TRANSESOPHAGEAL ECHOCARDIOGRAPHY AS A GUIDE TO CENTRAL VENOUS CATHETER PLACEMENT IN CONGENITAL CARDIAC SURGERY

Abstract

Introduction: Transesophageal echocardiography (TEE) has become an essential monitor for the management of most patients undergoing surgery for congenital heart disease. Central venous access for monitoring and drug infusion is used in many centers, despite a recognized incidence of complications from malposition, most significantly cardiac perforation from right atrial positioning [1,2]. This study assesses the effect of TEE on correct catheter placement and complications. Methods: After informed consent, 143 patients age 1 day-29 years undergoing surgery for congenital heart disease were enrolled. Patients were randomized to the TEE group or the control group, and further randomized to receive an internal jugular or subclavian vein catheter. The TEE group had a TEE probe inserted, and a transverse plane four-chamber view obtained. Then the vein was entered and a guidewire advanced into the right atrium under direct TEE visualization. The catheter was advanced over the guidewire until its full length was inserted, and a longitudinal plane TEE view of the junction of the superior vena cava (SVC) and right atrium (RA) was obtained. Catheter position was adjusted until the tip was in the SVC at the superior edge of the crista terminalis. Control group patients had the central venous catheter (CVC) placed by standard methods, which included observing the electrocardiogram for premature atrial contractions to confirm atrial guidewire position. Catheter insertion length to the distal SVC was estimated to place the tip midway between the sternal notch and the nipples. The location of the CVC was assessed by TEE after placement. Both groups had catheter location assessed radiographically, with desired location in the SVC, parallel to the vessel wall. Results were compared using a paired T test or Chi square analysis. Results: 76 catheters were placed in the right subclavian vein, 2 in the left subclavian vein, 62 in the right internal jugular vein, and 1 each in the left internal jugular and right external jugular. There was no difference in rate of successful placement if the chest radiograph was used to determine correct placement. There was, however, a significant increase in success rate if the TEE was used to determine correct placement. The SVC/RA junction was an average of 15 mm lower by TEE than by CXR, explaining the difference in success rate. The complication rate, or number of attempts required between the two groups was not different. The time to placement was significantly shorter in the control group. (Table 1)Table 1All catheters inserted via the internal jugular vein were in the SVC or RA. 4 of 77 subclavian catheters were located in the contralateral innominate vein. There was one significant complication: an SVC perforation from a subclavian catheter in the control group necessitating surgical reexploration. Discussion: TEE can be reliably used to assist in the placement of CVC in pediatric cardiac surgical patients. Catheters located high in the RA by CXR are probably in the SVC and pose little risk of atrial perforation.