Background:
It is estimated over 5 million central venous catheters (CVC) are placed per year. A large bore MAC multi-lumen central venous access catheter is routinely placed in the internal jugular vein for central venous access during orthotopic liver transplantation (OLT). Central venous access is critical for intravascular resuscitation, vasopressor support, and hemodynamic monitoring via pulmonary artery (PA) catheter. Perforation of the heart during central line placement causing pericardial effusion and tamponade may not be readily present after central line placement. Prompt evaluation using echocardiography intraoperatively can easily detect the rare, life-threatening complication of pericardial tamponade.
Case Description:
63 year old female with Hepatitis C and alcoholic end stage liver disease was brought to the operating room for OLT. A 9 French MAC catheter and 8 French PA catheter were easily placed in the right internal jugular vein. MAC catheter position was confirmed with ultrasound, and PA catheter position was confirmed by waveform analysis and transesophageal echocardiography (TEE). Cardiac function appeared normal with no pericardial effusion seen on initial TEE. The patient was hemodynamically stable on low dose norepinephrine drip until 30 minutes after reperfusion of the transplanted liver. The patient required increasing norepinephrine and addition of vasopressin drip for hemodynamic support despite minimal bleeding noted by the surgical team. TEE was used to evaluate cardiac function and a new pericardial effusion with some right ventricle diastolic collapse was visualized. Cardiac surgery was consulted, and the surgeon performed a pericardial window with bloody fluid visualized in the pericardial space. A small perforation in the inferior wall of the right ventricle was actively bleeding and repaired with a pledgeted suture. The patient’s hemodynamics subsequently improved, and the patient was transferred to the ICU after successful OLT.
Discussion:
Complications of CVC may include infection, bleeding, pneumothorax, hemothorax, pericardial effusion, cardiac muscle or valve injury, thrombus, or arrhythmias. Since postoperative chest imaging for this case showed the tip of the CVC to be in the appropriate location in the lower portion of the superior vena cava, the cause of the right ventricle perforation is likely secondary to the guide wire or PA catheter placement instead of the CVC catheter itself. Postoperative imaging showed the tip of the MAC catheter to be 13 cm from the tricuspid valve eliminating the dilator as the cause of perforation. Though literature often cites difficulty in CVC line or PA catheter placement as an indicator of potential cardiac perforation, the CVC and PA catheter were both easily placed in this case. We hypothesize the low pressure system of the right heart minimized the amount of the blood flowing to the pericardial space and only until after reperfusion, where the patient’s preload substantially increased with return of blood flow from the IVC, did the pericardial effusion become hemodynamically significant and apparent on TEE. We recommend strong consideration of cardiac perforation with pericardial effusion when there is an increasing need in vasopressors even in easily placed CVC and PA catheters. Prompt evaluation can easily be accomplished intraoperatively with echocardiography.
