan, NJ) is placed at the conclusion of an intracardiac surgical procedure
by using
a 20-gauge
dle inserted into the right superior monary vein near its junction with left atrium. The needle is removed, the catheter is sutured in place with purse-string ligature, tight enough transfix it in position but not tight enough
to preclude
its easy
From the Department York University Medical I
nee-
pubthe and a to
removal
of Radiology, New Center, 566 First Aye,
New York, NY 10016. Received May 22, 1992; accepted July 1 . Address reprint requests to B.S.L. C RSNA, 1992
1
r!-i-*j_.___
Figure 2. On this ital chest radiograph, two LACs (arrows)
dig-
with their distal tips in the superior pulmonary
veins
bilaterally
are evident.
Radin1n’v
#{149} t11
a. Figure
d.
b.
(a) CT scan at the level of the right hemidiaphragm shows the proximal aspect of the LAC within epicardial fat (curved arrow). The distal tip (straight arrow) extends into the right inferior pulmonary vein. (b) CT scan at the level of the orifice of the right inferior pulmonary vein demonstrates the catheter extending into the vein (straight arrow); the proximal aspect of the catheter (curved arrow) is still within the epicardial fat. (c) CT scan at the level of the right interlobar pulmonary artery shows the distal limb of the catheter (straight arrow) within the left atrium, at the insertion of the right superior pulmonary vein. The LAC is also evident anterolateral to the superior vena cava (curved arrow). (d) CT scan at the level of the right main pulmonary artery shows the LAC (curved ar-
row)
3.
LAC
bypassing
extending
into
the superior
the
vena
right
inferior
cava
on its way
pulmonary
vein.
to entering
the right
superior
pulmonary
vein.
catheter removal. A computed tomography (CI) scan, obtained to more pnecisely locate the catheter, confirmed that
a catheter proximal
was indeed present. end was lying within
pentoneal
and
fat of the
the distal
upper
The the pro-
abdomen,
tip extended
into
the
right
inferior pulmonary vein (Fig 3). At surgery, the propentoneal fat was dissected and the LAC was mobilized for a short distance. With the carotid arteries compressed to obviate any risk of embolization, gentle traction was applied,
and 33 cm of catheter was easily removed. Because the proximal end was found
to be irregular,
it was
presumed
that the LAC had been broken by the needle used to suture it in place and that only the proximal fragment had been removed initially. The distal end was smooth, which confirmed complete removal of the LAC. The postoperative recovery
was
without
incident.
a.
b.
Figure diograph atrium tamed inferior
4.
LAC extending into the left inferior pulmonary vein. (a) Anteroposterior chest rain the immediate postoperative period shows an LAC (arrowheads) within the left and extending into the left inferior pulmonary vein. (b) Lateral chest radiograph obI week after surgery demonstrates the LAC (arrowheads) with its distal tip in the left pulmonary vein. This catheter was retained intentionally for vascular access.
Discussion Because of this case, we now routimely identify the presence of LACs. Typically, these devices can be visual-
ized
on chest
linear
radiographs
metallic
lines
within
as thin, the
the
curvi-
left
atrium (Figs 1, 2, 4). Any doubt as to the exact location of the catheter can be resolved
by obtaining
Identification portant, plications
a CT scan.
of these
catheters
fled by the ease report, these include line fragmentation and/or retention (7). A fragmented LAC may embolize and may also become infected (8). Additionally, if it slips into the pericardium, tamponade secondary to the infusing solution can result (9). Finally, these catheters may impinge on a prosthetic
valve,
with
Recognition
should
612
resultant
of these be facilitated
Radiology
#{149}
dysfunction complications by recognition
ance.
1.
2.
3.
4.
(10). 5.
of
of these
catheters radiographic
and
their
appear-
U
6.
References
is im-
as a number of potential comattend their use. As exempli-
use
characteristic
Kirklin JW, Theye RA. Cardiac performance after open intracardiac surgery. Circulation 1963; 28:1061-1070. Fishman NH, Hutchinson JC, Roe BB. Controlled atrial hypertension: a method for supporting cardiac output following open heart surgery. J Thorac Cardiovasc Surg 1966; 52:777-785. Sarin CL, Yalav E, Clement AJ, Baimbridge MV. The necessity for measurement of left atrial pressure after cardiac valve surgery. Thorax 1970; 25:185-189. Moorthy SS, LoSasso AM, Gibbs PS. Significance and application of blood gas determinations from the left atrial catheter. Crit Care Med 1979; 7:457-459. Yamada T. Simplified technique for insertion of indwelling catheters in the pulmo-
7.
8.
9.
