placement of central catheters in patients with congenital heart

8/3/2019 Placement of Central Catheters in Patients With Congenital Heart

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J Tisnado, MD, FACR, FACC, FSIR, FAHA1

J Tisnado2, D J Komorowski1, M K Sydnor11MCV Hospitals/VCU Medical Center, Richmond VA

2Hartford Hospital, Hartford CT


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Central catheterization, a well-established procedure managingclinical entities, such as: hemodialysis, total parenteral nutrition,IV access, blood draws, and apheresis, among others. Proceduresare simple and straight forward in patients with normal orconventional cardiac and central venous anatomy. We placecentral catheters in patients with different and varied congenitalcardiac and venous vascular abnormalities, both congenital andacquired. A review of our experience with central catheterizationin these circumstances is in order. We briefly discuss someinteresting instances of cardiovascular problems, and provideguides for successful insertions.

Patients with different cardiac anomalies, i.e. transposition ofgreat vessels, double SVC, left-sided SVC, Tetralogy of Fallot,post-Fontan and post-mustard procedures and others. Manypatients with left ventricular assist devices, aortic balloonpumps, and artificial hearts are also illustrated in thiseducational exhibit.


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Successful placements can be achieved in most, if not all, patients with

different cardiac and central venous vascular anomalies if one is aware of thevascular anatomy and cardiac malformation and base some information aboutthe different operations to correct congenital heart disease.

Placement of central catheters in patients with cardiac and central venousvascular anomalies is relatively easy and safe, especially if one has a basic

knowledge of the anatomical configuration prior to placement. Noninvasiveimaging: US, CTA, MRA are the main pre-procedure imaging methods to planthe approach. Digital subtraction venography is necessary in complicated andconfusing cases. We present a brief review with actual examples anddescribe some of the tricks-of-the-trade to be successful in the placement ofcentral catheter in these uncommon situations.

Percutaneous translumbar placement of central venous catheters can be donealso without any differences in complication rates than the "routine"placements of central catheter placement. The translumbar placement is safeand reliable in children.


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In general, children with congenital heart disease need long-term

indwelling catheters for a long time for a long-term administration ofIV fluids and drugs, samplings of blood and/or TPN. Sometimes thecentral veins are no longer available for us. Sometimes the patientsneed preservation of the SVC or IVC for future interventions, surgeryand/or catheterizations.

Central venous catheterization is nowadays "routine" management inthe armamentarium of an aggressive health care team.

A) percutaneous non-tunneled catheter placement in the SVC, IJV, Externaljugular veins (EJV), femoral veins (FV)B) peripherally inserted central catheters (PICCs)C) percutaneous tunneled catheters

valved: Groshongnon-valved: Hickman, Broviac

D) implantable ports

If the access is difficult or depleted or needs to be preserved,alternative approaches are needed. The translumbar approach to the

IVC and right atrium may be the ideal in some aspects.


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In general, 9 out of 1000 (1%) babies are born with a congenital heart abnormality. Inorder to prevent the death of those babies, 2.3 of those babies need some type oftreatment of the congenital heart disease.

Further, 1 million of people in USA were born with some type of congenital heartdefects.

Furthermore,

15% of children 12-17 are smokers already;

1/2 of children 12-21 do not exercise daily;

30% of children in USA are obese.

About 3.5-5 million of central venous catheters are placed annually in USA -- 250,000CVC related infections in this group.

The Fontan procedure is initially a connection between the right atrium to thepulmonary arteries.

Variations:

A cavopulmonary connection with a tunnel either intracardiac or extracardiac.

Placement of an external conduit bypassing the right atrium completely.

Central venous catheter placement is preferred from the IJV in to the brachiocephalicveins only. No attempts to place catheters into the SVC should be made.


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VCU is one of the leading institutions in the country in placing TAH. Usually the TAH is powered by a large, 400 lbs console. Hopefully, in the near future, it will be powered by a 13-pound backpack so the

patients can go home to wait for a heart. TAH is indicated as a bridge to a human heart transplant, in patients dying from

end-stage biventricular failure.

Average waiting time for a heart is about 3 months for patients with artificial heart.

Since the console to drive the TAH is a large one, 400 lbs., the patients must stay inthe hospital awaiting for an organ.With the new back pack power, the patients could go home to await for a heart.SynCardia: Total temporary artificial heart. Therefore, in the future, we may see

outpatients with TAH and we must be prepared to insert central venous cathetersin those patients. Furthermore, it is very important to know the anatomy of thosepatients before insertion of central catheters.

