2019 Scientific Sessions

Title: Percutaneous Removal of a Pulmonary Artery Catheter (PAC) Inadvertently Sutured to the Heart during “Mini-Mitral” Valve Repair. Introduction: A retained PAC inadvertenly sutured to the heart is a serious complication of "Mini-Mitral" valve surgery and traditionally requires surgical removal. Utilizing techniques borrowed from lead extraction, we attempted to remove the catheter percutaneously. Clinical Case: A 74-year-old woman underwent a minimally-invasive mitral valve repair via a right thoracotomy without difficulty. Intra-operative hemodynamics were monitored by a PAC placed within the right internal jugular (IJ) vein. On post-operative day #1, it was noted that the PAC could not be removed from the neck. One of the catheter ports was non-functional, suggesting that a suture was through the catheter rather than around it. In an effort to avoid a new sternotomy, she was referred for percutaneous removal. The patient was placed under general anesthesia and sheaths were inserted into the right internal jugular (IJ) vein (adjacent to the PAC) and femoral veins, bilaterally. Cardiothoracic surgery was immediately available in the case of an emergency. An intracardiac echocardiography catheter was used to monitor for complications. A 20 mm GooseNeck snare was placed through an Agilis sheath, guided over the PAC, and secured below the suture. Endobronchial forceps were placed within the right IJ and used to snare the PAC above the suture. Simultaneous traction resulted in the forceps repeatedly slipping off the catheter. Due to this, lead locking stylets (LLS) were placed within the lumens of the PAC with the distal tip ending just above the suture. This strengthened that portion of the PAC and rendered the section distal to it vulnerable to disruption with traction. Simultaneous traction with the GooseNeck from below and the externalized PAC from above lacerated the PAC just above the suture. That portion of the PAC was removed from the neck. The snare was removed and a separate GooseNeck snared the PAC in the IVC and was brought up just below the suture. A second GooseNeck from the femoral vein snared the PAC and was secured just below the first. Simultaneous traction resulted in complete disruption of the PAC between the two snares, just below the suture. The PAC was removed from the femoral vein. A small piece of catheter with the suture remained in its original location within the heart. There were no complications over 6-months. Discussion: Traditional treatment of a retained PAC inadvertently sutured to the heart is surgical removal. Percutaneous removal utilizing tools and techniques borrowed from lead extraction proved successful in this case. Since the suture that pierced the PAC was also securing the atriotomy incision, it was imperative that it was not disrupted. Utilizing LLS from above allowed for the top portion to be removed above the suture. Utilizing a double snare technique from below allowed the lower portion to be removed similarly. Both techniques resulted in a stable suture position during traction. The resulting PAC fragment is likely to become completely endothelialized and unlikely to cause harm. This technique should be considered in similar cases.