[Intracardial knotting of a Swan-Ganz catheter. Description of a clinical case].

A 79 year old female was admitted to CTO Intensive Care Unit in the immediate postoperative period of orthopedic surgery. A Swan-Ganz fiber optic catheter was inserted through the right internal jugular vein but it was not possible to obtain a satisfactory tracing off pulmonary artery occlusion pressure. We experienced a remarkable trouble to withdraw the catheter in order to repeat the insertion. A chest-X-ray was performed and it showed a knot of the catheter in the right ventricle. It was possible to extract the knotted catheter through original venotomy so avoiding surgery. We want to emphasize that it is of fundamental importance in the insertion of the Swan-Ganz catheter to respect the recommended distances and to avoid repeated attempts to advance and withdraw the catheter.