Coronary sinus catheters

[ProRealDoc]

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Any of you have any experience with placement of these catheters?

 

[Tdean001]

Like guiding placement intraoperatively via TEE?

 

[proman]

We help placement with TEE (some surgeons do it by feel). Monitor pressure. What else is there?

 

[ProRealDoc]

Like guiding placement intraoperatively via TEE?

yup

 

[ProRealDoc]

We help placement with TEE (some surgeons do it by feel). Monitor pressure. What else is there?

Who places it at your institution?

At my institution it is placed by the anesthesiologist. I have found it pretty challenging to say the least and feel that the catheter has room for design 'refinement' to aid in placement.

 

[starsop93]

Well, people are talking about two different things here. For a standard "maximally invasive" procedure the surgeon places the coronary sinus catheter and sometimes needs assistance which you can provide with the TEE. For a "minimally invasive" procedure, some methods require the CS catheter to be placed via the Rt IJ by the anesthesiologist. This requires the assistance of TEE and fluoro and is notoriously challenging.

It's not always easy for a less experienced anesthesiologist to get an image of the CS, but slight retroflex from the 4 chamber view usually brings it into view. That being said, for a minimally invasive case, a different view is used. This is what is called the "modified bicaval view", for which I can't say I am an expert at achieving yet. For full disclosure, I have been preparing for them at our institution, yet we haven't done one yet.

This best source I've seen for info on this is a publication by Edwards called "Coronary Sinus Catheter Placement" by Greg Miller, MD in Spokane, WA. According to him: ".. from a midesophageal long axis view. Probe depth is adjusted so that the aortic valve is on (or slightly above) an imaginary line drawn to bisect the imaging sector. The multiplane angle is adjusted to the lowest angle that still displays the left ventricular chamber. Turning the probe right from this position will display the modified bicaval view..." I encourage you to get a copy of the entire booklet. It is very detailed and very good. The Edwards people will be more than happy to pass one on to you.

Unfortunately, even in the best of hands, guiding the catheter into the sinus and accurately placing it past the ostium and to the correct depth is hard. And it is a real pain when it comes out during the procedure. Also, any coronary sinus injury is now your fault.

I'm cautiously awaiting the beginning of our minimally invasive program here... Unfortunately it will turn our quickest cases into our longest.🙁

 

[dhb]

Any of you have any experience with placement of these catheters?

Never heard of these, would anybody care to elaborate on the goals of said catheters?

 

[lvspro]

Like the above poster, i have seen 3-4 placed at our institution, and they are quite challenging. I don't have any other tips/tricks, and we have one designated anesthesiologist who does all of them. I believe she runs the cardiac section for our program, and even she says that they are tricky.
For the one that asked what the purpose of these is, its for the cardioplegia.

 

[SleepIsGood]

Like the above poster, i have seen 3-4 placed at our institution, and they are quite challenging. I don't have any other tips/tricks, and we have one designated anesthesiologist who does all of them. I believe she runs the cardiac section for our program, and even she says that they are tricky.
For the one that asked what the purpose of these is, its for the cardioplegia.

why is the anesthesiologist doing it? the CV surgeon can do this in like 5 min or so?

 

[deleted59964]

Like the person above mentioned, it's placed by the anesthesiologist if the heart surgery is "minimally invasive" and the surgeon doesn't have the access he needs to place it himself.

I havent seen much cardiac surgery in the last 6 years or so, used to be minimally invasive cardiac surgery was done with an octopus thingy that held the part of the heart the surgeon was operating on still -- ie. no cardioplegia ... what happens now?

PS - I'm a med student with a nursing background (ICU)- thanks.

 

[lvspro]

why is the anesthesiologist doing it? the CV surgeon can do this in like 5 min or so?

I think b/c we are usually slicker with floating swans, and TEE, the assumption is that we are better qualified for this step. As mentioned earlier, the surgeon may be able to provide minimal assistance with external hand guidance, but it raises the risk of CS tear.

Do the surgeons use a different method than the ones pointed out here? Every one I've seen took more than 5 minutes by an experienced anesthesiologist, so if you know a slick method that hasn't been mentioned, please share.

 

[proman]

Who places it at your institution?

At my institution it is placed by the anesthesiologist. I have found it pretty challenging to say the least and feel that the catheter has room for design 'refinement' to aid in placement.

I get the confusion. To me, a coronary sinus catheter is used to administer retrograde cardioplegia and obviously placed by the surgeon. We transduce the pressure for perfusionists. It's placed blindly using TEE to confirm position.

Like someone else mentioned, what PRD is referring to is a venous return cannula used for CPB in minimally invasive procedures. We (anesthesiologists) place them as part of our lines. It's also called an SVC cannula. Something like 18 or 19 french garden hose that has to have heparinized saline in it.

It's high risk as far as lines go but I don't find it that much more difficult. What's the trouble?

 

[periopdoc]

I get the confusion.

Nope, you are still confused. PRD IS talking about a percutaneously placed coronary sinus catheter for providing cardioplegia. This is placed via an internal jugular approach, usually by the anesthesiologist. It is facilitated by TEE and fluoro and can be a real B**** to get in. The quoted success rates are in the high 80% to low 90%.

