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Rapid Echocardiographic Detection of a Massive Air Embolism in a Patient With a Single-Lung Transplant
Matteo Cameli, MD, Matteo Lisi, MD, Sergio Mondillo, MD, Luca Luzzi, MD, Elisa Bigio, MD, Luca Marchetti, MD, Bonizzella Biagioli, MD

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Abbreviations CVP, central venous pressure; ICU, intensive care unit

Received April 20, 2010, from the Department of Cardiovascular Diseases (M.C., M.L., S.M.), Thoracic Surgery Unit (L.L.), and Anesthesia and Intensive Care Units, Department of Surgery and Bioengineering (E.B., L.M., B.B.), University of Siena, Siena, Italy. Revision requested May 6, 2010. Revised manuscript accepted for publication May 17, 2010. Address correspondence to Matteo Cameli, MD, Department of Cardiovascular Diseases, University of Siena, Viale Bracci 1, 53100 Siena, Italy. E-mail: [email protected] Videos online at www.jultrasoundmed.org

46-year-old woman underwent a single-lung transplant for severe pulmonary fibrosis aggravated by recurrent episodes of a hypertensive pneumothorax and an emaciated state. On postoperative day 5, she was extubated, and a right internal jugular Swan-Ganz catheter was changed via a guide wire to a triple-lumen central venous pressure (CVP) line. For respiratory muscle fatigue, the patient needed several cycles of noninvasive ventilation and bronchoscopy, and for this reason, she was transferred out of the intensive care unit (ICU) on postoperative day 15. Approximately 2 hours after her transfer from the ICU, the patient became acutely confused, dyspneic, tachypneic (4050 breaths per minute), and tachycardic (120 beats per minute) and had severe rapid oxygen desaturation to approximately 45%, as measured by pulse oximetry. Urgent chest radiography showed modest nonspecific signs of edematous imbibition of the transplanted lung. Urgent bedside transthoracic echocardiography revealed hyperdynamic left ventricular function and dilatation of the right ventricle (42 mm) and pulmonary artery (33 mm) with preserved right ventricular function. The cavities of both right and left chambers contained numerous air bubbles (Figures 1 and 2 and Videos 1 and 2). This echocardiographic picture strongly suggested that a massive pulmonary and systemic air embolism, arising from right-to-left passage of intravenous air across a patent foramen ovale, was the etiology of the clinical presentation. The number of air bubbles increased substantially during inspiratory phases (Figure 3).

2010 by the American Institute of Ultrasound in Medicine J Ultrasound Med 2010; 29:15111513 0278-4297/10/$3.50

Rapid Echocardiographic Detection of an Air Embolism

Figure 1. Air bubbles in the left chambers moving to the aortic tract in a parasternal apical long-axis view. Ao indicates aortic bulb; asterisks, air bubbles; LA, left atrium; and LV, left ventricle.

Figure 2. A, Massive arrival of air bubbles in the right chambers of the heart. The right ventricular (RV) end-diastolic diameter was 42 mm. Some bubbles were also present in the left chambers. B, Thirty minutes later, no more air bubbles were seen in the right chambers. Note the normalization of right ventricular dimensions with a diameter of 30 mm. LA indicates left atrium; LV, left ventricle; and RA, right atrium.

Considering that patients with lung transplants can generate an enormous negative intrathoracic pressure and are generally emaciated and have little subcutaneous tissue, allowing for a short tract from the CVP insertion site to the opening of the central vein, an air embolism in this clinical setting is a less rare event and may also occur from infusion of fluids or medications through a central line. However, in this case, the presumable cause of the clinical picture was apparent closure of the CVP line with only a catheter clamp. Approximately 30 minutes after the first echocardiographic examination and subsequent CVP line adjustment, the cavities of both left and right chambers were free of air bubbles, and the right ventricular dimensions were substantially reduced (30 mm; Figure 2). Transesophageal echocardiography confirmed the presence of a patent foramen ovale.
Figure 3. A, Apical 4-chamber image showing a fair number of air bubbles moving form the right atrium to the right ventricle during an expiratory phase. B, Apical 4-chamber image showing a massive increase of air bubbles in the right chambers during an inspiratory phase.

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The patients persisting unstable conditions did not allow further examinations and required return to the ICU and sedation. The following day, after the cessation of sedation, left hemiparesis became evident. Fortunately, the patients neurologic and pulmonary conditions improved slowly until complete normalization 9 days after the critical event. Follow-up transthoracic echocardiography performed 2 months later showed normal right ventricular size and function as well as near-normal pulmonary arterial systolic pressure (30 mm Hg). Rapid diagnosis, quick referral for CVP line adjustment, and immediate intensive treatment most likely contributed to the good outcome. This case highlights the uncommon but potentially life-threatening complications1,2 of central line management and the clinical utility of echocardiography their its rapid evaluation.

References
1. Flanagan JP, Gradisar IA, Gross RJ, Kelly TR. Air embolus: a lethal complication of subclavian venipuncture. N Engl J Med 1969; 281:488489. Mennim P, Coyle CF, Taylor JD. Venous air embolism associated with removal of central venous catheter. BMJ 1992; 305:171172.

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