Background:
We experienced a rare malposition of a pulmonary artery catheter due to kinking in a 63-year-old male who was scheduled for an off-pump coronary artery by-pass graft.
Findings:
Given the difficulty to obtain stable pulmonary artery waveform, we discovered that the two waveforms of the distal and proximal ports of the pulmonary artery catheter were completely identical. Subsequent fluoroscopy revealed that because the catheter had formed a kink around the apex of the right ventricle, the distal port faced the proximal port of the catheter.
Conclusions:
We recommend that both ports of the pulmonary artery catheter need to be monitored simultaneously in case neither portable fluoroscopy nor transesophageal echo is available.