Search

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.

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

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.

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.

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.

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.

Balloon floatation pulmonary artery catheters (PACs) have been used for hemodynamic monitoring in cardiac, medical, and surgical intensive care units since the 1970s. With the availability of newer noninvasive diagnostic modalities, particularly echocardiography, the frequency of diagnostic pulmonary artery catheterization has declined. In this review, the evolution of PACs, the results of nonrandomized and randomized studies in various clinical conditions, the uses and abuses of bedside hemodynamic monitoring, and current indications for pulmonary artery catheterization are discussed.

A patient was scheduled for open infrarenal abdominal aortic aneurysm repair and the procedure was performed without complication. The pulmonary artery catheter (PAC) was unintentionally placed in the coronary sinus via an undiagnosed persistent left superior vena cava anomaly. Interpreting the waveform produced by the PAC in standard and abnormal locations such as the coronary sinus is equally as important as measuring and monitoring hemodynamic status.

Three patients who presented with massive hemoptysis after the insertion of a Swan-Ganz catheter for cardiac surgery are reported. Pulmonary artery pseudoaneurysms were diagnosed and successfully treated by embolization with a vascular plug. Follow-up at 15 months showed no recurrence of hemoptysis, and computed tomography helped confirm complete occlusion of the pseudoaneurysms.

Cardiac function, including cardiac index (CI), traditionally has been measured by a pulmonary artery catheter (PAC). A noninvasive alternative for measuring cardiac function would offer obvious advantages.A prospective study of trauma and nontrauma patients was performed in a surgical intensive care unit over a 3-month period. CI was determined using both a standard PAC and a continuous-wave Doppler ultrasound (UTS). The study had 2 phases: phase I was nonblinded and phase II was blinded; the correlation between UTS- and PAC-derived CI was assessed.A total of 120 paired measurements of CI were observed in 31 patients. The UTS-derived CI measurements showed agreement with PAC measurements in both phase I and phase II of the study with a bias of .06 L/min/m(2) +/- .4 L/min/m(2). Paired measurements correlated well in both phase I (r = .97, R2 = .95, P.0001) and phase II (r = .93, R2 = .86, P.0001) of the study.Doppler UTS correlates well with PAC measurements of CI. This noninvasive modality is an accurate and safe alternative to PAC.

Advances in medical care have led to increasing numbers of complex, high-risk obstetric patients. Specialist training and a sound knowledge of normal maternal physiology are essential to optimize outcomes. One of the earliest observed changes is peripheral vasodilatation; this causes a fall in systemic vascular resistance and triggers physiological changes in the cardiovascular and renal systems, with 40-50% increases in cardiac output and glomerular filtration rates. Safety concerns over Swan Ganz catheters have driven the increasing interest in alternative techniques, such as echocardiography, thoracic bioimpedance and pulse contour analysis, although their exact roles in future obstetric high-dependency care have yet to be established. Analysis of arterial blood gases is fundamental to the management of sick patients, and correct interpretation can be aided by a systematic approach. Observation charts are almost ubiquitous in all aspects of medicine, but little evidence exists to support their use in the high-dependency setting.

The Swan-Ganz catheter makes it possible to monitor important hemodynamic parameters to control the critical patient: pressure in several cavities and large veins, calculation of cardiac output, measurement of central temperature and oxygen saturation, drug administration and drawing of blood samples. The catheter has different lumens and devices to perform these functions. Nurses have a very important role in the placement, maintenance and removal of the catheter, both to maintain optimum functioning and to reduce the risks involved.

