Inadvertent placement of a flow-directed pulmonary artery catheter in the coronary sinus, detected by transesophageal echocardiography.
We report a case in which flow-directed placement of the pulmonary artery catheter led to its inadvertent placement in the coronary sinus, in the absence of congenital anomalies. Incorrect placement was diagnosed by use of the transesophageal echocardiography. If unrecognized, the catheter might have provided misleading information and led to mismanagement of the patient.
Matyal
Robina
R
Department of Anesthesia and Critical Care & of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts 02215, USA. rmatyal@bidmc.harvard.edu
Mahmood
Feroze
F
Panzica
Peter
P
Mitchell
John
J
Barnett
Sheila
S
Hyde
Marybeth
M
Campbell
David
D
Park
Kyung W
KW
D000369:Aged, 80 and over; D002407:Catheterization, Swan-Ganz / Q000009:adverse effects*; D003331:Coronary Vessels / Q000000981:diagnostic imaging; D017548:Echocardiography, Transesophageal; D005260:Female; D006801:Humans; D019300:Medical Errors