Echocardiographic interpretation in the presence of Swan-Ganz intracardiac catheters

Using Transthoracic Two-Dimensional Echocardiography to Guide the Placement of Coronary Sinus Catheters: A Randomized Study

OBJECTIVE

To assess the value of transthoracic echocardiography (TTE) as an image guide in placing a coronary sinus catheter into the coronary sinus.

METHODS

Sixty consecutive patients undergoing electrophysiologic study were randomized to TTE (30 patients, "TTE group") or x-ray fluoroscopy (30 patients, "x-ray group") as an image guide to assist in the placement of a coronary sinus catheter.

RESULTS

The success rate of placing the coronary sinus catheter was 96.7% in TTE group and 100% in x-ray group (P > 0.05). The procedure duration was 5.8 +/- 5.7 minutes in TTE group and 5.9 +/- 3.3 minutes in x-ray group (P > 0.05), The x-ray exposure time was 0.15 +/- 0 minute in TTE group and 4.2 +/- 2.8 minutes in x-ray group (P < 0.0001).

CONCLUSION

Using TTE as an image guide, coronary sinus cannulation is feasible and as rapid as standard x-ray fluoroscopy, without the radiation risk.

The transponder system: a new method of precise catheter placement in the right atrium under echocardiographic guidance

The ability to localize catheters within the heart has gained importance with the use of percutaneous catheter ablation and the transseptal approach for valvuloplasty. A prototype interactive transponder catheter system, specifically designed to mark the catheter tip for echocardiographic visualization, was used to place catheters at the tricuspid anulus and the fossa ovalis in anesthetized dogs. Catheter tip location was marked by lesions produced by radiofrequency energy delivered at the distal catheter electrode. At autopsy, the center of the radiofrequency-induced lesion was located 2.8 +/- 0.7 mm from the edge of the lateral tricuspid anulus and 3.5 +/- 3.1 mm from the center of the fossa ovalis. The transponder catheter system offers the ability to precisely position catheters in the right atrium under echocardiographic guidance.

Use of two-dimensional echocardiography during transseptal cardiac catheterization

Inadvertent puncture of the intrapericardial aorta is a serious complication of transseptal catheterization. Two-dimensional echocardiography allows delineation and spatial resolution of the aorta and interatrial septum. Thirteen patients underwent transseptal catheterization with simultaneous monitoring of needle and catheter position using fluoroscopy and two-dimensional echocardiography. The interatrial septum was demonstrated in the short-axis and four chamber views, and clearly separated from the ascending aorta. The transseptal needle and catheter were visualized by echocardiography while the needle tip was manipulated into the fossa ovalis avoiding puncture of the aortic root. In some cases, under pressure from the needle tip just before puncture, the interatrial septum appears to bulge toward the left atrium. Saline solution contrast echocardiography helped to confirm the needle position in the right atrium, and in the left atrium after puncture. These data suggest that two-dimensional echocardiography is a useful adjunct to fluoroscopy during transseptal catheterization that may improve its safety and prevent complications.

Two-dimensional echocardiographic localization of a malpositioned pacing catheter

The precise intracardiac localization of transvenous pacing catheter electrodes is sometimes difficult yet crucial to patient management. We describe a patient in whom standard indirect studies failed to locate a malpositioned pacing catheter. Two-dimensional (2-D) echocardiographic examination revealed its entire aberrant course, from the right atrium, across the interatrial septum, through the mitral valve and on to the apex of the left ventricle. The value of this technique is reviewed.

Two-dimensional echocardiographic evaluation of intracardiac transvenous pacemaker leads

A two-dimensional (2-D) echocardiographic study was performed on 40 consecutive patients presenting for a routine check-up of their transvenous pacemaker devices, in order to assess the visibility of the intracardiac portion of the pacemaker lead. In 34 patients (85%) the presence of the lead could be demonstrated satisfactorily. In 4 of these 34 patients the entire intracardiac portion of the pacing wire was imaged, in 20 the distal fragment bearing the electrode(s) was seen, and in 10 an intermediate segment was visible. In 6 of the 40 patients (15%) the lead was not visible. In 3 of these 40 patients it was virtually impossible to image any cardiac structure. The less than 100% visibility of the pacing wire may be due to our randomized patient group with a high mean age of 75 years. We conclude that during follow-up examinations or when problems arise in patients with transvenous pacemakers, 2-D echocardiography may be an alternative to roentgenograms, especially if simultaneous information about heart function is desired or septal perforation is suspected. However, chest roentgenograms are still more accurate and remain the technique of choice under normal circumstances.

