A Single Catheter to Monitor Both Central Venous Pressure and Left Atrial Pressure*

Left atrial pressure (LAP) monitoring is a useful tool in the management of patients after congenital heart surgery. The LAP reflects left ventricular filling and helps to guide management. For example, a low LAP and low central venous pressure (CVP) suggest hypovolemia, a low LAP and a high CVP may reflect high pulmonary vascular resistance, and a high LAP and high CVP suggest either depressed myocardial function or volume overload. At our institution, LA lines are commonly placed in patients undergoing the arterial switch operation, common atrioventricular canal repair, and heart transplant, among others. Similar to most congenital cardiac centers in the United States, we use transthoracic catheters placed before separating from cardiopulmonary bypass to monitors LAP. They are inserted through the chest wall and into the LA, usually via the right superior pulmonary vein. The main risks to this monitoring relate to removal, which can result in bleeding from the site and potential cardiac tamponade requiring emergent chest exploration. Even though this complication is rare (< 1%), before removing these catheters, we prepare blood for transfusion and have a cardiac surgeon at the bedside prepared to emergently open the chest. Other complications include catheter breakage during removal, leaving fragments in the LA or along its tract, and catheter displacement providing inaccurate data (1, 2). In this issue of Pediatric Critical Care Medicine, Ding et al (3) describe and test a new catheter they developed to monitor LAP via the transseptal route that can potentially eliminate the risk of cardiac tamponade and reduce the risk of displacement. At the author’s institution, they routinely place two catheters into the right atrium (RA) using the “double-stick” technique. The internal jugular is accessed twice: once with a triple lumen central line and once with a single lumen catheter for intraoperative transseptal placement. The novel combined catheter is a triple lumen catheter that incorporates a single lumen catheter that can be placed in the LA intraoperatively, necessitating only one “stick.” Also, the LA portion of the catheter is spiraled at the distal end reducing the chance of migration into the RA. In this study of 113 patients, the authors show that their novel catheter can reliably and accurately measure atrial pressure and reduce the risk of the LA catheter migrating into the RA (3). Unfortunately, a study of this size cannot determine whether this technique for monitoring LAP reduces the risk of rare, but devastating complications. Clearly, a transseptal catheter will eliminate the risk of atrial bleeding upon removal that can produce cardiac tamponade. However, this new catheter positions a relatively large catheter in the internal jugular vein, passing into the superior vena cava (SVC) and into the RA. This large catheter in the SVC increases the risk of venous thrombosis (4). This technique also positions a relatively stiff catheter in the RA, a catheter position associated with potential atrial perforation (4–6). At our institution, we track the prevalence of central line complications, and more than 10 years ago, we found close to a 10% prevalence of SVC thrombosis when using 4F catheters inserted into the SVC in newborns. Because of this finding, we no longer place SVC catheters in infants under 5 kg. Also, because most reported cases of cardiac perforation have developed in patients with catheters in the RA or right ventricle, we are careful to avoid inserting catheters into the RA. In summary, we are intrigued by the potential ease of insertion of this novel catheter and the potential to eliminate the risk of cardiac tamponade with catheter removal. However, we caution against the routine use of this catheter until more information is available regarding the risk of venous thrombosis and cardiac perforation.