External

Name the Hardware

2. Findings and Diagnosis

Hardware in the Chest: Function, Appropriate Positioning, and Common Malpositioning

Hardware	Function	Appropriate Positioning	Common Malpositioning & Complications
Right IJ Venous Catheter/Introducer Sheath	Venous access for medications, fluids, or monitoring	Tip should project over the brachiocephalic/SVC junction	Arterial malposition (carotid or subclavian artery, risk of stroke), malposition into the right atrium (risk of arrhythmias), retrograde placement into the subclavian vein
Swan-Ganz Catheter (Pulmonary Artery Catheter)	Measures pulmonary artery pressures, cardiac output, and preload	Tip should be in the proximal right or left pulmonary artery	Too proximal in the right atrium (ineffective readings), too distal in the pulmonary artery branches (risk of infarction), rupture of the pulmonary artery (leading to massive hemorrhage or pseudoaneurysm [PSA])
Right and Left Basilar Chest Tubes	Drainage of pleural effusions, hemothorax, pneumothorax	Positioned at the lung bases within the pleural space	Intrathoracic malposition (intraparenchymal placement causing lung injury or hemorrhage), subcutaneous misplacement, incomplete insertion (ineffective drainage)
2 Mediastinal Chest Tubes	Drainage of postoperative mediastinal fluid or air	Positioned in the anterior mediastinum near the cardiac silhouette	Too posterior (ineffective drainage), dislodgement, kinked tubing, injury to great vessels or heart
Enteric Tube	Provides enteral feeding and decompression	Tip should be within the fundus of the stomach	Placement in the trachea or bronchus (risk of aspiration pneumonia), esophageal coiling, pleural placement causing pneumothorax (PTX)
Right Upper Extremity Midline/PICC (Peripherally Inserted Central Catheter)	Long-term IV access for medications, fluids, or nutrition	Tip should project over the axilla or terminate in the SVC	Arterial malposition (risk of stroke or limb ischemia), misplacement into the jugular vein, azygos vein, or right atrium
Median Sternotomy Wires (7 wires)	Maintain sternal stability post-cardiac surgery	Intact and should be seen over the sternum	Fractured or displaced wires, sternal nonunion (if wires are widened or disrupted)
Mediastinal Surgical Clips	Mark sites of previous surgical intervention	Appear over the mediastinum	Migration of clips (risk of embolization to vessels, bronchi, or peritoneal cavity in diaphragmatic repairs)
Cardiac Impella Device	Temporary mechanical circulatory support by unloading the left ventricle	Tip should project into the left ventricle	Displacement into the ascending aorta (ineffective support), migration into the left atrium, vascular perforation
Inferior Approach ECMO Catheter	Provides veno-arterial (VA) extracorporeal life support	Tip should project over the right atrium	Misplacement in the hepatic vein, too distal into the right ventricle (risk of arrhythmias), too proximal (ineffective flow), arterial injury
Epicardial Pacing Wires	Temporary cardiac pacing post-cardiac surgery	Thin wires seen over the cardiac silhouette	Dislodgement (risk of pacemaker failure), migration into the pericardium or pleural space
Superficial Surgical Clips (Right Lower Neck)	Mark sites of prior surgical intervention or vessel ligation	Should project over the right lower neck	Clip migration (rare but can embolize to vessels or airways)
Epicardial Temporary Pacing Wire	Provides temporary pacing of the heart postoperatively	Positioned near the cardiac silhouette	Displacement leading to ineffective pacing, wire fracture

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Key Takeaways:

• Venous catheters can malposition into arteries, causing stroke, limb ischemia, or arterial injury.
• Swan-Ganz catheters may rupture the pulmonary artery, leading to massive hemorrhage or pseudoaneurysm (PSA).
• Chest tubes should be placed in the pleural space—malposition in lung parenchyma can cause lung laceration or hemorrhage.
• Enteric tubes should always be confirmed in the stomach—pleural misplacement can cause pneumothorax (PTX).

1. Which coronary artery is typically responsible for supplying the anterior wall of the left ventricle?

A) Right coronary artery (RCA)
B) Left circumflex artery (LCx)
C) Posterior descending artery (PDA)
D) Left anterior descending artery (LAD)

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2. What embryologic structure gives rise to the left ventricle?

A) Truncus arteriosus
B) Bulbus cordis
C) Sinus venosus
D) Primitive ventricle

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🩺 Clinical

3. What is the most likely cause of cardiogenic shock in this patient?

A) Left ventricular failure due to anterior STEMI
B) Septic shock
C) Pericardial tamponade
D) Massive pulmonary embolism

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4. Which imaging finding best correlates with mechanical circulatory support in this patient?

A) Enteric feeding tube
B) Chest tubes
C) Impella device in the left ventricle
D) Mediastinal clips

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🩻 Radiology

5. What is a serious complication of Swan-Ganz catheter misplacement?

A) Hemothorax
B) Pulmonary artery rupture
C) Pleural effusion
D) Lobar pneumonia

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6. Which device on imaging should project over the right atrium if placed correctly?

A) ECMO catheter (inferior approach)
B) Left basilar chest tube
C) Sternotomy wire
D) Enteric tube

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✅ Answer Key & Explanations

1. Answer: D — Left anterior descending artery (LAD)

• The LAD supplies the anterior wall and septum — most commonly affected in anterior STEMI.

