Perforación de la pared del ventrículo izquierdo por catéter de arteria pulmonar Swan-Ganz. A propósito de un caso / Perforation of the left ventricle wall due to the insertion of a pulmonary artery catheter. A case report

A pesar de la extendida y frecuente utilización del catéter de arteria pulmonar en nuestro medio para el manejo hemodinámico en pacientes críticos y particularmente en pacientes tras cirugía cardiaca, en la actualidad siguen planteándose dudas sobre la necesidad de su uso. Es preciso valorar el riesgo/beneficio de su colocación y tener en cuenta sus posibles complicaciones, que aun siendo poco frecuentes, pueden llegar a ser potencialmente graves. En este artículo exponemos una complicación muy poco frecuente ocurrida en nuestro centro sobre el uso del catéter de arteria pulmonar de la que no teníamos constancia hasta ahora. Se trata de una perforación del tabique interventricular y de la pared libre del ventrículo izquierdo debido a una acodadura firme del catéter de arteria pulmonar, que no fue sospechada ni diagnosticada salvo por la visión directa del corazón, tras la esternotomía, durante la cirugía cardiaca. La mejora de la seguridad del paciente implica reflexionar sobre el valor de los eventos adversos, de manera que al aumentar la conciencia de la situación y del mecanismo por el que se producen, pueda reducirse la probabilidad de repetición

Despite the widespread and frequent use in our setting of pulmonary artery catheters for haemodynamic management in critically ill patients, particularly after heart surgery, some experts continue to question the need for these devices. Clinicians need to weigh up the risks and benefits of pulmonary artery catheters placement and bear in mind the potential complications which, though rare, can be potentially fatal. We present a pulmonary artery catheters-related complication not hitherto described in the literature, involving perforation of the interventricular septum and left ventricular free wall caused by a kink in the pulmonary artery catheters that was not suspected, and only diagnosed by direct vision of the heart after pericardial opening. In the interest of patient safety, we must consider the impact of adverse events; improving our situational awareness and our understanding of the mechanisms behind such events can help reduce the likelihood of repetitions in the future

Perforation of the left ventricle wall due to the insertion of a pulmonary artery catheter. A case report. / Perforación de la pared del ventrículo izquierdo por catéter de arteria pulmonar Swan-Ganz. A propósito de un caso.

Despite the widespread and frequent use in our setting of pulmonary artery catheters for haemodynamic management in critically ill patients, particularly after heart surgery, some experts continue to question the need for these devices. Clinicians need to weigh up the risks and benefits of pulmonary artery catheters placement and bear in mind the potential complications which, though rare, can be potentially fatal. We present a pulmonary artery catheters-related complication not hitherto described in the literature, involving perforation of the interventricular septum and left ventricular free wall caused by a kink in the pulmonary artery catheters that was not suspected, and only diagnosed by direct vision of the heart after pericardial opening. In the interest of patient safety, we must consider the impact of adverse events; improving our situational awareness and our understanding of the mechanisms behind such events can help reduce the likelihood of repetitions in the future.