Anomalous Venous Drainage with Death from Cardiac Catheterisation

D E A T H D URI N G cardiac catheterisation is fortunately rare. Instances have been attributed to ventricular fibrillation in cases of Epstein's anomaly (Henderson, et al. 1953) and to catheterisation of the coronary sinus (McMichael & Mounsey, 1951). Endocardial damage has been described leading to death later (Goodwin, 1953) and the" wedge catheter" technique in pulmonary artery catheterisation has led to pulmonary artery thrombosis with a fatal outcome (Nightingale & Williams, 1955). We ourselves have had a case of atrial septal defect in which thrombosis of the superior vena cava followed catheterisation and death resulted a month later from multiple pulmonary emboli. The present death, however, seems to have been brought about mechanically in a case of anomalous venous drainage and it differs from any hitherto described. We feel that certain lessons may be learned from it which may perhaps help others to avoid similar tragedies.