Advertisement

Where Should We Leave the Wild “Raa Raa” During Cardiopulmonary Bypass?

  • Evangelia Samara
    Affiliations
    Department of Anesthesiology and Postoperative Intensive Care, Faculty of Medicine, School of Health Sciences, University of Ioannina, Ioannina, Greece
    Search for articles by this author
  • Mohamed R. El-Tahan
    Correspondence
    Address correspondence to Mohamed El Tahan, MD, Imam Abdulrahman Bin Faisal University, Aqrabiah, Al Khubar 31952, Saudi Arabia.
    Affiliations
    Cardiothoracic Anesthesia, Anesthesia, Surgical Intensive Care and Pain Medicine, College of Medicine, Mansoura University, Mansoura, Egypt

    Anesthesiology Department, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
    Search for articles by this author
      THE PULMONARY artery catheter (PAC), the Raa Raa, the noisy, wild lion in a British stop-motion animated children's television program

      Raa Raa the noisy lion. Available at: https://en.wikipedia.org/wiki/Raa_Raa_the_Noisy_Lion. Accessed July 17, 2022.

      (Fig 1), also known as the Swan-Ganz catheter, is used frequently during cardiac surgery. The PAC might provide clinicians with important information on the preload, afterload, and contractility through the measured and derived parameters for risks stratification and guide perioperative management, particularly in patients with advanced heart failure, pulmonary hypertension, cardiogenic shock, and those who undergo heart and lung transplantation and left ventricular assist device implantation.
      • Rozental O
      • Thalappillil R
      • White RS
      • et al.
      To swan or not to swan: Indications, alternatives, and future directions.
      Fig 1
      Fig 1Illustration of the wild Raa Raa.

      Raa Raa the noisy lion. Available at: https://en.wikipedia.org/wiki/Raa_Raa_the_Noisy_Lion. Accessed July 17, 2022.

      However, right-heart catheterization using a PAC might have severe complications like other medical procedures. In this issue of the Journal of Cardiothoracic and Vascular Anesthesia (JCVA), 3 interesting reports were presented by Cohen et al,

      Cohen SM, Gold AK, Augoustides JGT. Removal of a knotted Swan Ganz catheter in the superior vena cava post heart transplant—revisiting a rare complication of pulmonary artery catheter placement. J Cardiothorac Vasc Anesth. 2022;36: 4226–27.

      Gonzalez et al,

      Gonzalez LS, Coghlan C, Alsatli RA, et al. The entrapped pulmonary artery catheter. J Cardiothorac Vasc Anesth. 2022;36:4203–12.

      and Rawoot et al

      Rawoot I, Madathil T, Panidapu N, et al. Entrapped pulmonary artery catheter: What can be done. J Cardiothorac Vasc Anesth. 2022;36:4203–12.

      on the postoperative difficulty of removing twisted knotted and entrapped PACs after heart transplantation and mitral valve repair surgery. Cohen et al

      Cohen SM, Gold AK, Augoustides JGT. Removal of a knotted Swan Ganz catheter in the superior vena cava post heart transplant—revisiting a rare complication of pulmonary artery catheter placement. J Cardiothorac Vasc Anesth. 2022;36: 4226–27.

      described the successful removal of the distal tip of a knotted PAC beyond the superior vena cava through bedside cinching the knot tight to the introducer and removing them en bloc through a cutdown through the neck.
      Gonzalez et al

      Gonzalez LS, Coghlan C, Alsatli RA, et al. The entrapped pulmonary artery catheter. J Cardiothorac Vasc Anesth. 2022;36:4203–12.

      presented 2 cases—the first for the successful removal of an entrapped PAC after repeated orthotopic heart transplantation through manipulating the nonincluded PAC in the surgical anastomosis under general anesthesia and combined fluoroscopy and transesophageal echocardiography (TEE) guidance in the operating room. Although manipulating the PAC by small, intermittent advancements, withdrawals, and twisting motions succeeded in removing the PAC intact through the introducer in this patient,

      Gonzalez LS, Coghlan C, Alsatli RA, et al. The entrapped pulmonary artery catheter. J Cardiothorac Vasc Anesth. 2022;36:4203–12.

