To the Editor:--A 39-yr-old (height 171 cm, weight 50 kg) man was scheduled for mitral valve replacement and tricuspid annuloplasty. Preoperative cardiac angiography showed severe mitral regurgitation and severe tricuspid regurgitation. Cardiac enlargement with a cardiothoracic ratio of 82% was seen on chest x-ray, and atrial fibrillation was present.

After induction of anesthesia with 5 mg diazepam and 1.5 mg fentanyl, insertion of a pulmonary artery catheter (PAC, Opticath model P7110-EH, Oximetrix, Mountain View, CA) via the right internal jugular vein was attempted. The catheter failed to advance from the right atrium into the right ventricle, presumably because of regurgitant flow at the tricuspid valve. The PAC balloon was deflated, after which the catheter tip passed easily into the right ventricle. The PAC balloon was inflated, and the catheter was easily advanced into the pulmonary artery. Insertion length was 48 cm. When the surgery began and the right atrium was opened, the PAC was found to be passing between the chordae tendineae of the posterior leaflet of the tricuspid valve (Figure 1).

If we had not recognized this problem early and had attempted to withdraw the catheter while the balloon was inflated, the chordae tendineae might have been ruptured. Although we have not experienced such a complication, the passage of a PAC through the chordae tendineae of the tricuspid valve may not be rare if the catheter is inserted with the balloon deflated in patients with tricuspid regurgitation.

Motoshi Kainuma, M.D., Associate Professor of Anesthesiology.

Morimasa Yamada, D.D.S., Assistant Professor of Anesthesiology.

Toshiyuki Miyake, M.D., Professor of Anesthesiology, Department of Anesthesiology, Fujita Health University, 1–98 Dengakugakubo, Kutsukake-cho Toyoake, Aich, Japan.

(Accepted for publication August 3, 1995.)

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