The document provides information on pulmonary artery catheters including their history, indications, contraindications, preparation, technique, interpretation of measurements, complications, and a review of literature on their use. Some key points: - Pulmonary artery catheters, also called Swan-Ganz catheters, were invented in 1970 and allow for measurement of cardiac output and pressures in the heart and lungs. - They can provide diagnostic and therapeutic benefits but their routine use has declined due to risks of complications and lack of clear benefits shown in studies. - Current indications are mainly for critically ill patients with conditions like shock, heart failure, or pulmonary hypertension. - Placement requires sterile technique and monitoring pressures during

1. Pulmonary Artery Catheter
Dr. Ashish Sharma
1

2. • Historical perspectives
• Introduction
• Physiologic Measurements
• Indications
• Contraindications
• Preparation
• Technique
• Interpretation of hemodynamic values
and waveforms
• Complications
• Review of litrature 2

3. 3
 1929 - Dr Warner Forssmann
 In 1956,Drs Forssmann,
Cournand, and Richards
received the Nobel Prize
 Invented in 1970 by Swan,
Ganz

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. Introductio
n
5
• 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

6. Hemodynamic Parameters-Measured
6

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)
7
Hemodynamic Parameters- Derived

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
8
Circulation 2009

9. Indication
s
9
• 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

10. Contraindicatio
ns
• 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. Preparatio
n
11
• 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

12. • Equipments:
– 2% chlorhexidine skin preparation solution
– Sterile gown, gloves, face shield and cap
– Sterile gauze pads
– 2% lidocaine -5 cc
– Seeker needle 23G
– Introducer needle  18G
– J-tip guidewire
– Transduction tubing
– Sterile catheter flush solution
– Sheath
– Pulonary catheter
– Sterile sleeve for catheter
– 2-0 silk suture
– Sterile dressing 12

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

14. 14

15. Pulmonary Artery Catheterization-Technique
15
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

16. Full body sheet
Barrier precautions
16

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

18. 18

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

20. Pulmonary Artery Catheterization
20
Continuous
pressure
monitoring during
PAC insertion is
required to
determine location
of the catheter
tip.

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
22
• Ensuring accurate measurements:
– Zeroing and Referencing
– Correct placement
– Fast flush test

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
24
• Pressure waveforms can be obtained from
– Right atrium
– Right ventricle
– Pulmonary artery

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

26. 26

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

30. Canon ‘a’ wave- AV dissociation 30

31. Prominent ‘V’ wave- TR
31

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

33. 33

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

36. 36

37. • Normal pulmonary artery pressures:
– Systolic  20-35mmHg
– Diastolic  8-15 mmHg
– Mean  18 (10-22mmHg)
– Pulmonary artery hypertension-
– Mild PAH- 35-50 mmhg
– Moderate PAH- 50-70 mmhg
– Severe PAH > 70mmhg
37

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
39
• 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

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

41. 41

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
43
Laboured breathing (high
negative intra-thoracic
pressure) may lead to false
low PAWP

44. Respiratory Variation of PCWP Waveform
44

45. • Abnormal PAOP:
– Increased LVEDP  Increased PAOP
• LV systolic HF
• LV Distolic HF
• Mitral and Aortic valve disease
• Hypertrophic cardiomyopathy
• Hypervolemia
• Large R-L shunts
• Pericardial disease
45

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

49. Complicatio
ns
49
• General:
– Immediate:
• Bleeding
• Arterial Puncture
• Air embolism
• Thoracic duct injury ( Lt side)
• Pneumothorax/hemothorax
– Delayed:
• Infections
• Thrombosis

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

51. Review of literature
51

52. A Randomized, Controlled Trial of the Use of Pulmonary-
Artery Catheters in High-Risk- Surgery patients
Sandham et al
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%
52
 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
NEJM2003

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

56. PAC Vs Cost analysis
56

57. PAC Vs Length of stay
57

58. 58

59. 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

60. To Swan or Not to
Swan?
INDIVIDUALIZE CARE
Understanding Swan Ganz Catheters=Understanding
Hemodynamics
60

61. Thank
You
61