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Background Simultaneous left ventricular (LV) and aortic (Ao) pressure gradient assessment has been rendered challenging since the recall of the Langston catheter. Here we describe a simple method for simultaneous LV and Ao pressure gradient assessment using a Swan-Ganz catheter. Case summary We describe two cases where assessment of simultaneous left ventricle and Ao valve gradients was done using a Swan-Ganz catheter to assess the degree of Ao stenosis and dynamic LV outflow obstruction. Discussion Using Swan-Ganz catheter assessment of simultaneous left ventricle and Ao valve gradients can simplify the procedure with reduced cost and increased patient safety.

Funding Acknowledgements Type of funding sources: None. Background Cardiovascular dysfunction is common after out-of-hospital cardiac arrest (OHCA). Cardiac output measurements can be used to guide treatment during post-resuscitation care and echocardiography allows noninvasive cardiac output estimation. Purpose The aim of the present study was to compare Doppler echocardiography (doppler_CO) with thermodilution using pulmonary artery catheters (PAC_CO) for cardiac output estimation in a large and consecutively included cohort of comatose OHCA-patients undergoing targeted temperature management (TTM). Methods Single-center substudy of 171 patients included in the TTM-trial randomly assigned to 33 or 36 degrees C for 24 hours after OHCA. We measured PAC_CO and doppler_CO simultaneously shortly after admission and again after 24 hours. Measurements and Main Results We excluded 19 (11%) patients without PAC-measurement and 31 (18%) without doppler-measurements resulting in 120 paired measurements at admission. Patients were 61 (±11) years old, 86% were men and 91% had a witnessed OHCA. At ICU-admission, PAC_CO was 4.81 (±1.81) L/min. and doppler_CO was 3.74 (±1.38) L/min., with a mean bias of 1.07 (±1.65) L/min (with 95% limits of agreement of –2.16 to 4.04) L/min. Examining the Bland-Altman plot, precision fell with higher cardiac output (figure). A statistically significant, but moderate correlation was found between doppler_CO and PAC_CO at admission (r = 0.49), p < 0.0001). After 24 hours, PAC_CO was 4.63 (±1.38) L/min. and doppler_CO was 3.61 (±1.14) L/min, with a mean bias of 0.96 L/min. Assessing the change from admission to 24 hours, PAC_CO decreased averagely -0.12 (±2.22) L/min. and doppler_CO decreased -0.19 (±1.91) L/min. The changes from admission to 24 hours correlated between doppler_CO and PAC_CO (r = 0.55), p < 0.0001) with a mean bias of the changes of 0.07 L/min, with 95% limits of agreement of –3.76 to 3.91 L/min. Conclusions Changes in cardiac output during TTM may be evaluated with Doppler echocardiography with little mean bias compared to changes in CO measured with thermodilution, but relatively large changes are needed in the individual patient before it can be considered as real. Abstract Figure. Comparing Doppler vs. thermodilution

We describe a case of pulmonary tumor embolism (PTE) from breast cancer diagnosed by selective aspiration cytology using a Swan-Ganz catheter. A 60-year-old woman was referred to Hamanomachi Hospital because of increased levels of tumor markers. The patient complained only of slight exertional dyspnea and a dry cough. Due to breast cancer, she had undergone a mastectomy followed by radiation and chemotherapy one year earlier. Positron emission tomography scanning with CT images revealed no evidence of malignancy. Repeated chest CT images showed emerging wedge-shaped nodules in the subpleural zones of the left lower lobe with diffuse ground-glass opacities in the bilateral lower lobes. The D-dimer level was negative. Pulmonary perfusion scintigraphy showed multiple small wedge-shaped defect areas on the peripheral sides of the bilateral lungs. Suspecting PTE, we performed selective aspiration cytology from the left pulmonary arteries. Cancer cells were detected from selected branches of left A8 and A9. Morphology and immunostaining led to a final diagnosis of PTE of recurrent breast cancer. Pulmonary embolism of cancer is a progressive, fatal condition with challenging diagnosis. Selective aspiration cytology with a Swan-Ganz catheter is a useful, less invasive option in patients with suspected PTE.