• Incorrect:

  • RCA → inferior wall

  • LCx → lateral wall

  • PDA → inferior septum

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2. Answer: D — Primitive ventricle

• The left ventricle develops from the primitive ventricle.

• Incorrect:

  • Truncus arteriosus → aorta & pulmonary trunk

  • Bulbus cordis → right ventricle & outflow

  • Sinus venosus → atria & vena cava

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3. Answer: A — Left ventricular failure due to anterior STEMI

• Severe EF drop, anterior akinesis, and LAD occlusion explain the cardiogenic shock.

• Incorrect:

  • Septic shock → no signs of infection

  • PE → no RV strain

  • Tamponade → no effusion on echo

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4. Answer: C — Impella device in the left ventricle

• Impella provides temporary LV mechanical support.

• Incorrect:

  • Feeding tube → for nutrition

  • Chest tubes → drain air/fluid

  • Clips → surgical markers only

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5. Answer: B — Pulmonary artery rupture

• Swan-Ganz placed too far can rupture PA → hemorrhage or pseudoaneurysm.

• Incorrect:

  • Hemothorax → more common with chest tubes

  • Pleural effusion → not Swan-Ganz related

  • Pneumonia → unrelated to catheter placement

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6. Answer: A — ECMO catheter (inferior approach)

• Tip should terminate in the right atrium for veno-arterial ECMO.

• Incorrect:

  • Chest tube → pleural space

  • Sternotomy wire → over sternum, not cardiac chamber

  • Feeding tube → stomach

  • 1. Which coronary artery is typically responsible for supplying the anterior wall of the left ventricle?

    A) Right coronary artery (RCA)
    B) Left circumflex artery (LCx)
    C) Posterior descending artery (PDA)
    D) Left anterior descending artery (LAD)

    ✅ Correct Answer: D — Left anterior descending artery (LAD)

    • The LAD is the primary blood supply to the anterior wall and anterior septum of the left ventricle.

    ❌ Incorrect Answers:

    • A) RCA supplies the inferior wall and right ventricle.

    • B) LCx supplies the lateral wall of the LV.

    • C) PDA supplies the inferior septum and posterior wall.

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    2. What embryologic structure gives rise to the left ventricle?

    A) Truncus arteriosus
    B) Bulbus cordis
    C) Sinus venosus
    D) Primitive ventricle

    ✅ Correct Answer: D — Primitive ventricle

    • The primitive ventricle forms the future left ventricle during cardiac development.

    ❌ Incorrect Answers:

    • A) Truncus arteriosus becomes the aorta and pulmonary trunk.

    • B) Bulbus cordis contributes to the right ventricle and outflow tract.

    • C) Sinus venosus contributes to the atria and great veins.

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    🩺 Clinical

    3. What is the most likely cause of cardiogenic shock in this patient?

    A) Left ventricular failure due to anterior STEMI
    B) Septic shock
    C) Pericardial tamponade
    D) Massive pulmonary embolism

    ✅ Correct Answer: A — Left ventricular failure due to anterior STEMI

    • The LAD was occluded, leading to extensive anterior/apical wall motion abnormalities and low EF (25%).

    ❌ Incorrect Answers:

    • B) Septic shock presents with signs of infection and vasodilation — not present here.

    • C) Tamponade would show large effusion or diastolic collapse — not seen.

    • D) PE often involves RV dysfunction — not described in this case.

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    4. Which imaging finding best correlates with mechanical circulatory support in this patient?

    A) Enteric feeding tube
    B) Chest tubes
    C) Impella device in the left ventricle
    D) Mediastinal clips

    ✅ Correct Answer: C — Impella device in the left ventricle

    • The Impella is a temporary mechanical circulatory support device that unloads the LV.

    ❌ Incorrect Answers:

    • A) Feeding tube provides nutrition, not circulatory support.

    • B) Chest tubes manage air or fluid — not heart function.

    • D) Surgical clips are inert and used for localization only.

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    🩻 Radiology

    5. What is a serious complication of Swan-Ganz catheter misplacement?

    A) Hemothorax
    B) Pulmonary artery rupture
    C) Pleural effusion
    D) Lobar pneumonia

    ✅ Correct Answer: B — Pulmonary artery rupture

    • Over-advancement of the catheter can cause rupture of the PA, resulting in life-threatening hemorrhage or pseudoaneurysm.

    ❌ Incorrect Answers:

    • A) Hemothorax is more common with chest tube misplacement.

    • C) Pleural effusion may occur postoperatively but is not a Swan-Ganz complication.

    • D) Pneumonia is unrelated to catheter placement.

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    6. Which device on imaging should project over the right atrium if placed correctly?

    A) ECMO catheter (inferior approach)
    B) Left basilar chest tube
    C) Sternotomy wire
    D) Enteric tube

    ✅ Correct Answer: A — ECMO catheter (inferior approach)

    • ECMO catheter inserted via femoral vein should terminate in the right atrium for effective veno-arterial support.

    ❌ Incorrect Answers:

    • B) Chest tubes should lie in the pleural space, not the heart.

    • C) Sternotomy wires are surgical markers — not devices with intracardiac position.

    • D) Enteric tube should end in the stomach.

  • Memory Image

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Memory Image?  – not really Just a fun image