Case Of Cardiac Perforation Research Articles

805 Case Report: Atrial Perforation in the Setting of Electrical Injury and Subsequent Cardiopulmonary Resuscitation

IntroductionElectrical injuries cause 500 to 1000 deaths per year in the United States and are the fourth leading cause of death in the workplace. Rates and types of cardiac complication secondary to electrical injuries vary widely throughout the literature. Case reports describing cardiac perforation in the setting of electrical injury are exceedingly sparse. To our knowledge, there are no documented cases of cardiac perforation as a direct result of electrical injury.MethodsThis is a case report and review of relevant literature.ResultsCase Description:We present a case of myocardial perforation in the setting of high voltage electrical injury. An otherwise healthy 46-year old male sustained a 13.8 kV electrical. Resuscitation included bystander cardiopulmonary resuscitation (CPR), defibrillation by emergency medical responders, finger thoracostomies and massive transfusion protocol in the trauma bay, and finally emergent sternotomy and repair of two injuries to the right atrial appendage. Given this patient’s pattern of injury, including a sternal fracture and bilateral upper anterior rib fractures, the etiology of his right atrial perforation is more likely due to mechanical injury from CPR instead of thermal or electrical injury to the myocardium. However, intraoperative findings confound this theory as no defects were identified in the pericardium of the mediastinal pleura during the operation. This would argue against mechanical injury during CPR. However, the presence of a left hemothorax may could indicate that a pericardial injury was missed in the operation. We argue that the most likely cause of injury is mechanical perforation of the pericardium and myocardium during CPR with a possible missed pericardiotomy during surgical exploration. An alternative hypothesis is an isolated electrical injury to the myocardium and left hemothorax from rib fractures without communication between the two cavities. This patient expired on postoperative day two due to anoxic brain injury.ConclusionsThis case highlights myocardial injury as a rare but lethal complication of high voltage electrical injury and serves as a reminder that cardiac perforation and hemodynamic collapse due to hypovolemic shock can compound and complicate the resuscitation and management of a patient with electrical injury. Further, the widely varying data regarding cardiac complications secondary to electrical injury warrants further investigation and large-scale prospective data.

Multivariate analysis on complications of central venous access devices in children with cancer and severe disease influenced by catheter tip position and vessel insertion site (A STROBE-compliant study)

ContextReliable long-term central venous access device (CVAD) is essential for the management of pediatric patients with cancer or chronic diseases. However, there is no general consensus for optimal catheter tip location and vessel insertion site in children. ObjectiveThis single center study analyzes the risk of complications associated with long-term upper body CVAD and evaluates them with respect to catheter tip location as well as vessel insertion site. DesignPediatric patients who received long-term upper body CVAD from January 2008 through April 2017 and underwent radiographic documentation of the tip location were retrospectively included in the study. Data on demographics, catheter tip location on chest x-ray, intraoperative vessel insertion sites and postoperative complications were analyzed. Catheter tip location was categorized as “high” (above the right mainstem bronchus), “medium” (at the level of the bronchus), and “low” (below the right mainstem bronchus). Distance to the carina was measured as well. ResultsA total of 396 patients, 74.7% suffering from cancer were included in our study (mean age 6.3 ± 0.3 years). Complications occurred in about one fourth of all patients. Catheter-related blood stream infections (BSI) (n = 40, 36.4%) were most prevalent, but catheter tip position or vessel insertion site had no impact on the risk of infections. Dislodgement (n = 27, 24.6%) and occlusion (n = 11, 10.0%) were more frequent in “high” positioned catheter tips.While there was one patient who developed arrhythmia, no case of cardiac perforation, and in particular, no catheter-related death was recorded in our series. The vessel insertion site seemed to have no influence on the complication frequency of CAVDs. ConclusionThe catheter tip position seems to have an impact on the catheter-related complication profile in children. To avoid complications, we recommend avoiding a “high” localization of the catheter tip above the right main bronchus. “Low” catheter tip placement was associated with the lowest dislocation rate.Given the overall low complication rate, insertion and use of CVADs in children can generally be considered as safe.

Performance of the Durata implantable cardioverter defibrillator lead: results of an independent multicenter study.