      repeated manipulations of the PAC might have potential risks for knotting and lacerations of the PAC.
      • Garg L
      • Arkles JS
      • Schaller RD.
      Percutaneous removal of a pulmonary artery catheter inadvertently sutured to the heart during valve surgery.
      In the second patient, the authors

      Gonzalez LS, Coghlan C, Alsatli RA, et al. The entrapped pulmonary artery catheter. J Cardiothorac Vasc Anesth. 2022;36:4203–12.

      reported early identification of entrapped PAC after a mitral valve repair through observing blood returning from the thermistor connector and the need for resternotomy and reinstitution of cardiopulmonary bypass (CPB) to remove an entrapped PAC in the surgical suture line.
      Rawoot et al

      Rawoot I, Madathil T, Panidapu N, et al. Entrapped pulmonary artery catheter: What can be done. J Cardiothorac Vasc Anesth. 2022;36:4203–12.

      reported a diagnosed entrapped PAC in the right ventricle postoperatively after a combined mitral valve repair and coronary artery bypass graft (CABG). An acute angulation in the contour of the PAC resulted in the inability to withdraw the PAC beyond the tricuspid valve. In the catheterization laboratory, under fluoroscopy, a guidewire through the distal lumen of the PAC straightened the angle created and allowed a successful removal.

      PAC-associated Mechanical Complications

      Unfortunately, PAC-related mechanical complications, such as pulmonary artery rupture or perforation, knotting, entrapment, and entanglement in surgical anastomosis, are reported frequently in the literature. The most frequently reported PAC-related mechanical complication is pulmonary artery rupture, but it is yet a rare, life-threatening complication, with a mortality of ≤80%. Pulmonary artery catheter-associated pulmonary artery rupture can occur during the floating of the PAC and wedging of the balloon, or even with the withdrawal of the entrapped PCA in a surgical anastomosis suture line.
      • Huang GS
      • Wang HJ
      • Chen CH
      • et al.
      Pulmonary artery rupture after attempted removal of a pulmonary artery catheter.
      Dhamee and Pattison
      • Dhamee MS
      • Pattison CZ.
      Pulmonary artery rupture during cardiopulmonary bypass.
      suggested several predisposing factors for PAC-induced pulmonary artery rupture during CPB, including (1) the distal location or migration of the PAC tip; (2) surgical manipulation of the heart resulting in PAC movement; (3) a stiffened distal tip of the PAC because of the low body temperature during hypothermic CPB; and (4) an over-distended, over-pressured, or eccentrically inflated PAC, particularly for a prolonged duration.
      • Dhamee MS
      • Pattison CZ.
      Pulmonary artery rupture during cardiopulmonary bypass.
      Pulmonary artery rupture might require urgent inflating and wedging of the PAC balloon into the ruptured pulmonary artery, with selective lung, or lobar isolation,
      • Damm C
      • Degen H
      • Stoepel C
      • et al.
      Management of a catheter-induced rupture of a pulmonary artery.
      ,
      • Booth KL
      • Mercer-Smith G
      • McConkey C
      • et al.
      Catheter-induced pulmonary artery rupture: Haemodynamic compromise necessitates surgical repair.
      pulmonary angiography and transcatheter coil embolization, and surgical intervention with CPB.
      • Abreu AR
      • Campos MA
      • Krieger BP.
      Pulmonary artery rupture induced by a pulmonary artery catheter: A case report and review of the literature.
      Catheter knotting also has been described as a complication of using the PAC, mainly due to excessive insertion depth.
      • Evans DC
      • Doraiswamy VA
      • Prosciak MP
      • et al.
      Complications associated with pulmonary artery catheters: A comprehensive clinical review.
      In contrast to the 3 cases published in the issue of the JCVA,

      Cohen SM, Gold AK, Augoustides JGT. Removal of a knotted Swan Ganz catheter in the superior vena cava post heart transplant—revisiting a rare complication of pulmonary artery catheter placement. J Cardiothorac Vasc Anesth. 2022;36: 4226–27.

      Gonzalez LS, Coghlan C, Alsatli RA, et al. The entrapped pulmonary artery catheter. J Cardiothorac Vasc Anesth. 2022;36:4203–12.