Resumen Objetivos A pesar de la discusion sobre la utilidad del cateter de arteria pulmonar (CAP) en el manejo del paciente critico, se sigue utilizando frecuentemente y es conveniente tener en cuenta tambien sus posibles complicaciones. El objetivo del estudio es revisar las complicaciones mecanicas graves o potencialmente graves asociadas a CAP ocurridos en nuestro centro en los ultimos 15 anos. Pacientes y metodos Se ha realizado un estudio observacional retrospectivo sobre los pacientes sometidos a cirugia vascular, cardiaca y toracica en los que se coloco un CAP, considerandose las complicaciones graves de origen mecanico. Resultados Se incluyeron 7.540 pacientes, detectandose nueve casos de complicaciones graves entre los que se incluyen cinco rupturas de arteria pulmonar, tres de ellas con resultado de muerte; una perforacion de vena mamaria interna; un nudo; un acodamiento y un atrapamiento del cateter en la sutura quirurgica. Conclusiones Esto supone una incidencia de 0,12%, menor a la publicada. Aunque la frecuencia de estas complicaciones es baja, su aparicion inesperada obliga a estar alerta ante su posible aparicion, con una cuidadosa seleccion de los pacientes en que se emplea el CAP y especial vigilancia de los signos clinicos y radiologicos caracteristicos de complicaciones.

The interventional management of D-Transposition of great arteries DTGA is more required with the advances in NICU and pediatric cardiology. Objective To describe our experience in balloon atrial septestomy (BAS) in D-TGA patients weighing Methods we reported retrospectively all BAS in VLBW infants from January 2002 to June 2013. We collected information about the vital parameters before and after BAS. We described the atrial septestomy. Results We have 3 patients with a mean weight of 1333 g. D-TGA was diagnosed at a mean age of 3 days. Four atrial septestomy attempts were done at a mean age of 10.3 days. One infant had two attempts with balloon dilatation in the first, then BAS 24 h later. Procedures were done in catheterization laboratory in three cases and in NICU in one case. Patients were ventilated, sedated and transported by the NICU team. Venous access was obtained by the femoral vein puncture in two cases, femoral vein cutdown in one case and by the umbilical vein in one case. BAS were performed successfully in two cases, one using 4Fr. Swan Ganz catheter, and the other with 5 Fr. Z-Med septestomy catheter. BAS failed in two procedures, one because of atrial wall perforation, and the second because of restrictive foramen ovale which was dilated by a coronary balloon. Complications occurred in 3 cases, one minor (balloon rupture), and two major; atrial perforation in one patient, and severe bradycardia in one patient. BAS was effective with sustained clinical improvement. BAS failure in two patients was followed by heart failure in one patient and the death in the other. Conclusion BAS is mandatory in VLBW infants with D-TGA and restrictive atrial communication. It should be performed quickly if possible to use the valuable umbilical access, and to avoid the clinical compromise. A holeend BAS catheter is required for successful procedure. FO balloon dilatation constitutes another life-saving option.

Patients with an Eisenmenger syndrome have an instuble hemodynamic status. During a general anaesthesia, the intracardiac shunt has to maintain the correct orientation and volume, adapted to each patient, in such a condition, to avoid the risk of hypoxemia and cardiac failure. The haemodynamic monitoring with a Swan Ganz catheter could be useful. But it is necessary to evaluate the advantage and the risks when the technique is used in these pathological circumstances. Moreover, when the cardiac output is measured with the thermodilution technique, the right-left intra cardiac shunt volume, is not taking into account. The continuous haemodynamic monitoring, with a simplified transoesophageal echo-Doppler system, as it was done in this case, allows appreciate the real quantitative variations of the shunt. In this way the more adequate calculation of some others haemodynamic parameters, over all the total systemic vascular resistances, allows a more precise therapeutic approach.

Creation of either a natural arteriovenous graft or a fistula as a vascular access to support long-term hemodialysis can lead to "high-output" cardiac failure. The authors describe a patient who underwent surgical banding of an upper arm arteriovenous fistula. Access flow and cardiac output were measured not only pre- and postoperatively but also intraoperatively using a modified Swan Ganz catheter, originally developed to measure access flows during radiologic procedures. Banding resulted in a significant decrease in access flow and cardiac output, which was sustained for up to 1 year postoperatively.

