We appreciate Dr. Tewari’s comments (1) regarding our case report (2). The maneuver suggested by Dr. Tewari would have been impractical in our situation. Surgery was already in progress and we could directly visualize the pulmonary artery catheter (PAC) with the transesophageal echocardiography (TEE) images. The author who described the head-up and side-up technique for positioning of the PAC also used TEE to confirm positioning of the PAC in some cases (3). Direct visualization of the PAC with the already-placed TEE probe adequately confirms the position of the catheter.
Severe tricuspid regurgitation leads to systolic flow reversal in the coronary sinus (4). Although Mahmud et al. (5) showed that the coronary sinus dilation did not correlate with the severity of the tricuspid regurgitation, tricuspid regurgitation was severe in only nine patients and none of the patients had any structural abnormality of the tricuspid valve. Also, the study by Mahmud et al. only included patients with pulmonary hypertension and therefore these data might not apply to other patient groups.
Robina Matyal, MD
Feroze Mahmood, MD
Peter Panzica, MD
John Mitchell, MD
Adam Lerner, MD
Department of Anesthesia and Critical Care
Beth Israel Deaconess Medical Center
Harvard Medical School
1. Tewari P. Pulmonary artery catheter misplacement. Anesth Analg 2007;104:456.
2. Matyal R, Mahmood F, Panzica P, et al. Inadvertent placement of a flow-directed pulmonary artery catheter in the coronary sinus, detected by transesophageal echocardiography. Anesth Analg 2006;102:363–5.
3. Szabo Z. A simple method to pass pulmonary artery floatation catheter rapidly into the pulmonary artery in anaesthetized patients. Br J Anaesth 2003;90:794–6.
4. Zamorano J, Almeria C, Alfonso F, et al. Transesophageal Doppler analysis of coronary sinus flow: a new method to assess the severity of tricuspid regurgitation. Echocardiography 1997;14:579.
5. Mahmud E, Raisighani A, Kermati S, et al. Dilation of the coronary sinus on echocardiogram: prevalence and significance in patients with chronic pulmonary hypertension. J Am Soc Echocardiogr 2001;14:44–9.