Perforation of the Right Atrium by Coronary Sinus Catheter
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Researchers report an incidence of right atrial puncture using a percutaneous coronary sinus catheter (CSC) during a planned aortic valve replacement and aortic root plasty via mini-thoracotomy.

Minimally invasive surgical approaches are increasingly being adopted by cardiac surgeons to reduce incision size, decrease bleeding, and facilitate a more rapid recovery.

These smaller incisions limit the surgeon's ability to place a retrograde cardioplegia catheter, which can result in suboptimal cardioprotection. For this reason, percutaneous CSCs placed via the right internal jugular vein offer an alternative for the delivery of retrograde cardioplegia.

A 70-year-old woman with severe aortic stenosis, bicuspid aortic valve, and aortic root dilation presented for minimally invasive aortic valve replacement and aortic root repair. After several unsuccessful attempts at CSC placement with repeated buckling of the catheter, the catheter appeared to be positioned appropriately on TEE and fluoroscopy. The balloon was inflated and a ventricularized waveform further confirmed placement. However, injection of contrast under fluoroscopy showed pericardial spread. In the midesophageal 4-chamber view on TEE, a pericardial effusion was identified along with bubbles within the pericardial effusion from the injection of contrast.

The surgical team was notified immediately owing to concern for coronary sinus perforation and growing pericardial effusion. The catheter was left in place per request of the surgical team. Emergent sternotomy was performed to rapidly cannulate for cardiopulmonary bypass and identify the site of injury. Opening of the pericardium resulted in improved hemodynamics and discontinuation of vasopressors. Surgical exploration revealed the CSC in the posterior pericardial space through the punctured right atrium between the coronary sinus and the inferior vena cava. The catheter was withdrawn and the injury repaired with sutures.