Transesophageal Echocardiographic Diagnosis of Pulmonary Artery Catheter Entrapment caused by Left Atrial suture

Pulmonary artery catheter (PAC) is an important clinical tool that is used in the care of perioperative cardiac patients and unstable patients in the intensive care unit. Entrapment of the PAC by an intracardiac surgical suture is a rare complication. In open-heart surgery, the catheter may be caught by a suture placed through the right atrial wall because the catheter tends to lie against the anterior wall of the right atrium (RA).[1] In this letter, we describe the entrapment of the PAC to the interatrial septum by a left atrial suture, which was diagnosed using 2D- and 3D-transesophageal echocardiography (TEE).

A 77-year-old male patient with a history of mitral valve regurgitation, atrium fibrillation, and shortness of breath presented for mitral valve replacement. In the operating room, a PAC was inserted through the right internal jugular vein without complication. The patient's intraoperative course was uneventful. He was transferred to the intensive care unit in a stable condition and was extubated on postoperative day 1. PAC removal was also attempted but immediately aborted due to resistance with attempted withdrawal. The chest radiograph showed an unnatural curvature of the PAC in the RA (Figure 1, black arrow in the left panel). PAC entrapment by a suture used to close the venous cannulation site for cardiopulmonary bypass (CPB) was suspected and the decision was made to remove the PAC surgically. Upon re-operation, the surgeon removed the suture that had been used to close the venous cannulation site, but the PAC remained entrapped. After careful intraoperative TEE evaluation, an unusual protrusion of the interatrial septum was seen in both 2D and 3D images (Figure 1, white arrow in right panel). This protrusion was thought to be caused by the suture that had been used to close the left atriotomy during the mitral valve operation. Due to these intraoperative TEE findings, the decision was made to open the atrium and remove the suture. Following this, the PAC, which had been penetrated by the suture, was successfully removed. The patient was extubated in the operating theater and his clinical course after this procedure was uneventful.

Figure 1.

Chest X-ray and TEE image of the pulmonary artery catheter

PAC entrapment is a rare cause of PAC-associated complications with a reported incidence of 0.065%.[1] The possible causes of PAC entrapment include catheter knotting[2] and entrapment by suture.[3,4] Most often, suture entrapment of the PAC is due to the right atrial suture. In this case, however, PAC entrapment was caused by the left atrial suture that had extended into the interatrial septum. Intraoperative TEE was used to successfully identify this uncommon site of PAC entrapment and to guide surgical management.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.