In the Port-Access EndoCPB system, the anesthesiologist also places a pulmonary vent via the IJ, and the surgeon places the patient on Fem-Fem bypass for the procedure.

I believe there is also a percutaneous coronary sinus catheter that is designed to be placed femorally by the surgeon.

The key difficulty in all of this is that there is no surgical opening at the time of placement and so there is no direct help from the surgical field, the catheter has to be floated in a retrograde manner up the CS. Probably the best physician to do this would be a good interventional cardiologist

- pod

 

[lvspro]

Nope, you are still confused. PRD IS talking about a percutaneously placed coronary sinus catheter for providing cardioplegia. This is placed via an internal jugular approach, usually by the anesthesiologist. It is facilitated by TEE and fluoro and can be a real B**** to get in. The quoted success rates are in the high 80% to low 90%.

In the Port-Access EndoCPB system, the anesthesiologist also places a pulmonary vent via the IJ, and the surgeon places the patient on Fem-Fem bypass for the procedure.

I believe there is also a percutaneous coronary sinus catheter that is designed to be placed femorally by the surgeon.

The key difficulty in all of this is that there is no surgical opening at the time of placement and so there is no direct help from the surgical field, the catheter has to be floated in a retrograde manner up the CS. Probably the best physician to do this would be a good interventional cardiologist

- pod

Or an electrophysiologist. They get a lot of experience during pacer lead placement.

 

[proman]

Nope, you are still confused.

- pod

You were right. I had no idea that what was involved in the Port Access stuff. Our main minimally invasive surgeon does femoral arterial and uses our SVC venous return for bypass. When I interviewed with Ron Pearl he mentioned they stopped doing Port Access because of the complication rate was so much higher the median sternotomy. Ironically, our surgeon trained at Stanford (where they developed the Port Access technique).

If it were me, I'd want a sternotomy.

 

[starsop93]

You were right. I had no idea that what was involved in the Port Access stuff. Our main minimally invasive surgeon does femoral arterial and uses our SVC venous return for bypass. When I interviewed with Ron Pearl he mentioned they stopped doing Port Access because of the complication rate was so much higher the median sternotomy. Ironically, our surgeon trained at Stanford (where they developed the Port Access technique).

If it were me, I'd want a sternotomy.

You are correct to be worried about the complications. The complication rates, especially in less experienced hands, can be MUCH higher with a port access minimally-invasive case. Same with percutaneous valves and robotic surgery. Unfortunately in our free-market medical system (sorry I had to go there), the marketing seems far more important to patients (and cardiologists) than the outcomes. Our institution has lost almost all of our elective valve volume to several institutions in the area that advertise robotic and minimally-invasive valve replacement. A couple of the centers have terrible mortality rates for valves (we actually have the best in the state), but the cardiologists still send them there. And the patients want to get the "fanciest" surgery around. Unfortunately, our surgeons feel they must start doing these procedures or we won't ever see an isolated aortic valve younger than 90 yrs again.

 

[deleted59964]

I don't have much experience with this. I've seen only two cases.

The "octopus" is for an off-pump CABG.

The "minimally invasive" surgeries I am refering to were on-pump CABGs with much smaller incisions. The cardioplegia was administered by coronary sinus catheters placed by the anesthesiologist (my attending at the time).

There should be some cardiac guys out there that can elaborate...

Ah OK thanks - so it's done via a thoracotomy incision? rather than sternotomy.

 

[periopdoc]

Whether mini-thoracotomy or mini-sternotomy all depends on the procedure (valves vs CABG etc) and the surgeon.

Unfortunately, the minimally invasive stuff seems to be done by the more complication prone surgeons in our area which makes it difficult to determine whether the complications are due to technique, lack of experience, or simply lack of surgeon aptitude. As time progresses and the techniques are refined and tested, we will get a better idea of whether or not these minimally invasive techniques are superior or not.

Most of the percutaneous valves in our area are being done in patients who are not surgical candidates so once again it is hard to make a judgement.

- pod

 

[deleted59964]

Well, for the two that I saw, they did a "mini-sternotomy" (about 3-4 inches).

Whether mini-thoracotomy or mini-sternotomy all depends on the procedure (valves vs CABG etc) and the surgeon.

Unfortunately, the minimally invasive stuff seems to be done by the more complication prone surgeons in our area which makes it difficult to determine whether the complications are due to technique, lack of experience, or simply lack of surgeon aptitude. As time progresses and the techniques are refined and tested, we will get a better idea of whether or not these minimally invasive techniques are superior or not.

Most of the percutaneous valves in our area are being done in patients who are not surgical candidates so once again it is hard to make a judgement.

- pod

thanks for the info guys 👍

 

[UTSouthwestern]

Whether mini-thoracotomy or mini-sternotomy all depends on the procedure (valves vs CABG etc) and the surgeon.

Unfortunately, the minimally invasive stuff seems to be done by the more complication prone surgeons in our area which makes it difficult to determine whether the complications are due to technique, lack of experience, or simply lack of surgeon aptitude. As time progresses and the techniques are refined and tested, we will get a better idea of whether or not these minimally invasive techniques are superior or not.