Right atrial thrombus simulating myxoma on M-mode echocardiography in a patient with pulmonary emboli

Echoes from a right atrial mass in a patient with pulmonary embolism simulated a typical echocardiographic appearance of a right atrial myxoma. The patient was admitted with recurrent pulmonary emboli and had evidence of deep venous thrombosis on venography. M-mode echocardiography showed the appearance of a right atrial mass and right atrial angiography confirmed the presence of a mass prolapsing from right atrium into right ventricle. Subsequent 2-dimensional echocardiography and careful repeat M-mode echocardiography failed to demonstrate the mass suggesting embolisation to the lungs or lysis of the thrombus.

Umbilical vascular catheters: localization by two-dimensional echocardio/aortography

Umbilical vascular catheters are often necessary in the care of critically ill neonates. Position of the catheter tip is usually determined by roentgenography. Location of the umbilical arterial or venous catheter was determined by 2-dimensional echocardio/aortography in 55 consecutive infants and was compared to localization by thoraco-abdominal roentgenography. Most of the infants (76%) had respiratory distress syndrome or congenital heart disease. Echocaortographic localization of the umbilical arterial catheter correlated very closely (N = 50, sr = .90) with roentgenographic determination. For localization of the tip of the umbilical venous catheters, echocardiography was more accurate than roentgenography (employing contrast echocardiography for confirmation of cardiac chamber position). Two-dimensional echocardio/aortographic localization of the tip of indwelling umbilical vascular catheters is as accurate as roentgenography in the arterial system and more accurate than x-ray for umbilical venous catheters. Echocardio/aortography is superior to roentgenography (in localizing the catheter tip) because it 1) avoids ionizing radiation, 2) makes positioning of the patient unnecessary, 3) allows visualization of the catheter in relation to cardiovascular structures, and 4) may allow demonstration of intraarterial thrombo-emboli.

Subcostal echocardiography to determine right ventricular pacing catheter position and control advancement of electrode catheters in intracardiac electrophysiologic studies. M mode and two dimensional studies

To assess the value of subcostal echocardiography in determining the position of a right ventricular pacing catheter, M mode and two dimensional echocardiography was performed from four different locations in 30 patients. Subcostal M mode echocardiography had a higher detection rate of the pacing catheter than did the precordial M mode examination. However, with M mode echocardiography it was not possible to determine the position of the pacing catheter from any of the locations. The subcostal two dimensional echocardiography demonstrated the full length of the pacing catheter in the right heart chambers and its anatomic position in all patients and proved superior to the precordial approach. This technique allowed the detection of complications related to pacing catheters. A pacing catheter ejected from the ventricular cavity was found in the inferior vena cava. Perforation of the ventricular septum with a bipolar electrode for temporary pacing was also diagnosed. Subcostal two dimensional echocardiography was used in 20 patients as an additional technique for controlling the advancement of electrode catheters in right heart intracardiac electrophysiologic studies. The electrode catheters were successfully positioned at all routine sites in all patients except one. Thus, subcostal two dimensional echocardiography has advantages over fluoroscopy in the determination of pacing catheter position and in controlling the advancement of electrode catheters in intracardiac electrophysiologic studies.

Echocardiographic control of Swan-Ganz catheters

In 68 patients, subxiphoidal, percordial, and suprasternal echocardiography was used to trace the Swan-Ganz catheter during its passage to the pulmonary artery and to localize its position. The localization of the catheter could be exactly identified in 62 out of 68 patients in whom we managed to obtain a suprasternal echocardiogram. In one patient, the catheter was found (by chest x-ray film) in the left pulmonary artery (LPA) and was regarded to be in the right pulmonary artery according to suprasternal echocardiography. In two patients, the catheter could not be localized by suprasternal echocardiography although it was positioned in the LPA. In three patients, the catheters could not be advanced to the pulmonary circulation and were visualized within the right ventricular cavity by precordial and subxihpoid echocardiogarphy. Thus, echocardiography, particularly the suprasternal approach, has proven a safe, reliable, and easy way for position control of Swan-Ganz catheters.