      Rawoot I, Madathil T, Panidapu N, et al. Entrapped pulmonary artery catheter: What can be done. J Cardiothorac Vasc Anesth. 2022;36:4203–12.

      surgical intervention was needed sometimes to remove the knotted PAC. Perez d' Empaire et al
      • Perez d'Empaire P
      • Derzi S
      • Latter D
      • et al.
      Pulmonary artery catheter knotted in the tricuspid valve apparatus requiring surgery with cardiopulmonary bypass: A case report.
      described successful surgical removal of the PAC knotted near the tricuspid valve and in the right ventricle, likely because of too-deep insertion of the PAC beyond the 50-cm mark. Notably, a formula proposed to calculate the ideal PAC insertion depth potentially might decrease the risk of PAC knotting.
      • Walz R
      • Roth S
      • Hollmann MW
      • et al.
      Formula for safe insertion depth of a pulmonary artery catheter.
      Additionally, the use of PAC has the danger of being entrapped inside the right cardiac compartment, dictating the need for action. Colombier et al
      • Colombier S
      • Rancati V
      • Marcucci C
      • et al.
      Tricuspid valve Swan-Ganz catheter entrapment before cardiac surgery.
      described an intraoperative entrapped PAC within the tricuspid valve before the start of off-pump CABG surgery, leading to changing the surgical plan to on-pump CABG to safely remove the entrapped PAC.
      There are also risks of entangling the PAC into the surgical anastomosis suture line, particularly during right-side cardiac surgery (eg, tricuspid valve, pulmonary artery, and interatrial and interventricular septa surgical procedures) and heart transplantation. Trials for withdrawing the entangled PAC might result in hemodynamic compromise due to a distorted heart structure and chambers.

      Gonzalez LS, Coghlan C, Alsatli RA, et al. The entrapped pulmonary artery catheter. J Cardiothorac Vasc Anesth. 2022;36:4203–12.

      Surgical removal usually is required in these patients. Vigilance should be exercised for early identification of entrapped PAC into the surgical sutures through the early pick up of changed waveform trace, false temperature readings by the PAC's thermistor, resistance to withdrawal or further floating of the PAC, or leaking blood from the balloon's syringe for inflating the PAC's balloon or thermistor connector.
      • Chan WH
      • Hsu CH
      • Lu CC
      • et al.
      Early recognition of an entrapped pulmonary artery catheter by blood leaking into the syringe and thermistor connector during cardiac surgery.

      Should We Stop the Routine Use of PACs for Cardiac Surgery?

      Although surveying 705 North American cardiac anesthesiologists showed that 68% of the respondents used a PAC >75% of the time for cases using CPB,
      • Judge O
      • Ji F
      • Fleming N
      • et al.
      Current use of the pulmonary artery catheter in cardiac surgery: A survey study.
      the use of PACs has decreased over the last decades as a routine intraoperative monitoring tool. Meanwhile, the trend of regular PAC use in Europe, Asia, Australia, and Africa is unknown. The growing body of evidence demonstrated that the routine perioperative use of PAC is not associated with improved clinical outcomes, including the mortality rate.
      In an observational propensity-matched study that included 11,820 patients undergoing (Society of Thoracic Surgeons indexed) CABG or valvular surgery from 2010 to 2018 at a single high-volume center, 39% of them had a PAC, and researchers found that compared with the use of central venous pressure monitoring, PAC use was not associated with improved operative mortality but with statistically significant prolonged stay in the intensive care unit and more need for packed red blood cell transfusions.

      Brown JA, Aranda-Michel E, Kilic A, et al. The impact of pulmonary artery catheter use in cardiac surgery [e-pub ahead of print]. J Thorac Cardiovasc Surg. https://kdcanada.org/10.1016/j.jtcvs.2021.01.086. Accessed August 20, 2022.