Most of the percutaneous valves in our area are being done in patients who are not surgical candidates so once again it is hard to make a judgement.

- pod

I would bet that the lack of experience and aptitude has been the source of problems with the Heart Port access system.

At the Heart Hospital in Plano, Texas, we cover the guru of Heart Ports, William Ryan, who does about 5 a week. We place the CS catheters with TEE or contrast enhanced fluoro and we manage the bypass protocols with the perfusionists.

His outcomes are excellent with very few bringbacks or redos.

Unfortunately, this type of procedure requires volume and without it, the minimally invasive part tends to fall by the wayside.

 

[ProRealDoc]

Nope, you are still confused. PRD IS talking about a percutaneously placed coronary sinus catheter for providing cardioplegia. This is placed via an internal jugular approach, usually by the anesthesiologist. It is facilitated by TEE and fluoro and can be a real B**** to get in. The quoted success rates are in the high 80% to low 90%.

In the Port-Access EndoCPB system, the anesthesiologist also places a pulmonary vent via the IJ, and the surgeon places the patient on Fem-Fem bypass for the procedure.

I believe there is also a percutaneous coronary sinus catheter that is designed to be placed femorally by the surgeon.

The key difficulty in all of this is that there is no surgical opening at the time of placement and so there is no direct help from the surgical field, the catheter has to be floated in a retrograde manner up the CS. Probably the best physician to do this would be a good interventional cardiologist

- pod

Exactly right.

My short experience so far has been placement under TEE visualization. Agree fluoro would likely help but it is not available in our cardiac ORs. Our cardiac attendings are solely reponsible for placement. And you're right, it is a royal pain to place. Will have to wait until next year as a cardiac fellow to get more experience.

For the residents who are not familiar with these devices, here's a link to the manufacturer's website:
http://www.edwards.com/Products/PortAccess/ENDOCPB.htm

 

[periopdoc]

In all fairness

After what I said about the complications encountered by the surgeons who are doing these in our area, I should include my own mea culpa.

The last one I did was a minimally invasive valve through mini-thoracotomy. The case was complicated by more bleeding than expected and we ultimately did a midline sternotomy to find out why. When the surgeon opened the pericardium the first thing he saw was a bit of bright yellow plastic/rubber on top of the RVOT. The PA catheter was exiting and re-entering the RVOT even though the tip was definitively in the pulmonary circulation. Insertion of the PAC had been easy. It passed in a single attempt with the balloon fully inflated. It was the opinion of the surgeon that the catheter had in fact eroded through the RVOT, not penetrated it. However, I noticed that he closed the deficit with two distinct plegetted stitches.

Curious I do say.

- pod

 

[EtherBinge]

Placing CS catheters for MICS or robotic surgeries is a pain in the ass. It requires a solid knowledge of both TEE and fluroscopy and is quite dangerous in inexperienced hands. I have seen at least 3 CS ruptures with ensuing tamponade in people learning the technique. I recommend reading the Edward's article called Coronary Sinus Catheter Placement. They also have a good webinar if you call them. I also believe there are some courses that teach the techniques. If you are going to try it have someone with experience guide you.

 

[ProRealDoc]

Placing CS catheters for MICS or robotic surgeries is a pain in the ass. It requires a solid knowledge of both TEE and fluroscopy and is quite dangerous in inexperienced hands. I have seen at least 3 CS ruptures with ensuing tamponade in people learning the technique. I recommend reading the Edward's article called Coronary Sinus Catheter Placement. They also have a good webinar if you call them. I also believe there are some courses that teach the techniques. If you are going to try it have someone with experience guide you.

Here you go:
http://www.edwards.com/SiteCollectionImages/products/port%20access/ar04025.pdf

 

[Jay K]

Great thread and timely; I'm dreading the advent of robotic hearts at one of my current locales which the surgeon does with coronary sinus caths by an anesthesiologist. During residency I don't ever recall our robotic CT surgeon ever requesting these. The pamphlet nonetheless will make interesting reading. I don't think it's something I want to pickup just by reading a pamphlet though; I'll probably encourage our group to seek a CV fellowship trained and CS catheter experienced individual in the future.

 

[deleted87051]

For those doing these regularly, what cpt code are you using? Are you getting paid?

 

[Gas you down]

Great thread and timely; I'm dreading the advent of robotic hearts at one of my current locales which the surgeon does with coronary sinus caths by an anesthesiologist. During residency I don't ever recall our robotic CT surgeon ever requesting these. The pamphlet nonetheless will make interesting reading. I don't think it's something I want to pickup just by reading a pamphlet though; I'll probably encourage our group to seek a CV fellowship trained and CS catheter experienced individual in the future.

my hospital is obsessed with anything robotic/minimally invasive. they have been trying to bring in a new heart guy to do this. none of us have any experience with these techniques. personally, I don't feel comfortable doing them, and just hiring a new guy isn't always easy around here! I guess I will wait to really speak up when they actually come through. because they would also have to redesign an OR suite I believe.