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The present study was conducted to correlate PCWP estimated by Doppler Echocardiography with that obtained by Swan-Ganz catheter in patients with post coronary artery bypass graft surgery and to evaluate the feasibility and accuracy of Doppler Echocardiographic data. The present study provides evidence that in patients with coronary artery disease who underwent elective CABG surgery, PCWP can be reliably and accurately estimated by combining Doppler Echocardiographic variables of mitral flow and Tissue Doppler imaging and the relationship between E/Ea ratio and measured PCWP by Swan Ganz catheter was the strongest of all Doppler variables determined.

Pneumothorax and pneumomediastinum are known complications of COVID-19 patients. They have been documented to occur both with and without mechanical ventilation. There are several reports of cases further complicated by alveolopleural or bronchopleural fistulas. However, there are no studies and only a few case reports on the treatment options used for alveolopleural fistulas in COVID-19 patients. To our knowledge, there is only one report of bronchoscopic treatment with endobronchial valves in a COVID-19 patient. We present the case of a 63-year-old male with COVID-19, pneumothorax, and an alveolopleural fistula that was successfully sealed using bronchoscopic occlusion with a Swan-Ganz catheter.

Inadvertent fixation of a Swan-Ganz pulmonary artery catheter by a suture is a rare complication. We present a case report of a patient undergoing heart transplantation in whom the catheter was fixed by a suture at the upper venous cannulation site for the cardiopulmonary bypass. After diagnostics with fluoroscopy the chest was reopened and the suture was released. The catheter could then be removed. The patient did not suffer from any consequential damage. Die akzidentelle Fixierung eines Pulmonalarterienkatheters durch eine Naht ist eine seltene Komplikation. Dieser Fall handelt von einem Patienten zur Herztransplantation, bei dem der Katheter mittels Naht an der oberen venösen Kanülierungsstelle der Herz-Lungen-Maschine fixiert wurde. Nach Diagnostik mittels Fluoroskopie erfolgten die Resternotomie und die Lösung der Naht, woraufhin sich der Katheter entfernen ließ. Der Patient trug keine Folgeschäden davon.

A Swan‐Ganz catheter during cardiac surgery offers peri‐operative haemodynamic monitoring, although insertion of these catheters is not without risk. We report a case of Swan‐Ganz catheter entrapment within the tricuspid valve during elective off‐pump coronary artery bypass surgery. The diagnosis was made immediately by transoesophageal echocardiography, thus preventing forced withdrawal of the catheter. Intra‐operatively, the echocardiographically detected findings of complex entrapment was confirmed. The Swan‐Ganz catheter was tightly wrapped around the subvalvular apparatus, requiring on‐pump open surgical removal. This case illustrates the anatomical complexity of such a catheter entrapment around the tricuspid valve apparatus and the importance of rapid echocardiographic diagnosis to prevent iatrogenic damage.

Assessing hemodynamics, especially central venous pressure (CVP), is essential in heart failure (HF). Right heart catheterization (RHC) is the gold-standard, but non-invasive methods are also needed. However, the role of 2-dimensional echocardiography (2DE) remains uncertain, and 3-dimensional echocardiography (3DE) is not always available. This study investigated standardized and breathing-corrected assessment of inferior vena cava (IVC) volume using echocardiography (2DE and 3DE) versus CVP determined invasively using RHC. Sixty consecutive HF patients were included (82% male, age 54 ± 11 years, New York Heart Association class 2.23 ± 0.8, ejection fraction 46 ± 18.4%, brain natriuretic peptide 696.93 ± 773.53 pg/mL). All patients underwent Swan-Ganz RHC followed by 2DE and 3DE, and IVC volume assessment. On 2DE, mean IVC size was 18.3 ± 5.5 mm and 13.8 ± 6 mm in the largest deflection and shortest distention, respectively. Mean CVP from RHC was 9.3 ± 5.3 mmHg. Neither 2DE nor 3DE showed acceptable correlation with invasively measured CVP; IVC volume acquisition showed optimal correlation with RHC CVP (0.64; 95% confidence interval 0.46–0.77), with better correlation when mitral valve early diastole E wave and right ventricular end-diastolic diameter were added. Using a CVP cut-point of 10 mmHg, receiver operating characteristic curve showed true positivity (specificity) of 0.90 and sensitivity of 62% for predicting CVP. A validation study confirmed these findings and verified the high predictive value of IVC volume assessment. Neither 2DE nor 3DE alone can reliably mirror CVP, but IVC volume acquisition using echocardiography allows non-invasive and adequate approximation of CVP. Correlation with invasively measured pressure was strongest when CVP is > 10 mmHg.

The year 2020 marks the 50th anniversary of the landmark publication on the bedside clinical use of a flow-directed catheter. The catheter, now known as the Swan-Ganz catheter, truly revolutionized practice and care of the critically ill. Use of the catheter proliferated nearly without rigorous validation or evidence base until a moratorium was called in regard to its use. This article describes the history of the development of the Swan-Ganz catheter, its uses, and its near downfall. The authors, both involved in educating clinicians in the use of the pulmonary artery catheter, hope that telling this story shares tribal knowledge and lessons learned with newer generations of nurses who did not experience the explosion of development and knowledge in the area of hemodynamic monitoring. Partly because of advances in technology, and the catheter’s application for heart failure in particular, use of the pulmonary catheter is being resurrected.

The pulmonary artery catheter is a valuable tool available to the clinician for use in deciphering complex hemodynamic scenarios. Patients in shock, particularly those who are elderly or have premorbid conditions such as heart failure, may have atypical presentations. Additional hemodynamic data may help identify interventions that might seem counterintuitive, such as the use of vasoconstrictors in patients with low cardiac output. Interpretation of pulmonary artery hemodynamic data is a skill that should not be relegated to the past. This article reviews the use of a pulmonary artery catheter in mixed shock states. A case study is used to demonstrate how pulmonary artery catheter hemodynamic values can guide the care of these patients.

