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A 38-year-old, morbidly obese woman underwent surgery for debridement of necrotizing fasciitis of the abdominal wall. A pulmonary artery catheter was placed because of increasing fluid requirements. Despite multiple debridements and fluid resuscitation, the patient exhibited severe systemic inflammatory response. It was discovered that fluid placed in the introducer had extravasated into the subcutaneous tissues. In this obese patient, the pulmonary artery introducer was too short.

To the Editor .—The Swan-Ganz catheter has become an important tool for monitoring critically ill surgical patients in the intensive care unit. 1 Like all invasive diagnostic or therapeutic modalities, the Swan-Ganz catheter is associated with infrequent, but real, risks. Cardiac arrhythmias, perforation of the pulmonary artery, pulmonary infarction, and catheterassociated bacteremia are among such complications. The passage of the catheter in critically ill patients, even those with intrinsic cardiac disease, is reputed to be safe, although transient rhythm disturbances may be identified in as many as 30% of the patients at the time of placement. 2 Reports of fatal or near-fatal cardiac arrhythmias are rare. Thus, there are essentially no contraindications to Swan-Ganz catheter placement. Our recent experience suggests that a patient with hyperkalemia and metabolic acidosis may not warrant immediate catheter placement. Report of a Case .—A 73-year-old man underwent a coronary artery bypass for symptomatic ischemic heart

To the Editor.— Since its introduction in 1970, the Swan-Ganz catheter has proved extremely useful in the hemodynamic evaluation of cases of shock and myocardial infarction.1Under most circumstances, it can be passed at the bedside (under hemodynamic monitoring alone) with ease. However, some complications of catheter passage have been documented, including ventricular fibrillation,2intracardiac knotting,3,4and atrial arrhythmias.5We describe a previously unreported complication— entanglement of a Swan-Ganz catheter around a papillary muscle to the right ventricle. Report of a Case.— A 57-year-old man had a history of hypertension and a cerebrovascular accident eight years prior to admission. On the day of admission he complained of crushing substernal chest pain. His initial ECG showed an acute posterior- and lateral-wall myocardial infarction. He was admitted to the coronary care unit and had an uneventful initial course except for a period of transient atrial fibrillation. Serial enzyme

To the Editor.— The article by Van Deventer et al, "The Superior Vena Cava Syndrome: A Complication of the LeVeen Shunt" (242:1655, 1979), brings to mind another interesting point in reference to etiology. We recently performed an autopsy on a patient with similar pathological findings, involving the superior vena cava, right innominate vein, right subclavian vein, and right internal jugular vein that were related to insertion of a Swan-Ganz catheter. Report of a Case.— A 34-year-old man had an acute myocardial infarction in May 1979. Clinicians had difficulty inserting a Swan-Ganz catheter for a temporary pacemaker. They finally succeeded via the right internal jugular vein. The patient's illness was complicated by a postinfarction ventricular aneurysm and heart failure. Cardiac catheterization was done in July and August, which showed a nondominant, trivial right coronary artery, patent left circumflex artery, 70% occlusion of the left anterior descending artery, calcified aortic stenosis, and