A 58-year-old male patient with situs inversus totalis, a rare congenital malformation characterized by all asymmetric organs being formed as the mirror images of their normal morphologies, underwent mitral valve repair due to mitral valve prolapse. This case was reported to suggest that anesthesiologists should thoroughly understand the anatomy of these types of patients before providing cardiac anesthesia that often requires advanced monitoring and rely on their accurate interpretation. Accordingly, a few key points will be discussed with emphasis on reversing lead placement during electrocardiogram monitoring, using the left internal jugular vein for pulmonary artery catheterization, and firmly comprehending mirror image heart morphology to better conduct transesophageal echocardiography.
Anesthesia ; Catheterization, Swan-Ganz ; Echocardiography, Transesophageal ; Electrocardiography ; Heart ; Humans ; Jugular Veins ; Male ; Middle Aged ; Mitral Valve ; Mitral Valve Prolapse ; Situs Inversus ; Thoracic Surgery

Knotting of a pulmonary artery catheter (PAC) is a rare, but well-known complication of pulmonary artery (PA) catheterization. We report a case of a double-knotted PAC with a large loop in a patient with hepatocellular carcinoma (HCC) undergoing liver transplantation, which has been rarely reported in the literature. A PAC was advanced under pressure wave form guidance. PAC insertion was repeatedly attempted and the PAC was inserted 80 cm deep even though PAC should be normally inserted 45 to 55 cm deep. However, since no wave change was observed, we began deflating and pulling the balloon. At the 30-cm mark, the PAC could no longer be pulled. Fluoroscopy confirmed knotting of the PAC after surgery (The loop-formed PAC was shown in right internal jugular vein); thus, it was removed. For safe PA catheterization, deep insertion or repeated attempts should be avoided when the catheter cannot be easily inserted into the pulmonary artery. If possible, the insertion of PACs can be performed more safely by monitoring the movement of the catheter under fluoroscopy or transesophageal echocardiography.
Carcinoma, Hepatocellular ; Catheterization ; Catheterization, Swan-Ganz ; Catheters* ; Echocardiography, Transesophageal ; Fluoroscopy ; Humans ; Jugular Veins* ; Liver Transplantation ; Pulmonary Artery*

We report an extremely rare case of right ventricle perforation by a Swan-Ganz catheter during open heart surgery. Even when pulmonary artery catheters are inserted with the utmost care, serious complications such as hematoma formation, pneumothorax, hemothorax, perforation of the cardiac chambers, and rupture of the pulmonary artery may occur. We present a case of primary closure of a right ventricle perforation discovered during coronary artery bypass graft surgery. In this case, the Swan-Ganz catheter was found penetrating the anterior wall of the right ventricle during the surgery. The location of the Swan-Ganz catheter, the stiffness of the catheter caused by hypothermia, and excessive surgical manipulation were supposed to be the etiologies. Therefore, the location of the Swan-Ganz catheter and increased stiffness from hypothermia should be taken into consideration during heart surgery.
Catheterization, Swan-Ganz* ; Catheters ; Coronary Artery Bypass ; Heart Ventricles* ; Hematoma ; Hemothorax ; Humans ; Hypothermia ; Pneumothorax ; Pulmonary Artery ; Rupture ; Thoracic Surgery ; Transplants

We present a case of pulmonary artery catheter (PAC) placement through the right internal jugular vein, bridging vein and coronary sinus in a patient with previously unrecognized persistent left superior vena cava (LSVC) and diminutive right superior vena cava. A 61-year-old male patient was scheduled for mitral valve repair for regurgitation. Preoperative transthoracic echocardiography revealed dilated coronary sinus, but no further evaluations were performed. During advancement of the PAC, right ventricular and pulmonary arterial pressure tracing was observed at 50 and 60 cm, respectively. Transesophageal echocardiography ruled out intracardiac knotting and revealed the presence of the PAC in the LSVC, entering the right ventricle from the coronary sinus. Diminutive right superior vena cava was observed after sternotomy. The PAC was left in place for 2 days postoperatively without any complications. This case emphasizes that the possibility of LSVC and associated anomalies should always be ruled out in patients with dilated coronary sinus.
Arterial Pressure ; Catheterization, Swan-Ganz* ; Catheters ; Coronary Sinus ; Echocardiography ; Echocardiography, Transesophageal ; Heart Ventricles ; Humans ; Jugular Veins ; Male ; Middle Aged ; Mitral Valve ; Pulmonary Artery ; Sternotomy ; Vascular Malformations ; Veins ; Vena Cava, Superior*