To the Editor, We present the case of a 65-year-old woman without any known drug allergies and with a previous cardiac history of atrial fibrillation treated with warfarin and rheumatic poly-valve disease with double mitral valve lesion (severe mitral stenosis and moderate-to-severe mitral regurgitation) and severe tricuspid regurgitation with indirect data of pulmonary hypertension admitted due to progressive worsening of her usual dyspnea until becoming dyspnea of minimal exertion and with important limitations in activities of daily living.

Despite the widespread and frequent use in our setting of pulmonary artery catheters for haemodynamic management in critically ill patients, particularly after heart surgery, some experts continue to question the need for these devices. Clinicians need to weigh up the risks and benefits of pulmonary artery catheters placement and bear in mind the potential complications which, though rare, can be potentially fatal. We present a pulmonary artery catheters-related complication not hitherto described in the literature, involving perforation of the interventricular septum and left ventricular free wall caused by a kink in the pulmonary artery catheters that was not suspected, and only diagnosed by direct vision of the heart after pericardial opening. In the interest of patient safety, we must consider the impact of adverse events; improving our situational awareness and our understanding of the mechanisms behind such events can help reduce the likelihood of repetitions in the future.

The aim of the present investigation was to retrospectively evaluate the utilization of Swan-Ganz catheter during orthotopic liver transplantation as opposed to FloTrac/Vigileo in selected cases, comparing a number of clinical outcomes across postoperative hospitalization.Before 2015 all recipients received pulmonary artery catheter (Swan-Ganz group, n = 109). After 2015 Swan-Ganz was used only if coronary artery disease or high-grade portal hypertension or Child-Pugh C were present; the remaining recipients were assigned to FloTrac/Vigileo monitoring (Mini group, n =100). A number of clinical outcomes were considered.Donor's Risk Index was similar between groups (median value 1.7, P = .27). Anthropometric characteristics of the recipients were similar in the 2 groups. There were no significant differences in the proportion of patients with Child-Pugh C (P = .873), coronary artery disease (P = .18), and grade of portal hypertension (P = .733). The Model for End-Stage Liver Disease score was slightly higher in the Mini group: (9 [7-11] vs 9 [8-12], Swan-Ganz vs Mini, respectively, P .035). Swan-Ganz utilization decreased over time (92% vs 26%, Swan-Ganz vs Mini, P .001). Upon admission to the intensive care unit, patients of the Mini group presented a higher SAPS II score with similar values of Sequential Organ Failure Assessment score. Days on mechanical ventilation were similar between groups. The incidence of graft failure was similar between groups (2% vs 5%, Swan-Ganz and Mini group respectively, P = .376). Recipients' hospital length of stay was similar (13 days [11-19] vs 14 [11-20], P .083).Our data suggest that the intraoperative utilization of FloTrac/Vigileo for oncologic patients with low grade end stage liver disease is reasonably safe.

espanolIntroduccion: La cirugia mediante mini-toracotomia lateral presenta ventajas comparativas sobre el acceso convencional comomenor trauma quirurgico, reducida morbimortalidad y un resultado estetico superior, pero plantea dificultades en caso denecesitar estimulacion electrica temporal.Objetivo: Valorar el empleo terapeutico del cateter de Swan-Ganz con marcapasos incorporado como solucion a dicho problemay analizar sus complicaciones.Material y metodos: Se incluyeron pacientes programados para cirugia mini-invasiva mitral mediante mini-toracotomia lateral.Se definio empleo terapeutico del cateter al uso debido a bradiarritmias o trastornos de conduccion o necesidad de incrementarla frecuencia cardiaca con fines hemodinamicos. Pacientes intervenidos de urgencia o emergencia, fueron excluidos del estudio.Resultados: Fueron incluidos 517 pacientes (289 de sexo masculino, con edad promedio de 68,3 ± 10,4 anos); se efectuaron 115(22,2%) reemplazos y 402 (77,7%) plasticas mitrales. Simultaneamente, se realizaron 294 (56,9%) procedimientos de Maze, 182(35,2%) cierres de orejuela izquierda, 9 (1,7%) cierres de defectos septales y 14 (2,7%) plasticas tricuspideas. Ciento sesenta ydos (313%) pacientes necesitaron ser marcapaseados; debido a bradiarritmias, 85 (52,47%) pacientes; por trastornos de conduccion,50 (30,86%) pacientes; mientras que otros 27 (16,66%) requirieron incrementar su frecuencia debido a bajo volumenminuto. La mortalidad resulto de 12 (2,32%) casos. Catorce (2,7%) pacientes presentaron perdida de captura y se resolvieroncon el reposicionamiento del cateter, mientras que 2 (0,6%) pacientes presentaron atrapamiento y requirieron reintervencion.Conclusiones: Casi un tercio de los pacientes intervenidos mediante mini-toracotomia lateral requirieron del empleo terapeuticodel cateter de Swan-Ganz con marcapasos. Dos pacientes presentaron atrapamiento y requirieron resolucion quirurgica. EnglishThe use of a lateral mini-thoracotomy presents several advantages over the standard access, such as less surgical trauma, reduced morbidity and mortality, shorter recovery time and better cosmetic results, but presents difficulties iftemporary pacing is required.Objective: The aim of this study was to evaluate the therapeutic use of a Swan-Ganz catheter with pacing capabilities andanalyze its complications.Methods: Patients undergoing scheduled minimally invasive mitral valve surgery through lateral mini-thoracotomy wereincluded in the study. Therapeutic use of the pacing catheter was defined as the need for pacing due to bradyarrhythmiasor conduction disorders or need of increasing heart rate in case of hemodynamic instability. Patients undergoing urgent oremergency surgery were excluded from the study.Results: A total of 517 patients were included in the study; mean age was 68.3 ± 10.4 years and 289 (55.9%) were men; 115 patients(22.2%) underwent mitral valve replacement and 402 (77.7%) mitral valve repair. The following concomitant procedureswere carried out: 294 (56.9%) Maze procedures, 182 (35.2%) left atrial appendage closures, 9 (1.7%) atrial septal defect closuresand 14 (2.7%) tricuspid valve repair surgeries. In the postoperative period 162 (31.3%) patients required pacing due to bradyarrhythmiasin 85 cases (52.47%), conduction disorders in 50 (30.86%), and need to increase heart rate in 27 (16.66%) patientswith low cardiac output syndrome. Postoperative mortality was 2.32% (n=12). Fourteen (2.7%) patients presented loss of capturethat was resolved with catheter repositioning, while 2 (0.6%) patients presented catheter entrapment requiring reintervention.Conclusion: Almost one-third of the patients undergoing lateral mini-thoracotomy required therapeutic use of the pacingSwan-Ganz catheter. Two patients presented catheter entrapment and required surgical reintervention

