title: Inadvertent placement of a flow-directed pulmonary artery catheter in the coronary sinus, detected by transesophageal echocardiography.
abstract: 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.
authors.affiliation: Department of Anesthesia and Critical Care & of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts 02215, USA. rmatyal@bidmc.harvard.edu
authors.forename: Robina
authors.initials: R
authors.lastname: Matyal
authors.forename: Feroze
authors.initials: F
authors.lastname: Mahmood
authors.forename: Peter
authors.initials: P
authors.lastname: Panzica
authors.forename: John
authors.initials: J
authors.lastname: Mitchell
authors.forename: Sheila
authors.initials: S
authors.lastname: Barnett
authors.forename: Marybeth
authors.initials: M
authors.lastname: Hyde
authors.forename: David
authors.initials: D
authors.lastname: Campbell
authors.forename: Kyung W
authors.initials: KW
authors.lastname: Park
mesh_terms: 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