      Shaw et al
      • Shaw AD
      • Mythen MG
      • Shook D
      • et al.
      Pulmonary artery catheter use in adult patients undergoing cardiac surgery: A retrospective, cohort study.
      demonstrated that compared with nonuse of the PAC, the PAC was associated with a similar 30-day in-hospital mortality, increased infectious morbidity, decreased length of stay, and reduced cardiopulmonary morbidity in a propensity-matched cohort study that included 6,844 patients who underwent different types of cardiac surgery.
      • Shaw AD
      • Mythen MG
      • Shook D
      • et al.
      Pulmonary artery catheter use in adult patients undergoing cardiac surgery: A retrospective, cohort study.
      In addition to the complications associated with using the PAC, there are concerns regarding the accuracy of PAC-measured parameters. Compared with the Fick principle, cardiac output values measured with the thermodilution technique have been reported to have a percentage error of >60% precluding their accuracy.
      • Dhingra VK
      • Fenwick JC
      • Walley KR
      • et al.
      Lack of agreement between thermodilution and Fick cardiac output in critically ill patients.
      Additionally, the cardiac output measured by the PAC was found to be inferior to those measured by transpulmonary thermodilution precision of 15% versus 7%, respectively.
      • Rozental O
      • Thalappillil R
      • White RS
      • et al.
      To swan or not to swan: Indications, alternatives, and future directions.
      • Monnet X
      • Persichini R
      • Ktari M
      • et al.
      Precision of the transpulmonary thermodilution measurements.
      The costs of pulmonary artery catheterization, including the costs of equipment (eg, PAC, pressure transducers, electronic monitoring devices, and solutions), personnel (eg, physician costs for insertion and interpretation, nurses, and technicians), and PAC-related complications (eg, arrhythmias, catheter-related infection, and mechanical complications) should be taken into account.
      American Society of Anesthesiologists Task Force on Pulmonary Artery Catheterization. Practice guidelines for pulmonary artery catheterization: An updated report by the American Society of Anesthesiologists Task Force on Pulmonary Artery Catheterization.
      The cost-effectiveness of PAC cannot be ascertained appropriately without establishing its clinical effectiveness, such as costs for managing postoperative complications, particularly after hospital discharge, loss of productivity, transportation cost, and caregivers.
      • Stevens M
      • Davis T
      • Munson SH
      • et al.
      Short and mid-term economic impact of pulmonary artery catheter use in adult cardiac surgery: A hospital and integrated health system perspective.
      The cost-benefits of routine use of the PAC during cardiac surgery should be individualized based on the risks related to the local practice, patient, and surgery.
      Additionally, it is assumed that PAC-related complications increase the aforementioned overall costs and also decrease patient satisfaction.

      Where Should We Leave the Wild “Raa Raa” PAC During Cardiopulmonary Bypass?

      Several strategies have been proposed to avoid PAC-related mechanical adverse events.
      First, caution is required to avoid advancing the PAC beyond the estimated means (standard deviation) of depths from the skin to the right ventricle, pulmonary artery, and pulmonary artery wedge pressure without obtaining the expected waveform, which are equal to 24.6 cm (3), 36 cm (4), and 42.8 cm (5.7), respectively.
      • Tempe DK
      • Gandhi A
      • Datt V
      • et al.
      Length of insertion for pulmonary artery catheters to locate different cardiac chambers in patients undergoing cardiac surgery.
      Second, using a proper imaging modality, TEE can confirm the appropriate position and exclude improper placement of the PAC, particularly in the cardiac operating room settings (Table 1, Video 1, A-G).
      • Orihashi K
      • Nakashima Y
      • Sueda T
      • et al.
      Usefulness of transesophageal echocardiography for guiding pulmonary artery catheter placement in the operating room.
      • Raut MS
      • Hanjoora VM
      • Chisti MA.
      Transesophageal echocardiography guidance for expedited pulmonary artery catheter insertion and accurate estimation of cardiac output.
      • Tempe DK
      • Batra UB
      • Datt V
      • et al.
      Where does the pulmonary artery catheter float: Transesophageal echocardiography evaluation.
      Baer et al
      • Baer J
      • Wyatt MM
      • Kreisler KR.
      Utilizing transesophageal echocardiography for placement of pulmonary artery catheters.
      concluded that the proper final destination of the PAC in the wedge position could be secured safely at the 1 o'clock position in the TEE upper esophageal short-axis aorta and long-axis main and right pulmonary arteries views.
      Table 1Transesophageal Echocardiography-Guided Confirmation of the Proper Positions of the Pulmonary Artery Catheter
      Position of the PACTEE ViewFindings
      Proper insertion of the PAC's introducerMidesophageal bicaval view

      Midesophageal modified bicaval view
      The guidewire can be identified as a small, strongly echogenic dot in the SVC and RA (Video 1, A).