On the 50th anniversary of the invention of the Swan-Ganz catheter, the untold, intimate details of its development deserve recounting, in part because it illustrates how often advances in science require equal measures of brilliant intuition, persistence in adversity, stunning serendipity, plain

Background Early mobilization of patients in the intensive care unit can be beneficial, but evidence is insufficient to indicate whether allowing patients with an indwelling pulmonary artery catheter to walk is safe. Objective To describe the physiological and emotional responses to ambulation in patients with heart failure and a pulmonary artery catheter. Methods This prospective, descriptive study included 19 patients with heart failure monitored with a pulmonary artery catheter in a cardiac intensive care unit. Each patient, accompanied by a nurse, walked with continuous observation of heart rate and rhythm and pulmonary artery tracing on a transport monitor. Pulmonary artery catheter position and waveform, arrhythmias, and perceived levels of exertion and fatigue were recorded before and after each walk. The distance ambulated was documented. One to 3 times per week, nurses administered a questionnaire addressing patients’ sense of well-being. Results The 19 patients had 303 walks (range, 1–68; median, 7). During 7 patient walks (2.4%), catheter migration of 1 to 5 cm occurred, but no arrhythmias or waveform changes were observed. Changes in exertion and fatigue were significant (P < .001, paired t test), but levels of both were minimal after walking. Patients expressed physical and emotional benefits of walking. Conclusions This study provides preliminary evidence that for hemodynamically stable patients with heart failure, ambulating with a pulmonary artery catheter is safe and enhances their sense of well-being. The presence of an indwelling pulmonary artery catheter should not preclude walking.

Tubes and Catheters are very important devices for saving patients' lives. There is a variety of tubes and Catheters; those especially used during this study are: Endotracheal tube (ETT), Nasogastric (NG)], and Swan Ganz catheter. Errors in positioning these kinds of devices, if not detected early my caused crucial complications (even death). Airway tube malposition in adult patients intubated is seen in up to 25% of cases. Doctors and nurses use checklists to make sure the medical procedure goes smoothly, but these steps take a long time and more resources with the possibility of human errors during verification protocols especially when hospitals are at full capacity. In this article, we propose using transfer learning to train and compare several Keras applications on classification tube problems; the best-selected networks can help in the development of CAD (Computer Aided Detection). The main advantage of using a single Deep Convolutional Neural Network DCNN to detect abnormal positioning of several lines based on chest X-ray image processing is to avoid the complexity caused by using a DCNN (Deep Convolutional Neural Network) network for each type of line. Efficient DCNN can detect abnormal positioning in real-time and immediately notify doctors to adjust tube position. All tested networks during this work are improved after augmentations and parameters tuning, we get the best score for Resnet50V2 model AUC (80%).

Funding Acknowledgements Type of funding sources: Private hospital(s). Main funding source(s): Sanatorium Mitre Introduction invasive hemodynamic monitoring with Swan-Ganz catheter (SGC) has been the gold standard to determine the cardiac index. However, in many centres is not always available, and the Fick method is also validated for that purpose, but without the same accuracy. There are other used laboratory parameters; nonetheless there is lack of evidence about its association with the cardiac index. We aim to describe the association between these parameters and the patient"s hemodynamic condition. Objectives to assess the association between hemodynamic parameters obtained by SGC and data obtained with a jugular central venous catheter, in critically ill cardiac patients hospitalised in the Intensive Care Unit. Methods prospective, double-blind, observational study, conducted from September 2019 to November 2020. A total of 45 patients with SGC were enrolled. We measured cardiac output and cardiac index (by thermodilution method and Fick estimated method), other hemodynamic parameters, lactic acid, central venous oxygen saturation (CVO2) and venous-to-arterial carbon dioxide difference (VACO2). The variables were analysed with t-test, Wilcoxon and chi2, as appropriate. Statistical significance was assumed when p was less than .05. Results we analysed 45 patients (mean age 58 years; 87% men; 23% postoperative cardiac surgery subjects; mean ejection fraction 30%). We registered a 6% in-hospital mortality and the mean in-hospital stay was 19 days (IQR 25-75: 8-25). We observed a significative correlation between impaired cardiac index (≤2.2 L/min/m2) obtained by SGC and Fick method (r 0.43; p= .0041). Elevated lactic acid and reduced CVO2 were not well correlated with impaired cardiac index (r 0.51, CI 95%: 0.32-0.71; r 0.30, CI 95%: 0.13-0.48; respectively). Among patients with impaired cardiac index, all of them had a VACO2 over 7 mmHg. The c-statistic to predict impaired cardiac index using VACO2 over 7 mmHg was 0.66 (CI 95%: 0.48-0.84), correlation not observed for the CVO2 values. Elevated lactic acid (≤1.9 mmol/L) was only associated with noradrenaline infusion over 0.7 g/kg/min (c-statistic 0.55; p= .0002). Conclusions when invasive hemodynamic monitoring with SGC is not available, the VACO2 value over 7 mmHg (obtained with a central venous catheter) appeared to be a better predictor of impaired cardiac index than the determination of CVO2. The Fick method was an acceptable replacement of the invasive monitoring. Also, noradrenaline infusion over 0.7 g/kg/min, but not cardiac index or other laboratory parameters, showed a better correlation with elevated lactic acid.

