Identification of Coronary Sinus Injury by Transesophageal Echocardiography During Placement of a Retrograde Cardioplegia Catheter for Minimally Invasive Cardiac Surgery

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A 70-year-old man presented with chest pain and progressive shortness of breath. Written consent for publication of this case has been obtained from the patient. His medical history was significant for coronary artery bypass grafting through a full sternotomy 16 years previously. Transthoracic echocardiography showed a severely calcified aortic valve (AV) with moderate to severe aortic stenosis, mild aortic regurgitation, mild concentric left ventricular hypertrophy, and left ventricular ejection fraction of 55% to 60%. He was scheduled for AV replacement via a reoperative upper hemisternotomy.After induction of anesthesia, transesophageal echocardiography (TEE) confirmed severe aortic stenosis. We then attempted to place a coronary sinus (CS) catheter (EndoplegeTM sinus catheter, Edwards Lifesciences LLC, Irvine, CA) through the right internal jugular vein via an 11 Fr introducer sheath. The CS was visualized in the modified midesophageal 4-chamber view and the modified midesophageal bicaval view. After multiple attempts, the catheter was successfully engaged just beyond the ostium of the CS with the aid of echocardiography. There was some difficulty in advancing the catheter further into the CS. Venous angiogram under fluoroscopy, using manual injection of 6 to 8 mL of contrast diluted 1:1 with saline, was performed to determine vascular anatomy. Fluoroscopy confirmed catheter tip engagement in the CS ostium; however, it also suggested extravasation of contrast (Fig. 1 and Video 1, see Supplemental Digital Content 1, On TEE, air and fluid were noticed in the pericardial space in the posterior left atrioventricular groove (Fig. 2 and Video 2, see Supplemental Digital Content 2,, along with a small generalized pericardial effusion (Video 3, see Supplemental Digital Content 3, without signs of tamponade. Close to the CS ostium a bifurcation was noticed in the CS, which was possibly the junction of the middle cardiac vein into the CS (Video 3, This combination of radiographic and echocardiographic signs suggested possible injury to the CS. The CS catheter was consequently removed. Since the patient was hemodynamically stable at this point, the surgical procedure was abandoned to allow the CS time to heal. The patient was admitted to the intensive care unit for overnight observation. Continuous invasive hemodynamic monitoring and serial transthoracic echocardiograms were performed to monitor the pericardial effusion. He remained stable and was discharged home on postoperative day 3. An AV replacement was subsequently performed without complication 3 weeks later, through a full sternotomy and with conventional CS catheter placement via the right atrium.DISCUSSIONWe report a case of CS injury during retrograde cardioplegia catheter placement through the right internal jugular vein, identified by TEE. The TEE images showed air and fluid in the left posterior atrioventricular groove and a small pericardial effusion.CS catheter placement via the right internal jugular vein is increasingly performed1 for retrograde administration of cardioplegia in patients undergoing minimally invasive cardiac surgery. Possible complications include CS injury and right ventricle perforation. Fluoroscopy allows visual confirmation of CS cannulation and detects extravasation. Hence, contrast injection is recommended before advancement and balloon inflation during CS catheter placement by the manufacturer (Coronary Sinus Catheter Placement, 2nd ed., Gregory S. Miller available at, accessed June 20, 2012).

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