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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.

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 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.

Background Simultaneous left ventricular (LV) and aortic (Ao) pressure gradient assessment has been rendered challenging since the recall of the Langston catheter. Here we describe a simple method for simultaneous LV and Ao pressure gradient assessment using a Swan-Ganz catheter. Case summary We describe two cases where assessment of simultaneous left ventricle and Ao valve gradients was done using a Swan-Ganz catheter to assess the degree of Ao stenosis and dynamic LV outflow obstruction. Discussion Using Swan-Ganz catheter assessment of simultaneous left ventricle and Ao valve gradients can simplify the procedure with reduced cost and increased patient safety.

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.

Funding Acknowledgements Type of funding sources: None. Background Cardiovascular dysfunction is common after out-of-hospital cardiac arrest (OHCA). Cardiac output measurements can be used to guide treatment during post-resuscitation care and echocardiography allows noninvasive cardiac output estimation. Purpose The aim of the present study was to compare Doppler echocardiography (doppler_CO) with thermodilution using pulmonary artery catheters (PAC_CO) for cardiac output estimation in a large and consecutively included cohort of comatose OHCA-patients undergoing targeted temperature management (TTM). Methods Single-center substudy of 171 patients included in the TTM-trial randomly assigned to 33 or 36 degrees C for 24 hours after OHCA. We measured PAC_CO and doppler_CO simultaneously shortly after admission and again after 24 hours. Measurements and Main Results We excluded 19 (11%) patients without PAC-measurement and 31 (18%) without doppler-measurements resulting in 120 paired measurements at admission. Patients were 61 (±11) years old, 86% were men and 91% had a witnessed OHCA. At ICU-admission, PAC_CO was 4.81 (±1.81) L/min. and doppler_CO was 3.74 (±1.38) L/min., with a mean bias of 1.07 (±1.65) L/min (with 95% limits of agreement of –2.16 to 4.04) L/min. Examining the Bland-Altman plot, precision fell with higher cardiac output (figure). A statistically significant, but moderate correlation was found between doppler_CO and PAC_CO at admission (r = 0.49), p < 0.0001). After 24 hours, PAC_CO was 4.63 (±1.38) L/min. and doppler_CO was 3.61 (±1.14) L/min, with a mean bias of 0.96 L/min. Assessing the change from admission to 24 hours, PAC_CO decreased averagely -0.12 (±2.22) L/min. and doppler_CO decreased -0.19 (±1.91) L/min. The changes from admission to 24 hours correlated between doppler_CO and PAC_CO (r = 0.55), p < 0.0001) with a mean bias of the changes of 0.07 L/min, with 95% limits of agreement of –3.76 to 3.91 L/min. Conclusions Changes in cardiac output during TTM may be evaluated with Doppler echocardiography with little mean bias compared to changes in CO measured with thermodilution, but relatively large changes are needed in the individual patient before it can be considered as real. Abstract Figure. Comparing Doppler vs. thermodilution

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

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.

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.

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.

There are several devices for haemodynamic monitoring in the ICU. In low-risk postsurgical patients, haemodynamic monitoring of noninvasive blood pressure, heart rate and EtCO2 will be able to provide sufficient data to diagnose an unexpected haemodynamic instability. In high-risk or in intermediate-risk postsurgical patients, it may be sufficient to perform a SVV monitoring to guide the haemodynamic optimization and the patient’s preload management. In major and more complex surgical procedures, where “mixed shock” can occur (e.g. in abdominal emergency surgery or in a patient with pre-existing cardiomyopathy or valve disease or pulmonary hypertension), a complete and more invasive haemodynamic assessment must be performed with a calibrated device for the cardiac output measurement or a combined PAC with a SVV measuring tool.

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.

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.

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.

