Ann Thorac Surg 1998;65:254
© 1998 The Society of Thoracic Surgeons
Branch Retinal Artery Occlusion From a Retained Left Atrial Catheter 21 Years After Operation
Jonathan J. Drummond-Webb, FCS(SA),
Paula M. Bokesch, MD,
Makram R. Ebeid, MD,
Daniel J. Murphy, MD,
George E. Sarris, MD,
Roger B. B. Mee, FRACS
Center for Pediatric and Congenital Heart Diseases, The Cleveland Clinic Foundation, Cleveland, Ohio, USA
Department of Cardiothoracic Anesthesia, The Cleveland Clinic Foundation, Cleveland, Ohio, USA
Accepted for publication September 4, 1997.
Dr Drummond-Webb, Department of Pediatric and Congenital Cardiac Surgery, Area M41, The Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH 44145 (e-mail: email@example.com).
A case of branch retinal artery occlusion due to an embolus from a retained left atrial catheter is presented. Removal was accomplished by reoperation. Prompt removal of any retained intracardiac catheter is recommended.
A previously healthy 25-year-old woman had undergone closure of a ventricular septal defect at the age of 4 years in another institution. She presented to the emergency room with sudden, complete, painless loss of vision in her left eye. She reported no other symptoms aside from an isolated episode of syncope 5 months prior. Angiographic and opthalmologic studies documented a left-sided branch retinal artery occlusion. A Holter monitor failed to document any atrial fibrillation. A transthoracic and subsequent transesophageal echocardiogram showed a small residual ventricular septal defect with left-to-right shunting. Surprisingly, a long, linear echo density consistent with a foreign body covered with thrombus was demonstrated in the left atrium.
Review of the medical records from the time of ventricular septal defect closure revealed that, with left atrial catheter removal on postoperative day 2, the catheter had broken and a segment had been left in the patient. No further action had been taken, and she recovered uneventfully and remained asymptomatic for 21 years.
It was thus thought that her branch retinal artery occlusion represented a cerebral embolic episode originating from the retained catheter. She was given intravenous heparin and urgent resternotomy was undertaken. At operation, manipulation was minimized and only enough of the cardiac structures and left atrium were exposed to allow safe aortic and bicaval cannulation. Mild hypothermia and cold blood cardioplegic arrest were used. The tip of a plastic catheter was encountered firmly anchored in the interatrial groove. The left atrium was entered through a right atrial transeptal incision to avoid disturbing the thrombus. A polyethylene left atrial catheter, 10 cm long and coated with both organized and more recent thrombus, was found. The catheter was tethered to the mitral valve and anchored to the base of the right superior pulmonary vein, making a loop within the left atrium (Fig 1).
The catheter was extracted, and the left heart was carefully examined and lavaged to remove any residual thrombus. The residual ventricular septal defect was approached through the tricuspid valve, and the small defect was closed with a few interrupted Teflon-pledgeted sutures. After closure of the atrial incisions, weaning and separation from bypass were unremarkable. Transesophageal echocardiography confirmed complete removal of the left atrial catheter and the absence of any residual ventricular septal defect.
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Intraoperative photograph of left atrium through a transeptal approach. The retained catheter is shown with fresh thrombus on its surface (arrow). The tip (*) is attached to the mitral annulus posteriorly. (IAS = interatrial septum; LA = left atrium.)|
The patient recovered uneventfully and was discharged home on the third day postoperatively. Her visual field defect remains unchanged 1 year after the operation.
Indwelling intracardiac monitoring lines are frequently used in congenital cardiac operations. Surprisingly there is little information regarding complications related to retained left-sided catheters. However, right-sided indwelling catheters are not without risk, especially in infants . Possible, but infrequent complications include dislodgement or bleeding at the time of removal. On rare occasions (0.2% over a 4-year period at our institution), a catheter can break at the time of removal, probably due to technical factors, resulting in a fragment being retained in the patient. Our policy is immediate removal of any retained catheter fragment, by mediastinal reexploration if necessary, to prevent late complications. Percutaneous, basket catheter removal of retained intravascular foreign bodies has successfully been described . However, the presence of thrombus and the recent branch retinal artery occlusion precluded this approach in our patient. This case of late embolism from a retained left atrial catheter reinforces this policy of immediate removal.
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