Background Pulmonary artery thermodilution is the clinical reference method for cardiac output monitoring. Because both continuous and intermittent pulmonary artery thermodilution are used in clinical practice it is important to know whether cardiac output measurements by the two methods are clinically interchangeable. Methods We performed a systematic review and meta-analysis of clinical studies comparing cardiac output measurements assessed using continuous and intermittent pulmonary artery thermodilution in adult surgical and critically ill patients. 54 studies with 1522 patients were included in the analysis. Results The heterogeneity across the studies was high. The overall random effects model-derived pooled estimate of the mean of the differences was 0.08 (95%-confidence interval 0.01 to 0.16) L/min with pooled 95%-limits of agreement of − 1.68 to 1.85 L/min and a pooled percentage error of 29.7 (95%-confidence interval 20.5 to 38.9)%. Conclusion The heterogeneity across clinical studies comparing continuous and intermittent pulmonary artery thermodilution in adult surgical and critically ill patients is high. The overall trueness/accuracy of continuous pulmonary artery thermodilution in comparison with intermittent pulmonary artery thermodilution is good (indicated by a pooled mean of the differences PROSPERO registration number CRD42020159730.

Background Accurate volume status assessment is crucial for the treatment of acute decompensated heart failure (ADHF). Volume status assessment by physical exam is inaccurate, necessitating invasive measurement with right heart catheterization (RHC), which carries safety, pragmatic (scheduling, holding anticoagulants, etc) and financial burdens. Therefore, a reliable, non-invasive, cost-effective alternative is desired. Previously, we developed an ultrasound (US) based technique to measure internal jugular vein (IJV) compliance during RHC which was used for single time point central venous pressure (CVP) predictions. We now aim to apply this technique to track acute changes in CVP during diuresis for ADHF in patients with an in-dwelling pulmonary artery catheter. Purpose The objective of our study was to devise a rapid, portable and reliable alternative to RHC to track acute volume changes during treatment of ADHF. Methods We used an observational, prospective study design and recruited 15 patients from the CCU between 7/19–12/19 being treated for ADHF (systolic or diastolic) with IV diuretics +/−inotropic agents who underwent PA catheter insertion for continuous CVP monitoring. 13 of 15 patients received milrinone infusions. US images of the IJV were obtained at end expiration and during the strain phase of Valsalva at multiple 2–3 hr intervals. Change in IJV cross sectional area (ImageJ) was used as a measure of IJV compliance. Patients unable to perform the Valsalva maneuver and on mechanical circulatory support were excluded. Results Calculated % change in CSA of IJV was plotted against CVP. An inverse relationship was observed between CVP and % change in CSA of IJV. The data was fit with an inverse exponential regression shown in Figure 1 (R2=0.36, root mean square error = 3.19). Fivefold cross validation showed a stable model for predicting CVP based CSA (R2=0.34, root mean square error = 3.26) Conclusion Serial portable US assessment of IJV compliance can act a surrogate measure of CVP and,therefore, can provide reliable information on acute hemodynamic changes in ADHF. Funding Acknowledgement Type of funding source: None

Background The Swan-Ganz catheter plays an important role in gaining understanding of cardiac pathophysiology and in the hemodynamic monitoring of critically ill patients. Difficult removal of the Swan-Ganz catheter is a rare but serious complication. Case presentation This case presents the difficult removal of a Swan-Ganz catheter in a 28-year-old female patient after cardiac surgery. Fluoroscopy and chest X-ray revealed that a portion of the Swan-Ganz catheter was coiled on the central venous catheter at the level of the superior vena cava. Under X-ray guidance, the central venous catheter was first removed, and then the Swan-Ganz catheter was successfully withdrawn through the percutaneous introducer sheath. Conclusions This case report provides an unreported reason for difficult removal and describes a successful solution. This report suggests that X-ray examinations may be necessary before removing the Swan-Ganz catheter.

