Cardiovascular Journal of Africa: Vol 31 No 4 (July/August 2020)

CARDIOVASCULAR JOURNAL OF AFRICA • Volume 31, No 4, July/August 2020

220

AFRICA

between the puncture point and mid clavicle, and the distance

between the suprasternal notch and acromioclavicular joint was

then added to this.

However, the predicted length of the PICC

obtained using anatomical landmarks is not always precise

enough to reflect the real anatomical distance, and the reported

rate of tip malpositioning using anthropometric measurements

varies among studies from 10 to over 70%.

Some researchers have recently evaluated new techniques to

resolve this issue. Liu

et al

. demonstrated that ECG-assisted tip

localisation of the PICC, based on the P wave, was accurate and

safe for patients without heart disease.

Fluoroscopic guidance is

also recommended for optimal tip positioning but a limitation

of this technique is that the patient and operator are exposed

to X-ray radiation.

Finally, precise real-time ultrasound-guided

PICC positioning was confirmed as an effective technique in

neonates in a randomised, controlled trial;

however, this method

remains problematic in adult patients because the superior vena

cava is not easily accessible on such images.

With consideration of the limitations of these assisted

techniques, we believe the performance of echocardiography

may help to ensure that the PICC tip is not in the right heart. In

addition to cardiac infection, potentially serious complications

of incorrect PICC placement include arrhythmias and pericardial

tamponade/perforation. Moreover, caudal migration of the

PICC line tip with arm abduction has been demonstrated, and

the magnitude is about 21 mm with a range of 2 to 53 mm.

In our case, the PICC was confirmed to have optimal tip

positioning as displayed on the postero-anterior chest X-ray

before chemotherapy, but it migrated to the deep right heart 15

months later. Additionally, no follow-up inspection of the PICC

position was performed during this time. Therefore, considering

the possibility of PICC migration, periodic checks of the PICC

tip are very important, especially for patients requiring long-term

PICC placement. Furthermore, evaluation of cardiac function

by echocardiography is always performed multiple times while

patients are undergoing chemotherapy; this may provide a good

opportunity to check whether the tip is located in the right heart.

Unfortunately, the position of the PICC line was not mentioned

in the multiple echocardiography reports in our case.

Moreover, echocardiographic findings can help to predict the

prognosis by showing the size of the vegetation and the status of

the right heart. A vegetation of less than 1 to 2 cm in patients with

right-sided endocarditis has a better prognosis and frequently

responds to conservative treatment.

However, because of the

lower pressure and lower flow velocities within the right heart,

such vegetations grow faster and are frequently larger, and

they can be found at any site on the endocardium.

Vegetations

larger than 2 cm are associated with in-hospital mortality, and

surgical intervention is indicated when it is associated with other

predictors of a complicated clinical course (e.g. heart failure,

persistent infection despite appropriate antimicrobial therapy,

abscess formation and progressive valve destruction), despite the

probable imperfect outcomes after surgery.

In addition, echocardiographic evaluation of the systolic

pulmonary pressure may provide evidence of pulmonary

embolism because vegetations have the potential for

embolisation to the pulmonary vasculature. Right ventricular

systolic dysfunction was independently associated with increased

in-hospital mortality, and it may serve as an echocardiographic

marker to identify high-risk patients with right-sided infective

endocarditis for more aggressive intervention.

Therefore, a

thorough echocardiographic examination is important to aid

clinicians in devising an optimal treatment strategy. In our case,

the vegetation was relatively small and medical therapy was

effective after removal of the PICC line as the initial therapeutic

manoeuvre.

Importantly, our patient didnot undergo an echocardiographic

examination at the outside hospital. We speculate that the

recurrent mixed infection may have predominantly occupied

the clinician’s mind and that the risk of PICC-related infective

endocarditis was not realised. PICC lines are not benign and

have been associated with serious bloodstream infection as

well as fatal bacteraemia and fungaemia, and nearly 9 to 25%

of patients with such infections die as a direct result.

PICC-

related complications should always be kept in mind by both the

clinician and sonographer.

Conclusion

This unique case highlights the significance of appropriate tip

location of PICC lines and the importance of awareness of

PICC-related complications, especially in patients with low

resistance. Periodic checks of the position of the PICC tip are

necessary for patients requiring long-term PICC placement.

A complete echocardiographic evaluation is important in any

patient with a PICC line because it may influence the clinical

strategy by confirming the tip position, showing the vegetation

in detail and allowing for evaluation of the cardiac condition.

This work was supported by the Health and Family Planning Commission

of Zhejiang Province (No. 2018KY070) and by Zhejiang Provincial Natural

Science Foundation, PR China (No LSD19H180002).

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