      Injecting 5-10 cc of normal saline solution through the introducer can detect a spontaneous echo contrast in the right atrium.
      Floating the PAC's balloon beyond the 20cm markMidesophageal RV inflow outflow

      Midesophageal 4-chamber view
      A large, strong echo with side lobes and an acoustic shadow, approximately 1 cm wide, with pulsatile, swinging motion can be seen in the RA and then observed while entering the RV through the tricuspid valve (Video 1, B-D).
      Suggested coiling of the PACMidesophageal RV inflow outflow

      Midesophageal bicaval view

      Midesophageal modified bicaval view
      When the PA catheter did not enter the RV

      The balloon can be found in the inferior vena cava or the right atrium without shuttle movement.

      These findings indicate that the PAC should be withdrawn once.
      Floating the PAC's balloon to the PAMidesophageal RV inflow outflow view

      Modified aortic valve long-axis

      Ascending aortic SAX
      It shows pulsatile to-and-from movement (shuttle movement) (Video 1, E and F) and then disappears into the distal right PA in the lung parenchyma (Video 1, G).

      A bright echogenic mobile spot might be detected in the right PA in all 3 views.

      Visualization of the left PA is challenging due to the interposed air-filled left bronchus, so nonvisualization of the PAC in the RPA and main PA was assumed to have reached the LPA.
      Obtaining the wedge pressure tracingMidesophageal AA

      SAX
      The catheter portion is simultaneously immobilized with the loss of shuttle movement "anchoring sign."
      NOTE. Produced from Raut et al,25 Tempe et al,26 and Orihashi et al.27
      Abbreviations: AA, ascending aorta; LPA, left pulmonary artery; PA, pulmonary artery; PAC, pulmonary artery catheter; RA, right atrium; RV, right ventricle; RPA, right pulmonary artery; SAX, short axis; SVC, superior vena cava; TEE, transesophageal echocardiography.
      Third, low-threshold suspicion of PAC entrapment should be considered in case of altered or lost previously obtained PAC waveform, observing visible blood inside the PAC balloon-inflating syringe, or returning blood through the thermistor's connection.
      • Chan WH
      • Hsu CH
      • Lu CC
      • et al.
      Early recognition of an entrapped pulmonary artery catheter by blood leaking into the syringe and thermistor connector during cardiac surgery.
      Moreover, the freely mobilized PAC for a few centimeters through the introducer without associated hemodynamic compromise always should be confirmed before closing the cardiac chambers and sternum to exclude entrapped or entangled PAC and avoid the need for redo surgery or interventions to remove the catheter.
      • Chan WH
      • Hsu CH
      • Lu CC
      • et al.
      Early recognition of an entrapped pulmonary artery catheter by blood leaking into the syringe and thermistor connector during cardiac surgery.
      There is no substantial body of evidence supporting the optimal placement of the PAC during CBP. There are several suggested options (Fig 2, A-E); each has possible advantages and disadvantages. First, leaving the PAC in place in the pulmonary artery and excluding wedged or inflated balloon (Fig 2, A) might offer the availability of measured and calculated data needed to guide weaning off CPB after the conclusion of the surgical procedure, particularly in case of difficult weaning. However, this option might increase the risks for all possible mechanical complications, including pulmonary artery injury by the stiffened PAC's tip during the hypothermic CPB.
      • Dhamee MS
      • Pattison CZ.
      Pulmonary artery rupture during cardiopulmonary bypass.
      Second, some anesthesiologists prefer withdrawing the catheter 5 cm into the main pulmonary artery (Fig 2, B),
      • Mittnacht AJC
      • Reich DL
      • Sander M
      • et al.
      Monitoring of the heart and vascular system.
      ,
      • Stone JG
      • Khambatta HJ
      • McDaniel DD.
      Catheter-induced pulmonary arterial trauma: Can it always be averted?.
      which does not preclude the possibility of entangling the PAC into surgical sutures in the pulmonary trunk or tricuspid valve.
      • Huang GS
      • Wang HJ
      • Chen CH
      • et al.
      Pulmonary artery rupture after attempted removal of a pulmonary artery catheter.
      ,
      • Chan WH
      • Hsu CH
      • Lu CC
      • et al.
      Early recognition of an entrapped pulmonary artery catheter by blood leaking into the syringe and thermistor connector during cardiac surgery.
      Third, withdrawing the PAC to the right ventricle (Fig 2, C) or right atrium (Fig 2, D) still risks being entrapped in the surgical suture line, especially in the case of right-heart surgery.