PURPOSE: We compared the efficacy of postoperative hemodynamic goal-directed therapy (GDT) using a pulmonary artery catheter (PAC) and bioreactance-based noninvasive cardiac output monitoring (NICOM) in patients with atrial fibrillation undergoing valvular heart surgery. MATERIALS AND METHODS: Fifty eight patients were randomized into two groups of GDT with common goals to maintain a mean arterial pressure of 60-80 mm Hg and cardiac index > or =2 L/min/m2: the PAC group (n=29), based on pulmonary capillary wedge pressure, and the NICOM group (n=29), based on changes in stroke volume index after passive leg raising. The primary efficacy variable was length of hospital stay. Secondary efficacy variables included resource utilization including vasopressor and inotropic requirement, fluid balance, and major morbidity endpoints. RESULTS: Patient characteristics and operative data were similar between the groups, except that significantly more patients underwent double valve replacement in the NICOM group. The lengths of hospital stay were not different between the two groups (12.2+/-4.8 days vs. 10.8+/-4.0 days, p=0.239). Numbers of patients requiring epinephrine (5 vs. 0, p=0.019) and ventilator care >24 h (6 vs. 1, p=0.044) were significantly higher in the PAC group. The PAC group also required significantly larger amounts of colloid (1652+/-519 mL vs. 11430+/-463 mL, p=0.004). CONCLUSION: NICOM-based postoperative hemodynamic GDT showed promising results in patients with atrial fibrillation undergoing valvular heart surgery in terms of resource utilization.
Aged ; Aged, 80 and over ; Cardiac Output/*physiology ; Cardiac Surgical Procedures/*methods ; Catheterization, Swan-Ganz ; Female ; Goals ; Heart Valves/*surgery ; Hemodynamics ; Humans ; Length of Stay/*statistics & numerical data ; Male ; Middle Aged ; Monitoring, Intraoperative/methods ; Monitoring, Physiologic/methods ; Postoperative Complications/epidemiology/prevention & control ; Postoperative Period

We present a case of pulmonary artery catheter (PAC) placement through the right internal jugular vein, bridging vein and coronary sinus in a patient with previously unrecognized persistent left superior vena cava (LSVC) and diminutive right superior vena cava. A 61-year-old male patient was scheduled for mitral valve repair for regurgitation. Preoperative transthoracic echocardiography revealed dilated coronary sinus, but no further evaluations were performed. During advancement of the PAC, right ventricular and pulmonary arterial pressure tracing was observed at 50 and 60 cm, respectively. Transesophageal echocardiography ruled out intracardiac knotting and revealed the presence of the PAC in the LSVC, entering the right ventricle from the coronary sinus. Diminutive right superior vena cava was observed after sternotomy. The PAC was left in place for 2 days postoperatively without any complications. This case emphasizes that the possibility of LSVC and associated anomalies should always be ruled out in patients with dilated coronary sinus.
Arterial Pressure ; Catheterization, Swan-Ganz ; Catheters ; Coronary Sinus ; Echocardiography ; Echocardiography, Transesophageal ; Heart Ventricles ; Humans ; Jugular Veins ; Male ; Middle Aged ; Mitral Valve ; Pulmonary Artery ; Sternotomy ; Vascular Malformations ; Veins ; Vena Cava, Superior

We report an extraordinary case in which the venous route for pulmonary artery catheterization was unusual. A 41 year-old woman with an end-stage liver disease underwent a living-donor liver transplantation. After induction of anesthesia, the pulmonary artery catheter was revealed to be advanced into the left brachiocephalic vein and then slipped into another vein that drains into the left brachiocephalic vein. In this case, we assumed that the catheter had most likely slipped into the left pericardiophrenic vein since the catheter follows the left heart border similarly to the route of this vein according to the chest X-ray. Patients with liver cirrhosis develop many collateral vessels and have enlarged veins due to portal hypertension, which makes this vascular route possible. We present this case for anesthesiologists to be aware of the possibilities of unusual venous route due to dilated collateral vessels especially in liver transplant patients.
Anesthesia ; Brachiocephalic Veins ; Catheterization, Swan-Ganz ; Catheters* ; Female ; Heart ; Humans ; Hypertension, Portal ; Liver Cirrhosis ; Liver Diseases ; Liver Transplantation ; Liver* ; Pulmonary Artery* ; Thorax ; Transplantation* ; Veins*

Pulmonary artery (PA) rupture caused by a PA Swan-Ganz catheter is a rare complication but remains fatal in almost 50% of cases. False aneurysm of the PA is a rare presentation of PA rupture and should be considered as a possible diagnosis in a patient with a new lung mass after PA catheterization. We present a case of sudden-onset pulmonary alveolar hemorrhage during cardiovascular surgery due to a traumatic PA false aneurysm. The Swan-Ganz catheter might have been displaced by the thoracic aortic aneurysm with displacement of the catheter causing the false aneurysm and bleeding.
Aneurysm, False* ; Aortic Aneurysm, Thoracic* ; Catheterization ; Catheterization, Swan-Ganz* ; Catheters ; Diagnosis ; Hemorrhage* ; Humans ; Lung ; Pulmonary Artery* ; Rupture

