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Right Ventricular Perforation by a Pulmonary Artery Catheter
During Coronary Artery Bypass Surgery
Michael A. Lyew, MB, FRCA, Douglas R. Bacon, MD, and Moses S. Nesarajah, MD
The Anesthesiology Service, Buffalo Veterans Administration Medical Center, Buffalo, New York
M yocardial perforation is a rare, vaguely re- pledgets. Myocardial revascularization was accomplished
ported complication of pulmonary artery (PA) and the patient was weaned from CPB with atria1 pacing
catheterization (1,2). Rupture of the PA is and nitroglycerin. The catheter was easily readvanced into
more commonly recognized (0.1%-l .5% incidence), the pulmonary artery. Increased bleeding from the chest
drains occurred postoperatively and required a second op-
with over a third of these cases occurring in cardiac eration to replace a leaking internal mammary artery graft.
surgical patients and a mortality of up to 53% (3,4). We The RV perforation site was intact. Thereafter, the patient’s
describe a case of perforation of the right ventricle recovery was smooth, apart from episodes of supraventric-
(RV) caused by a PA catheter during coronary artery ular tachycardia and rapid atria1 fibrillation that were con-
bypass surgery. trolled with esmolol, metoprolol, digoxin, and procain-
amide. Peak creatine kinase (1584 IU/mL) and its muscle
and brain (MB) fraction (5.6%) were nonspecific for catheter-
induced myocardial injury. On follow-up, the patient re-
Case Report mained stable in sinus rhythm with occasional premature
A 75-yr-old man with multivessel coronary artery disease ventricular contractions.
presented with increasingly unstable angina. Thallium scin-
tigraphy showed a fixed perfusion defect in the inferior wall
of the left ventricle consistent with previous infarction. Pre-
induction monitoring included electrocardiogram leads II Discussion
and V5, a radial artery catheter, and pulse oximetry. A 7.5 Fr
PA catheter (model 93A 831H, Baxter, Irvine, CA) was in- In our case, RV perforation occurred either during the
serted via an 8.5 Fr introducer in the right internal jugular initial difficult passage of the PA catheter or later
vein. The balloon had been checked for proper inflation over during cardiac examination and manipulation. The
the end of the catheter. The catheter was difficult to pass into latter procedure is the more likely cause. Withdrawal
and out of the RV, causing premature atria1 and ventricular
contractions. After several attempts, it was successfully of the catheter 5 cm probably placed its tip in the main
guided into the PA, giving a pressure of 34/15 mm Hg and PA, from which it then slipped into the RV during this
a wedge pressure of 13 mm Hg at 55 cm insertion. Postin- examination. The PA pressure of 23/7 mm Hg prob-
duction transesophageal echocardiography (TEE) showed ably indicated an RV catheter position that was not
enlargement of the atria and ventricles, mild mitral and identified, because the wave form was soon obscured
tricuspid regurgitation, but no thinning of the RV wall. The
by rapid dysrhythmias precipitated by further cardiac
catheter was adjusted several times to resolve spontaneous
wedging and to regain the normal PA pressure trace. This manipulation. Perforation is unlikely to have occurred
trace was present when the catheter was withdrawn another earlier, as a PA rather than an RV wave form was seen
5 cm in preparation for cardiopulmonary bypass (CPB). before the wedge pattern on the initial advancement
Supraventricular tachycardia occurred when the heart was of the catheter and after this pattern on its subsequent
lifted for examination. This resolved with esmolol 12.5 mg withdrawals.
and cardioversion. The PA pressure was 23/7 mm Hg. Fur-
ther manipulation of the heart led to rapid atria1 fibrillation. Factors that predispose to ventricular perforation
Hypothermic CPB was promptly instituted. When the heart during catheterization include small chamber size,
was again elevated, the tip of the PA catheter was seen stiff catheter, outflow tract obstruction, and myocar-
protruding through the normal-appearing inferior wall of dial infarction (2,5). There was no RV involvement in
the RV. The catheter was withdrawn to a right atria1 posi- infarction of the inferior left ventricular wall in our
tion, and the perforation was closed with 3/O sutures on
case (6). There was diminished ventricular filling
on TEE before the heart was manipulated. The perfor-
Accepted for publication February 5, 1996. ating potential of PA catheters is increased by
Address correspondence and reprint requests to Michael A.