      Gonzalez LS, Coghlan C, Alsatli RA, et al. The entrapped pulmonary artery catheter. J Cardiothorac Vasc Anesth. 2022;36:4203–12.

      ,
      • Garg L
      • Arkles JS
      • Schaller RD.
      Percutaneous removal of a pulmonary artery catheter inadvertently sutured to the heart during valve surgery.
      Finally, although withdrawal of the PAC into the superior vena cava (Fig 2, E) during CPB seems a safe option, there is a need to readvance the PAC after separation from the CPB, which can be associated with the possible complications of PAC floatation attempts.
      • Evans DC
      • Doraiswamy VA
      • Prosciak MP
      • et al.
      Complications associated with pulmonary artery catheters: A comprehensive clinical review.
      Additionally, this option results in missing the valuable measurements needed in complicated cases while discontinuing the CPB.
      Fig 2
      Fig 2The recommended different locations of the simulated pulmonary artery catheter with the wild “Raa Raa,” the noisy, wild lion in a British stop-motion animated children's television program

      Raa Raa the noisy lion. Available at: https://en.wikipedia.org/wiki/Raa_Raa_the_Noisy_Lion. Accessed July 17, 2022.

      inside, (A) the right pulmonary artery, (B) withdrawn 5 cm in the main pulmonary artery, (C) RV, (D) right atrium, and (E) SCV during the cardiopulmonary bypass. Abbreviations: PA, pulmonary artery; RA, right atrium; RPA, right pulmonary artery; RV, right ventricle; SCV, superior vena cava.
      The data available regarding the proper location of the PAC during CPB to avoid PAC-related mechanical complications are derived from individual care reports, case series, or personal experiences. The authors think that the reported cases in this issue of the JCVA

      Cohen SM, Gold AK, Augoustides JGT. Removal of a knotted Swan Ganz catheter in the superior vena cava post heart transplant—revisiting a rare complication of pulmonary artery catheter placement. J Cardiothorac Vasc Anesth. 2022;36: 4226–27.

      Gonzalez LS, Coghlan C, Alsatli RA, et al. The entrapped pulmonary artery catheter. J Cardiothorac Vasc Anesth. 2022;36:4203–12.

      Rawoot I, Madathil T, Panidapu N, et al. Entrapped pulmonary artery catheter: What can be done. J Cardiothorac Vasc Anesth. 2022;36:4203–12.

      showed the need for the JCVA to, firstly, lead a survey of the current worldwide practice to manage the PAC during CPB. Secondly, these cases showed the need for the development of multinational societies' consensus on the recommended location of the PAC during CPB through collaboration between the 2 societies, considering the JCVA as the official journal, including the European Association of Cardiothoracic and Vascular Anaesthesiology and Intensive Care and the Chinese Society of Cardiothoracic and Vascular Anesthesiology, until there is a large multicenter observational study to evaluate the adverse event incidence with regard to the different recommended PAC locations during CPB.

      Conflict of Interest

      MRT received free airway devices from Ambu and Airtraq used in 3 published studies. The author has no direct or financial interest in any industry, including Ambu and Airtraq.

      Acknowledgments

      The authors thank Dr. Theofani Antoniou, Dr. Theofili Koussi, and Dr. Areti Falara, Onassis Cardiac Surgery Centre, for providing the transesophageal echocardiography loops included.

      Appendix. Supplementary materials

      References

      1. Raa Raa the noisy lion. Available at: https://en.wikipedia.org/wiki/Raa_Raa_the_Noisy_Lion. Accessed July 17, 2022.

        • Rozental O
        • Thalappillil R
        • White RS
        • et al.
        To swan or not to swan: Indications, alternatives, and future directions.
        J Cardiothorac Vasc Anesth. 2021; 35: 600-615
      2. Cohen SM, Gold AK, Augoustides JGT. Removal of a knotted Swan Ganz catheter in the superior vena cava post heart transplant—revisiting a rare complication of pulmonary artery catheter placement. J Cardiothorac Vasc Anesth. 2022;36: 4226–27.