PURPOSE: To investigate the accuracy, precision and validity of fever detection of tympanic membrane (TM), temporal artery (TA) and axillary temperature (AT) compared with pulmonary artery temperature (PA). METHODS: Repeated-measures design was conducted for one year on 83 adult cardiac care unit patients with pulmonary artery catheters after open heart surgery. Sequential temperature measurements were taken three times at 20-minute intervals. Accuracy, precision, repeatability, and validity of fever detection were analyzed. RESULTS: Mean pulmonary artery temperature was 37.04degrees C (SD 0.70degrees C). The mean (SD) offsets from PA, with the mean reflecting accuracy and SD reflecting precision, were -1.31degrees C (0.75degrees C) for TA, -0.20degrees C (0.24degrees C) for TM, and -0.97degrees C (0.64degrees C) for AT. Percentage of pairs with differences within +/-0.5degrees C was 9.6% for TA, 19.7% for AT, and 91.6% for TM. Repeated measurements with all three methods had mean SD values within 0.04degrees C. Sensitivity, specificity, and positive and negative predictive values of tympanic measurements were 0.76, 1.0, and 1.0, and 0.90, respectively. CONCLUSION: Results show that TM best reflects PA, and is most consistent, accurate, and precise. AT tends to underestimate PA, and TA is least accurate and precise. Therefore tympanic membrane measurement is a reliable alternative to other non-invasive methods of measuring temperatures.
Aged ; Axilla/physiology ; Body Mass Index ; *Body Temperature ; Cardiac Care Facilities ; Catheterization, Swan-Ganz ; Female ; Fever/*diagnosis ; Heart Diseases/surgery ; Humans ; Male ; Middle Aged ; Pulmonary Artery/physiology ; Temporal Arteries/physiology ; Thermometers ; Tympanic Membrane/physiology

BACKGROUNDFor patients undergoing off-pump coronary artery bypass grafting (OPCABG), it is important to establish a hemodynamic monitoring system to obtain powerful parameters for better intraoperative treatment. This study aimed to observe the clinical feasibility of arterial pressure-based cardiac output (APCO) for cardiac output (CO) monitoring and to evaluate the correlation between APCO and pulmonary artery catheter (PAC) for CO measurement for patients undergoing OPCABG intraoperatively.

METHODSFifty patients of American Society of Anaesthesiologists (ASA) classification II-III, undergoing elective OPCABG at Beijing Anzhen Hospital were randomly enrolled into this study. All patients were assigned to CO monitoring by PAC and APCO simultaneously. Patients with pacemaker, severe valvular heart disease, left ventricular ejection fraction (EF) < 40%, cardiac arrhythmias, peripheral vascular disease, application of intra-aortic balloon pump (IABP) and emergent diversion to cardiac pulmonary bypass were excluded. The radial artery waveform was analyzed to estimate the stroke volume (SV) and heart rate (HR) continuously. CO was calculated as SV ' HR; other derived parameters were cardiac index (CI), stroke volume index (SVI), systemic vascular resistance (SVR), and systemic vascular resistance index (SVRI). PAC was placed via right internal jugular vein and the correct position was confirmed by PAC waveforms. Continuous cardiac output (CCO), CI and other hemodynamic parameters were monitored at following 5 time points: immediate after anesthesia induction (baseline value), anastomosis of left internal mammary artery to left anterior descending artery (LAD), anastomosis of left circumflex (LCX), anastomosis of posterior descending artery (PDA) and immediate after sternal closure.

RESULTSIn the 50 patients, preoperative echocardiography measured left ventricular EF was (52.8 ± 11.5)%, and 35 patients (70%) showed regional wall motion abnormalities. The correlation coefficient of CO monitored by APCO and PAC were 0.70, 0.59, 0.78, 0.74 and 0.85 at each time point. The bias range of CI monitored from both APCO and PAC were (0.39 ± 0.06) L×min(-1)×m(-2), (0.48 ± 0.12) L×min(-1)×m(-2), (0.26 ± 0.06) L×min(-1)×m(-2), (0.27 ± 0.06) L×min(-1)×m(-2), (0.30 ± 0.05) L×min(-1)×m(-2) at each time point. The results of SVR by two hemodynamic monitoring techniques had good correlation during OPCABG. The variation trends of SVR were opposite comparing with the results of CO. SVR collected from PAC obtained the highest value of (1220.0 ± 254.0) dyn×s×cm(-5) at PDA anastomosis, but the highest value obtained from APCO was (1206.0 ± 226.5) dyn×s×cm(-5) in LCX anastomosis.

CONCLUSIONSAPCO is feasible in hemodynamic monitoring for patients undergoing OPCABG. The results of hemodynamic monitoring derived from APCO and PAC are closely correlated. Its characterizations of timely, accurate and continuous display of hemodynamic parameters are also obviously demonstrated in the present study.

Aged ; Arterial Pressure ; physiology ; Cardiac Output ; physiology ; Catheterization, Swan-Ganz ; methods ; Coronary Artery Bypass ; methods ; Female ; Hemodynamics ; Humans ; Male ; Middle Aged ; Monitoring, Intraoperative ; methods