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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.

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.

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.

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.

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.

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.

Introduction: Totally implantable venous access systems (TIVAS), Swan-Ganz (SG) and central venous catheters (CVC) allow easy and repetitive entry to the central cardiovascular system. Fragments of them may be released inadvertently into the cardiovascular system during their insertion or as a result of mechanical complications encountered during long-term utilization. Aim : To present results of percutaneous retrieval of embolized fragments of central venous devices or knotted SG and review the procedural aspects with a series of detailed angiographies. Material and methods : Between January 2003 and December 2012 there were 14 (~0.025%) successful retrievals in 13 patients (44 ±16 years, 15% females) of embolized fragments of TIVAS (n = 10) or CVC (n = 1) or of dislodged guide-wires (n = 2) or knotted SG (n = 1). Results : Foreign bodies with the forward end located in the right ventricle (RV), as well as those found in the pulmonary artery (PA), often required repositioning with a pigtail catheter as compared to those catheter fragments which were located in the right atrium (RA) and/or great vein and possessed an accessible free end allowing their direct ensnarement with the loop snare (57.0% (4/7) vs. 66.7% (2/3) vs. 0.0% (0/3); p = 0.074 respectively). Procedure duration was 2–3 times longer among catheters retrieved from the PA than among those with the forward edge located in the RV or RA (30 (18–68) vs. 13.5 (11–37) vs. 8 min (8–13); p = 0.054 respectively). The SG catheter knotted in the vena cava superior (VCS) was encircled with the loop snare introduced transfemorally, subsequently cut at its skin entrance and then pulled down inside the 14 Fr vascular sheath. Conclusions : By using the pigtail catheter and the loop snare, it is feasible to retrieve centrally embolized fragments or knotted central venous access devices.

Introduction: The placement of a Swan-Ganz catheter into the pulmonary artery may lead to a number of complications (2–17%). In less than 0.2% of cases Swan-Ganz catheterization results in serious vascular damage – pulmonary artery rupture (PAR). This paper presents two distinct forms of iatrogenic PAR treated endovascularly using different vascular devices. Aim: To evaluate the effectiveness of endovascular treatment and the application of different types of vascular devices in the management of pulmonary artery rupture caused by Swan-Ganz catheterization. Material and methods : In this retrospective study we evaluated 2 patients in whom Swan-Ganz catheter application was used for perioperative monitoring and resulted in pulmonary artery rupture. This complication was treated endovascularly by means of interventional cardiology. Results : We report the cases of 2 patients with a pulmonary artery pseudoaneurysm formed in the perioperative period. In case 1, a single, 4-loop, 3 mm diameter coil was implanted. In case 2, a 5 mm Amplatzer Vascular Plug IV was applied. In both cases, the endovascular approach resulted in total occlusion of the feeding artery and reduced further extravasation of the blood. Conclusions : Despite its extremely low incidence, iatrogenic PAR is a serious, life-threatening complication of Swan-Ganz catheterization that requires urgent attention. Among available methods of treatment, percutaneous embolization is a relatively quick, safe, accurate and highly effective alternative to traumatizing surgery.

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.

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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.

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.

The following case report describes a complication of Swan-Ganz catheterization and its endovascular treatment with a single coil. Application of this particular catheter in the pulmonary artery during cardiac surgery may lead to mechanical perforation and creation of an extravascular sac, which is called a pseudoaneurysm. There are different methods that lead to tamponade or closure of the leakage. Interventional cardiology procedures are nowadays the most appropriate way of treatment of Swan-Ganz catheter induced vascular complications.

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.

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.

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.

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.

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.

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.

Dissecting aneurysm of the pulmonary artery is a rare (1 : 3000) but life threatening complication of the use of Swan-Ganz catheters. The most typical clinical manifestation is hemoptysis, even a asymptomatic aneurysm causes pathognomonic X-ray findings. The eventually long free intervall between catheterisation and formation of the dissecting aneurysm requires thorough follow up of the concerning patients, e. g. chest roentgenograms and thorax CT-scans. The endovascular therapy of this lesion has replaced surgery due to a much better risk profile. The aim of the endovascular treatment is a coil-occlusion of the parent artery immediately proximal to the aneurysm. The success of this procedure will be instantaneously evident.