Introduction The Pulmonary Artery Catheter (PAC) Swan-Ganz, despite the widespread rumours regarding the possible complications that correlate with its insertion, such as the pulmonary artery rupture, is still - in the experienced hands - an essential tool of hemodynamic monitoring in cardiac surgery. In combination with Transoesophageal Echocardiography (TOE) though, they offer to the Anaesthesiologist an integrated profile of pressure, volume, flow velocity and anatomical information. However, there can still be occasions where the above mentioned hemodynamic and non-hemodynamic data are not enough to guide the surgical decision-making process intraoperatively. In this case report, we present the contribution of the difficulty in advancing the PAC into the Right Atrium (RA), as an indication of Superior Vena Cava (SVC) stenosis, and the need to return to CardioPulmonary Bypass (CPB) to repair it, during a surgery of totally endoscopic Atrial Septal Defect (ASD) closure. Methods A 40yr old female patient is undergoing totally endoscopic cardiac surgery with CPB for the closure of a Superior Sinus Venosus ASD with simultaneous anomalous drainage of the Right Upper Pulmonary Vein (RUPV) into the SVC. The anaesthetic monitoring includes arterial line, PAC and TOE, which confirms the preoperative findings (Figure 1,2,3), while for the needs of the operation the Anaesthesiologist inserts also a CPB cannula in the Right Internal Jugular Vein. Later on, during the phase that the surgeon is advancing the second venous CPB cannula through the femoral vein and the Inferior Vena Cava (IVC) into the RA, the PAC is being withdrawn from its wedge position and is left high inside the SVC, showing the Central Venous Pressure (CVP). Results After the closure of the ASD and the flow diversion of the RUPV into the Left Atrium with a bovine pericardial patch, deairing is taking place, the restoration of the ASD is being confirmed with the TOE and successful CPB weaning occurs. A subsequent TOE scan shows turbulence inside the SVC with the colour Doppler (Figure 4), indicative of stenosis, while the CVP is 15mmHg, and the dilemma that is coming up is if the stenosis is clinically significant or not. However, at the same time it is impossible to readvance the PAC into the RA, an indication of severe SVC stenosis, and the team decides to return to CPB to repair it. After the placement of a second pericardial patch that widens the RA-SVC junction on a beating heart, laminar flow is being depicted inside the SVC (Figure 5), the PAC is being seamlessly floated into the RA (Figure 6) until its wedge position, and the CVP is 8mmHg. The short and the long-term postoperative periods were uncomplicated. Discussion The intraoperative use of the PAC in the current case report, and the difficulty in readvancing it more specifically, proved to be crucial in making an undoubtedly critical decision towards repairing a stenosis that could have been overlooked, if we had simply relied on the CVP, and become even fatal in case of delayed diagnosis. The mechanical contribution of the PAC has been underlined.

This chapter describes the routine appearance and abnormal positions of a variety of monitoring and support devices, including endotracheal and tracheostomy tubes, nasogastric and Dobhoff tubes, PICC lines, and other vascular catheters, chest tubes, and pacer/ICD wires.

Purpose Myocardial dysfunction and low cardiac output are common after out-of-hospital cardiac arrest (OHCA) as part of the post-cardiac arrest syndrome. This study investigates the association of cardiac output during targeted temperature management (TTM) with mortality. We hypothesized that low cardiac output during TTM is associated with mortality. Methods In the TTM-trial, which randomly allocated patients to TTM of 33°C or 36°C for 24 hours, we prospectively and consecutively monitored 171 patients with protocolized measurements from pulmonary artery catheters (PAC). Clinical and hemodynamic variables were registered at pre-specified time points in addition to 30-day survival status. Lactate, heart rate and cardiac index were measured at 3 time-points during TTM and averaged. We defined low cardiac output as a cardiac index during TTM Results Of 152 patients with available hemodynamic measurements, 71 (47%) had low cardiac output during TTM (TTM33: 38 (49%), TTM36: 33 (44%)). Low cardiac output was not associated with mortality in univariate analysis (hazard ratio (HR): 1.47 [0.83–2.59], p=0.19) or multivariate analysis adjusted for potential confounders (HRadjusted: 0.74 [0.38–1.44], p=0.37). Low cardiac output combined with HR>65 was associated with increased mortality (HR: 2.69 [1.51–4.79], p=0.0007) in univariate, but not in multivariate analysis (p=0.22) (Figure). Low cardiac output and HR2mmol/L was associated with increased mortality (HR: 2.73 [1.49–4.99], p=0.001) in univariate, but not in multivariate analysis (p=0.53), whereas patients with low cardiac output and lactate Figure 1 Conclusion This study found, that a frequent symptom during TTM is low cardiac output, which was not associated with mortality. However, patients with low cardiac output combined with either increased lactate or heart rate seems to be a population at risk. Whether low cardiac output should be corrected by inotropes or mechanical support to reduce mortality remains to be studied in prospective trials, but the efficacy of goal-directed therapy to increase cardiac output during TTM may be modest, especially if lactate and heart rate are normal. Acknowledgement/Funding The research fund Gangstedfonden and the Research fund of Rigshospitalet has supported this study with unrestricted salary in Dr. Grand's PhD project.

Background Appropriate pulmonary artery catheter (PAC) use may effectively decrease mortality in acute heart failure patients. The concept that the pulmonary artery catheter (PAC) is a valuable tool for hemodynamic monitoring when used in appropriately selected patients and by physicians trained well to interpret and apply the data correctly provided has not been evaluated adequately yet in acute heart failure patients with preserved ejection fraction (HFpEF). Methods The PERSUIT-HFpEF Registry is a prospective, observational, multicenter cohort study on prognosis of HFpEF in Japan. Patients hospitalized for heart failure (diagnosed by using Framingham criteria) who met both of the following criteria were enrolled: 1) a left ventricular ejection fraction of 50% or more as measured at the local site by echocardiography; 2) an elevated level of N terminal pro brain natriuretic peptide (NT proBNP) (400 pg per milliliter or more) or brain natriuretic peptide (BNP) (100 pg per milliliter or more). In the present study, we evaluated the impact of PAC on all-cause death of the patients with HFpEF. PAC use was left at the discretion of attending physicians. Results The PERSUIT-HFpEF Registry enrolled 486 patients (81±9 years, 259 females, mean follow-up duration 198±195 days). Of these, data of PAC usage was available in 434 patients. Patients were further stratified according to use of a PAC: PAC 153 patients vs. non-PAC 281 patients. Length of hospitalization was numerically shorter in the PAC group than in the non-PAC group [20.3±14.7 vs. 22.5±17.4 days, p=0.182]. Kaplan-Meier estimated 1-year all-cause death rate was significantly lower in the PAC group than in the non-PAC group (9.5% vs. 19.1%, p=0.019). PAC use was associated with significant risk reduction of all-cause death [hazard ratio (HR) 0.425, 95% confidence interval (CI), 0.203–0.890, p=0.023] in the crude analysis. The significant risk reduction still existed after multivariate adjustment including potential confounders [HR 0.427, 95% CI, 0.185–0.984, p=0.046] Kaplan Meier analysis Conclusions In the real-world Asian registry data, PAC use was associated with the improved all-cause death rate, suggesting that the PAC might be a useful guidance tool for treatment of the patients with HFpEF. Acknowledgement/Funding Roche diagnostics FUJIFILM Toyama Chemical