Andropoulos et al reported 450 central venous catheter placements in children with

congenital heart disease. They recommended that the tip of the central catheter beplaced in the SVC, just above the right atrium. They presented an interestingformula to predict the placement of the tip of the catheter and to prevent seriousperforations of the heart or great vessels. Other complications mentioned are:dysrhythmia, extravasation of IV fluids, thrombosis, inaccurate measurements ofcentral venous pressures and tamponade due to cardiac perforation. Theyrecommend to place the central venous catheters with the patients inTrendelemburg and using anatomic landmarks or palpation of the carotid arteries

or with Doppler US guidance.


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This is routine for us as we always use US to access the central veins. Weassume that those guidelines are for those operators inserting centralvenous catheters with no imaging guidance which is not recommendedby us, especially when one is dealing with children with congenital heartdisease.

Qureshi et al advocate a transhepatic placement of central catheters to avoid

or prevent central venous thrombosis and also to preserve the centralveins for future use, specially in children with complex congenital heartdiseases. In their experience 32 children had 40 transhepatic placements.A complication rate of 8.8% was reported.

We have not done this since we believe that the transhepatic approach is tooaggressive and drastic and we reserve these optional approaches such atranshepatic and translumbar for patients with depleted central veins.

An interesting study comparing thrombotic complications between heparin-coated central catheters vs. non-heparin-coated catheters was reportedrecently. No advantage of one over the other was demonstrated in infantswith congenital heart diseases. Both exhibited similar rates ofcomplications (42% vs 44%).


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Some patients with patent foramen ovale (PFO) who need central venouscatheters must have continued treatment with "blood thinning" drugssuch as clopidogril , aspirin or Coumadin. These patients have a high rate(40%) of stroke. In addition these patients must have "endocarditisprevention" with antibiotics, specially if they are having dental work, any"invasive" test, or minor or mayor surgery. Otherwise, the methods of

placement of central catheters are the normal ones, i.e. the tip of thecatheter in the right atrium-SVC junction or in the right atrium.Regarding PICCs they must be placed always under fluoroscopic guidance. A

study of 843 PICCs placed in 698 children by the "PICC" team oroperators without fluoroscopy showed that 86% of central catheters weremisplaced and needed repositioning under fluoroscopy to achieve a 90%success of correct central venous catheter placement.

Conclusion of the study: PICCs must be placed under fluoroscopy. Thisapplies to children with and without congenital heart disease.By the way. The tips of the PICC were considered as central if placed

anywhere within the SVC. Superior border limited by the righttracheobronchial angle. The inferior border defined at slightly below theright lateral border of the heart in the chest X ray.


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VADs are used to assist the failing heart, usuallytemporarily after a MI or permanently in patients withend-stage heart failure. VAD aid the heart inmaintaining the ventricular output. Initially, and still

are used temporarily to help the ventricle to recover oras a bridge for heart transplantation. Sometimes theVAD are permanent is some patients who are notcandidates for heart transplant and whose heart willnot recuperate.

In general the indications for a VAD are:

a) temporary to recovery of the heart (days and weeks).b) temporary, as a bridge for heart transplantation. Patients are

awaiting for an organ.c) permanent for patients no candidates for transplant. Use until

death.


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The device is normally inserted in the thorax and abdomen. Theinflow cannula is connected into the tip of the ventricle andthe outflow cannula returns the blood to the ascending aortaor main pulmonary artery. The pump is usually located inthe abdomen either intra- or extra-peritoneal.

In general there are two types of VAD.a) continuous flowb) pulsatile flow

Regardless of the type of VAD, the patients may have, theplacement of central catheters is rather straightforward. Theaccess can be the IJV or the EJV or the SCV for centralcatheters and the arm veins (basilic) for PICCs. The tip of thecatheter is placed usually in the SVC-right atrial junction orpreferable in the middle of the right atrium as we prefer.


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Placement of central catheters in patients with patentforamen ovale (PFO) is rather straightforward.However, care must be taken to make sure no clot orforeign body (fibrin deposits) form around the catheter.

Otherwise, serious paradoxical emboli may occur. Asmall clot could embolize and result in a stroke if enterthe cerebral arteries or a MI if enter the coronaryarteries.

There have been studies demonstrating that heparin-coated-bonded central venous catheters do not reduce

thrombosis incidence, at least in infants less than oneyear-old with congenital heart diseases. Therefore,special care is needed in these infants since theyusually require for a much longer time the centralvenous catheters.


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The total artificial heart (TAH) is a temporary device forpatients who have lost the function of both ventricles and,therefore, cannot have a VAD. The TAH allows the recoveryof patients for them to be in better shape for a hearttransplant be done in about 2-3 months ideally. More than

20 patients have been done at our institution.The patients must remain in the hospital as the console to drive

the unit is huge. Portable devices are being developed now.In these patients care must be taken during placement of thecentral catheters as a too long catheter into the right atriumcould result in prolapse of the catheter into the artificial

heart creating problems for functioning.Ideally the central venous catheters in these patients should be

in the SVC-right atrial junction. Placement of the tip inthe right atrium is also acceptable.