• Background Pulmonary artery catheters are widely used invasive monitoring devices in critically ill patients. Clinicians disagree about whether daily chest radiographs are needed or clinical parameters alone are sufficient to verify catheter placement.• Objectives To determine whether daily chest radiographs are needed to assess migration of pulmonary artery catheters.• Methods One hundred consecutive patients with pulmonary artery catheters were prospectively evaluated. Clinical criteria for optimal position of the pulmonary artery catheters and findings on chest radiographs were compared. Optimal clinical criteria were (1) amount of air required to measure pulmonary capillary wedge pressure: 1.25 to 1.5 mL and (2) pulmonary artery catheter migrated 1 cm or less from initial position.• Results Three hundred ninety comparisons of clinical criteria and radiographic findings were done. Chest radiographs indicated the catheter required repositioning in 15 (4%) of 390 instances but in only 4 (1%) of 310 instances in which bedside clinical findings indicated adequate catheter position. In 69 (18%) of the 390 cases, the clinical criteria for adequate catheter position were not met, but radiographs showed the catheter in an appropriate position. The sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of abnormal clinical criteria were 73%, 82%, 81%, 14%, and 99%, respectively.• Conclusions Chest radiographs indicated that about 4% of catheters required repositioning. Catheter malposition can be reliably excluded (negative predictive value, 99%) by close observation of specific clinical criteria, so routine daily chest radiographs do not seem justified.

Introduction. Adult extracorporeal carbon dioxide removal (ECCO2R) systems and pediatric ECMO share the common objectives of having a low blood flow rate and low priming volume while safely maintaining sufficient respiratory support. The Hemolung is a highly simplified adult ECCO2R system intended for partial respiratory support in adult patients with acute hypercapnic respiratory failure. The objective of this work was to conduct pre-clinical feasibility studies to determine if a highly efficient, active-mixing, adult ECCO2R system can safely be translated to the pediatric population. Methods. 14 healthy nonsedated juvenile sheep were used for acute (2 animals) and 7-day chronic (12 animals) in-vivo studies to evaluate treatment safety independently of respiratory related injuries. In all evaluations, we hypothesized that gas exchange capabilities of the Hemolung RAS in this model would be equivalent to the adult configuration performance at similar blood flows - minimum CO2 removal of 50 mL/min at a venous partial pressure of CO2 equal to 45 mmHg. Target blood flow rates were set to a minimum of 280 mL/min. Swan Ganz catheters were used under general anesthesia in the two acute subjects to evaluate blood gas status in the pulmonary artery.Results. The Hemolung RAS was found to have adequate gas exchange and pumping capabilities for full respiratory support for subjects weighing 3 – 25 kg. The Hemolung device was estimated to provide a partial respiratory support for subjects weighing 27 – 34 kg. The seven-day studies in juvenile sheep demonstrated that veno-venous extracorporeal support could be provided safely at low flows with no significant adverse reactions related to device operation.Conclusion. The study outcomes suggest the potential use of the Hemolung RAS in a veno-venous pediatric configuration to safely provide respiratory support utilizing a significantly less complex system than traditional pediatric ECMO.

Introduction: The Swan-Ganz catheter for pulmonary artery (PA) cannulation was introduced in 1970 and has been utilized in the management of critically ill and cardiac patients. Although the routine use of this catheter has not been associated with better patient outcomes in prospective randomized trials, their ability to provide crucial hemodynamic measurements and the ease of bedside insertion makes them valuable in certain complex clinical scenarios. However, Swan-Ganz catheter insertion is not without complications. PA injury is the most serious complication suspected by the occurrence of hemoptysis after the procedure. We present a case of PA injury with pseudoaneurysm formation after Swan-Ganz catheterization along with a comprehensive review of literature. Methods: We reviewed all PubMed/Medline indexed articles published between 1993-2013, reporting the development of PA pseudoaneurysm after Swan-Ganz catheter use. Cases were analyzed with specific reference to patient demographics, indication for Swan-Ganz insertion, initial presenting symptom, duration between insertion and first evidence of PA injury, inciting event, site of pseudoaneurysm, treatment and outcome. Results: Forty-one patients were identified from 27 papers. In the reviewed population, 87.8% were older than 60 years of age and 82.9% were females. Fifty-one percent of the patients had an episode of hemoptysis on the day of Swan-Ganz catheter insertion. Ninety-seven percent of the patients had PA pseudoaneurysm in the right pulmonary circulation. The admission-to-discharge mortality rate in the reviewed cohort was 15%. Cause of death in 22% of the cases was hemoptysis, while non-catheter related complications were responsible for the remaining deaths. Conclusion: PA injury is a feared complication after Swan-Ganz catheterization and can be fatal. In patients who develop massive or recurrent hemoptysis after Swan-Ganz catheter use, PA injury must be considered and airway protection should be employed along with appropriate catheter based or surgical interventions.

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.

