Interactive Cardiovascular and Thoracic Surgery 2:293-294(2003)
© 2003 European Association of Cardio-Thoracic Surgery
Work in progress report - Congenital |
Securing atrial lines with Silastic ligatures
Pietro Angelo Abbruzzese,
Stefano Longo,
Enrico Aidala and
Andrea Valori*
Division of Cardiac Surgery, Ospedale Infantile Regina Margherita, P.zza Polonia 94, 10126 Turin, Italy
* Corresponding author. Tel.: +39-011-3-13-5807; fax: +39-011-3-13-5208
cardio{at}oirmsantanna.piemonte.it
Received October 27, 2002;
received in revised form February 28, 2003;
accepted March 4, 2003
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Abstract
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We present a safe and easy-to-apply method of securing monitoring atrial cannulae after pediatric cardiac operations. We used Silastic ligatures together with purse strings on the tip of the atrial appendages in more than 350 cases, in a 5-year period. We never reported malfunctioning during their use, and no bleeding or rupture complication was detected by echocardiographic control after withdrawal.
Key Words: Cannula; Pressure monitoring; Pediatric cardiac surgery
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1. Introduction
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Atrial monitoring lines are often indispensable to continuously monitor post-operative pressures in cardiac surgery. While right atrial lines are usually inserted percutaneously through a neck vein, occasionally they are directly inserted through the tip of the right atrial appendage [1]. Conversely, left atrial lines always require direct insertion, not uncommonly through the left atrial–right superior pulmonary vein junction. A purse string or a horizontal mattress suture is used to secure lines in place. Other methods have been described in Ref. [2] and transatrial insertion of pulmonary artery pressure monitoring lines in Ref. [3]. Occasionally, significant bleeding can occur following removal of the lines, sometimes requiring urgent reopening of the chest incision.
We describe a method of atrial lines insertion in pediatric and neonatal cases that offers some advantages over the previously described ones and guarantees bloodless removal of the catheters.
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2. Materials and methods
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Three hundred and fifty pediatric patients required post-operative direct insertion of one or two atrial monitoring lines during the past 5 years at the Ospedale Infantile Regina Margherita, Torino, Italy. All patients were informed of the procedure and an informed consent was obtained; the procedure was approved by our hospital Ethics Committee. The technique consistently employed during this period includes a purse string of polypropilene suture on the outermost surface of the atrial appendages and insertion of the catheters through a small stab incision in their midportions. In fact, we often use this polypropilene purse string during complex surgery in the great vessels area for temporary dislocation of the atrial appendages. At the end of the surgical procedure, after verification of the adequate positioning of the catheters, checking free flow of their lumen, the purse strings are tightened. At that point the assistant surgeon gently holds up the tip of the atrial appendage while the surgeon secures the catheter by tying a Silastic vesseloop around the atrial appendage proximal to the purse string (Fig. 1). Finally, gentle traction on the catheter confirms the minimal resistance required to rule out a too loose ligature. We now use a subxyphoid insertion of the catheters, because in the previous era, with a suprasternal approach, we had two entrapments of the cannula at removal, which required a small surgical reopening of the wound to loosen the trapped cannula.
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Fig. 1 Right and left atrial appendages with left atrial cannula. In the insert: vessel loop plus purse string ligature. RAA, right atrial appendage; LAA, left atrial appendage; SVL, Silastic vessel loop; AC, atrial cannula.
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At the end of their use for monitoring and/or blood samples, the lines were withdrawn the day before hospital discharge. We routinely performed a control transthoracic echocardiography after about half an hour to detect bleeding.
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3. Results
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Neither did cannula ever fall out accidentally due to loosening of Silastic ligature, nor was the ligature too tight not to allow pressure monitoring. No post-removal bleeding occurred during the considered period, or during the previous era, in which the same technique was consistently used. At reoperations, the presence of the Silastic strings did not apparently cause excessive adhesions; on the contrary it often helped defining the atrial structures. We have no report, until today, of any complication in non-reoperated patients.
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4. Discussion
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The great elasticiy of the Silastic strings, routinely used as vesseloops, prompted their use as ligatures around the left and right atrial appendages to further secure placement of atrial lines. At the time of removal, the ligature squeezes the wall of the atrial appendage proximal to the incision, automatically sealing it. The adequacy of this mechanism was experimentally tested using progressively larger catheters and cannulae inserted with the same method, obtaining excellent results even with large bore cannulae. During a certain number of routine cannulations for bypass, we randomly chose to secure the SVC cannula using only a Silastic vesseloop instead of normal purse strings. The biggest cannula we were able to remove effectively, without any bleeding, was a 18 Fr. Bard straight cannula for the superior vena cava.
The safety of this method allowed late removal of the catheters in the absence of chest tubes, when prolonged monitoring of the atrial pressure was judged necessary.
Even though other methods can be effectively used, we believe that the elasticity of the Silastic ligature proximal to the purse string contributes to the safe removal of the lines. This fact, together with the usefulness of previously placed left atrial appendage purse string, prompted our preference for the left atrial appendage as site of insertion of left atrial monitoring lines, over the more commonly used left atrial–right superior pulmonary vein junction.
doi:10.1016/S1569-9293(03)00060-4
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References
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- Gold JP, Jonas RA, Lang P, Elixson EM, Mayer JE, Castaneda AR. Transthoracic intracardiac monitoring lines in pediatric surgical patients: a ten-years experience. Ann Thorac Surg. 1986;42(2):185–191[Abstract]
- Rao PS, Sathyanarayana PV. Transeptal insertion of left atrial line: a simple and safe technique. Ann Thorac Surg. 1993;55(3):785–786[Abstract]
- Muralidhar K, Dixit MD, Shetty DP. A safe technique to monitor pulmonary artery pressure during and after pediatric cardiac surgery. Anaesth Intensive Care. 1997;25(6):634–636[Medline]
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Abstract
1. Introduction