Inadvertent placement of a flow-directed pulmonary artery catheter in the coronary sinus, detected by transesophageal echocardiography

Anesth Analg. 2006 Feb;102(2):363-5. doi: 10.1213/01.ane.0000195340.65783.81.

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.

Publication types

  • Case Reports

MeSH terms

  • Aged, 80 and over
  • Catheterization, Swan-Ganz / adverse effects*
  • Coronary Vessels* / diagnostic imaging
  • Echocardiography, Transesophageal*
  • Female
  • Humans
  • Medical Errors*