      3. Gonzalez LS, Coghlan C, Alsatli RA, et al. The entrapped pulmonary artery catheter. J Cardiothorac Vasc Anesth. 2022;36:4203–12.

      4. Rawoot I, Madathil T, Panidapu N, et al. Entrapped pulmonary artery catheter: What can be done. J Cardiothorac Vasc Anesth. 2022;36:4203–12.

        • Garg L
        • Arkles JS
        • Schaller RD.
        Percutaneous removal of a pulmonary artery catheter inadvertently sutured to the heart during valve surgery.
        JACC Case Rep. 2020; 2: 2323-2326
        • Huang GS
        • Wang HJ
        • Chen CH
        • et al.
        Pulmonary artery rupture after attempted removal of a pulmonary artery catheter.
        Anesth Analg. 2002; 95: 299-301
        • Dhamee MS
        • Pattison CZ.
        Pulmonary artery rupture during cardiopulmonary bypass.
        J Cardiothorac Anesth. 1987; 1: 51-56
        • Damm C
        • Degen H
        • Stoepel C
        • et al.
        Management of a catheter-induced rupture of a pulmonary artery.
        Dtsch Med Wochenschr. 2010; 135 ([article in German]): 1914-1917
        • Booth KL
        • Mercer-Smith G
        • McConkey C
        • et al.
        Catheter-induced pulmonary artery rupture: Haemodynamic compromise necessitates surgical repair.
        Interact Cardiovasc Thorac Surg. 2012; 15: 531-533
        • Abreu AR
        • Campos MA
        • Krieger BP.
        Pulmonary artery rupture induced by a pulmonary artery catheter: A case report and review of the literature.
        J Intensive Care Med. 2004; 19: 291-296
        • Evans DC
        • Doraiswamy VA
        • Prosciak MP
        • et al.
        Complications associated with pulmonary artery catheters: A comprehensive clinical review.
        Scand J Surg. 2009; 98: 199-208
        • Perez d'Empaire P
        • Derzi S
        • Latter D
        • et al.
        Pulmonary artery catheter knotted in the tricuspid valve apparatus requiring surgery with cardiopulmonary bypass: A case report.
        A A Pract. 2019; 13: 181-184
        • Walz R
        • Roth S
        • Hollmann MW
        • et al.
        Formula for safe insertion depth of a pulmonary artery catheter.
        Br J Anaesth. 2021; 127 (e25-e-27)
        • Colombier S
        • Rancati V
        • Marcucci C
        • et al.
        Tricuspid valve Swan-Ganz catheter entrapment before cardiac surgery.
        Anaesth Rep. 2020; 8: e12085
        • Chan WH
        • Hsu CH
        • Lu CC
        • et al.
        Early recognition of an entrapped pulmonary artery catheter by blood leaking into the syringe and thermistor connector during cardiac surgery.
        Acta Anaesthesiol Taiwan. 2012; 50: 38-40
        • Judge O
        • Ji F
        • Fleming N
        • et al.
        Current use of the pulmonary artery catheter in cardiac surgery: A survey study.
        J Cardiothorac Vasc Anesth. 2015; 29: 69-75
      5. Brown JA, Aranda-Michel E, Kilic A, et al. The impact of pulmonary artery catheter use in cardiac surgery [e-pub ahead of print]. J Thorac Cardiovasc Surg. https://kdcanada.org/10.1016/j.jtcvs.2021.01.086. Accessed August 20, 2022.