Perforation of a pulmonary artery after placement of a Swan-Ganz catheter is a serious complication that requires immediate management. Exact description of size and anatomic localization of a pulmonary pseudoaneurysm is crucial for planning further therapy. This report describes a patient who experienced such a complication, but in whom primary pulmonary angiography failed to demonstrate bleeding. However, multislice computed tomography not only correctly demonstrated the anatomic location of the pseudoaneurysm but was also able to directly visualize the feeder vessel and its connection to the aneurysm. This information was essential for subsequent superselective angiographic visualization of the feeder vessel and for successful embolization as the least invasive method of choice.

Background. The classic increase in P wave size, known as ‘P-atriale', is a widely accepted criterion for determination of proper positioning of central venous catheter tips. Recent transoesophageal echocardiography (TOE) studies did not confirm intra-atrial position despite advancing the central venous catheter further than indicated by ECG guidance. We postulate that the pericardial reflection rather than the entry into the right atrium corresponds to the ECG changes. In order to test our hypothesis we sought to determine the anatomical substrate for the electrical changes in an animal study. Subsequently, a modified version of the study was undertaken in man and is also reported. Methods. In six juvenile pigs the left external jugular vein and right carotid artery were cannulated. A triple-lumen central venous catheter was positioned by ECG guidance using a Seldinger wire as an exploring electrode. The venous and arterial catheters were suture fixed 2 cm beyond the onset of an increase in P wave size. The corresponding anatomical catheter tip position was determined by open exploration of the vessels and the heart. Subsequently the catheter tip position (during advancement) of a pulmonary artery catheter and the corresponding electrical ECG changes were examined in 10 patients during open chest cardiac surgery. Results. All catheters—arterial and venous, in animals and humans—revealed an increase in size of the P wave as well as the QRS complex. All venous catheters were positioned in the superior vena cava, beyond the pericardial reflection but outside the right atrium. All arterial catheters were positioned in the ascending aorta thus also beyond the pericardial reflection. Conclusions. The start of an increase in P wave size does not correspond with the entrance of the right atrium. The anatomic equivalent for the electrophysiological changes of the ECG is the pericardial reflection. ECG guidance is unable to distinguish between venous and arterial catheter position.

The use of Swan-Ganz catheters has increased tremendously since they were first introduced in 1970. Their ability to give vital hemodynamic measurements in critically ill patients makes their use invaluable when providing quality medical care. The formation of pulmonary artery (PA) pseudoaneurysm from a Swan-Ganz catheter-induced perforation of the PA is a rare but potentially fatal complication of Swan-Ganz catheter use. Three case presentations and a review of the literature are presented.

Pulmonary artery catheters are widely used in intensive care, but evidence to support their widespread use is sparse. Some published data suggest that greater mortality is associated with use of these catheters. The largest study to date looked at >5500 patients in several centres in America and found a greater 30 day mortality in those patients receiving a pulmonary artery catheter. We tested the hypothesis that, on our intensive care unit, mortality was greater for those patients receiving a pulmonary artery catheter. Using a propensity score to account for severity of illness, the odds ratio for mortality in those patients receiving a pulmonary artery catheter was 1.08 (95% confidence interval 0.87–1.33). We believe that continued use of the pulmonary artery catheter is safe; a large randomized controlled trial examining outcome is unlikely to provide an adequate answer.

Although, guidelines related to length of insertion of a pulmonary artery catheter to reach a particular cardiac chamber are available, these are not backed by clinical studies. We measured the length of insertion of pulmonary artery catheters to locate the right ventricle, pulmonary artery and pulmonary capillary wedge positions in 300 adult patients undergoing elective cardiac surgery.The pulmonary artery catheters were inserted using a standard technique through the right internal jugular vein. The right ventricle, pulmonary artery and wedge position of the catheter were confirmed by the characteristic waveforms, and the length of insertion to these points was measured.The right ventricle was reached at 24.6 (3) cm (95% CI 24.2-24.9 cm), pulmonary artery at 36 (4) cm (95% CI 35.6-36.5 cm) and wedge position at 42.8 (5.7) cm (95% CI 42.2-43.5 cm). The length of catheter to reach the right ventricle, pulmonary artery and wedge position was significantly more in patients undergoing valve surgery as compared with those undergoing coronary artery bypass grafting [26 (3.8) and 24 (2.5) cm; 38.5 (4.6) and 35 (3.2) cm; and 47.8 (6.9) and 41.2 (4.1) cm, respectively, P0.001]. The length of insertion to reach pulmonary artery and pulmonary capillary wedge position was directly related to height of the patient (Pearson's correlation 0.157 and 0.15, respectively).We have provided the norms related to length of insertion of pulmonary artery catheter, which should be useful in accurate placement of the catheter and minimize complications related to coiling of the catheter.