Background Assessing hemodynamics, in particular central venous pressure (CVP) is essential in heart failure diagnostics, leading individual therapy. Hereby, invasive measurement through Swan-Ganz right heart catheterization (RHC) is considered gold standard for patient evaluation, but catheterization implies risks of invasiveness including bleeding, infection, vessel and nerve injury, as well as patient discomfort. Non-invasive methods are warranted, but no alternative technique is validated yet. Two-dimensional echocardiography (2DE) is believed to be uncertain in this approach as vena cava often shows ellipse-shapes. Therefore, this study sought to investigate standardized and breathing corrected three-dimensional inferior vena cava echocardiography (3DE) to directly compare CVP with right heart catheterization. Methods and results We prospectively included 100 consecutive heart failure patients in this study (mean age 53±12 years, body mass index 27±5, New York Heart Association functional class 2.3±0.6, left ventricular ejection fraction 34.1±12.8%, brain natriuretic peptide 658.13±974.03, 76% male), all underwent Swan-Ganz right-heart catheterization and immediately both 2DE and 3DE (Philips EPIQ 7G) of inferior vena cava. From two-dimensional data the diameter of IVC was measured perpendicularly in long and short-axis. From 3DE data a cross-sectional image of IVC was reconstructed for both vertical and horizontal diameters of IVC as well as the area of IVC. Established 2DE images revealed mean vena cava sizes of 15.9±5.9 mm, while standardized cross-sectional breathing corrected 3DE images showed diameters of 19.8±7.8 mm in longitudinal axis and 15.74±7.8 in short axis. RHC mean CVP was 9.00±5.4 mmHg and correlation of CVP and 2DE measurements failed adequate correlation (2DE 95% CI 0.19–1.61; r=0.25; p=0.312). However, 3DE axis ratio assessment correlated well with invasive CVP and showed reproducible results (3DE 95% CI 0.26–0.69; r=0.89; p Conclusions Standardized 3DE correlates well with invasive CVP while established 2DE usual care assessment does not show reliable CVP correlation. 3DE CVP assessment may represent a more feasible and easily applicable method for CVP measurement, including absence for risks of right heart catheterization. Further studies are ongoing to validate these findings in the future.

Chest radiographs (CXRs) are the most common imaging investigations undertaken because of their value in evaluating the cardiorespiratory system. They play a vital role in intensive care units for evaluating the critically ill. It is therefore very common for the radiologist to encounter tubes, lines, medical devices and materials on a daily basis. It is important for the interpreting radiologist not only to identify these iatrogenic objects, but also to look for their accurate placement as well as for any complications related to their placement, which may be seen either on the immediate post-procedural CXR or on a follow-up CXR. In this article, we discussed and illustrated the routinely encountered tubes and lines that one may see on a CXR as well as some of their complications. In addition, we also provide a brief overview of other important non-cardiac medical devices and materials that may be seen on CXRs.

Background In 1970, Harold James Charles Swan and William Ganz published their work on the pulmonary artery catheter (PAC or Swan-Ganz catheter). They described the successful bedside use of a flow-directed catheter to continuously evaluate the heart, and it was used extensively in the years following to care for critically ill patients. In recent decades, clinicians have reevaluated the risks and benefits of the PAC. Aim We acknowledge the contributions of Swan and Ganz and discuss literature, including randomized controlled trials, and new technology surrounding the rise and fall in use of the PAC. Methods We performed a literature search of retrospective and prospective studies, including randomized controlled trials, and editorials to understand the history and clinical outcomes of the PAC. Results In the 1980s, clinicians began to question the benefits of the PAC. In 1996 and 2003, a large observational study and randomized controlled trial, respectively, showed no clear benefits in outcome. Thereafter, use of PACs began to drop precipitously. New less and noninvasive technology can estimate cardiac output and blood pressure continuously. Conclusions Swan and Ganz contributed to the bedside understanding of the pathophysiology of the heart. The history of the rise and fall in use of the PAC parallels the literature and invention of less-invasive technology. Although the PAC has not been shown to improve clinical outcomes in large randomized controlled trials, it may still be useful in select patients. New less-invasive and noninvasive technology may ultimately replace it if literature supports it.

