3. • 1929 - Dr Warner Forssmann
• In 1956,Drs Forssmann,
Cournand, and Richards received
the Nobel Prize
• Invented in 1970 by Swan, Ganz
3
4. • “Swan” soon became a verb –
• A common expression in the critical care units during
clinical rounds was, “We swanned the patient.”
• The Swan- Ganz catheter was used by residents and fellows in
coronary care, medical, surgical, and other critical care units
and during cardiac and non-cardiac surgery
• The PAC 1970-2007: rest in peace?
4
5. Introduction
• Pulmonary artery catheters (also called as Swan-
Ganz catheter) are used for evaluation of a range
of condition
• Although their routine use has fallen out of
favour, they are still occasionally placed for
management of critically ill patients
5
7. Oxygen Transport Parameters
• Oxygen Delivery (DO2)
• Rate of oxygen delivery in arterial blood
DO2 = CI x 13.4 x Hgb x SaO2
• Mixed Venous Oxygen Saturation (SVO2)
• Oxygen saturation in pulmonary artery blood
• Used to detect impaired tissue oxygenation
• Oxygen uptake (VO2)
• Rate of oxygen taken up from the systemic microcirculation
VO2 = CI x 13.4 x Hgb x (SaO2 - SVO2)
Hemodynamic Parameters- Derived
7
8. Current indications - PAC
• Not indicated as routine pulmonary
artery catheterization in high-risk
cardiac and noncardiac patients
• In patients with cardiogenic shock
during supportive therapy
• Patients with discordant right and
left ventricular failure
• Patients with severe chronic heart
failure requiring inotropic,
vasopressor, and vasodilator therapy
• Indicated in patients with suspected
“pseudosepsis” (high cardiac output,
low systemic vascular resistance,
elevated right atrial and PCWP
• Patients with potentially reversible
systolic heart failure such as
fulminant myocarditis and
peripartum cardiomyopathy
• Hemodynamic differential diagnosis
of pulmonary hypertension
• To assess response to therapy in
patients with precapillary and
pulmonary hypertension
• Transplant workup
Circulation 2009
8
9. Indications
• Diagnostic:
– Differentiation among causes
of shock
– Differentiation
between mechanisms
of pulmonary edema
– Evaluation of pulmonary
hypertension
– Diagnosis of pericardial
tamponade
– Diagnosis of right to left
intracardiac shunts
– Unexplained dyspnea
Therapeutic:
– Management of perioperative patients with
unstable cardiac status
– Management of complicated myocardial
infarction
– Management of patients
following cardiac surgery/high
risk surgery
– Management of severe preecclampsia
– Guide to pharmacologic therapy
– Burns/ Renal Failure/ Heart
failure/Sepsis/ Decompensated
cirrhosis
– Assess response to pulmonary hypertension
specific therapy
9
10. Contraindications
• Absolute:
• Infection at insertion site
• Presence of RV assist device
• Tricuspid or pulmonary valve
mechanical prosthesis
• Right heart mass (thrombus
and/or tumor)
• Tricuspid or pulmonary valve
endocarditis
• Insertion during CPB (cardio
pulmonary bypass)
• Lack of consent
• Relative:
• Coagulopathy
• Thrombocytopenia
• Electrolyte disturbances
(K/Mg/Na/Ca)
• Severe Pulmonary HTN
10
11. Preparation
• Patient has to be monitored with continuous
ECG throughout the procedure, in supine
position regardless of the approach
• Aseptic precautions must be employed
• Cautions should be taken while cannulating
via IJV/ Subclavian vein
11
13. Pulmonary Artery Catheter-Kit
• The standard PAC kit includes:
• Standard PAC is 7.0, 7.5 or 8.0
French in circumference and
110 cm in length divided in 10
cm intervals
• Syringe that can be filled with
only 1.5 mL of air to prevent
overinflation of the balloon
• Plastic sheath that is used to
maintain sterility of the PAC as
it is advanced and withdrawn
13
15. Pulmonary Artery Catheterization-Technique
1. Aseptic precautions undertaken
2. Local infiltration done
3. Check balloon integrity by inflating with 1.5ml of air
4. Check lumens patency by flushing with saline 0.9%
5. Cover catheter with sterile sleeve provided
6. Cannulate vein with Seldinger technique
7. Place sheath
8. Pass catheter through sheath with tip curved towards the heart