Latex-induced anaphylactic reactions are often underestimated in patients having procedures in a catheterization lab, intensive care units, or in operating rooms. Most physicians are not aware that almost all balloons in the Swan-Ganz catheter (SGC) are made up of latex. Direct exposure of these latex balloons in the blood can cause severe anaphylactic reactions, even in patients with no previous history of allergies. We present a case of a 53-year-old male, who underwent a SGC placement for cardiovascular evaluation. Immediately after the SGC insertion, he developed circulatory shock. On further investigation, we discovered that SGC balloon contained latex as one of the components. Physicians should be aware of latex-based products such as SGC balloon, which can cause anaphylactic shock even in case of no prior allergies to latex.

There are several devices for haemodynamic monitoring in the ICU. In low-risk postsurgical patients, haemodynamic monitoring of noninvasive blood pressure, heart rate and EtCO2 will be able to provide sufficient data to diagnose an unexpected haemodynamic instability. In high-risk or in intermediate-risk postsurgical patients, it may be sufficient to perform a SVV monitoring to guide the haemodynamic optimization and the patient’s preload management. In major and more complex surgical procedures, where “mixed shock” can occur (e.g. in abdominal emergency surgery or in a patient with pre-existing cardiomyopathy or valve disease or pulmonary hypertension), a complete and more invasive haemodynamic assessment must be performed with a calibrated device for the cardiac output measurement or a combined PAC with a SVV measuring tool.

Introduction: Totally implantable venous access systems (TIVAS), Swan-Ganz (SG) and central venous catheters (CVC) allow easy and repetitive entry to the central cardiovascular system. Fragments of them may be released inadvertently into the cardiovascular system during their insertion or as a result of mechanical complications encountered during long-term utilization. Aim : To present results of percutaneous retrieval of embolized fragments of central venous devices or knotted SG and review the procedural aspects with a series of detailed angiographies. Material and methods : Between January 2003 and December 2012 there were 14 (~0.025%) successful retrievals in 13 patients (44 ±16 years, 15% females) of embolized fragments of TIVAS (n = 10) or CVC (n = 1) or of dislodged guide-wires (n = 2) or knotted SG (n = 1). Results : Foreign bodies with the forward end located in the right ventricle (RV), as well as those found in the pulmonary artery (PA), often required repositioning with a pigtail catheter as compared to those catheter fragments which were located in the right atrium (RA) and/or great vein and possessed an accessible free end allowing their direct ensnarement with the loop snare (57.0% (4/7) vs. 66.7% (2/3) vs. 0.0% (0/3); p = 0.074 respectively). Procedure duration was 2–3 times longer among catheters retrieved from the PA than among those with the forward edge located in the RV or RA (30 (18–68) vs. 13.5 (11–37) vs. 8 min (8–13); p = 0.054 respectively). The SG catheter knotted in the vena cava superior (VCS) was encircled with the loop snare introduced transfemorally, subsequently cut at its skin entrance and then pulled down inside the 14 Fr vascular sheath. Conclusions : By using the pigtail catheter and the loop snare, it is feasible to retrieve centrally embolized fragments or knotted central venous access devices.

Introduction: The placement of a Swan-Ganz catheter into the pulmonary artery may lead to a number of complications (2–17%). In less than 0.2% of cases Swan-Ganz catheterization results in serious vascular damage – pulmonary artery rupture (PAR). This paper presents two distinct forms of iatrogenic PAR treated endovascularly using different vascular devices. Aim: To evaluate the effectiveness of endovascular treatment and the application of different types of vascular devices in the management of pulmonary artery rupture caused by Swan-Ganz catheterization. Material and methods : In this retrospective study we evaluated 2 patients in whom Swan-Ganz catheter application was used for perioperative monitoring and resulted in pulmonary artery rupture. This complication was treated endovascularly by means of interventional cardiology. Results : We report the cases of 2 patients with a pulmonary artery pseudoaneurysm formed in the perioperative period. In case 1, a single, 4-loop, 3 mm diameter coil was implanted. In case 2, a 5 mm Amplatzer Vascular Plug IV was applied. In both cases, the endovascular approach resulted in total occlusion of the feeding artery and reduced further extravasation of the blood. Conclusions : Despite its extremely low incidence, iatrogenic PAR is a serious, life-threatening complication of Swan-Ganz catheterization that requires urgent attention. Among available methods of treatment, percutaneous embolization is a relatively quick, safe, accurate and highly effective alternative to traumatizing surgery.