Intracardiac masses. Tumors, vegetations, thrombi, and foreign bodies

Echocardiography has enhanced our diagnostic capability in the detection of cardiac myxomas and, to some degree, metastatic tumor. It has assisted in the evaluation and treatment of certain patients with infective endocarditis and now appears to be providing insight into the recognition and course of some cases of intracardiac thrombosis. However, the limitations in the latter conditions are still significant and careful interpretation and clinical correlation should be the rule.

Echocardiographic detection of a retained left atrial catheter

An 18-year-old woman underwent the repair of traumatic lacerations of the mitral valve, tricuspid valve, and interventricular septum. At the time of surgery, an indwelling left atrial catheter was placed for postoperative hemodynamic manangement. An attempt to remove the catheter completely several days following surgery was unsuccessful, but it was initially assumed by the surgeon that the tip of the catheter had been withdrawn from the left atrium. When the patient developed neurologic signs suggesting a cerebral embolism, an echocardiogram was performed. Echo demonstration of the catheter in the left atrium led to repeat thoracotomy for removal of the retained line. Baseline echocardiograms are indicated in cardiac surgical patients with indwelling left atrial catheters and echo study can be diagnostic if catheter retention occurs.

Two dimensional echocardiographic recognition of the descending thoracic aorta

Two dimensional echocardiography was used to identify the descending thoracic aorta in 106 subjects. In 12 of these subjects, contrast injection techniques were used to identify this structure as it descended posteriorly adjacent to the atrioventricular groove. The course of the descending thoracic aorta was mapped using both the long axis and transverse axis views. The normal descending thoracic aorta (26 subjects) measured 10 +/- 1.4 mm/m2 during diastole. Unusual M mode echocardiographic patterns of the descending aorta may be confused with other disease states; they are clarified with the two dimensional study. The size and appearance of the descending aorta in different types of cardiovascular disease, including aortic aneurysm, in 80 patients are described. It is anticipated that two dimensional echocardiography will prove to be a useful method of studying patients with aortic disease.

Systolic click from a Swan-Ganz catheter: phonoechocardiographic depiction of the underlying mechanism

Although echocardiographic manifestations of Swan-Ganz catheters have received increasing attention, auscultatory sequelae have not previously been described. In the patient described in this report, insertion of a Swan-Ganz catheter resulted in a loud mid systolic click; removal of the catheter eliminated the click. Simultaneous phonoechocardiograms suggest that the click resulted from crisp contact of the catheter against the ventricular septum. Catheter momentum was enhanced by wide excursion and systemic pressures in the right ventricle; paradoxical motion of the septum during systole may have accentuated the force of its contact with the catheter.

Echocardiographic evaluation of intracardiac pacing catheters: M-mode and two-dimensional studies

Thirty patients with right ventricular (RV) and 15 with coronary sinus (CS) pacing catheters were studied by M-mode echocardiography. RV catheters, detected in 23, appeared as linear echoes in the right ventricle during mitral valve recordings in 12, adjacent or superimposed on the tricuspid valve (TV) in 14, and immediately anterior to aortic root and pulmonary valve echoes in two with a redundant loop in RV outflow. In three with complete heart block, prominent systolic anterior movements of the TV occurred when atrial systole coincided with ventricular systole, probably due to catheter-induced TV "buckling" or exaggerated TV annular motion. Catheter echoes mimicked TV recordings in three, since its motion pattern was similar, although delayed and mimicked prolapsing right atrial myxomas in two because of multilayered complexes behind TV, while reverberations cluttering the left ventricle simulated structural echoes present in that cavity. CS catheters, detected in 14 as linear echoes in the area of atrial septum recorded behind the TV, showed typical small humps in late diastole/early systole. Cross-sectional echocardiography with a mechanical sector scanner demonstrated RV catheters at the RV apex in five of seven patients, while CS catheters were detected near the base of the atrial septum in three of five patients. Echocardiography has the potential to localize pacing catheters which are occasionally difficult radiologically or electrocardiographically. Failure to recognize catheter echo patterns may result in errors in echocardiographic interpretation.