The high rate of implantable cardioverter defibrillator (ICD) lead failures related to the Sprint Fidelis' and Riata's design have raised serious concerns about the reliability of ICD leads. The St. Jude Medical Durata family of leads replaced the preceding Riata line following increased rates of lead failure (1.17% per year). The aim of our study was to evaluate the long-term performance of the Durata lead. Eight hundred and eighteen Durata ICD leads were implanted in 11 Italian centers. The incidence of lead failure, defined as a sudden rise in long-term pacing or defibrillation impedance and/or a sudden change in R-wave amplitude and capture thresholds, was assessed. The incidences of lead dislodgment and lead perforation were also evaluated. During a median follow-up of 1353 days (3.7 years; 25-75th interquartile range 806-1887 days) lead failure occurred in 16/818 leads (0.54%/year). The overall survival, free of lead failure, was 98.9% at 3 years, 98.2% at 4 years and 97.5% at 5 years. Lead dislodgment occurred in 12/818 leads with an incidence of 0.4%/year. No cases of cardiac perforation were reported. No major adverse events were reported except for two cases of inappropriate shocks as a consequence of failure or dislodgment. Our study suggests that the Durata lead does not engender a higher risk of failure. Overall survival, free from lead failure, was found to be higher than previously reported for the Riata lead.

Perforation of Cardiac Wall by Cement Embolism after Vertebral Augmentation for Thoracic Spinal Fracture: A Case Report

We describe a rare case of cardiac perforation caused by cement emboli after vertebral augmentation technique two months after the procedure. The patient was sent to a local hospital due to progressive dyspnea and chest tightness. Massive pericardial effusion was first diagnosed at the hospital, and therefore he was transferred to our hospital's emergency department. Multidetector computed tomography (MDCT) showed a string-like foreign body over the right atrium and ventricle which had apparently caused perforation of cardiac wall. Under the diagnosis of cement spike perforation, we performed percutaneous endovascular retrieval. We failed to extract the cement due to its fragile characteristic of the fragment and further migration of cement into the right middle lobe of lung was noted. The patient's symptoms improved after the penetrating emboli was removed from the cardiac wall, and no symptoms of pulmonary embolism occurred. The patient was discharged 5 days later with aspirin treatment for prevention of pulmonary embolism.

Balloon Valvuloplasty Through the Right Ventricle: Another Treatment of Pulmonary Atresia With Intact Ventricular Septum

This was a study to evaluate the safety and feasibility of balloon valvuloplasty of the pulmonary valve through the right ventricle (RV) for the treatment of pulmonary atresia with intact ventricular septum (PA-IVS). Ten neonates with PA-IVS, who underwent balloon valvuloplasty of the pulmonary valve through the RV at our institution from January 2008 to May 2010, were enrolled in this study. The oxygen saturation range was 60% to 83% (median 76%). The Z-value range of the tricuspid valve annulus was -2 to 2 (median 0.15), the diameter range of the pulmonary valve annulus was 4.6 to 8.6 mm (median 7.3), and the RV systolic pressure range was 88 to 124 mm Hg (median 106.5). A guidewire was used to perforate the pulmonary valve through the RV, followed by balloon dilation of the valve. The procedure was guided by transesophageal echocardiography. The procedure was carried out successfully in all patients. The procedure time ranged from 64 to 110 minutes (median 82.5). Mechanical ventilation time ranged from 8 to 36 hours (median 11), and hospital stay ranged from 7 to 13 days (median 9). After the procedure, the median oxygen saturation increased to 89.5%, the median RV systolic pressure decreased to 45 mm Hg, and the gradient across the pulmonary valve ranged from 20 to 45 mm Hg (median 27.5). Minor complications included transient supraventricular tachycardia (n = 1), blood loss requiring transfusion (n = 2), moderate pulmonary regurgitation (n = 1), and mild pulmonary regurgitation (n = 3). There were no cases of cardiac perforation, main pulmonary artery aneurysm, or low output syndrome. Follow-up of patients ranged from 8 to 15 months (median 12.3). All patients remained clinically well. Balloon valvuloplasty of the pulmonary valve through the RV is a safe and feasible alternative to surgical valvotomy or percutaneous balloon dilation. Early results are encouraging.