10.
nary artery and left atrium. J Cardiovasc Surg 1975; 16:205-207. Steedman RA. Post-operative care of the adult cardiac surgical patient. In: Zschoche DA, ed. Mosby’s comprehensive review of critical care. St Louis: Mosby, 1981; 359361. Win A, Pastore JO, Coletta D, Junda RJ. Echocardiographic detection of a retained left atrial catheter. Am Heart J 1980; 99:9395. Freeman R, Holden MP, Lyon R, Hjersing N. Addition of sodium metabisulphite to left atrial catheter infusates as a means of preventing bacterial colonization of the catheter tip. Thorax 1982; 37:142-144. Bricker DL, Dalton ML. Cardiac tamponade following dislodgement of a left atrial catheter after coronary artery bypass. Thorac Cardiovasc Surg 1973; 66:636-638. Porter EJ, Norfleet EA, Boone FD, Battaglini J, Starek PJ. Entrapment of a mitral valve prosthesis with a left atrial catheter. Anesthesiology 1984; 60:246-248.
November
1992
Left
Atrial
Barry David
S. Leitman, P. Naidich,
MD MD
Georgeann
Catheter:
McGuinness,
Dorothy
MD
I. McCauley,
Its
subsequently replacement
chest
sis
wall,
Index
terms:
565.122 cations,
#{149} Catheters 565.447
Radiology
T
Catheters
1992;
and catheterization,
and Heart,
catheterization, foreign bodies,
#{149}
compli565.447
connected
and saline
(Fig
of this report
to monitor
tam blood
left
samples,
atrial
and
of
pressure,
ob-
to deliver
pharthat freto
our knowledge, no recent publication within the radiobogie literature has detheir
use.
Because
use
of this
catheter is not without complications, familiarity with its typical radiographic appearance should be of value in the interpretation of postoperative radiographs, tensive
especially care units.
Catheter
poor
vascular
usually
in
access,
two
simultaneously are
removed
be-
drains
orrhage resulting can be detected. usually retained as most mediastinal
from LAC removal The LAC is therefore for only a short period, tubes are removed
within
following
24 hours
unstable patients, may be retained sary.
are, so that
hem-
surgery.
however, for as long
Jude,
which
was
lion
valve
disk
prosthe-
St Paul).
The postoperative cated by sternal with Staphylococcus bridement
aortic 25
course was compliosteomyelitis associated aurcus septieemia,
successfully
and
treated
intravenous
of antibiotics
d#{233}-
with
administra-
for 6 weeks.
At this
time, radiography revealed a previously unsuspected catheter in the region of
the left atrium. mitted
for
The
evaluation
patient and
was
read-
potential
In
the catheter as neces-
those
obtained
Report
A 66-year-old
catheter (LAC). LACs have been
maceuticals (1-4). Despite the fact these devices are well known and quently used by cardiac surgeons,
seribed
at a
fore mediastinal
is to de-
and highlight awareness used intracardiac device
known as the left atrial For more than 30 years, used
typically
(St
underwent with a size
185:611-612
purpose
scribe a commonly
of 5% dextrose
(5,6) (Fig 1). Rarely,
be placed
2). LACs
to
The
to a pressure
is infused,
with
may
is used
to the skin.
a solution
of 50 mL/h
patients
LACs
suture
is then
in 0.25N
rate
a single
relative
monitor,
Case HE
and
its position
catheter
The authors describe the radiographic appearance of the left atrial catheter, a widely used postsurgical intracardiac device. Recognition of the characteristic appearance of this catheter should be of value in detection of potential complications, including line fracture with resultant retention and/or embolization, infection, prosthetic valve dysfunction, and even cardiac tamponade.
Complications’
and
when appropriate. The proximal end of the catheter is then brought through the hold
MD
Uses
aortie
valve
man
was admitted
replacement.
Eleven
for years
prior to admission, he had undergone uncomplicated triple coronary artery bypass graft surgery. Six years prior to admission, he started to experience lightheadedness; subsequent cardiac catheterization revealed patency of all
three across
grafts but a gradient of 45 mm Hg the aortic valve. Conservative
therapy
was
continued
before admission, gan experiencing lightheadedness
until
3 months
when the patient beincreasingly severe associated
with
the
new onset of angina. Cardiac catheterization at this time showed a transaortic gradient of 100 mm Hg. The patient
Figure
1. Normal position of LAC. Collimated view of a digital anteroposterior chest radiograph obtained after aortic valve replacement demonstrates the LAC (arrowheads) projecting over the right side of the mediastinum and within the left atrium.
in in-
Placement
The LAC (ITE Iubing Zens Industrial Products, Raritan, NJ) is placed at the conclusion of an intracardiac surgical procedure
by using
a 20-gauge
dle inserted into the right superior monary vein near its junction with left atrium. The needle is removed, the catheter is sutured in place with purse-string ligature, tight enough transfix it in position but not tight enough
to preclude
its easy
From the Department York University Medical I
nee-
pubthe and a to
removal
of Radiology, New Center, 566 First Aye,
New York, NY 10016. Received May 22, 1992; accepted July 1 . Address reprint requests to B.S.L. C RSNA, 1992
1
r!-i-*j_.___
Figure 2. On this ital chest radiograph, two LACs (arrows)
dig-
with their distal tips in the superior pulmonary
veins
bilaterally
are evident.