A new indicator dilution technique for measurement of cardiac output is described. Lithium chloride is injected via a central venous catheter and its dilution curve measured in arterial blood using a lithium-selective electrode. We assessed the lithium dilution cardiac output measurement (LiDCO) and a conventional thermodilution cardiac output measurement (ThDCO) by comparing the results of both with cardiac output determined by electromagnetic flowmetry (EMCO) under controlled laboratory conditions in 10 swine. They were monitored with a pulmonary artery catheter, femoral artery catheter and electromagnetic flowmeter placed around the ascending aorta. LiDCO, ThDCO and EMCO measurements were determined at baseline, in a hyperdynamic state produced by administration of dobutamine, at a second baseline and finally in a hypodynamic state induced by propranolol during deep anaesthesia. Data were analysed by linear regression analysis and the comparison method described by Bland and Altman; bias and precision of both LiDCO and ThDCO compared with EMCO were calculated by the method of Sheiner and Beal. The correlation coefficient between LiDCO and EMCO (0.95) was higher than that between ThDCO and EMCO (0.87). The precision value of LiDCO (0.04) was significantly less (i.e. better) than that of ThDCO (0.09). The results of this study indicated that LiDCO was more reliable compared with conventional ThDCO.

The years that have passed since the introduction of the pulmonary artery catheter have been marked by radical changes in the practice of general and critical care medicine. There has been an increase in the application of physiologic principles to the management of shock states, myocardial infarction, and respiratory failure. These developments have caused an increase in the expectations of patients and physicians alike and in the general preparedness to offer critical care to extremely aged or infirmed patients.

A Swan-Ganz catheter entrapment by a suture in the right atrial wall during open heart operation is presented. The diagnosis of the suture entrapment of the Swan-Ganz catheter to the right atrial wall was established by direct observation of the specific movement pattern of the cardiac structures when manual traction was applied from outside by a transesophageal echocardiographic examination.

John Matzko, MD Alan H. Matsumoto, MD Charles J. Tegtmeyer, MD William D. Spotnitz, MD T H E Swan-Ganz catheter (SGC) (Edwards Lab, Santa Ana, Calif) is used extensively in cardiac surgery to monitor right heart pressures, indirectly measure left atrial pressure, and determine cardiac output (1). An infrequent complication related to the use of a SGC in cardiac surgery is entrapment of the catheter by surgically placed sutures, resulting in the inability to manipulate or remove the catheter (2-7,9,10). We describe a modification of a previously described technique for percutaneously removing a SGC that had been inadvertently sutured to the superior vena cava (SVC).

We describe a new indicator dilution method of measuring cardiac output in man. A bolus injection of lithium chloride 0.6 mmol was given via a central venous catheter and arterial plasma [Li + ] recorded using a specially developed sensor incorporating an Li + -selective electrode. Cardiac output was derived from the lithium dilution curve, with a correction for packed cell volume. Lithium dilution cardiac output (LiDCO) was compared with thermodilution cardiac output (TD) using 22 lithium sensors in nine patients. For each sensor, one LiDCO was measured immediately before and one immediately after three TD estimations and mean values of LiDCO and TD derived. The correlation coefficient, r , was 0.89; slope of the regression 0.84; Y intercept 0.72; bias 0.3 (0.5) litre min −1 (mean (TD-LiDCO) (1 SD). LiDCO appeared to be a safe, simple and accurate technique which does not require insertion of a pulmonary artery catheter.

