Description of Event or Problem · 1
IT WAS REPORTED IN PACING AND CLINICAL ELECTROPHYSIOLOGY, VOLUME 26 ISSUE 7 P1 PAGE 1548 - JULY 2003, PATIENT HAD A PERMANENT VVI PACEMAKER WITH SEVERE POSTINFARCTION LEFT VENTRICULAR DYSFUNCTION. THEY SUDDENLY DEVELOPED CARDIOGENIC SHOCK AFTER UNDERGOING RADIOFREQUENCY ABLATION OF VENTRICULAR TACHYCARDIA ORIGINATING IN THE RIGHT VENTRICULAR OUTFLOW TRACT. AN INTRAAORTIC BALLOON PUMP WAS INSERTED AND MECHANICAL VENTILATION WAS NEEDED. AFTER PROVIDING ADEQUATE OXYGENATION, THE DECISION WAS MADE TO WITHDRAW THE CATHETERS; HOWEVER, THE ELECTRODE CATHETER IN THE RIGHT FEMORAL VEIN COULD NOT BE REMOVED A 20-CM END PART OF A FOUR-POLAR 6 FR JSN-O ELECTRODE CATHETER PROTRUDED FROM THE SITE SHEATH INSERTION. A PHILLIPS BV 25 GOLD MOBILE FLUOROSCOPIC DEVICE AT THE PATIENT'S BEDSIDE REVEALED THE FORMATION OF AN EIGHT-SHAPED KNOT IN THE GROIN. THE TIP OF THE CATHETER WAS CLOSE TO THE TRICUSPID VALVE. WHEN PULLING THE CATHETER, THE KNOT TIGHTENED AND THE SHEATH EDGE PREVENTED SUBSTANTIAL MOTION OF THE CATHETER TIP. THE FLUOROSCOPY PICTURE DID NOT ALLOW THE TYPE OF THE KNOT TO BE IDENTIFIED (I.E. FALSE KNOT IN THE FORM OF A "0" RESEMBLING AN "8" OR A TRUE KNOT). THE NEXT TRIAL INVOLVED THE ADVANCEMENT OF THE CATHETER: THE RESULT WAS THE MOTION OF THE KNOT IN THE DIRECTION OF BLOOD FLOW, HOWEVER, BY ONLY 5 CM. AS THE ELECTRODE CATHETER COULD NOT BE SIMPLY RETRACTED FROM THE BODY AND SURGERY WAS NOT APPROPRIATE UNDER THE CIRCUMSTANCES, THE AUTHORS DECIDED TO INTERVENE AT THE SITE OF THE CATHETER KNOT. AN 8 FR SHEATH WAS INSERTED VIA THE RIGHT INTERNAL JUGULAR VEIN. THE SHEATH WAS USED TO ADVANCE A 5 FR PIGTAIL CATHETER AND THE PROXIMAL EYE OF THE KNOT WAS GRASPED USING A 0.038-INCH, 150-CM LONG J WIRE. MANIPULATION INVOLVED A GRADUAL JERKY MOVEMENT AND ADVANCEMENT OF THE ELECTRODE CATHETER INTO THE PATIENT UNTIL THE END OF THE CATHETER WAS STOPPED BY THE SHEATH IN THE FEMORAL VEIN, AND CONCOMITANT PULLING OF THE PIGTAIL REINFORCED BY THE WIRE FROM THE JUGULAR VEIN. GRADUALLY THE AUTHORS MANAGED TO PARTIALLY LOOSEN THE EYE OF THE KNOT. HOWEVER, THE CATHETER STIFFNESS, THE FRICTION IN THE AREA OF THE PELVIC VEINS, AND THE MECHANISM OF THE "KNOT" ON THE ONE HAND, AND THE "SOFTNESS" OF THE PIGTAIL ON THE OTHER MADE IT IMPOSSIBLE TO MAKE FURTHER ADVANCEMENTS. THIS WAS FOLLOWED BY ANOTHER ATTEMPT AT GRASPING THE EYE OF THE "KNOT." THIS TIME, THE WIRE WAS CAREFULLY MOVED TO PROTRUDE FROM THE PIGTAIL CATHETER BY SEVERAL CENTIMETERS. ANOTHER 8 FR SHEATH WAS SUBSEQUENTLY INSERTED INTO THE RIGHT INTERNAL JUGULAR VEIN. THIS SHEATH WAS USED TO ADVANCE A 4.5 FR 90-CM LONG SEGURA BASKET RETRIEVAL CATHETER WITH AN OPENING WIDTH OF 20.0 MM AND THE J WIRE END WAS GRASPED. THE WIRE SUBSEQUENTLY EXTERIORIZED CREATING A LOOP WHOSE TOP WAS MADE BY THE "KNOT EYE"; BOTH WIRE HALVES (E.G., THE ONE WITH THE J-SHAPED END, AND THE OTHER ONE WITH RIGID END) WERE PASSED THROUGH THE INDIVIDUAL 8 FR SHEATHS IN THE INTERNAL JUGULAR VEIN. THE PIGTAIL WAS SUBSEQUENTLY NO LONGER NEEDED AND WAS REMOVED. BY PULLING AND ROTATING BOTH ENDS OF THE WIRE LOOP, THE WHOLE EYE WAS LOOSENED AND THE ELECTRODE CATHETER BECAME DISENTANGLED AND WAS RETRACTED THROUGH THE SITE OF ITS ORIGINAL INSERTION. THE J WIRE WAS SUBSEQUENTLY REMOVED (BY PULLING THE STRAIGHT END WHILE ADVANCING THE J-SHAPED END INTO THE PATIENT). THE WHOLE PROCEDURE TOOK NO MORE THAN 70 MINUTES TO COMPLETE (INCLUDING 16 MINUTES OF FLUOROSCOPY). NO INTERFERENCE WITH THE PERMANENT PACEMAKER LEAD WAS OBSERVED. THE EXTRACTED CATHETER WAS GROSSLY TWISTED AND DEFORMED WITH TWO CLEAR-CUT NOTCHES 3 CM APART.