Recurrent ventricular arrhythmia can be fatal and cause serious complications, particularly when it is caused immediately after an operation. Incorrect placement of a Swan-Ganz catheter can trigger life-threatening ventricular arrhythmia, but even intensive care specialists tend to miss this fact. Here, we report a case of recurrent ventricular arrhythmia causing a severe hemodynamic compromise; the arrhythmia was induced by a severely angulated Swan-Ganz catheter. The recurrent ventricular arrhythmia was not controlled by any measures including repositioning of the catheter, until the complete removal of the Swan-Ganz catheter. It is necessary to keep in mind that the position of the pulmonary artery catheter should be promptly checked if there is intractable recurrent ventricular arrhythmia.

Background Central line-associated bloodstream infections (CLABSI) are a known complication of central venous access. Pulmonary artery catheters (PAC) are frequently used in status 1A pre-heart transplant patients, at the top of the heart transplant waiting list. These patients often have a PAC in place for extended periods of time and are thus at risk for CLABSI. Our institution’s practice includes routine PAC exchange after 21 days of use. We sought to estimate the risk of CLABSI and determine whether factors influenced infection rate. Methods We conducted a retrospective, descriptive study from January 2013 to December 2016 identifying characteristics of PAC use and infection rate in adult status 1A pre-heart transplant patients. Time to CLABSI was analyzed with Kaplan–Meier estimates. The effect of CLABSI on time to transplant and death were analyzed in time-dependent Cox models. Results We identified 61 status 1A pre-heart transplant patients with PACs during this time period with 219 PACs and 2566 line-days. Median duration of PAC was 11 days. There were 14 CLABSIs for an infection rate of 5.46/1,000 line-days (95% CI: 2.98–9.15), compared with 1.06/1,000 line-days for our institution’s intensive care unit rate. Causative organisms were coagulase-negative Staphylococcus (79%), Enterobacter (7%), E. coli (7%), and Klebsiella (7%). There was a trend toward higher infection rate per 1,000 line-days with longer duration of PACs. Lines in place for 0–10 days resulted in an infection rate of 3.14 (1.02–7.32); 11–20 days with a rate of 8.70 (3.19–18.94); and >20 days with a rate of 32.61 (6.72–95.30). There was a trend toward higher infection rate with more concomitant non-PAC lines used (0 other lines, 4.57; 1 line, 6.21; 2 or more, 11.56). Median time to infection diagnosis from PAC placement was 29 days (23–49). Line infection was associated with shorter time to transplant (hazard ratio 2.49; P = 0.027), but no effect on mortality (hazard ratio 1.79; P = 0.355). Conclusion Our study demonstrated a high rate of CLABSI with PAC, with a trend toward increased risk with longer use, and presence of concomitant lines. Infection was associated with a shorter time to transplant, though not with time to death. Prolonged PAC use in the status 1A population should be revisited. Disclosures All authors: No reported disclosures.

Pulmonary artery catheterization is a useful tool for the diagnosis and management of lung or cardiac disease. This procedure is considered safe and associated with a low incidence of major complications. However, pulmonary artery rupture during right heart catheterization, albeit rare, remains a severe complication. Despite modern management with metal-coil embolization, selective intubation and deployment of bronchial blocker, the mortality rate may be as high as 50%. In this case, we report a new approach to deal with a Swan-Ganz-induced pulmonary artery rupture based on stent graft implantation leading to successful sealing of the pulmonary perforation with final patency and normal antegrade blood flow in the pulmonary branch.

It has been agreed that pulmonary hypertension should be determined by right heart catheterization. However, being invasive and refused by many patients, echocardiography was thought to be a reasonable substitute to determine a solid diagnosis of pulmonary arterial hypertension. So fourteen patients with pulmonary arterial hypertension (class I) were studied by estimating pulmonary artery systolic pressure by both transthoracic echocardiography and right heart catheterization using Swan-Ganz catheter. The patients were 4 males and 10 females with mean ages about 46.25 ± 23.33 in males and 36.8 ± 11.63 in females (total mean age was about 39.5 ± 15.46 years). Mean value of the Echo SPAP: 82.79 + 34.25 mmHg, however in the RHC SPAP 76.21 + 24.97. Comparing both clinical procedures via the Altman and Bland statistical method showed discrepancy between both procedures. Results showed that the 6MWD (mean + SD 262.64 ± 85.98) is significantly correlated with the mean pulmonary arterial pressure only. Conclusion: Echocardiography cannot be reliable alone in the proper decision making of diagnosis and management of pulmonary arterial hypertension.