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BACKGROUND: The role of Swan-Ganz catheterization for cardiac surgery and perioperative management has recently been scrutinized. METHODS: Prospective observational study for serious complications related to Swan-Ganz catheterization. 7150 patients undergoing cardiac operations at a major European heart center and academic setting. 3730 Swan-Ganz catheter placements for cardiac surgery (7.5 French Swan-Ganz Catheter Baxter, heparin coated). RESULTS: We observed four serious complications related to Swan-Ganz catheterization and placement (0.1%): A right ventricular free wall perforation occurred, one trouble with knotting, and two pulmonary artery ruptures. The right ventricular perforation was controlled with a suture, the knot was tightened, and the catheter withdrawn through insertion. The first case of pulmonary artery rupture was treated conservatively. All of these patients survived. The other pulmonary artery rupture occurred during coronary artery bypass grafting. Emergency lobectomy was performed. This patient died due to bleeding during the early postoperative course. CONCLUSION: The incidence of serious Swan-Ganz catheter complications in our patient population is comparable to the incidence reported in the literature. Based on these results the use of Swan-Ganz catheters in cardiac surgery is still justified since the rate of associated serious complications is extremely low. Despite the rare occurrence of serious complications and the infrequent fatal outcomes, the benefit of its use in selected cases of cardiac surgery overweight its associated complications.