Prevention, Causes and Management of Entrapped Central Venous Line after Mitral Valve Replacement: A Rare Case Report and Review of Literature

Abstract

Objectives: Management of entrapped central venous line by a suture after mitral valve replacement in the context of a rare clinical case report. Possible causes and preventive measures are explored to prevent the occurrence of a similar complication of cardiac surgery. Presentation of case: After an uneventful cardiac surgery for mitral valve replacement and a single coronary artery bypass grafting, the patient was extubated few hours after the procedure and had minimal inotropic support. On the third postoperative day, the patient was transferred to the ward. Decision was taken to remove the central venous catheter one week postoperatively. Nurses and physicians noticed that the CVC was stuck and could not be removed. The patient was transferred to the catheterization laboratory where the interventional radiologists tried to explore the cause of the CVC entrapment under fluoroscopy using contrast enhanced venography. The radiologists concluded that the CVC was entrapped into a cardiac structure. After explaining the situation to the patient and family, consent was obtained from the patient to reopen the chest under general anaesthesia. During the exploratory re-sternotomy, cardiopulmonary bypass using bi-caval venous cannulation was initiated. Subsequently, the heart was arrested using aortic cross clamp and cardioplegia solution. It was noticed that the CVC was low lying in the right atrium and was inadvertently stitched by the suture line for left atrial closure. After cutting the sutures, the CVC was easily removed by the anaesthetist. The patient recovered in few days and was discharged home. The two main causes of the entrapment of CVC during cardiac surgery are deep advancement of the CVC further than the cavo-atrial junction by the anaesthetist and unrecognising the catheter during atrial closure by the surgeon. Prevention of this complication is by ensuring that the tip of the CVC is located in the superior vena cava (SVC) and is above the cavo-atrial junction. For this purpose, we suggest using mathematical formulae based on patients’ height and the use of imaging.