Right heart catheterization (RHC) should be performed on all candidates in preparation for listing for cardiac transplantation. Patient, 64 y. o., with chronic heart failure NYHA III class, had developed a rare complication while performing that procedure – a rupture of segmental branch of pulmonary artery (PA) with pulmonary haemorrhage. The episode of pulmonary bleeding was stopped conservatively without surgical management. There was a pseudoaneurysm formation of segmental branch of PA 2,7 × 2,8 cm with signs of thrombosis. After fi ve months the patient underwent heart transplantation without severe complications in perioperative period. No more recurrent episodes of pulmonary haemorrhage were identifi ed.

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.

Swan-Ganz catheter entrapment in the heart, vena cava, or pulmonary artery is rare but may lead to life-threatening events. We report a case of severe tricuspid regurgitation resulting from papillary muscle rupture during percutaneous removal of a Swan-Ganz catheter (SCG) caught by a surgical suture. We performed urgent tricuspid valve repair by suturing the ruptured papillary muscle. This report highlights preventive measures to avoid suture-related entrapment and raises a word of caution regarding percutaneous removal of accidentally entrapped SCGs.

In the catheterization laboratory and the intensive care unit, right heart catheterization (RHC) can provide vital physiologic information. Although clinical trials have never demonstrated improved outcomes with RHC, when used appropriately, it is viewed as an invaluable tool for the hemodynamic monitoring and management of critically ill patients with cardiovascular disease.

Pulmonary artery catheters have been extensively used for hemodynamic assessment over the past several decades. We present a case that highlights the management of a known, but rare and catastrophic complication of pulmonary artery catheter based therapy. An elderly lady with acute decompensated heart failure, severe pulmonary hypertension, and atrial fibrillation on anticoagulation had a pulmonary artery catheter inserted for hemodynamic monitoring. Subsequently, the patient developed acute hemoptysis and damped pulmonary artery pressure waveforms during inflation of the catheter tip balloon. The possibility of pulmonary artery rupture was immediately recognized and confirmed with CT angiogram of the chest. Emergent interventional radiology guided coil embolization of pulmonary artery rupture and pseudoaneurysm was successful.

Pulmonary artery catheterisation, and right heart catheterisation in general, is an essential tool for the Cardiologist. It is the gold standard for assessing cardiac hemodynamics and it is routinely used in most areas of Cardiology, including heart failure, valve disease, congenital heart disease and pulmonary hypertension. However, as a result of major improvements in non-invasive imaging, right heart catheterisation has been used ever less frequently, possibly resulting in a degree of “detraining” of many Cardiologists in terms of performing the investigation and interpreting the information acquired. Accessing the pulmonary arteries and obtaining accurate pulmonary arterial and pulmonary wedge pressures traces can, in fact, be particularly difficult in patients with enlarged right cardiac chambers and tricuspid regurgitation. In this chapter, we provide full description of the technique used for accessing the pulmonary arteries in the catheter lab, potential difficulties and pitfalls, as well as tips on how to overcome these.

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.