        • Shaw AD
        • Mythen MG
        • Shook D
        • et al.
        Pulmonary artery catheter use in adult patients undergoing cardiac surgery: A retrospective, cohort study.
        Perioper Med (Lond). 2018; 7: 24
        • Dhingra VK
        • Fenwick JC
        • Walley KR
        • et al.
        Lack of agreement between thermodilution and Fick cardiac output in critically ill patients.
        Chest. 2002; 122: 990-997
        • Monnet X
        • Persichini R
        • Ktari M
        • et al.
        Precision of the transpulmonary thermodilution measurements.
        Crit Care. 2011; 15: R204https://doi.org/10.1186/cc10421
      6. American Society of Anesthesiologists Task Force on Pulmonary Artery Catheterization. Practice guidelines for pulmonary artery catheterization: An updated report by the American Society of Anesthesiologists Task Force on Pulmonary Artery Catheterization.
        Anesthesiology. 2003; 99: 988-1014
        • Stevens M
        • Davis T
        • Munson SH
        • et al.
        Short and mid-term economic impact of pulmonary artery catheter use in adult cardiac surgery: A hospital and integrated health system perspective.
        Clinicoecon Outcomes Res. 2021; 13: 109-119
        • Tempe DK
        • Gandhi A
        • Datt V
        • et al.
        Length of insertion for pulmonary artery catheters to locate different cardiac chambers in patients undergoing cardiac surgery.
        Br J Anaesth. 2006; 97: 147-149
        • Orihashi K
        • Nakashima Y
        • Sueda T
        • et al.
        Usefulness of transesophageal echocardiography for guiding pulmonary artery catheter placement in the operating room.
        Heart Vessels. 1994; 9: 315-321
        • Raut MS
        • Hanjoora VM
        • Chisti MA.
        Transesophageal echocardiography guidance for expedited pulmonary artery catheter insertion and accurate estimation of cardiac output.
        Ann Card Anaesth. 2018; 21: 339-340
        • Tempe DK
        • Batra UB
        • Datt V
        • et al.
        Where does the pulmonary artery catheter float: Transesophageal echocardiography evaluation.
        Ann Card Anaesth. 2015; 18: 491-494
        • Baer J
        • Wyatt MM
        • Kreisler KR.
        Utilizing transesophageal echocardiography for placement of pulmonary artery catheters.
        Echocardiography. 2018; 35: 467-473
        • Mittnacht AJC
        • Reich DL
        • Sander M
        • et al.
        Monitoring of the heart and vascular system.
        in: Kaplan JA Kaplan's cardiac anesthesia: For cardiac and noncardiac surgery. 7th ed. Elsevier, Philadelphia, PA2017
        • Stone JG
        • Khambatta HJ
        • McDaniel DD.
        Catheter-induced pulmonary arterial trauma: Can it always be averted?.
        J Thorac Cardiovasc Surg. 1983; 86: 146-150

      Linked Article

      • The Entrapped Pulmonary Artery Catheter
        Journal of Cardiothoracic and Vascular AnesthesiaVol. 36Issue 11
        • Preview
          ALTHOUGH USE of the pulmonary artery catheter (PAC) continues to decline because of a lack of robust evidence proving benefit and/or presence of some evidence supporting the notion that it may cause harm, it continues to be used by many clinicians.1-3 Complications of PAC insertion and/or use thankfully are rare yet can be deadly.4 PAC entrapment is quite rare and usually occurs during cardiac surgery when the catheter is inadvertently sutured to a portion of the heart.5 The authors report here 2 cases of PAC entrapment in patients undergoing cardiac surgery.
        • Full-Text
        • PDF
      • Entrapped Pulmonary Artery Catheter: What Can Be Done
        Journal of Cardiothoracic and Vascular AnesthesiaVol. 36Issue 11
        • Preview
          Pulmonary artery catheter (PAC) insertion and manipulation are inherently associated with mechanical complications, including entrapment by knotting or surgical sutures, and rarely life-threatening complications like pulmonary artery (PA) perforation or rupture.1,2 We describe the inability to remove a PAC in a 49-year-old male patient who underwent mitral valve repair and coronary artery bypass grafting under cardiopulmonary bypass. A continuous cardiac output PAC (Edwards Lifesciences, Irvine, CA) and a 7-Fr central venous catheter were placed under ultrasound guidance.
        • Full-Text
        • PDF
      • Removal of a Knotted Swan Ganz Catheter in the Superior Vena Cava After Heart Transplant—Revisiting A Rare Complication of Pulmonary Artery Catheter Placement
        Journal of Cardiothoracic and Vascular AnesthesiaVol. 36Issue 11
        • Preview
          We report a rare complication of pulmonary artery catheter (PAC) knotting during its placement in a heart transplant patient. Although the placement of PACs is considered safe, attention must be paid to potential complications. Reviewing the potential complications of PAC placement is crucial as new providers establish their careers. During the removal of a PAC in the intensive care unit, firm resistance was noted when attempting to retract the catheter beyond the 20-cm mark. Fluoroscopy demonstrated a knot at the tip of the PAC (Fig 1).
        • Full-Text
        • PDF