It has been argued that the poor correlation between cardiac output and mixed venous oxygen saturation (SvO2) reduces the value of SvO2. Routine use of Swan Ganz catheters is also controversial in cardiac surgery. Here our clinical experience with a simplified method for routine hemodynamic monitoring and the short-term prognostic value of SvO2 after CABG surgery is presented.Peroperatively an epidural catheter is routinely introduced through the outflow tract of the right ventricle into the pulmonary artery for monitoring of pressure and blood sampling. Clinical data were retrospectively retrieved from the records and related to SvO2 routinely obtained on admission to the ICU after 488 CABG procedures.Average SvO2 on arrival to ICU was 67+/-7%. The SvO2 value of 55% represented a cut off point below which a high incidence of complications were found. Outcome after 456 procedures with SvO2or = 55% compared with 32 procedures with SvO255%: mortality 0 vs. 9.4% (P = 0.0003), perioperative myocardial infarction 6.2 vs. 29% (P0.0001), ventilator treatment 8.9+/-10.1 vs. 25.7+/-54.9 h (P = 0.0074), ICU stay 1.4+/-1.2 vs. 2.1+/-1.7 days (P = 0.0010).SvO2 was of prognostic value and due to its specificity it seems particularly useful for telling which patients are unlikely to develop cardiorespiratory problems. Thus, this simple method for hemodynamic monitoring could contribute to cost containment as it seems that we can safely reserve Swan Ganz catheters for high-risk patients.

Objective: It has been recently shown that there is a match between dicrotic notch and mean pulmonary artery (PA) pressures in spontaneously breathing patients studied by means of high-fidelity pressure catheters. The aim of the study was to analyze the relation between mean PA pressure and PA pressure at the incisura by using a Swan-Ganz catheter in critically ill, mechanically ventilated patients. Measurements and results: Fluid-filled PA pressures were obtained over four ventilatory cycles in 32 consecutive, mechanically ventilated patients in the intensive care unit. We measured mean PA pressure and dicrotic notch pressure. We also calculated the widely used approximation of mean PA pressure (mean PAPapprox = diastolic + 1/3 pulse pressure). Cardiac output was measured in triplicate by using the thermodilution technique. Dicrotic notch was clearly identified in 30 of 32 patients. Mean PA pressure (32.1 ± 10.2 mm Hg) and PA dicrotic notch pressure (31.8 ± 10.4 mm Hg) were linearly related (r = 0.989, p < 0.001). Agreement between dicrotic notch and mean PA pressures was suggested (mean difference ± SD = − 0.3 ± 1.5 mm Hg). Similar agreement was found between mean PAPapprox and mean PA pressure (mean difference ± SD = − 0.7 ± 0.8 mm Hg; p = 0.20). Conclusion: By using a Swan-Ganz catheter we found that dicrotic notch pressure equalled mean PA pressure in the critically ill, mechanically ventilated patients studied. This indicated that right-sided ejection was completed at a PA pressure equal to mean PA pressure in these patients.

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.

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.

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.

Invasive hemodynamic monitoring has become standard in the management of aneurysmal subarachnoid hemorrhage. This study is a retrospective analysis of 630 Swan-Ganz catheters placed in 184 patients with aneurysmal subarachnoid hemorrhage. Evaluation of complications demonstrated a 13% incidence of catheter-related sepsis (81 of 630 catheters), a 2% incidence of congestive heart failure (13 of 630 catheters), a 1.3% incidence of subclavian vein thrombosis (8 of 630 catheters), a 1% incidence of pneumothorax (6 of 630 catheters), and a 0% incidence of pulmonary artery rupture. In the management of patients with aneurysmal subarachnoid hemorrhage, invasive hemodynamic monitoring continues to be an important tool with acceptable complications.

Pulmonary artery rupture (PAR) is a rare but deadly complication (incidence of 0.03-0.2% of all PA cannulations), with mortality in the region of 70%. We report a case of an 88-year-old woman with iatrogenic PAR as a result of Swan-Ganz catheter placement. A rapid successful isolation and occlusion of the culprit PA branch via the deployment of an Amplatzer Vascular Plug (AGA Medical Corporation, North Plymouth, MN) was performed. To our knowledge, this is the first case report where this device has been used as therapy in PAR.

The pulmonary artery catheter will likely earn a place in the history of medicine as one of the most useful tools that shaped our understanding and management of various diseases. An intense assessment of its application in nonacute and nonshock decompensated heart failure has been provided by the ESCAPE trial, a landmark investigation that showed an overall neutral impact of pulmonary artery catheter–guided therapy over therapy guided by clinical evaluation and judgment alone. The current guidelines reserve the use of a pulmonary artery catheter for the management of refractory heart failure and select conditions. The pulmonary artery catheter remains a useful instrument in clinical situations when clinical and laboratory assessment alone is insufficient in establishing the diagnosis and pathophysiologic condition, and in guiding effective, safe therapy.