The use of pulmonary artery catheter (PAC) is controversial. The purpose of this study was to document the changing pattern of PAC use and to determine its effect on outcome.The use of PAC was analyzed in patients ≥16 years old admitted to the surgical intensive care unit (SICU) over a 9-year period starting in 2000. Patients with SICU length of stay exceeding 30 days were excluded. For the evaluation of PAC's effect on outcome, PAC and no-PAC patients were matched utilizing propensity scores.During the 9-year study period, a total of 5,192 trauma patients were admitted to the SICU. Of these, 426 (8.2%) were16 years old, and 174 (3.4%) had a SICU length of stay that exceeded 30 days. For the remaining 4,592 patients, the mean ± SD age was 39.5 ± 18.8 years, and the mean ISS was 19.9 ± 12.4. PAC was utilized in 19.5% (n = 896) of all the patients admitted to the SICU. The trend for PAC use decreased significantly over the years (P value for trend0.001), from 38.6% in the year 2000 to 4.2% in the year 2008. This decrease was noted in all age and injury severity groups of patients. The overall mortality, however, remained at the same levels (P value for trend = 0.111). Patients managed with a PAC were significantly older, more severely injured, more frequently injured by a blunt mechanism, and were admitted more often in a hypotensive or comatose status. In the early part of the study, the PAC was utilized on the first day and for 4.1 days on average. In the later part of the study, however, the PAC was used on the second day and for a shorter period of time (3 days on average, P0.001). In the matched study population, patients in the PAC group had almost twofold higher odds for death, when compared to the no-PAC group [34.2% vs. 22.5%, Odds Ratio (95% CI): 1.78 (1.42, 2.26), P0.001]. Patients younger than 50 years of age who had an ISS ≥16 had worse outcome when managed with a PAC, whereas patients aged 30-69 years with an ISS16 had a higher survival. The overall complication rate was fivefold higher in patients receiving a PAC [46.3% vs. 14.2%, Odds Ratio (95% CI): 5.22 (4.04, 6.74), P0.001].The use of PAC has decreased almost 10-fold over the last decade at our institution. The PAC is being used later during the ICU course and for a shorter period of time. In a matched population, the use of PAC is associated with a significantly higher mortality and complication rate, but the reason for this association remains uncertain. The use of PAC is invasive and is associated with known complications and financial costs. While the use of PAC maybe useful in a select population, routine and widespread use of the PAC should be avoided.

Background— Although several studies have demonstrated a good correlation between Doppler echocardiographic and invasive measurements of single hemodynamic variables, the accuracy of echocardiography in providing a comprehensive assessment in individual patients has not been validated. The aim of this study was to assess the accuracy and clinical applicability of Doppler echocardiography in determining the entire hemodynamic profile in stable patients with advanced systolic heart failure. Methods and Results— Doppler echocardiography and Swan-Ganz catheterization were simultaneously performed in 43 consecutive patients with advanced heart failure. Echocardiographic data required for estimation of right atrial, pulmonary artery systolic, and pulmonary capillary wedge pressures; cardiac output; and pulmonary vascular resistance were obtained and compared with hemodynamic data. For all variables, invasive and noninvasive hemodynamic values were highly correlated ( P 3 Wood U) and pulmonary capillary wedge pressures (>20 mm Hg) at baseline, hemodynamic and Doppler measurements were simultaneously repeated after unloading manipulations. Absolute values and changes of pulmonary vascular resistance and pulmonary capillary wedge pressures after unloading were still accurately predicted ( r =0.96 and r =0.92, respectively). Conclusions— Doppler echocardiography may offer a valid alternative to invasive cardiac catheterization for the comprehensive hemodynamic assessment of patients with advanced heart failure, and it may assist in monitoring and optimization of therapy in potential heart transplant recipients.

A case of cardiac arrhythmias related to continuous thermodilution cardiac output (CCO) is reported. A sheep anaesthetized for experimental purpose was instrumented with a special Swan-Ganz catheter-type to be used for CCO measurements. One hour after starting the CCO monitoring, isolated ventricular extrasystoles were noticed on the electrocardiogram with an increasing frequency. Subsequently bursts of extrasystoles occurred. Atrioventricular dissociation was also observed. The peaks of temperature of the thermal filament were within the normal range and their presence was noticed when arrhythmias appeared. Mean blood pressure and cardiac output did not change during this episode. When the CCO was switched off, no more arrhythmias were observed. The CCO Swan-Ganz by itself did not generate any arrhythmia. The sheep recovered uneventfully. When arrhythmias occur during anaesthesia where CCO is used, a thermal filament induced origin of the arrhythmia must be considered.