To compare cardiac output measurements by transthoracic echocardiography and a pulmonary artery catheter in mechanically ventilated patients with high positive end-expiratory pressure. To evaluate the effect of tricuspid regurgitation.Sixteen mechanically ventilated patients were studied. Cardiac output was measured by pulmonary artery catheterization and transthoracic echocardiography. Measurements were performed at different levels of positive end-expiratory pressure (10cmH2O, 15cmH2O, and 20cmH2O). The effect of tricuspid regurgitation on cardiac output measurement was evaluated. The intraclass correlation coefficient was studied; the mean error and limits of agreement were studied with the Bland-Altman plot. The error rate was calculated.Forty-four pairs of cardiac output measurements were obtained. An intraclass correlation coefficient of 0.908 was found (p0.001). The mean error was 0.44L/min for cardiac output values between 5 and 13L/min. The limits of agreement were 3.25L/min and -2.37L/min. With tricuspid insufficiency, the intraclass correlation coefficient was 0.791, and without tricuspid insufficiency, 0.935. Tricuspid insufficiency increased the error rate from 32% to 52%.In patients with high positive end-expiratory pressure, cardiac output measurement by transthoracic echocardiography is comparable to that with a pulmonary artery catheter. Tricuspid regurgitation influences the intraclass correlation coefficient. In patients with high positive end-expiratory pressure, the use of transthoracic echocardiography to measure cardiac output is comparable to invasive measures.Comparar las medidas de gasto cardiaco por ecocardiografía transtorácica y por catéter arterial pulmonar en pacientes en ventilación mecánica con presión positiva al final de la espiración elevada. Evaluar el efecto de la insuficiencia tricúspide.Se estudiaron 16 pacientes en ventilación mecánica. El gasto cardiaco se midió con el catéter arterial pulmonar y por ecocardiografía transtorácica. Las medidas se realizaron en diferentes niveles de presión positiva al final de la espiración (10cmH2O, 15cmH2O, y 20cmH2O). Se evalúo el efecto de la insuficiencia tricúspide sobre la medida de gasto cardiaco. Se estudió el coeficiente de correlación intraclase; el error medio y los límites de concordancia se estudiaron con el diagrama de Bland-Altman. Se calculó el porcentaje de error.Se obtuvieron 44 pares de medidas de gasto cardiaco. Se obtuvo un coeficiente de correlación intraclase de 0,908, p0,001; el error medio fue 0,44L/min para valores de gasto cardíaco entre 5 a 13L/min. Los límites de concordancia se encontraron entre 3,25L/min y -2,37L/min. Con insuficiencia tricúspide el coeficiente de correlación intraclase fue 0,791, sin insuficiencia tricúspide el coeficiente de correlación intraclase fue 0,935. La presencia de insuficiencia tricúspide aumentó el porcentaje de error de 32 % a 52%.En pacientes con presión positiva al final de la espiración elevada la medida de gasto cardiaco por ecocardiografía transtorácica es comparable con catéter arterial pulmonar. La presencia de insuficiencia tricúspide influye en el coeficiente de correlación intraclase. En pacientes con presión positiva al final de la espiración elevada, el uso de ecocardiografía transtorácica para medir gasto cardiaco es comparable con las medidas invasivas.

A variety of pathologies lead to pulmonary hypertension (PH), which is defined as a mean pulmonary artery pressure exceeding 25 mmHg at rest. To further diagnose and manage PH, patients undergo repeated right heart catheterizations (RHC) wherein a Swan-Ganz catheter is advanced into a branch of the pulmonary artery and a balloon is inflated to wedge the catheter tip. This article illustrates a protocol whereby pulmonary artery endothelial cells (PAECs) may be harvested from the balloon tips of Swan-Ganz catheters after RHC, and purified with an anti- CD146 affinity column technique to purify putative PAECs. These cells might be used to provide an in situ snapshot of the biological state of the pulmonary vasculature endothelium to complement hemodynamic measurements obtained during RHC. Harvested and purified PAECs may be used for either cell culture or for subsequent analytical assays such as flow cytometery.

Positive end-expiratory pressure (PEEP)-induced increase in central venous pressure (CVP) has been suggested to be a robust indicator of fluid responsiveness, with heart rhythm having minimal influence. We compared the ability of PEEP-induced changes in CVP with passive leg raising (PLR)-induced changes in stroke volume index (SVI) in patients with atrial fibrillation after valvular heart surgery.In 43 patients with atrial fibrillation after cardiac surgery, PEEP was increased from 0 to 10 cm H2O for 5 min and changes in CVP were assessed. After returning the PEEP to 0 cm H2O, PLR was performed for 5 min and changes in SVI were recorded. Finally, 300 ml of colloid was infused and haemodynamic variables were assessed 5 min after completion of a fluid challenge. Fluid responsiveness was defined as an increase in SVI ≥10% measured by a pulmonary artery catheter.Fifteen (35%) patients were fluid responders. There was no correlation between PEEP-induced increases in CVP and changes in SVI after a fluid challenge (β coefficient -0.052, P=0.740), whereas changes in SVI during PLR showed a significant correlation (β coefficient 0.713, P0.001). The area under the receiver operating characteristic curve of the PEEP-induced increase in CVP and changes in SVI during PLR for fluid responsiveness was 0.556 [95% confidence interval (CI) 0.358-0.753, P=0.549) and 0.771 (95% CI 0.619-0.924, P=0.004), respectively.A PEEP-induced increase in CVP did not predict fluid responsiveness in patients with atrial fibrillation after cardiac surgery, but increases in SVI during PLR seem to be a valid predictor of fluid responsiveness in this subset of patients.

To determine whether a pulse waveform analysis in the optic nerve head (ONH) circulation as determined by laser speckle flowgraphy (LSFG) can provide systemic hemodynamic values — the systemic vascular resistance (SVR) in particular — similar to those obtained by using a Swan–Ganz catheter, which is an invasive method. Sixteen consecutive subjects were examined. Hemodynamic monitoring was obtained from right heart catheterization with a Swan–Ganz catheter and coronary angiography without an intracoronary nitroglycerin administration. Direct blood pressure was measured with a trans-radial approach. Single regression analyses were used to determine the relationship between the blowout score and blowout time, which are the items of the pulse waveform analysis in the ONH, by using LSFG and the hemodynamic parameters. The blowout time was significantly and negatively correlated with the SVR (r = −0.52, p = 0.04), the ocular perfusion pressure with the mean arterial blood pressure of the radial artery (r = −0.52, p = 0.04) and the radial artery pulse pressure (r = −0.52, p = 0.04).The pulmonary capillary wedge pressure (r = −0.44, p = 0.09) and the mean arterial blood pressure of the radial artery (r = −0.44, p = 0.09) tended to be correlated with the blowout time, but did not reach significance. The blowout score was significantly and negatively correlated with the radial artery blood pressure (r = −0.51, p = 0.046). A pulse waveform analysis in the ONH by LSFG may be one of the useful methods for understanding the SVR.

