Interact CardioVasc Thorac Surg 2008;7:136-137. doi:10.1510/icvts.2007.158865
© 2008 European Association of Cardio-Thoracic Surgery
Negative results - Valves |
Mitral valve injury by cardiotomy suction during aortic valve replacement – a near miss
Dharmendra Agrawal*,
Keng Leong Ang,
Tina Mittal and
Sai Prasad
Department of Cardiothoracic Surgery, Royal Infirmary Edinburgh, Edinburgh EH16 4SA, UK
Received 23 May 2007;
received in revised form 3 October 2007;
accepted 4 October 2007
*Corresponding author. Fax: +44 131 242 3929.
E-mail address: adharmendra{at}hotmail.com (D. Agrawal).
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Abstract
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Mitral valve injury due to cardiotomy suckers during aortic valve surgery has never been reported. We highlight the possibility of such injury experienced in our unit. We also discuss its preventive measures.
Key Words: Aortic valve surgery; Mitral valve injury; Cardiotomy suction
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1. Case report
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A 61-year-old man underwent elective aortic valve replacement for aortic stenosis. Cardiopulmonary bypass (CPB) was instituted via aortic arterial cannulation and two-staged right atrial venous cannulation. The left ventricle (LV) was vented through a transmitral LV vent inserted through the right superior pulmonary vein. Standard aortotomy was performed and the native aortic valve was excised without complications. As there was intermittent ‘flooding’ of the operative field by blood, ‘Sump’ cardiotomy suction was given for use in the LV. However, high cardiotomy suction pressure was noted, and the cardiotomy suction catheter became entangled with the mitral valve chord. The suction was reduced and the removal of cardiotomy suction was attempted. It became apparent that a mitral valve chord had become entangled within the spiral coil of the tip of the suction catheter. The mitral valve chord was ‘unscrewed’ along the metal spiral coil of the suction catheter, whereby the coil was stretched and cut to release the mitral valve chord safely. The mitral valve primary chord was freed without any permanent injury. The operation was then completed uneventfully.
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2. Discussion
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Due to the continuity of the anterior mitral valve annulus with that of the aortic valve between the aortic non-coronary and left coronary cusps, mitral valve injury is possible during aortic valve procedures, especially during valve debridement and suture placement.
Mitral valve injury was reported during endomyocardial biopsy [1] and String-Plucking as a mechanism of chordal rupture during balloon mitral valvuloplasty using an inoue balloon catheter [2]. To our knowledge, mitral valve injury as a result of cardiotomy suction during aortic valve procedures has not been previously reported. Our experience of this case raised the awareness that such injury mechanism could occur, and complicate an otherwise uneventful procedure.
To achieve a relative bloodless field during aortic valve surgery, the left ventricle can be vented either through the superior pulmonary vein as a trans mitral vent, a pulmonary artery vent or insertion directly into the LV apex as apical vent. Occasionally, this may still be insufficient, and cardiotomy suction can be used intermittently in the LV outflow tract to achieve a bloodless field.
There are two types of cardiotomy suction catheters: those for extra-cardiac use and those for intra-cardiac use (Fig. 1). Even though the distinction is made in the external non-sterile packaging, this distinction is lost once this packaging is removed. There is no obvious identification on the actual suction catheter itself. Accidental placement of the wrong type of cardiotomy suction catheter can thus occur when both types of suction catheters are used in the same procedure. This near miss is more likely to occur when there are inexperienced staff assisting the procedure or when urgent intra-cardiac suction is suddenly required. In our case, the inappropriate cardiotomy suction catheter was given by the scrub team. This can be prevented if intra-cardiac cardiotomy suction catheter is used for all procedures requiring intra-cardiac cardiotomy suction.
When using intra-cardiac cardiotomy suction, care must be taken not to apply excessive suction pressure. This can lead to the introduction of air emboli. As illustrated in our case, it can also cause entanglement of LV structures like the mitral valve chord by the suction itself. If the mitral valve apparatus becomes entangled with the suction catheter, identifying the causes and the structures involved is paramount to prevent significant damage to the mitral valve. In our case, this involved reducing the suction pressure applied on the cardiotomy suction catheter to release the part of the chord, which became entangled within the spiral coil of the suction catheter tip. The mitral valve chord was gently ‘unscrewed’ from the spiral coil of the suction catheter. It was eventually released without damaging the mitral valve by cutting the spiral coil of the suction tip at a segment near to the chord entanglement (Fig. 2).
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Fig. 2. Mitral valve chord is entangled within the spiral coil of the tip of the suction. The mitral valve chord is ‘unscrewed’ along the spiral coil to a section, whereby the coil is cut to release the mitral valve chord.
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Fortunately on this occasion there was no permanent damage to the mitral valve as a result. However, our case highlights the possibility of this injury by cardiotomy suction during the aortic valve replacement. Avoiding the use of extra-cardiac cardiotomy suction catheter and excessive cardiotomy suction pressures during open-heart valve procedures will prevent such occurrences. This can also be avoided if the manufacturer's labelling is clearly visible both on the outer non-sterile packaging and on the suction catheter.
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References
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- Tokuda Y, Matsumoto M, Sugita T, Nishizawa J, Matsuyama K, Yoshida K, Matsuo T. Mitral valve repair for severe mitral regurgitation caused by endomyocardial biopsy. J Heart Valve Dis Nov 2002; 11:837–838.[Medline]
- Chern MS, Chang HJ, Lin FC, Wu D. String-plucking as a mechanism of chordal rupture during balloon mitral valvuloplasty using inoue balloon catheter. Catheter Cardiovasc Interv Jun 1999; 47:213–217.[CrossRef][Medline]
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Abstract
1. Case report