Ann Thorac Surg 2009;88:2050-2051. doi:10.1016/j.athoracsur.2009.03.063
© 2009 The Society of Thoracic Surgeons
How To Do It
Use of the Seldinger Type Movement Over a J-Shaped Stylet for Left Ventricular Vent Insertion
Lucas H.A. Sanders, MD, FRACSa,b,*,
Weiwen Chen, MDb,
Jacques P.A.M. Schönberger, MD, PhDa,
Jaffar Shehatha, MD, FRCSb,
Mark A.J. Newman, MD, FRACSb
a Department of Cardiothoracic Surgery, Catharina Hospital, Eindhoven, the Netherlands
b Department of Cardiothoracic Surgery, Sir Charles Gairdner Hospital, Nedlands, Perth, Australia
Accepted for publication March 20, 2009.
* Address correspondence to Dr Sanders, Department of Cardiothoracic Surgery, Sir Charles Gairdner Hospital, Nedlands, Perth, Australia, Hospital Ave, Perth, WA 6009, Australia (Email: lucmedi{at}hotmail.com).
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Abstract
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Access through the right superior pulmonary vein is a commonly used route for left ventricular vent insertion. Complex reshaping of the stylet and vent into a certain position or external guidance do not guarantee successful placement. In this article we describe a modified technique where the stylet sets up the position to allow consistent atraumatic advancement of the catheter across the mitral valve.
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Introduction
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Left ventricular venting is commonly performed through the right superior pulmonary vein for reasons of left ventricular decompression and visibility during aortic valve surgery. Despite being a common procedure, there are few reports in the literature on the technique and problems encountered during insertion. An insertion technique that is safe, effective, and applicable in various clinical situations was tested in our study.
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Technique
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Left ventricular (LV) vent insertion was accomplished through the right superior pulmonary vein prior to cross clamping of the aorta. The venous pressure is increased by decreasing venous drainage, thereby increasing the volume of blood in the heart to prevent air being introduced to the left atrium, causing air embolization. Before insertion, the vent is angled with the stylet in place to 75° to 90° degrees, 5 to 7 cm from the tip. The vent is placed in the left atrium up to the point of the preformed angle, directing the tip of the vent toward the apex of the heart and mitral valve orifice (Fig 1). The stylet is then held in this position while the outer vent is slid over the stylet through the mitral valve into the LV in a Seldinger-type movement. Insertion is confirmed by observing high-pressure pulsatile blood flow emanation from the vent. Having used this technique successfully in the past, a short prospective study was conducted to observe the effectiveness of this method. A 20-French DLP left heart vent catheter (Medtronic, Minneapolis, MN) was used, although a Sarns vent catheter (Terumo, Ann Arbor, MI) has been used with confidence in the past as well. In 10 consecutive cases, the LV vent was inserted at first attempt in 8 cases, including one redo operation at the second attempt in 1 case and with failure in 1 case, probably due to extensive mitral annular calcification (Fig 2). In this case, no further attempts were made because of the risk of calcium emboli.
This technique was tested in a cadaver viewing the vent through a left atriotomy in the Waterston's groove. Approval for cadaver study was granted by the University of Western Australia Clinical Training & Education Center Interdepartmental Ethics Committee. After insertion of the vent through the opening in the right superior pulmonary vein, the distal end was found to be in line with the mitral valve orifice and the LV apex. Advancement of the outer vent catheter over the stylet and insertion into the LV was effortless.
Inserting the vent and stylet together as one was also tested in this setting. During advancement, the vent hugs the posterior wall of the right superior pulmonary vein and subsequently the posterior wall of the left atrium. This results in posterior bowing of the vent and turns the vent in an anterior direction. The vent then approaches the plane of the mitral valve in a tangential fashion from a posterior position and bypasses the mitral valve (Fig 3).
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Fig 3. Advancement of vent catheter and stylet together, posterior bowing, and bypassing of mitral valve.
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Comment
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The technique previously described has been reported in the Japanese literature as a "method with the J-shaped left ventricular vent catheter" [1]. No description was found in the English literature.
Hammon [2] and Kouchoukos and colleagues [3] report insertion of a left ventricular vent in their textbook. Two methods that can be used to prevent air being introduced into the left atrium during vent insertion are increasing the volume and venous pressure in the heart by reducing the venous drainage and clamping the aorta prior to vent insertion [3]. The J-shaped vent and Seldinger-type movement are not described [2, 3]. Kouchoukos and colleagues [3] advise the use of a hand placed behind the heart to guide the vent toward the mitral valve and left ventricle [3]. Despite this maneuver, insertion of the vent into the LV is not always successful or requires multiple attempts. When a mini-sternotomy is used, guidance with a hand is not possible [4]. Similarly with redo operations, a hand can not be placed behind the heart unless all adhesions around the heart are dissected. A large left atrium is also mentioned as a technical challenge to insert the vent into the LV [5]. Intentionally or because of failure of insertion into the LV, the vent can be left in the left atrium or left pulmonary veins. In this position, the vent might unnecessarily introduce air into the left atrium and will be less effective in decompressing the LV [5]. Due to the stiffness of the vent with the stylet in place, perforation of cardiac chambers is a possibility [4].
We recommend the J-shaped catheter and Seldinger-type movement for its ease of insertion into the LV and are confident it is applicable in situations of a mini-sternotomy, redo surgery, and large cardiac chambers, even when insertion is urgent for decompression of a distended left ventricle. As the rigid stylet is only advanced into the left atrium for 5 to 7 cm, the potential risk of perforation of a cardiac chamber is reduced.
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References
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- Hibi M, Matsuura A, Ohshima H. Cardiac surgery by the safe and easy insertion method with the J-shaped left ventricular vent catheter [Article in Japanese] Kyobu Geka 1998;51:106-107.[Medline]
- Hammon JW. Extracorporeal circulation: perfusion systemIn: Cohn LH, editor. Cardiac surgery in the adult. 3rd ed.. New York: McGraw-Hill Inc; 2008.
- Kouchoukos NT, Blackstone EH, Doty DB, Hanley FL, Karp RB. Hypothermia, circulatory arrest and cardiopulmonary bypass Kirklin/Barratt-Boyes cardiac surgery. 3rd ed.. England: Churchill Livingston Oxford; 2003.
- De Smet JM, Rondelet B, Jansens JL, De Canniere D, Antoine M, Le Clerc JL. Conversion from mini-sternotomy to full sternotomy in aortic valve replacement Heart Surg Forum 2002;5(Suppl 4):S296-S300.[Medline]
- Tempe DK, Khanna SK, Banerjee A. Importance of venting the left ventricle in aortic valve surgery Indian Heart J 1999;51:532-536.[Medline]
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Abstract
Introduction
