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Table of Contents
Year : 2012  |  Volume : 15  |  Issue : 2  |  Page : 138-140
Dilated ascending aorta is associated with the difficulty in correct placement of pulmonary artery catheter

1 Department of Anesthesiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
2 Department of Emergeny Medicine, Provincial Medial Services Uttar Pradesh, Lucknow, India

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Date of Web Publication16-Apr-2012


The present case report highlights that a tense mega-sized aortic root and ascending aorta can mechanically resist the passage of fully inflated (1.5 ml air) balloon to wedge-trace position in the pulmonary artery. Any attempt to push the catheter rather predisposed its recoiling and rebutting into the right ventricle and the cardiac arrhythmia. Inflating continuous cardiac output catheter balloon with lesser volume of air (1 ml) is suggested to overcome this problem.

Keywords: Bentalls procedure, cardiac output, monitoring, pulmonary artery catheter

How to cite this article:
Tripathi M, Pandey M. Dilated ascending aorta is associated with the difficulty in correct placement of pulmonary artery catheter. Ann Card Anaesth 2012;15:138-40

How to cite this URL:
Tripathi M, Pandey M. Dilated ascending aorta is associated with the difficulty in correct placement of pulmonary artery catheter. Ann Card Anaesth [serial online] 2012 [cited 2022 Dec 8];15:138-40. Available from:

   Introduction Top

In continuous cardiac output (CCO) monitoring, a balloon-tipped catheter is floated through the right internal jugular vein (IJV) to the right atrium, right ventricle (RV) and the pulmonary artery (PA) till the point of "wedge trace." While in securing tip of CCO catheter into PA, the important factor is the floatation of balloon rather than the blood flow direction. [1] The risk of complications to a large extent depend on the patient factors (morbidity, underlying disease, cardiac anatomy), [2],[3],[4] the time (before or after induction) to place catheter and the experience of the physician. [5] The difficulty in securing catheter into PA is expected in tricuspid regurgitation, pulmonary hypertension and the dilated heart. However, aorta has not been reported for the same. We wish to share our experience of difficulty faced in passing the CCO catheter into the PA in a patient with dilated aortic root and the ascending aorta.

   Case Report Top

A 32-year-old young male (body weight 55 kg, height 165 cm and body surface area 1.72 m 2 ) was evaluated in the preoperative anesthesia clinic for Bentall's aortic root replacement surgery. The patient had coarctation of the descending part of the aorta. A functional stent was present in it. He was on regular oral doses of enalapril (25 mg twice daily) to control hypertension. Three-dimensional reconstructed computerized tomography (CT) scan showed mega-sized ascending aorta (62 mm) and the coarcted descending aorta [Figure 1]. Preoperative echocardiography measured aortic annulus 22 mm, dilated aortic root 57 mm, diastolic left ventricle 60 mm and end systolic 10 mm, with ejection fraction 65%.
Figure1: Computerized three-dimensional tomography of the upper part of the chest showing mega-sized ascending aorta and dilated root with coarctation segment distal to the origin of the left subclavian artery

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As per our protocol, we cannulated the radial artery and performed right IJV puncture under local anesthesia before induction of anesthesia. The right IJV was punctured using ultrasound guidance. The Intro-Flex polyurethane sheath with AMC thrombo-shield (8.5 F) (Edward Lifesciences, Irvine, CA, USA) was placed. The Swan-Ganz CCO thermodilution catheter (7.5 F) (Edwards Lifesciences, Irvine, CA, USA), was floated through the sheath under pressure wave guidance. The catheter got through the RA to RV and the PA in a 15° head-up position of the patient. In an attempt to place the catheter tip till the point of wedge trace, the CCO tip got rebutted into the RV. After deflating the balloon, the catheter was withdrawn to RV and re-inserted into PA with similar problem in securing the tip well within the PA. The patient also developed cardiac arrhythmia (bigeminy), which responded to xylocard (2%) 60 mg intravenously. We considered the probability of the PA tip getting resistance at some point due to the balloon size.

We decided to float the catheter once more, but inflated the balloon with lesser air (1 ml) in place of the recommended 1.5 ml [Figure 2]. On this occasion, PA trace was maintained till the catheter got in till the 45-cm mark. Because the balloon was inflated to a smaller volume, we did not try to get wedge trace but left it at the 46 cm mark just outside the sheath. The PA tip did not rebut this time. The cardiac output monitor (Vigilance II, Edwards Lifesciences LLC) started measuring cardiac output after calibration and stabilization of the monitor.
Figure 2: "A" Diameter of balloon is significantly larger by inflating it with 1.5 ml air than on inflating it with 1 ml air "B"

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On opening of the chest, we noticed a huge dilated aortic root and the tense ascending aorta lying by the side of the PA, which was normal in anatomy. The PA was looking quite flat and acutely directed posteriorly to lie behind the dilated aorta arch [Figure 3]. Because PA trace was seen and CCO value was stable, no further manipulation was done. The diastolic PA pressure was considered as wedge pressure. Rest of the surgery of Bentall's root replacement surgery with aortic valve was unremarkable. The postoperative chest X-ray showed that the tip of the CCO catheter was located in the main PA only [Figure 4]. The patient was discharged from the hospital on the 7 th postoperative day.
Figure 3: Peroperative picture of dilated root of aorta and black arrows mark the mega-sized ascending aorta seen normally adjacent to the pulmonaryartery. Pulmonary artery is seen curving acutely posterior to theaorta

