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Coronary Sinus Catheter Placement Procedure

 

Video on Bi-Ventricular Defibrillator lead placement

https://www.youtube.com/watch?v=1kHKakGI3WI

There are three phases to placement:

  1. Screening exam
  1. Introducer placement and catheter preparation
  2. Engaging the CS ostium with the catheter tip
  3. Advancing the catheter beyond the CS ostium
  4. Verifying that balloon is in the correct position
  5. Testing for satisfactory occlusion of the coronary sinus by inflation

Imaging is used to ensure catheter placement and reduce complications

  • transesophageal echocardiography
  • fluoroscopy

1) Screening exam

Look out for heart conditions that can cause complications:

  • atheromatous aortic disease – possibly pass guidewires into aorta or use retrograde aortic flow
  • previously undiagnosed thrombi, masses, valvular disease, etc. might require surgical exposure or standard sternotomy
  • persistent left superior vena cava – prevents retrograde cardioplegia depending on the caliber of the vessel; confirm with bubble contrast study or occlusive venography

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  • aortic insufficiency – may cause difficulty for antegrade cardioplegia

Investigate diameter, taper, and angle of coronary sinus

  • “deep” 4-chamber view (non-standard view)

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    • assess size of proximal CS and CS ostium to prevent occlusion by balloon placed in tapered area; if proximal CS dilated → use 2-chamber view to check dilation more distally
    • visualize side branches joining CS near ostium to prevent obstruction
    • check proximity of IVC and tricuspid valve to prevent cannulation of wrong structure
  • 2-chamber view

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    • assess CS taper and diameter to prevent balloon overinflation, occlusion, and CS injury
  • modified bivaval view (non-standard; classic working view for catheter placement)

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    • assess angle between axes of proximal CS and superior vena cava (angle typically 90⁰, guides catheter; catheters too small may dislodge, and too large may enter side branches)

2) Introducer placement and catheter preparation

  • give heparin before insertion (5000 units recommended)
  • use ultrasound for screening or real-time guidance to ensure proper right internal jugular placement
  • use shallow angle of entry (45⁰ or less) to avoid small-radius curve in catheter at insertion point
  • consider securing introducer at 2 anchor sites
  • check stopcocks of all catheter ports; locking tab for stylet should be engaged to prevent folding of the tip within CS
  • thoroughly flush pressure channel of CS catheter to get rid of bubbles (prevents poor signaling which can lead to balloon overinflation)
  • prime the cardioplegia channel with radiopaque contrast (fill the hub and channel)
  • adjust curvature of the distal catheter based on angle in modified bicaval view

3) Engaging the coronary sinus ostium with the catheter tip

It’s vital to understand the relationship between the coronary sinus, tricuspid valve, and IVC:

The IVC is right (C), CS is in a mid position (D), and tricuspid is left (E)

 

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[Deep 4-chamber view of a catheter

directed toward the tricuspid valve. The catheter

[white arrow] is again directed toward the tricuspid valve,

and appears to need to be turned “counterclockwise”

from “4 o’clock” toward the CS ostium near 1 o’clock. A

catheter directed toward the tricuspid valve does need to

be torqued counterclockwise to direct it toward the CS

ostium. The needed action is the same as what is

suggested by a direct reading of the TEE display.]

 

Identifying the coronary sinus in the modified bicaval view:

There are three “identification” landmarks that will identify the coronary sinus reliably: the Eustachian ridge, the insertion point of the tricuspid valve leaflets and tracking back from the coronary sinus in short axis.

As the catheter is approaching the ostium, a characteristic increase in amplitude of the atrial component of the electrogram as compared to the ventricular signal is noted. When such a

typical signal is obtained, the catheter is carefully advanced into the CS under fluoroscopic guidance in the LAO 30-45 view. The sheath is advanced over the EP catheter and the EP

Actual Maneuvering of the Catheter:

If the catheter tip is in the right ventricle, a small degree of counterclockwise torque is applied prior to withdrawal of the catheter to the point where the waveform changes

to a venous pattern. If IVC entry is suspected, a slight clockwise torque is applied prior to withdrawal of the catheter to the point where it appears (or to a depth of 20 cm). Either correction will usually cause the catheter to appear in the TEE image, often with the tip very near the CS ostium. (If a pulsatile waveform is seen, the catheter tip is in the RV. A venous waveform suggests IVC cannulation, but is also seen when the catheter is in the RA appendage)

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Difficulties in engaging the CS:

 

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  • Advancement beyond the coronary sinus ostium
    1. after engagement, the catheter should only be advanced centimeters at a time.
    2. fluoroscopy should be engaged at this point in order to visualize advancement and impediments
      1. these will appear as either bowing of the cath or by stopping completely
    3. catheters will advance through one of two possible routes
      1. left-superior- this is where you want to be
      2. towards the cardiac apex
    4. halting advancement
      1. Deeper placement (approx. 6-10 cm from tip to ostium) reduces the likelihood of catheter dislodgment, but obstacles may prevent deeper placement in some patients.
      2. can be achieved with pullback and turning the catheter
      3. but ultimately the “correct” depth is based on operator judgement
    5. troubleshooting
      1. pullback with turning usually helps
      2. adjustment of the distal curve which i think is based on a tool
      3. careful injection of contrast to help figure out the tributaries making sure not to cause the vessel to burst
  • Verification of Placement
    1. Done by non-occlusive fluoroscopic imaging , which is injection of contrast into a deflated balloon.
    2. Determination of fluoroscopic placement
      1. How to tell between the RVOT and the Coronary sinus: Containment of contrast within a tube like structure vs seeing dilution of the contrast with blood
  1. Final Positioning of the Cath
    1. Dependant on
      1. location of the catheter tip relative to the true location of the CS ostium.
      2. taper of the coronary sinus, you may want to adjust so that the tip of the catheter is just beyond an area of significant taper.

6) Verification of occlusion

  • estimate balloon volume to avoid CS injury from over-inflation

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  • monitoring balloon inflation – continuous fluoroscopic monitoring is done while the balloon is inflated with diluted contrast

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  • stop inflation if:
    • expanding diameter matches venography diameter
    • ventricularization pattern begins to appear
    • predicted volume reached
    • maximum recommended volume (1 mL) reached
  • inject small amount of contrast (small leak is okay if ventricularization trace present ← desired endpoint)
  • stop movement of balloon toward ostium (normal during inflation) if:
    • balloon contacts sides of CS
    • bowing of proximal catheter
  • confirm catheter depth using 2.5 cm distance between catheter tip to proximal side of balloon as reference
  • occlusive venography: after satisfactory occlusion, inject radiopaque contrast with balloon inflated
    • contrast from middle cardiac vein confirms retrograde cardioplegia will be widely distributed, persistent left SVC (vertical vessel slightly left of pulmonary artery) is absent, CS catheter depth

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    • after the balloon is deflated, check the fluoroscopic field for injury, i.e. extravasation
    • tighten the locking ring at the base of the sheath to secure the catheter
    • tape the hub to the patient’s head

 

Sources:

http://market360online.com/sqlimages/1246/119090.pdf

http://cdn.intechopen.com/pdfs-wm/27006.pdf

https://crbard.com/uploadedFiles/CorpSite/Healthcare_Professionals/lt04z0094a.pdf

http://www.eplabdigest.com/article/971

https://www.youtube.com/watch?v=nxJXzYEA-WM

 

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