9. Once tip of catheter passed through introducer sheath inflate balloon at level of
right ventricle
10. The progress of the catheter through right atrium and ventricle into
pulmonary artery and wedge position can be monitored by changes in
pressure trace
11. After acquiring wedge pressure deflate balloon
15
17. • Prior to PAC insertion
• Connect the distal port (yellow)
to the pressure transducer
• Level the transducer at the level
of the patient’s heart
• No air bubble /Air tight
• Zero the transducer
17
19. PAC as seen on chest x-ray
19
Ideally the catheter is placed in the right/left main pulmonary arteries, and should not lie
more than 1cm lateral to the mediastinum
21. • Important points:
– When advancing catheter- always inflate tip
– When withdrawing catheter- always deflate
– Once in pulmonary artery - NEVER INFLATE AGAINST
RESISTANCE - RISK OF PULMONARY ARTERY RUPTURE
21
22. Interpretation of hemodynamic values and
waveforms
• Ensuring accurate measurements:
– Zeroing and Referencing
– Correct placement
– Fast flush test
22
23. • Zeroing and Referencing:
– PAC must be appropriately zeroed and referenced
to obtain accurate readings in supine
position/30 degrees semi-recumbent position
• Correct placement :
– By either pressure waveform/ fluoroscopic
guidance
23
24. Catheter waveforms and pressures
• Pressure waveforms can be obtained from
– Right atrium
– Right ventricle
– Pulmonary artery
24
25. • RIGHT ATRIUM:
– In presence of a a competent tricuspid valve, RA
pressure waveform reflect both
• Venous return to RA during ventricular systole
• RV End Diastolic Pressure
– Normal RA pressure: 0-8 mmHg
25
27. • Elevated RA pressure:
– Diseases of RV( infarction/ cardiomyopathy)
– Pulmonary hypertension
– Pulmonic stenosis
– Left to right shunts
– Pericardial diseases
– LV systolic failure
– Hypervolemia
27
28. • Differentiating among etiologies depends on
– Clinical
– Radiographical
– Echocardiographic features
+
PAC findings
Eg: Increased RA Pressure and Mean pulmonary
Pressure PAH
Increased RAP and Normal Pa pressures RV
disease/ Pulmonary stenosis
28
29. • Abnormal RA waveforms:
– Tall v waves: Tricuspid Regurgitation
– Giant/ cannon a waves:
• Ventricular tachycardia
• Ventricular pacing
• Complete heart block
• Tricuspid stenosis
– Loss of a waves:
• Atrial fibrillation/ Atrial flutter
29
32. • RIGHT VENTRICLE:
– Transitioning from SVC or RA to RV:
• Once balloon is inflated in the SVC/RA the catheter is
slowly advanced
When catheter tip is across tricuspid valve pressure
waveform changes and systolic pressure increases
• 2 pressures are typically measured in right
ventricular pressure waveform
– Peak RV systolic pressure 20-30mmHg
– Peak RV diastolic pressure 0-8 mmHg
32
34. • As a general rule elevations in RV pressure:
– Diseases increasing pulmonary artery pressure
– Pulmonic valve disorders
– Diseases affecting right ventricle
• Pulmonary vascular and pulmonary valve disorders a/w
increased RV systolic pressures
• RV disorders – ischemia/infarction/failure – a/w increased
RV End diastolic pressure
34
35. • PULMONARY ARTERY:
– The risk of arrhythmias is greatest while catheter tip is in
RV
Thus, catheter should be advanced from RV to PAwithout
delay
– When catheter tip passes pulmonary valve
Diastolic pressure increases and characteristic
dichrotic notch appears in waveform
35
38. • Increase in mean pulmonary pressure:
– Acute:
• Venous Thromboembolism
• Hypoxemia induced Pulmonary Vasoconstriction
– Acute on Chronic:
• Hypoxemia induced pulm VC in patient with chronic
cardiopulmonary disease
– Chronic:
• Pulmonary hypertension
38
39. PULMONARY ARTERIAL OCCLUSION PRESSURE
• Once catheter tip has reached PA, it should be advanced until
PAOP is identified by decrease in pressure and change in
waveform
The balloon should then be deflated and PAtracing should
reappear
If PCOP tracing persists catheter should be withdrawn with
definitive PA tracing obtained
39
40. • Final position of the catheter within PA must be such that
PAOP tracing is obtained whenever 75-100% of 1.5ml
maximum volume of balloon is insufflated
– If < 1ml of air is injected and PAOP is seen then it is