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Figure 4: Black arrow on the postoperative chest X-ray showing the tip of the continuous cardiac output (CCO) catheter tip at the main pulmonaryartery. Replaced aortic valve is also seen adjacent to the CCOcatheter

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   Discussion Top

PA catheterization is required for the CCO monitoring during cardiac surgery. Inconsistency in hemodynamic monitoring with the overall clinical picture has been correlated with malposition of the catheter, i.e. lodging in the RV [6] or the left PA. [7] Recoiling of the tip into the RV was probably related to resistance met by the fully inflated balloon through the PA with restricted distensibility at the point crossed over by the tense mega-sized ascending aorta [Figure 2].

A relative increase in PA catheter balloon size due to diffusion of nitrous oxide has also been correlated with difficulties during floating and/or manipulating the PA catheter. [8] We too found that the fully inflated balloon was associated with difficulty in its placement into the PA than at lesser volume of air inflation. Later on, the position of the catheter tip in the main PA was also confirmed on chest X-ray [Figure 4].

Recoiling of the PA catheter is associated with cardiac arrhythmia, [9] and has the potential hazard of knotting. Therefore, multiple attempts in floating PA catheter and/or floating an excessive length of PA catheter in the heart is not recommended. [10] Considering the recurrent problem of rebutting of PA catheter tip into RV at full-balloon inflation, we did not try to pass the tip till the point of wedge trace once we could successfully advance the PA catheter by use of smaller air volume in the balloon.

The catheter position showing wedge-trace on inflation of the balloon is recommended to accurately measure left atrial filling pressure or the preload. However, on getting "wedge-trace" without full-balloon inflation warrants the withdrawal of the catheter until a normal PA waveform. [6] Because in our patient attempt to place the CCO catheter into the wedge position was triggering cardiac arrhythmia and rebutting of the catheter tip into RV due to recoiling, we decided to keep it at a level with PA trace. As recommended, [6] we also considered PA diastolic pressure as the PA wedge pressure for calculating hemodynamic parameters, and could satisfactorily manage the patient during weaning from cardiopulmonary bypass.

We wish to emphasize in this case report that a mega-sized, dilated ascending aorta can resist free passage of normal-sized PA catheter balloon. Balloon inflation with smaller volume of air can be tried to secure the CCO catheter in the PA. In the absence of wedge-trace, the diastolic PA pressure shall be used as the wedge pressure to derive the trend of the calculated values.

   References Top

1.Parlow JL, Milne B, Cervenko FW. Balloon flotation is more important than flow direction in determining the position of flow-directed pulmonary artery catheters. J Cardiothorac Vasc Anesth 1992;6:20-3.  Back to cited text no. 1
2.Polderman KH, Girbes AJ. Central venous catheter use. Part 1: Mechanical complications. Intensive Care Med 2002;28:1-17.  Back to cited text no. 2
3.Stoiser B, Vorbeck F, Kofler J, Locker GJ, Burgmann H. Placement of a pulmonary artery catheter via a previously unrecognized persistent left superior vena cava. Vasa 1999;28:53-4.  Back to cited text no. 3
4.Tripathi M, Kumar N, Singh PK. Pulmonary artery catheter insertion in a patient of dextrocardia with anomalous venous connections. Indian J Med Sci 2004;58:353-6.  Back to cited text no. 4
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5.Wall MH, MacGregor DA, Kennedy DJ, James RL, Butterworth J, Mallak KF, et al. Pulmonary artery catheter placement for elective coronary artery bypass grafting: Before or after anesthetic induction? Anesth Analg 2002;94:1409-15.  Back to cited text no. 5
6.McGee DC, Gould MK. Preventing complications of central venous catheterization. N Engl J Med 2003;348:1123-33.  Back to cited text no. 6
7.Tripathi M, Pandey M. Intrathoracic pulmonary artery catheter allocation in the background of left atrial dilatation. J Cardiovasc Surg (Torino) 2003;44:719-24.  Back to cited text no. 7
8.Kaplan R, Abramowitz MD, Epstein BS. Nitrous oxide and air-filled balloon-tipped catheters. Anesthesiology 1981;55:71-3.  Back to cited text no. 8
9.Iberti TJ, Benjamin E, Gruppi L, Raskin JM. Ventricular arrhythmias during pulmonary artery catheterization in the intensive care unit. Prospective study. Am J Med 1985;78:451-4.  Back to cited text no. 9
10.Shah KB, Rao TL, Laughlin S, El-Etr AA. A review of pulmonary artery catheterization in 6,245 patients. Anesthesiology 1984;61:271-5.  Back to cited text no. 10

Correspondence Address:
Mukesh Tripathi
Type V B/20, Campus, SGPGIMS, Lucknow 226 014
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0971-9784.95078

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]