*From the Departments of Internal Medicine (Drs. Arnaout, Diab, and Jamaleddine) and Radiology (Dr. Al-Kutoubi), American University of Beirut-Medical Center, Beirut, Lebanon.
Correspondence to: Ghassan Jamaleddine, MD, FCCP, Associate Professor of Clinical Medicine, American University of Beirut-Medical Center, Department of Internal Medicine, PO Box 113-6044, Beirut, Lebanon; e-mail: email@example.com
A case is presented in which the insertion of a pulmonary artery
catheter was complicated by the formation of a knot around the chordae
tendineae of the tricuspid valve. The catheter was pulled out under
fluoroscopic guidance using a guidewire inserted through the femoral
Swan and colleagues in 19701initially described it, the
pulmonary artery catheter has been widely used as a valuable tool for
monitoring patients and guiding therapy in the ICU. Complications
resulting from this technique have been reported to occur in up to 24%
of cases.2 We report a case in which catheterization of
the pulmonary artery was complicated by knot formation around the
chordae tendineae of the tricuspid valve requiring removal of the
catheter under fluoroscopic guidance.
A 43-year-old woman was admitted to the ICU after respiratory
failure necessitating intubation and septic shock developed following
amputation of a right foot ulcer. Her medical history was significant
for diabetes type I and congestive heart failure with severe left
ventricular dysfunction secondary to ischemia. The patient also had
evidence of grade 2 mitral regurgitation and mild tricuspid
regurgitation on echocardiography done 3 months prior to hospital
admission. In the ICU, treatment with inotropes was started and she
underwent insertion of a Swan-Ganz catheter via the left subclavian
vein. A chest radiograph obtained after catheter insertion showed that
the catheter was looped and knotted within the heart. Echocardiography
revealed a grade 2 tricuspid regurgitation. The Swan-Ganz catheter was
seen under the posterior leaflet of the tricuspid valve. Percutaneous
removal of the stuck catheter was then attempted under fluoroscopic
guidance. The catheter was found to be tightly knotted around the
chordae of the tricuspid valve. Attempts at snaring the free end of the
catheter were unsuccessful; therefore, a “closed-loop” technique
was used. The curve of a sidewinder-shaped catheter was hooked over the
Swan-Ganz followed by the advancement of a guidewire into the inferior
vena cava (Fig 1
). The tip of the guidewire was then snared in the inferior vena cava,
allowing the formation of a closed loop around the knotted catheter.
The proximal end of the catheter at the insertion point was then cut,
which allowed the pulling of the fragment through the right femoral
vein (Fig 2
). This fragment also pulled out part of the chordae tendineae. Repeated
echocardiography showed evidence of severe tricuspid regurgitation with
rupture of the chordae of the free wall leaflet. The patient remained
in hemodynamically stable condition until 2 weeks later, when multiple
system organ failure developed and she died.
Both minor and major complications have been described with the
use of pulmonary artery catheterization. Major complications have been
reported to occur in 3 to 17% of cases.3 These include
atrial and ventricular arrhythmias, pneumothorax, intracardiac rupture,
pulmonary embolism, pulmonary hemorrhage, pulmonary artery rupture,
balloon rupture, bacteremia, and death.3
The first case of a ruptured chordae of the tricuspid valve as a
complication of Swan-Ganz catheterization was reported in 1976 by Smith
et al.4 The authors emphasized the fact that Swan-Ganz
catheters, once inserted, should never be withdrawn with the balloon
inflated, as this might result in tearing the chordae if the catheter
was entangled in the tricuspid valve.
In 1995, Kainuma et al5 reported a patient undergoing
mitral valve replacement and tricuspid annuloplasty because of
tricuspid regurgitation in whom a deflated Swan-Ganz catheter was found
to have passed between the chordae tendineae of the tricuspid valve.
They postulated that this is an underrecognized possible complication
of catheter insertion in patients with tricuspid regurgitation. In the
case we report, the patient had evidence of mild tricuspid
regurgitation on echocardiography done a few months prior to hospital
admission. The possibility that this could have increased the risk of
passage of the catheter between the chordae tendineae and subsequently
forming a knot is a plausible hypothesis.
In our patient, the pulmonary artery catheter was removed under
fluoroscopic guidance using a right femoral vein approach. This led to
worsening of tricuspid regurgitation, but it was the only way to get
the catheter out without performing an open-heart procedure, which
obviously was impossible in this patient. This technique was reported
previously to extract a knotted pulmonary artery
catheter.6 In that report, however, the knot did not form
around the chordae of the tricuspid valve. It was therefore possible to
pull out the catheter without causing damage to the valve, and the
patient had a better outcome.6
The use of pulmonary artery catheters in the ICU has proved to be
extremely helpful in managing critically ill patients. Nevertheless,
there is a risk of serious complications, such as knotting around the
cordae and injury to the tricuspid valve. The physician should be aware
of these complications, especially when resistance is encountered
during the pulling of the catheter. Removal of a knotted Swan-Ganz
catheter under fluoroscopic guidance is a useful technique if such a
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