Emergent cardiopulmonary bypass during pectus excavatum repair

Pectus excavatum is a chest wall deformity that produces significant cardiopulmonary disability and is typically seen in younger patients. Minimally invasive repair of pectus excavatum or Nuss procedure has become a widely accepted technique for adult and pediatric patients. Although it is carried out through a thoracoscopic approach, the procedure is associated with a number of potential intraoperative and post-operative complications. We present a case of cardiac perforation requiring emergent cardiopulmonary bypass in a 29-year-old male with Marfan syndrome and previous mitral valve repair undergoing a Nuss procedure for pectus excavatum. This case illustrates the importance of vigilance and preparation by the surgeons, anesthesia providers as well as the institution to be prepared with resources to handle the possible complications. This includes available cardiac surgical backup, perfusionist support and adequate blood product availability.

Pectus Excavatum Repair According to Nuss: Is It Safe to Place a Retrosternal Bar by a Transpleural Approach, Under Thoracoscopic Vision?

We present a new case of cardiac perforation during retrosternal dissection beginning a Nuss procedure for pectus excavatum repair in an 18-year-old boy. The true incidence of life-threatening complications, such as heart injuries during Nuss bar placement for pectus excavatum repair, as well as cardiac lacerations during removal of the bar, remains unknown. Many papers suggest measures to prevent these complications: approaching the retrosternal space through an additional subxiphoid short incision, lifting the sternum during bar placement, or placing the bar extrapleuraly. Nuss procedure is gaining more and more popularity due to its apparent simplicity; however, its operational complications should be well known and discussed to be avoided later on.

Complications of Endomyocardial Biopsy in Heart Transplant Patients: A Retrospective Study of 2117 Consecutive Procedures

Background Endomyocardial biopsy (EMB) remains the gold standard for the diagnosis of graft rejection after heart transplantation (HT). Our purpose was to evaluate the rate of complications of this invasive procedure. Methods This was a retrospective study of 175 patients, who were transplanted between November 2003 and October 2010 and survived more than 1 month after surgery. We evaluated the number of inconclusive EMB and described the incidence, nature, and subsequent management of several complications associated with this procedure. Results Over a period of approximately 7 years, we performed 2217 EMB yielding 4972 specimens, namely, an average of 2.3 fragments per procedure. The majority of EMBs (95.3%) were performed by the femoral approach. Only 12 EMB (0.57%) were inconclusive. The overall complication rate was 0.71%. During puncture, one patient experienced a vasovagal reaction and another one, a femoral artery false aneurysm. During the biopsy, there was one case of cardiac perforation with tamponade, two cases of supraventricular tachycardia, and three atrioventricular conduction abnormalities. In 19 patients, histological analysis revealed chordal tissue, but only two patients developed mild tricuspid regurgitation. We observed five cases of coronary artery fistulae. The clinical outcomes were favorable in all cases. Conclusion EMB proved to be a suitable, safe method to monitor rejection after HT.

Cardiac perforation following transcatheter PFO closure

From December 1998 to August 2001, transcatheter closure of patent foramen ovale (PFO) with an Amplatzer PFO occluder has been successfully performed in our center in 102 patients without severe complications. We are reporting the first known case of cardiac perforation by an Amplatzer PFO occluder.

Cardiac Tamponade and Death in a Patient Receiving Total Parenteral Nutrition

ADMINISTRATION of hypertonic solutions for parenteral nutrition necessitates the use of a central venous catheter, a procedure fraught with complications.1We are reporting a case of cardiac perforation, tamponade, and death resulting from this procedure. Report of a Case A 63-year-old woman underwent partial gastrectomy and excision of the distal section of the esophagus in December 1970 for an adenocarcinoma of the gastroesophageal junction. Her immediate postoperative course was uneventful. Preoperatively, her weight was 45 kg (99 lb). Her late postoperative course was complicated by severe dumping symptoms, early satiety, and weight loss. During the subsequent 17 months, in spite of numerous attempts to increase the patient's caloric intake with various oral food supplements, her weight declined to 30 kg (66 lb). Repeated esophagoscopy, biopsy, cytologic studies, and barium contrast examinations of the upper gastrointestinal tract failed to disclose any evidence of recurrent neoplasm. We decided to begin total