Purpose of review In an attempt to make cardiovascular monitoring less invasive and more effective, transesophageal echocardiography is progressively being used in critically ill patients suffering from hemodynamic instability. This review analyses the capacity of transesophageal echocardiography to fully replace the pulmonary artery catheter in the management of hemodynamic impairment, as transesophageal echocardiography similarly allows for the measurement of central venous pressure, pulmonary arterial pressure, pulmonary capillary wedge pressure, pulmonary vascular resistance, stroke volume and cardiac output, and systemic vascular resistance. Recent findings Recently, the accuracy and clinical applicability of transthoracic echocardiography to establish the entire hemodynamic profile in patients with decompensated heart failure has convincingly been demonstrated. Because many principles are similar in transthoracic and transesophageal echocardiography, it has been hypothesized that the latter modality is also qualified to quantitatively determine intracardiac hemodynamics, including pressure and flow. Summary Transesophageal echocardiography has the potential to offer a noninvasive, valid alternative to Swan-Ganz catheters in the hemodynamic assessment of patients in the perioperative period.

Background Introduced in 1970, the Swan–Ganz catheter (SGC) soon became widely used because of its unique usefulness in managing intensive care patients. Unfortunately, SGC usage was complicated by pulmonary artery rupture (PAR) with a 50% mortality rate that led to a near banning of the SCG in the late 1980s. Increasing knowledge and decreasing incidence of SGC-related PARs (SGPARs) led to the current feeling that the present SGPAR incidence is now low enough to tolerate given the lives saved by SGC usage. However, an important unknown is that, to our knowledge, pathologists have never published a comprehensive microscopic description of a SGPAR. Case report A 73-year-old woman with moderate pulmonary hypertension died from a SGPAR soon after single SGC measurements of right ventricular and pulmonary capillary wedge pressures. By using what we thought to be an appropriate method of dissection, we did a complete microscopic step section study of the 1.6 cm SGPAR revealing 12 relatively uniform longitudinal tears (one perforating) consistent with an overinflated SGC balloon or a weakened arterial wall. Literature review A MEDLINE search of 38 consecutive SGPARs from 2014 to 1980 found 52 cases in 38 papers. Analysis revealed that all 46 SGPARs suitable for study came from large institutions, and confirmed that elderly women were more likely to have SGPARs than elderly men. Conclusions More and better data are needed before fully informed decisions can be made regarding future SGC usage.

International audience

While the pulmonary artery catheter (PAC) is still interesting in specific situations, there are many alternatives. A group of experts from different backgrounds discusses their respective interests and limitations of the various techniques and related measured variables. The goal of this review is to highlight the conditions in which the alternative devices will suffice and when they will not or when these alternative techniques can provide information not available with PAC. The panel concluded that it is useful to combine different techniques instead of relying on a single one and to adapt the “package” of interventions to the condition of the patient. As a first step, the clinical and biologic signs should be used to identify patients with impaired tissue perfusion. Whenever available, echocardiography should be performed as it provides a rapid and comprehensive hemodynamic evaluation. If the patient responds rapidly to therapy, either no additional monitoring or pulse wave analysis (allowing continuous monitoring in case potential degradation is anticipated) can be applied. If the patient does not rapidly respond to therapy or complex hemodynamic alterations are observed, pulse wave analysis coupled with TPTD is suggested.

The pulmonary artery catheter has a rich history in modern critical care medicine and provided the basis for the science of advanced hemodynamic monitoring. While significant controversy exists regarding the current utility of the catheter, an understanding of the hemodynamic data provided by the pulmonary artery catheter, as well as limitations and potential complications, is essential for any critical care practitioner. When used correctly, this invasive monitoring device can provide a wealth of information regarding the patient’s cardiopulmonary function as well as the impact of therapeutic interventions. However, the nuances of appropriate catheter use, data interpretation, and application are complex and easily misinterpreted even by seasoned intensivists.

A pulmonary artery catheter (PAC) is a useful tool for monitor haemodynamics during cardiac surgery in patients with compromised ventricular function and helps in the perioperative patient management. During open heart surgery entrapment of a Swan-Ganz catheter to an intracardiac structure is rare but may lead to potentially life-threatening complications. Here, we report a case of an entrapped pulmonary artery catheter by accidental surgical suturing at the entry point of Superior vena cava into right atrium that necessitated reopening the chest and removing the catheter.

Background During pulmonary artery catheter (PAC) implantation, inaccurate measurements of hemodynamic parameters due to infection or thrombosis of PAC can result in severe complications. Method In order to develop a new PAC material, we evaluated the antibacterial and antithrombotic activities of the two types of PAC (Swan Ganz catheter and prototype catheter) in 14 pigs. Results In the 3-day group, bacterial infection rate was not different between the two types of PAC. In the 7-day group, bacterial infection rate of the prototype catheter was twice as elevated as that of the Swan-Ganz catheter. In the 3-day group, thrombus formation rate of the prototype catheter was twice as elevated as that of the Swan-Ganz catheter. In the 7-day group, thrombus formation rate was the same for the two types of PAC. Conclusion Here, we report an experimental pig model that confirms differences in antibacterial and antithrombotic activities.

Massive pulmonary thromboembolism (PE) is an acute-onset, life-threatening disease in the perioperative period. Massive PE led to severe hypoxemia and cor pulmonale in our patient who had undergone an operation for thalamic hemorrhage. Mechanical clot fragmentation using a Swan–Ganz catheter was attempted, because thrombolytic therapy was contraindicated for our patient. This procedure was successful, resulting in a decrease in pulmonary artery pressure with improvement in hypoxemia. Thus, this procedure may be useful for patients with massive PE with contraindications to thrombolytic therapy.