Although cardiac output (CO) by pulmonary artery catheterization (PAC) has been an important guideline in clinical management for more than four decades, some studies have questioned the clinical efficacy of CO in certain patient populations. Further, the use of CO by PAC has been linked to numerous complications including dysrhythmia, infection, rupture of pulmonary artery, injury to adjacent arteries, embolization, pulmonary infarction, cardiac valvular damage, pericardial effusion, and intracardiac catheter knotting. The use of PAC has been steadily declining over the past two decades. Minimally invasive and noninvasive CO monitoring have been studied in the past two decades with some evidence of efficacy. Several different devices based on pulse contour analysis are available currently, including the uncalibrated FloTrac/Vigileo system and the calibrated PiCCO and LiDCO systems. The pressure-recording analytical method (PRAM) system requires only an arterial line and is commercially available as the MostCare system. Transesophageal echocardiography (TEE) can measure CO by non-Doppler- or Doppler-based methods. The partial CO2 rebreathing technique, another method to measure CO, is marketed by Novametrix Medical Systems as the NICO system. Thoracic electrical bioimpedance (TEB) and electric bioreactance (EB) are totally noninvasive CO monitoring. Nexfin HD and the newer ClearSight systems are examples of noninvasive CO monitoring devices currently being marketed by Edwards Lifesciences. The developing focus in CO monitoring devices appears to be shifting to tissue perfusion and microcirculatory flow and aimed more at markers that indicate the effectiveness of circulatory and microcirculatory resuscitations.

The aim of this prospective study was to compare continuous cardiac output measurements of the non-invasive cardiac output system (NICO) with the pulmonary artery catheter during off-pump coronary bypass surgery.Twenty-two patients enrolled for off-pump coronary surgery received both a pulmonary artery catheter and a non-invasive cardiac output system for measurement of cardiac output. Data were compared by the Bland-Altman method to calculate the degree of agreement and to analyse if a significant difference existed between the two methods of cardiac output measurements.Perioperatively, the non-invasive cardiac output underestimated cardiac output, but postoperatively overestimated it. The limits of agreement were larger during surgery compared to the postoperative period (-3.1; +2.5 vs. -1.4; +2.2 L min(-1)). Perioperatively, cardiac output measured with the pulmonary artery catheter varied from 0.5 to 7.5 L min(-1) (mean 3.6 L min(-1)) and with the non-invasive cardiac output from 0.5 to 8.4 L min(-1) (mean 3.9 L min(-1)). Postoperatively, these were 2.5-7.7 L min(-1) (mean 4.5 L min(-1)) and 2.3-8.4 L min(-1) (mean 4.9 L min(-1)), respectively.During off-pump cardiac surgery, the non-invasive cardiac output reliably measures cardiac output and does it more rapidly than a pulmonary artery catheter and may be more useful in order to detect rapid haemodynamic changes.

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.

Objective: The objective of the study is to determine the utility and practicality of Cheetah noninvasive cardiac output monitoring (NICOM) as a means of hemodynamic monitoring of adult patients after open heart surgery (OHS) in Sub-Saharan Africa (SSA). Materials and Methods: This was a single-institutional prospective study of eight adult patients undergoing OHS with cardiopulmonary bypass between August 2015 and April 2016. Cardiac output (CO) was calculated utilizing three measuring techniques; (1) Cheetah NICOM through skin electrodes, (2) FloTrac Vigileo through an arterial line, and (3) Vigilance through an oximetry Swan Ganz catheter (pulmonary artery catheter). CO readings were grouped into four intervals; precardiopulmonary bypass, postcardiopulmonary bypass, and first 24 h and second 24 h in Intensive Care Unit (ICU). The CO recordings from the three techniques were then compared for correlation between the noninvasive and two invasive techniques. Results: The mean patient age was 46.3 ± 15.7 years and 4 (50.0%) were males. Seven (87.5%) patients had acquired heart disease and 1 (12.5%) congenital heart disease. Three (37.5%) patients had severe pulmonary hypertension and 2 (25.0%) patients required intra-aortic balloon pump postoperatively. Correlation was highest in the ICU after patients were fully warm. Correlation coefficients were r = 0.56, bias 0.39 ± 2.34 between NICOM and Vigileo and r = 0.53, bias 1.43 ± 2.26 between NICOM and Vigilance within the first 24 h in ICU. In subsequent second 24 h in ICU, r = 0.84, bias − 0.16± −1.81 between NICOM and Vigileo and r = 0.29, bias 5.68 ± 1.55 between NICOM and Vigilance were the correlation coefficients. There was either none or poor correlation between NICOM and both the Vigileo or Vigilance pre- and post-cardiopulmonary bypass as most patients were still relatively hypothermic. Conclusion: NICOM reliably calculated CO in normothermic patients after OHS, showing average-to-high positive correlations with the Vigileo and Vigilance. Its easy applicability and cheaper cost make it more readily adaptable in SSA with limited finances and skilled healthcare workforce.