[Figure][1] [![Graphic][3] ][3][![Graphic][4] ][4] A 72-year-old woman presented with an out-of-hospital cardiac arrest and was successfully resuscitated. She remained in hemodynamic shock. A Swan-Ganz catheter was placed through the right internal jugular vein in the coronary

To delineate the pathogenesis and epidemiology of catheter-related infection with Swan-Ganz pulmonary artery (PA) catheters, a prospective clinical study of hospitalized adult medical and surgical patients was done. Role of catheter material was assessed by randomizing insertions to heparin-bonded PA catheters made of polyvinylchloride or polyurethane. Sources of infection and pathogenesis were studied by culturing skin, the introducer, the PA catheter tip, all hubs, infusate from each lumen, and the extravascular portion of the PA catheter beneath the external protective plastic sleeve. Concordance between isolates from sources and infected catheters was determined by speciation, antibiogram, and for coagulase-negative staphylococci, plasmid profile analysis. Risk factors for infection were determined by stepwise logistic regression. Overall, 65 (22%) of 297 Swan-Ganz catheters showed local infection of the introducer (58 catheters) or the intravascular portion of the PA catheter (20 catheters); only two catheters (0.7%) caused bacteremia. Eighty percent of infected Swan-Ganz catheters (the introducer or PA catheter) showed concordance with organisms cultured from skin of the insertion site, 17% with a contaminated hub and 18% with organisms contaminating the extravascular portion of the PA catheter beneath the sleeve. Isolates from infected PA catheters were most likely to show concordance with concomitantly infected introducers (71%). Cutaneous colonization of the insertion site with greater than 10(2) cfu/10 cm2 (relative risk [RR] 5.5; p less than 0.001), insertion into an internal jugular vein (RR 4.3; p less than 0.01), catheterization greater than 3 days (RR 3.1; p less than 0.01), and insertion in the operating room using less stringent barrier precautions (RR 2.1; p = 0.03) were each associated with a significantly increased risk of catheter-related infection. The risk of bacteremic infection with Swan-Ganz catheters is now low, in the range of 1%, with reasonable care. Swan-Ganz catheters are vulnerable to contamination from multiple sources, but the patient's skin is the single most important source of organisms causing invasive infection, which in most cases involves the introducer rather than the PA catheter. Heavy colonization of the insertion site, percutaneous insertion in the internal jugular vein rather than subclavian vein, catheterization longer than 3 days, and insertion with less stringent barrier precautions significantly increase the risk of catheter-related infection. These findings hold promise for application to management of Swan-Ganz catheters and research in catheter design to reduce the risk of catheter-related infection.

An eclamptic primigravid patient is presented in whom central monitoring by a Swan-Ganz pulmonary artery catheter led to a series of complications, including the Mendelson's syndrome of necrotisizing pneumonia, resulting in severe maternal morbidity and in fetal mortality.