Lyew, MB, FRCA, Anesthesiology Service, Buffalo V.A. Medical cooling and by the presence of multiple lumens, as in
Center, 3495 Bailey Ave., Buffalo, NY 14215. the case of central venous catheters (7,8). A thick
01996 by the International Anesthesia Research Society
0003.2999/96/$5.00 Anesth Analg 1996;82:1089-90 1089
1090 CASE REFORTS ANESTH ANALG
1996;82:1089-90
ventricular wall provides no assurance against cathe- corrected when the heart is already exposed, poten-
ter penetration (5). tially lessening its effect on surgical outcome.
Perforation of the RV may not be apparent during
open heart surgery. The RV can form a seal around a
penetrating pacing lead and a similar PA catheter (9). References
If the catheter tip appears just outside the epicardium,
1. Shah KB, Rao TL, Laughlin S, El-Etr AA. A review of pulmonary
the thermistor, located 4 cm from the end, will still be artery catheterization in 6,245 patients. Anesthesiology 1984;61:
intraventricular and will sense intracardiac blood tem- 2715.
perature. Heparinization will encourage bleeding, but 2. Domaingue CM, White AL. Right ventricular perforation in a
patient with a pulmonary artery catheter. J Cardiothorac Anesth
an opened pericardial space will limit the signs of 1988;2:223-4.
tamponade (10). Blood in the pericardial space may 3. American Society of Anesthesiologists Task Force on Pulmo-
obscure the catheter and may be related to other nary Artery Catheterization. Practice guidelines on pulmonary
sources in the surgical field. A change in the PA pres- artery catheterization. Anesthesiology 1993;78:380-94.
4. Kelly TF, Morris GC, Crawford ES, et al. Perforation of the
sure wave form may be attributed to wedging or rapid pulmonary artery with Swan Ganz catheters. Ann Surg 1981;
dysrhythmias instead of an external location of the 193:686-92.
catheter tip. With the heart empty on total CPB, a flat 5. Gorlin R. Perforation and other cardiac complications. Circula-
tion 1968;37(Suppl 111):36-8.
wave at low pressure will be shown by a properly
6. Wackers EL, Lie KI, Sokole EB, et al. Prevalence of right ven-
situated PA catheter or by a catheter with its tip in the tricular involvement in inferior wall infarction assessed with
open pericardial space. If perforation is suspected, myocardial imaging with thallium-201 and technetium-99m py-
multiplane TEE scans can be repeated to detect its rophosphate. Am J Cardiol 1978;42:358-62.
7. Cohen JA, Blackshear RH, Gravenstein N, Woeste J. Increased
presence. pulmonary artery perforating potential of pulmonary artery
In conclusion, RV perforation is a hazard of the PA catheters during hypothermia. J Cardiothorac Vast Anesth 1991;
catheter if the uninflated tip is present in the ventricle. 5:234-6.
8. Maschke SP, Rogove DO. Cardiac tamponade associated with a
Wall damage may be limited, but hemopericardium
multilumen central venous catheter. Crit Care Med 1984;12:
can occur unless the affected site is repaired. This site 6113.
may also become an additional cause of dysrhythmias 9. Cohn PF, Braunwald E. Traumatic heart disease. In: Braunwald
after cardiac surgery. Ensuring that the catheter re- E, ed. Heart disease: a textbook of cardiovascular medicine.
Philadelphia: WB Saunders, 1992:1517-27.
mains in the PA or is withdrawn to a right atria1 10. Tawa CB, Raizner AE. Complications of Swan Ganz catheters.
position will prevent this complication. Unlike PA In: Lutz J, ed. Complications of interventional procedures. New
rupture, myocardial perforation can be detected and York: Igaku Shoin, 1995:55-63.