overwedged needs to be withdrawn
– If after maximal inflation fails to result in PAOP tracing or
after 2-3 seconds delay too proximal
– advanced with balloon inflated
40
42. • PCWP/PAOP interprets Left atrial pressures
more importantly – LVEDP
– Best measured in
• Supine position
• At end of expiration
• Zone 3 (most dependent region)
– Normal PCWP- 8-15 mmHg ; Mean :9mmHg
42
43. Respiratory Artifacts
Mechanical lung ventilation (high
intra-thoracic pressure) may lead to
false high PAWP
Laboured breathing (high negative
intra-thoracic pressure) may lead
to false low PAWP
43
46. • Decreased PCWP:
– Hypovolemia
– Obstructive shock due to large pulmonary embolus
• Abnormal waveforms
– Large a waves:
• MS
• LV systolic /diastolic function
• LV volume overload
• MI
– Large v waves - MR
46
47. • Calculation of cardiac output:
– 2 methods
• Thermodilution method
• Fick’s Method
– Better measurement with Cardiac index
• Normal – 2.8- 4.2 l/min/m2
47
48. • Other uses of pulmonary artery catheter:
– Detection of Left to right shunts
– Estimation of systemic and pulmonary vascular
resistance
48
50. • Related to insertion of PAC:
– Arrhythmias (most common- Ventricular/ RBBB)
– Misplacement
– Knotting
– Myocardial/valve/vessel rupture
• Related to maintenance and use of PAC:
– Pulmonary artery perforation
– Thromboembolism
– Infection
50
52. A Randomized, Controlled Trial of the Use of Pulmonary-Artery
Catheters in High-Risk- Surgery patients
Sandham et al
• Comparing goal directed therapy guided by PAC with standard care without
PAC
• Patient population: high-risk patients >60 years old ASA -III/IV, scheduled for
urgent or elective major surgery
• Results
• Conclusions: No benefit to goal directed therapy by PAC over standard care
in elderly, high risk surgery patients
PAC group Standard care Group
Death 7.8% 7.7%
Pulmonary Embolism 8 0
6 month Survival 87.4% 88.1%
12 month Survival 83.0% 83.9%
NEJM2003
52
53. Randomized, Controlled Trial of the Use of Pulmonary-
Artery Catheters in High-Risk Surgical Patients.
• 1994 high-risk surgical patients underwent randomization for
PA catheters (RCT)
• Preop placement, for elective or urgent surgery
• Looked at 6mo and 12 mo mortality
• Conclusions
• No difference b/t PA catheter group from placebo in terms of
mortality and length of hospitalization
• Increased risk of complications in the catheter group and thus,
may be associated with increased morbidity
Sandman et al. NEJM-Jan, 2003
53
54. Is it unethical to withhold Swan Placement?
And are they better at predicting clinical outcomes?
• 1996 observational study in first 24 hours said NO.
1. Placement led to worse patient outcomes b/c of complications of placement or
misinterpretation of data
2. Use of catheter might be a marker of more aggressive care, which is associated with
higher mortality
3. Changes in therapy in response to the information might have led to high mortality (i.e.
using pressors
Limitations of this study-
1. Study might not have adequately adjusted for confounding factors
2. Only looked at SGC placed in first 24 hours.
• Connors AF Jr, et al. The effectiveness of right heart catheterization in the initial care of
critically ill patients. JAMA 1996;276:889-897
54
55. PAC and cost analysis -Cochrane review
• Five trials measured the costs
• Four trials in the US showed that on average the charges were higher for patients
who had PAC
• A study in the UK concluded that withdrawing the use of the pulmonary artery
catheter might result in a cost saving.
• Pitfalls
• Most of the trials identified were small
• conducted in a single hospital
• less than 200 patients taking part.
• Conclusion
Neither group of patients studied showed any evidence of
benefit or harm from a PAC.
55
59. Conclusions
PAC-guided therapy did not improve survival or organ function but was
associated with more complications than CVC-guided therapy.
Suggest ion was that the PAC should not be routinely used for the
management of acute lung injury
59
60. To Swan or Not to
Swan?
INDIVIDUALIZE CARE
Understanding Swan Ganz Catheters=Understanding Hemodynamics
60