zation among heart failure patients in the post-ESCAPE era are not known. In this study, we aim to determine the temporal trends in use of swan-ganz catheterization among hospitalized heart failure patients between 2004 and 2012. Methods: The 2004-2012 Nationwide Inpatient Sample (NIS), the largest database of in-patient hos- pital stays in the US, was used to identify hospitalizations with primary diagnosis of heart failure among patients $16 years using ICD-9 codes 402.xx, 404.xx, and 428.xx. Use of swan-ganz catheterization for monitoring among these patients was identified using the clinical classification software procedure code 204. Primary outcome of interest was annual swan ganz catheterization per 1000 heart failure ad- missions during the study period. Results: There were 9.2 million hospitalizations with a principal diagnosis of heart failure from 2004 - 2012 (mean age 72.6 years, 51% were women). The overall rate of utilization of swan-ganz catheterization was 6.2 per 1000 heart failure hospitalizations. There was a significant increase in the proportional utilization of swan-ganz catheterization from 5.7 per 1000 heart fail- ure admissions in 2004 to 8.9 per 1000 heart failure admissions in 2012 (p!0.001 for linear trend). In contrast, among patients who died during hospitalization, a group whose disease severity may be consistent across time, there was a relative decline in proportional utilization of swan ganz catheterization (3.05 per 1000 heart failure admissions in 2004 to 2.54 per 1000 heart failure admissions in 2012 (P-trend 5 0.02). Conclusions: Proportional utilization of swan-ganz catheters among patients hospitalized for heart failure has increased over time in the post ESCAPE era. This increase is likely due to its greater use in patients with less severe disease. ally, HFrEF was diagnosed in 0.045% in the total population, 0.69% of HbSS, 0.48% of HbS, 1.47% of HbSb, and 1.85% of HbSC. Compared with the total population, there was an increased prevalence of HFrEF in patients with HbSS (OR 15.4 (95% CI: 11.5-20.5), p!0.001), HbS (OR 10.6 (95% CI:8.3-13.5), p!0.001), HbSb (OR 33.1 (95% CI:16.7-63.4), p!0.001), and HbSC (OR 41.8 (95% CI:21.1-80.3), p!0.001). Conclusions: Patients with sickle cell variants are at an increased risk of heart failure with increased age. The prevalence of heart failure is higher in males compared to females except for HgSc. Patients with sickle cell variants are at an

Digital subtraction angiography is an indispensable complement to cut film studies for the detection of pulmonary artery injury. Immediate transcatheter embolization of catheter-induced pulmonary artery pseudoaneurysm is a safe, minimally invasive, fast, and cost-effective alternative to surgical treatment.

Introduction: PIMR is a novel index of pulmonary microvascular function calculated from PressureWirederived distal pressure and flow. While PIMR has been reported in a large animal model of pulmonary arterial hypertension (PAH), its utility in the clinical setting has not been explored. Methods: Patients referred for diagnostic right heart catheterisation underwent Swan Ganz catheter and PressureWire (placed in 3rd order PA branch) measurement of pulmonary haemodynamics both before and during adenosine infusion. PIMR was calculated as mean transit time× (distal PA pressure−PA wedge pressure). Results: Thirty-eight subjects (average age 61 years) were studied including five normal, eleven PAH, fifteen heart failure with normal ejection fraction (HFNEF), five mitral valve disease, and two interstitial lung disease patients. Adenosine infusion resulted in 28% fall in pulmonary vascular resistance (PVR) and a 29% fall in systemic vascular resistance driven mainly by an increase in cardiac output (5.9± 0.3 L/min vs. 8.6± 0.4 L/min, p< 0.001). PIMR was closely related to PVR during adenosine (r= 0.63, p< 0.001). PIMR was higher in patients with transpulmonary gradient greater than 12 (6.9± 1.3 vs. 3.6± 0.9, p< 0.018) and in patients with PAH compared to those with HFNEF (10.5± 1.7 vs. 3.2± 0.4, p< 0.001). Conclusions: PIMR is closely related to PVR, suggesting that resistance in the pulmonary circulation occurs mainly at the microvascular level. While adenosine is an effective pulmonary vasodilator, its substantial effect on systemic resistance may make alternative agents such as PDE-5 inhibitors more attractive for pulmonary vasodilator challenge.

Background:Neuregulin-1 is a naturally occurring human protein, which is known to play a critical role in embryonic heart development, in maintaining normal cardiac function after birth and in the adaptation of the adult heart to injury. Neuregulin-1 inhibits apoptosis by activating ErbB2/ErbB4 receptors. We report the first study to demonstrate the effects of rhNRG-1, a 61-amino acid recombinant neuregulin-1 (beta2a isoform) receptoractivepeptide, inpatientswith stable chronic heart failure. Methods:Sixpatients on standard therapy forheart failure received rhNRG-1 as a continuous intravenous infusion over 6 h. A baseline right heart catheterisation was performed and Swan Ganz catheter left in situ to monitor haemodynamics for 24 h. Serial NT-proBNP measurements were also made. R a ( t 1 b 5 w p 1 C a u l