Recruitment of the patent foramen ovale (PFO) while SCUBA diving has conventionally been thought to be caused by Valsalva maneuvers performed during ascent and may provide a route for venous air emboli to enter the arterial circulation. Alternatively, we hypothesized that mild increases in inspiratory and expiratory load, similar to that provided by a SCUBA regulator, would be sufficient to recruit the PFO. Two healthy adults with a PFO completed three randomized trials (inspiratory, expiratory, and combined (inspiratory/expiratory) loading) consisting of 6 levels of incrementally increasing load, to a maximum resistive load of 20 cmH2O/L/s. A saline contrast echocardiogram was performed at each resistive load to determine foramen ovale patency. Right atrial and pulmonary wedge pressures were obtained using a Swan Ganz catheter, and intrathoracic pressure was estimated using an esophageal balloon catheter. We found that PFO recruitment occurred in response to both inspiratory and expiratory loads. We will...

Swan-Ganz (S-G) catheters were introduced into pulmonary artery (PA) with the aid of multiplane transesophageal echocardiography (TEE) in 15 patients undergoing elective open heart surgeries. This method promptly allowed us to find the causes for the difficulties of the catheters in advancing through the tricuspid valve into the right ventricle and for the abnormalities in pressure waveform measured by the catheter. We could easily and safely place the S-G catheter in the PA by TEE guidance, indicating that TEE monitoring might be useful for placement of the S-G catheter in PA paticularly during operation and emergency situation.

We explored the possibility of using conventional right-heart catheterization data, gathered both prospectively and retrospectively, as a surrogate for high-fidelity micromanometery when analyzing systolic and diastolic RV function and calculating various ventricular and pulmonary hemodynamic parameters in the time domain. Right heart catheterizations were performed on 13 patients (7 female), who were suspected of having pulmonary hypertension. The procedure included use of both fluid-filled catheter and high-fidelity micromanometry to measure right ventricular and pulmonary arterial pressures. A digital data acquisition system was used to record micromanometer readings and data from the fluid-filled catheter system during prospective portion of the study. Retrospective data was obtained by direct digitization of screen captures taken by the conventional clinical system (fluid-filled catheter). From the 13 patients, 12–13 RV waveforms and 12 PA waveforms were acquired from each method. Basic measurements of heart rate, systolic pressure, diastolic pressure, dP/dt max, and dP/dt min were compared between micromanometry, direct acquisition from the PA catheter (voltage acquisition), and re-digitization of the hemodynamic waveforms (tracing). Correlation between Swan and tracing was stronger than that of Millar and Swan. SBP, followed by HR, has the strongest correlation of any parameter for all three methods, while DBP appears to be the weakest. Bland–Altman analysis shows all parameters to have minimal biases that are within clinical limits. Interoperator and intraoperator variability was minimal. Digital right-heart catheterization (RHC) data can be used as a surrogate for micromanometric data under ideal conditions for hemodynamic measures in the time domain. Pre-existing RHC data can be re-digitized for more rigorous hemodynamic analysis.

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.