Arlen G Fleisher, MD; G Frank O Tye...

Arlen G Fleisher, MD; G Frank O Tyer MD; vale T. Manning, M.D.; and Bill Nelem MD

Pulmonary artery perforation from flow-directed catheters is associated with high mortality, particularly in heparinized patients. We report a novel case and discuss recognition and management.

(Chest 1989;95:1340-41)

Pulmonary artery (PA) perforation is an remarkable complication of Swan-Ganz catheterization.[1] It has a particularly high mortality in heparinized cardiopulmonary bypass patients.[2,4] The design of this report is to increase awareness of this complication, outline a systematic approach when it come to passs and suggest methods to avoid it.

CASE REPORT

A 65-year-old dentist not past nor futureed with incapacitating angina, cardiac cachexia, and signs of pericardial constriction seven years after initial aortocoronary bypass surgery Therapy with long-acting nitrates, calcium blocker beta-blockers and afterload reduction was largely ineffective and associated with many side events Weight loss was 15 strikes over the previous few month 30 brays over two years. The ECG showed first rank and left anterior hemiblock. Catheterization showed critical three-vessel stenosis with no patent grafts. Ejection fraction was diffusely reduc to 37 percent An extensive workup for malignancy was negative.

The patient was admitted for coronary bypass surgery and after premedication with nitroglycerin paste and antibiotics, and induction of Fentanyl, isoflurane and [Osub2] anesthesia, a PA catheter (Oximetric, Mountainview, CA) was inserted between the sides of the right internal jugular vein to 62 cm for an initial and barely wedge pressure of 13 mm Hg The catheter was then withdrawn to 54 cm and the diastolic compressing was 12 mm Hg. The previous sternotomy was make opened revealing dense adhesions.

Following heparinization, aortic and two-stage right atrial cannulation, the patient was placed in succession cardiopulmonary bypass. Using hypothermic cardioplegic arrest, grafts were placed from the aorta to the anterior descending, diagonal, distal circumflex and posterior descending coronary arteries.

Prior to weaning from bypass, the right lung did not act upon well with ventilation, and a small amount of line was aspirated from the endotracheal tube. As pours were reduced, bleeding increased and a tenative diagnosis of PA perforation was made. The right PA was encircled between the aorta and superior vena cava, the catheter palpated within its lumen and a tourniquet placed and tightened. Fiberoptic bronchoscopy revealed bleeding from the posterior section of the right lower lobe. With the tourniquet released, bleeding increased markedly when attempting to wean from bypass. A chest x-ray film confirmed catheter tip location (Fig 1)

With the PA snare tightened, endobronchial bleeding blood-thirsty to a few ml/min onward partial bypass. A Fogarty balloon (American Edwards, Irvine, CA) inflated in the segmental bronchus reduc bleeding to a trickle. The catheter tip was twitched back into the main PA and the patient weaned from bypass throughout 20 minutes with satisfactory hemodynamics, mixed venous oxygen saturation, and arterial kin gases and pH, although dopamine, 6 [unkeyable]g/kg/min, and adrenaline, 5 [unkeyable]g/min, were required. Pulmonary artery diastolic constraining force was 15 mm Hg and nitroglycerin infusion was maintained at 02 to 05 [unkeyable]g/kg/min. Because of the catecholamine requirement, an intra-aortic balloon was inserted with of the highest order unloading of the left ventricle.

Protamine sulfate was given and a decision made to do a lobectomy from one side the median sternotomy rather than persist with endobronchial tamponade and right PA tourniquet. After completion, cardiopulmonary status restabilized, although an air leak persisted. The hurts were closed an the patient transferred to the intensive care unit in stable condition. Seven hours later he died abruptly following a bradycardic arrest.

The posterior basilar section of the resected lobe was replaced at a large hematoma (Fig 2) A major segmental arterial branch go intoed the hematoma, but fine sectioning could not demonstrate the point of quarrel Post-mortem examination showed main left coronary artery stenosis, diffuse distal disease, and four patent grafts with beneficial runoff. The kidneys, heart and lung showed extensive deposits of stiff proteinaceous material (amyloid) with involvement of pulmonary connective tissue and small vessels

DISCUSSION

This patient had individual of 852 open-heart procedures performed at the Vancouver General Hospital during 1986 Pulmonary artery catheters were placed in 85 percent of patients; 88 percent were pressing or emergent, and 87 percent in NYHA class 3 or 4 through the last seven years, 3900 PA catheters have been placed prior to spread heart surgery, with two perforations of clinical significance. The previous patient was also cachectic and, in addition, had chronic mitral regurgitation and PA hypertension. Our incidence of serious perforation is 005 percent with previous reports ranging from 006 to 0125 percent[15]