Knotting of Swan–Ganz and Central Venous Catheters in a Post-Heart Transplant Patient on Extracorporeal Membrane Oxygenation: A Rare Case Report

Background: The Swan–Ganz catheter is widely used for hemodynamic monitoring in critical care, particularly during the perioperative management of cardiac patients. Although complications such as catheter knotting are rare, these complications typically occur during or immediately after catheter insertion. Case: We report a unique case of delayed catheter knotting in a 63-year-old male who underwent heart transplantation while receiving venoarterial extracorporeal membrane oxygenation (ECMO) support. The patient initially presented with acute myocardial infarction, refractory heart failure, and multivessel coronary artery disease. Following an unsuccessful emergent coronary intervention, a heart transplant was performed. A Swan–Ganz catheter and a central venous catheter (CVC) were inserted pre-transplantation for monitoring purposes. Postoperatively, right atrial, right ventricular (RV), and pulmonary artery pressures (PAPs) were within normal ranges for the first 48 hours. However, at 55 hours post-transplant, only the right atrial pressure remained detectable, with loss of RV and PAP waveforms. A chest X-ray revealed a rare double-knot entanglement between the Swan–Ganz catheter and the CVC, prompting an urgent multidisciplinary consultation. Given the critical status of the patient, surgical removal via open thoracotomy was performed, successfully resolving the complication. The patient recovered well and remained asymptomatic at the one-year follow-up. This case underscores the uncommon, delayed onset of catheter entanglement, potentially associated with hemodynamic shifts following the transition from adrenaline to dobutamine. The reduced compliance and structural vulnerability of the transplanted heart may have contributed to this complication. The initial bedside ultrasound was inconclusive, highlighting the utility of early chest radiography in similar cases. Conclusions: Delayed catheter knotting is a rare but serious complication in heart transplant recipients, particularly those under ECMO support. Thus, proactive imaging and vigilant monitoring during transitions to vasoactive medications are essential to prevent such complications. Additional research is warranted to establish preventive measures and optimize management strategies for patients at high risk of complications.