Radin1n’v
#{149} t11
a. Figure
d.
b.
(a) CT scan at the level of the right hemidiaphragm shows the proximal aspect of the LAC within epicardial fat (curved arrow). The distal tip (straight arrow) extends into the right inferior pulmonary vein. (b) CT scan at the level of the orifice of the right inferior pulmonary vein demonstrates the catheter extending into the vein (straight arrow); the proximal aspect of the catheter (curved arrow) is still within the epicardial fat. (c) CT scan at the level of the right interlobar pulmonary artery shows the distal limb of the catheter (straight arrow) within the left atrium, at the insertion of the right superior pulmonary vein. The LAC is also evident anterolateral to the superior vena cava (curved arrow). (d) CT scan at the level of the right main pulmonary artery shows the LAC (curved ar-
row)
3.
LAC
bypassing
extending
into
the superior
the
vena
right
inferior
cava
on its way
pulmonary
vein.
to entering
the right
superior
pulmonary
vein.
catheter removal. A computed tomography (CI) scan, obtained to more pnecisely locate the catheter, confirmed that
a catheter proximal
was indeed present. end was lying within
pentoneal
and
fat of the
the distal
upper
The the pro-
abdomen,
tip extended
into
the
right
inferior pulmonary vein (Fig 3). At surgery, the propentoneal fat was dissected and the LAC was mobilized for a short distance. With the carotid arteries compressed to obviate any risk of embolization, gentle traction was applied,
and 33 cm of catheter was easily removed. Because the proximal end was found
to be irregular,
it was
presumed
that the LAC had been broken by the needle used to suture it in place and that only the proximal fragment had been removed initially. The distal end was smooth, which confirmed complete removal of the LAC. The postoperative recovery
was
without
incident.
a.
b.
Figure diograph atrium tamed inferior
4.
LAC extending into the left inferior pulmonary vein. (a) Anteroposterior chest rain the immediate postoperative period shows an LAC (arrowheads) within the left and extending into the left inferior pulmonary vein. (b) Lateral chest radiograph obI week after surgery demonstrates the LAC (arrowheads) with its distal tip in the left pulmonary vein. This catheter was retained intentionally for vascular access.
Discussion Because of this case, we now routimely identify the presence of LACs. Typically, these devices can be visual-
ized
on chest
linear
radiographs
metallic
lines
within
as thin, the
the
curvi-
left
atrium (Figs 1, 2, 4). Any doubt as to the exact location of the catheter can be resolved
by obtaining
Identification portant, plications
a CT scan.
of these
catheters
fled by the ease report, these include line fragmentation and/or retention (7). A fragmented LAC may embolize and may also become infected (8). Additionally, if it slips into the pericardium, tamponade secondary to the infusing solution can result (9). Finally, these catheters may impinge on a prosthetic
valve,
with
Recognition
should
612
resultant
of these be facilitated
Radiology
#{149}
dysfunction complications by recognition
ance.
1.
2.
3.
4.
(10). 5.
of
of these
catheters radiographic
and
their
appear-
U
6.
References
is im-
as a number of potential comattend their use. As exempli-
use
characteristic
Kirklin JW, Theye RA. Cardiac performance after open intracardiac surgery. Circulation 1963; 28:1061-1070. Fishman NH, Hutchinson JC, Roe BB. Controlled atrial hypertension: a method for supporting cardiac output following open heart surgery. J Thorac Cardiovasc Surg 1966; 52:777-785. Sarin CL, Yalav E, Clement AJ, Baimbridge MV. The necessity for measurement of left atrial pressure after cardiac valve surgery. Thorax 1970; 25:185-189. Moorthy SS, LoSasso AM, Gibbs PS. Significance and application of blood gas determinations from the left atrial catheter. Crit Care Med 1979; 7:457-459. Yamada T. Simplified technique for insertion of indwelling catheters in the pulmo-
7.
8.
9.
10.
nary artery and left atrium. J Cardiovasc Surg 1975; 16:205-207. Steedman RA. Post-operative care of the adult cardiac surgical patient. In: Zschoche DA, ed. Mosby’s comprehensive review of critical care. St Louis: Mosby, 1981; 359361. Win A, Pastore JO, Coletta D, Junda RJ. Echocardiographic detection of a retained left atrial catheter. Am Heart J 1980; 99:9395. Freeman R, Holden MP, Lyon R, Hjersing N. Addition of sodium metabisulphite to left atrial catheter infusates as a means of preventing bacterial colonization of the catheter tip. Thorax 1982; 37:142-144. Bricker DL, Dalton ML. Cardiac tamponade following dislodgement of a left atrial catheter after coronary artery bypass. Thorac Cardiovasc Surg 1973; 66:636-638. Porter EJ, Norfleet EA, Boone FD, Battaglini J, Starek PJ. Entrapment of a mitral valve prosthesis with a left atrial catheter. Anesthesiology 1984; 60:246-248.
November
1992
