PERFORATION of the right atrium or ventricle with vascular catheters or wires has been reported many times. With the advent of minimally invasive cardiac surgical procedures, new technologies in monitoring and catheter placement are evolving. One such system of monitoring catheters has been developed by Heartport, Inc. (Redwood City, CA). This case report illustrates inadvertent right ventricular perforation with the proprietary endocoronary sinus catheter inserted via the internal jugular vein.
A 63-yr-old, 1.65-m tall, 57-kg woman presented for minimally invasive coronary revascularization surgery. Preoperative history and physical examination were unremarkable except for an allergic response to intravenous contrast material. Electrocardiogram revealed sinus rhythm without signs of ischemia, and laboratory values were within normal limits.
The patient was sedated with intravenously administered midazolam, and standard monitors were placed. Anesthesia was induced and maintained with sodium thiopental, fentanyl, and pancuronium, and a double-lumen endotracheal tube was placed.
The Heartport system facilitates open heart surgery via small thoracotomy incisions. Venous drainage to the bypass machine is through a catheter inserted via a femoral vein, which radiologically guided to the junction of the superior vena cava and the right atrium. Oxygenated arterial blood is returned via the femoral artery. A balloon-tipped catheter is advanced via the femoral and placed just distal to the aortic valve for injection of cardioplegic solution once on bypass. Once extracorporeal circulation is established, the balloon is inflated to isolate the heart from the systemic circulation (an internal “aortic crossclamp”). Nine- and 11-French sheaths are then placed into the right internal jugular vein to permit placement of a pulmonary artery stent and coronary sinus catheter, the latter to be used for retrograde cardioplegic solution administration if required. Once catheters are placed, internal mammary artery dissection takes place via small thoracotomy incision; exposure is aided with single lung ventilation.
In the current case, the right internal jugular vein was cannulated easily with the two sheaths. Placement of the pulmonary artery stent was uneventful. A transesophageal echocardiography probe was then placed, and normal cardiac anatomy and function were recorded. With the aid of the transesophageal echocardiography and C-arm fluoroscopy, multiple attempts to pass the coronary sinus catheter were made. This is a balloon-tipped catheter with a J-shaped terminal that is stiffened with an internal guide wire; radioopaque dye is used to inflate the balloon, and distal pressures may be transduced. Each time the coronary sinus was thought to have been entered, the guide wire was extended through the tip of the catheter, the catheter tip was advanced over the wire, the balloon was inflated to note distal pressures, and radioopaque dye was injected via the lumen to confirm placement. After struggling for 20 min, however, the procedure was abandoned, and the surgeon was invited to proceed. The central venous pressure, measured now for the first time, was 12 mmHg. Gradually, the patient's heart rate increased and blood pressure decreased, which responded initially to small bolus doses of phenylephrine. When this no longer had the desired therapeutic effect, increasing doses of epinephrine were used; a diagnosis of allergic response to the intravenous dye used during catheter placement was entertained. Full cardiopulmonary resuscitation followed before the cardiac surgeon performed a median sternotomy on the already prepared and draped patient. The pericardium was seen to be tense with blood and this was incised. Drainage resulted in return of blood pressure and heart rate to baseline. The central venous pressure had increased to 15 mmHg at the time of incision. An obviously bleeding puncture site in the right ventricle was easily repaired. The minimally invasive procedure with its attendant catheter placement was abandoned, and successful revascularization of the left anterior descending artery was achieved with cardiopulmonary bypass on her cardioplegic-arrested heart (aortic crossclamp applied). The postoperative course was uneventful, and the patient was discharged home well.
Minimally invasive cardiac surgery has developed in response to the suggestion that nonpump coronary revascularization resulted in better left ventricular preservation. The current drive toward cost containment has led to surgical and anesthesia techniques intended to permit early discharge of the patient. Coronary artery bypass grafting using internal mammary arteries via a limited anterior thoracic incision is gaining acceptance as a surgical technique. 
Complications associated with central venous cannulation are well described and include pneumo- and hemothorax, air embolism, pneumo- and hydromediastinum, and injury to local structures. All of these may be associated with cardiovascular collapse. There are multiple reports regarding cardiac perforation with a wide variety of catheters, ranging from pacing electrode catheters to catheters placed for long-term parenteral nutrition. [5–10]Usually, the perforation is localized to the right atrium; the right ventricle is the next most common site, and even the superior vena cava has been perforated on rare occasion. Diagnosis is not commonly made; in a review of 67 published cases, Chabanier et al. noted a cardiac perforation rate of 5.9%, with a postmortem diagnosis made in 53% of patients. Onset of symptoms ranged from < 1 h after insertion (as in our report) up to 19 days. Circulatory arrest and irreversible collapse were common findings, but insidious symptoms, most commonly arrhythmias, often led to misleading diagnoses, the most common being pulmonary embolism. Often, the inability by nursing staff to aspirate from the catheter was later found to signify perforation. 
Despite the presence of radiologic and echocardiographic diagnostic equipment, we did not make the appropriate diagnosis until median sternotomy was performed. At the time of cardiovascular collapse, the transesophageal echocardiography picture was not helpful diagnostically. Initially, we entertained the diagnosis of allergic reaction to intravenous contrast media. In retrospect, the time course from injection of the material until clinical signs of collapse became evident was too long.
The high mortality associated with cardiac perforation with venous catheters (up to 85%) should arouse suspicion with any symptoms after placing a central intravenous line. Correct positioning of the catheter should be confirmed by either radiologic or echocardiographic study. Treatment, when possible, unfortunately is also associated with high mortality; the best option appears to be formal surgical drainage of the tamponade and closure of the perforation. Pericardiocentesis is not highly successful, with a mortality rate approaching 62%.