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Two infants with congenital heart disease had thrombosis of the veins afterplacement of a central catheter in the L IJV.

One woman with a persistent L SVC died due to extensive thrombosis of thecoronary sinus after placement of a central venous catheter in the L SVC.

Another infant with a total anomalous venous return had placement of acentral venous catheter in the L IJV which drained into a persistent LSVC, which became occluded after central venous catheterplacement with a resultant left upper lobe consolidation due toobstruction of the venous outflow of the left upper lobe. Therefore, acomplete evaluation of the venous anatomy, the systemic and thepulmonary venous anatomy is important before inserting central venouscatheters in children with congenital heart disease, particularly in cases oftotal or partial anomalous venous return.

Perhaps in these infants, placement of central catheters in the right side veins,such as R IJV, R SCV, R EJV, is preferred or else the central veins shouldbe avoided altogether and the central catheters inserted into the IVC andother alternate places like transhepatic, translumbar.


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AC is a localized "diaphragm-like" stenosis of thethoracic aorta occurring usually just distally tothe origin of the L SC artery. In addition there

is usually a bicuspid aortic valve. Most patientsare asymptomatic due to development ofcollaterals. In these patients the placement ofcentral venous catheters is rather simple and

straightforward as in the "normal patients.


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Total pulmonary venous return occurs when all thepulmonary veins return to the right atrium directlyor indirectly via the SVC or IVC.

Partial anomalous venous return occurs when not all

the pulmonary veins return to the systemiccirculation such as to the right atrium, SVC or IVC.

In these patients it is better not to place centralvenous catheters in the neck or chest, i.e. into thecentral veins, since thrombotic complications of

central venous catheterization could result inserious and even lethal "paradoxical" emboli. It isbetter to place catheters in the IVC or in thefemoral veins.


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The ductus arteriosus in the fetal stage usually connectsthe left pulmonary artery with the proximaldescending aorta, distally to the origin of the L SCartery. During fetal life the blood form the left

pulmonary artery bypasses the lungs directly into thedescending aorta.In patients with PDA (left to right shunt) the placement of

central venous catheters should be straightforward.Unless there has been a reversal of flow (right to leftshunt, Erlenmeyer complex).

In these cases care must be taken to prevent thrombiforming in the central catheter. A small thrombusassociated with the central catheter could be veryserious, indeed.


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Are communications between the atria. ASDare the most common congenital heart diseasesin adults, at least.

There are 3 types of ASD:1. Ostium primum,

2. Ostium secundum, and

3. sinus venosus.


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Are the most common congenital heart diseases inchildren. The VSD can be located in themembranous or in the muscular septum or abovethe atrioventricular septum or near the mitral and

tricuspid valves.The placement of central catheters in patients with

ASD or VSD should be straightforward too.However, in adults with large VSD withenlargement and hypertrophy of the right ventricle

and pulmonary hypertension, special care must betaken to make sure no thrombi form in the centralvenous catheter. Otherwise, serious paradoxicalemboli could occur.


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Consists of four anomalies:

1. subpulmonary infundibular stenosis,

2. VSD,

3. right ventricular hypertrophy, and

4. overriding aorta.

Patients with T of F usually are operated early inlife; therefore, the placement of centralcatheters can be done with no special orparticular problems or precautions.


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In these patients a single vessel (trunk) originatesfrom the heart. The patients are usuallyoperated early in life. The placement of central

catheters in these patients is done by punctureof the IJVs or the EJVs in either side. Ideally,short catheters with the tip in the innominateveins or the SVC should be used.


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Is one of the most common congenital heartdiseases. In these patients the aorta originatesfrom the right ventricle and the pulmonary

artery originates from the left ventricle. Mostpatients have no other cardiac anomalies. A leftto right shunt is necessary for life. Since thegreat vessels are reversed, one can place centralvenous catheters in the IJVs or EJVs or the SCV

or SVC. It is better not to place catheters in theatria as thrombi can develop and embolizewith resultant rather serious complications.


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ASD comprises about 19% of all congenital heartdiseases. There is a risk of paradoxical emboli.

VSD is one of the most common congenital heart

diseases. There are 4 types, depending onwhere in the septum is the defect.

PDA is a communication between the leftpulmonary artery and the descendingaorta which usually obliterates within 2-3weeks of life. It represents about 5-10% of allcongenital heart diseases.


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Surg. 1993; 8: 1776. Leschka S., et al. Pre and post operative evaluation of congenital heart disease in adults

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15699. Andropoulos DB., et al. The optimal length of insertion of central venous catheters.

Anesth Analg10. Qureshi Am., et al. Trans hepatic Broviac catheter placement for long tem central

venous access. Pediat Crit Car Med. 2007; 8: 24811. Frocke BL., et al. Placement of peripherally inserted central catheters without

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placement of central catheters in patients with congenital heart

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