The document discusses the history and development of pulmonary artery catheters. It describes how Dr. Swan and Dr. Ganz invented the balloon-tipped catheter and how it allows direct measurement of pressures in the heart and lungs. The document outlines the proper insertion technique and provides normal values for pressures measured in different areas of the heart and lungs. It also discusses indications, contraindications, and complications of pulmonary artery catheter use.

1. Pulmonary artery Catheter
and
Monitoring
Dr Jitendra Ramteke

2. History
 Introduction of Right Heart Catheterization- 1929 by
Forsmann.
 Urinary catheter into his own cubital vein and into his
right heart.
 Cournand and Richards developed catheters that can
be advanced upto pulmonary artery.

3.  1970 - Dr Swan noticed how easy it was for
a sailboat to move even in the slightest
breeze.
 Dr Swan then invented the balloon tipped
catheter.
 Dr Ganz was working on thermo dilution
methods to calculate cardiac output.
 So the pulmonary artery catheter was
named Swan Ganz.

5. Direct Measurements
– Central Venous Pressure(CVP).
– Right sided intracardiac pressures (RA)
– Pulmonary artery pressure(PAP)
– Pulmonary artery occlusion pressure (PAOP)
– Cardiac Output.
– Mixed Venous Oxygen Saturation(SvO2)

6. • Indirect measurements
– Systemic Vascular Resistance
– Pulmonary Vascular Resistance
– Cardiac Index
– Stroke volume index
– Oxygen delivery
– Oxygen uptake

7. Indications
• Diagnostic:
– Differentiation among causes of shock.
– Differentiation between mechanisms of
pulmonary edema.
– Evaluation of pulmonary hypertension.
– Diagnosis of pericardial tamponade.
– Unexplained dyspnea.

8. • Therapeutic:
– Management of perioperative patients with
unstable cardiac status
– Management of complicated myocardial
infarction.
– Management of patients following cardiac
surgery/high risk surgery
– Assess response to pulmonary
hypertension specific therapy.

9. Contraindications
• Absolute:
o Infection at insertion site.
o Tricuspid or pulmonary stenosis.
o Right atrial or ventricular mass.
• Relative:
 Coagulopathy.
 Thrombocytopenia.
 Electrolyte disturbances (K/Mg/Na/Ca)
 Severe Pulmonary HTN.
 Arrhythmia, LBBB.
 Newly inserted pacemaker.

13. Preparation
1. Patient has to be monitored with continuous
ECG throughout the procedure.
2. Check balloon integrity by inflating with 1.5ml
of air.
3. Check lumens patency by flushing with saline.
4. Cover catheter with sterile sleeve provided.

14. Technique
1. Local infiltration done.
2. Aseptic precautions must be employed.
3. Cannulate vein with Seldinger technique.
4. Place sheath.
5. Pass catheter through sheath with tip curved
towards the heart(11 o’clock).

15. 6. Once tip of catheter passed through introducer
sheath --- inflate balloon at level of right
atrium~20cm.
7. Continous waveform analysis through right
ventricle  pulmonary artery  wedge position.
8.After acquiring wedge pressure deflate
balloon.

16. • Important:
– When advancing catheter- always inflate tip.
– When withdrawing catheter- always deflate.
– Once in pulmonary artery - NEVER INFLATE
AGAINST RESISTANCE - RISK OF PULMONARY
ARTERY RUPTURE

19. • Elevated RA pressure:
– Diseases of RV(infarction/ cardiomyopathy)
– Pulmonary hypertension
– Pulmonic stenosis
– Left to right shunts
– Pericardial diseases
– LV systolic failure
– Hypervolemia

20. • 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

22. • Right Ventricle:
– Peak RV systolic pressure 15-25mmHg
– Peak RV diastolic pressure 3-12 mmHg

24. • Elevations in RV pressure:
– Diseases increasing pulmonary artery pressure
– Pulmonic valve disorders
– Diseases affecting right ventricle
• Pulmonary vascular and pulmonary valve disorders
increases RV systolic pressures.
• RV disorders – ischemia/infarction/failure 
RV End diastolic pressure

25. • Pulmonary artery:
– The risk of arrhythmias is greatest while
catheter tip is in RV
Thus, catheter should be advanced from RV to
without delay.
• Main components of PA tracing:
– Systolic and Diastolic pressure
– Dichrotic notch(due to closure of pulmonic
valve)

26. • Normal pulmonary artery pressures:
– Systolic -15-25mmHg
– Diastolic - 8-15 mmHg
– Mean - 10-22mmHg

28. • 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

29. Pulmonary arterial occlusion pressure
•Final position of the catheter must be such that
PCOP tracing is obtained whenever 1.5ml volume of
balloon is insufflated.
Overwedged- If < 1ml of air is injected and PAOP
is seen.
–needs to be withdrawn
Too proximal- If maximal inflation fails to result in
PCOP tracing or after 2-3 seconds delay.
-advance the PAC.

30. • PCWP/PAOP interprets Left atrial pressures
LVEDP
– Best measured in
• Supine position
• At end of expiration
• Zone 3 (most dependent region)
– Normal PCWP- 6-15 mmHg ; Mean :9mmHg

32. Lung zones by West and colleagues.
PAC wedged in lung zone 3 for accurate measure of
pulmonary venous (Pv) or left atrial (LA) pressure.

33. • 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

34. • 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

35. Complications
• General:
– Immediate:
• Bleeding
• Arterial Puncture
• Air embolism
• Thoracic duct injury ( L side)
• Pneumothorax/hemothorax
– Delayed:
• Infections
• Thrombosis

36. • Related to insertion of PAC:
– Arrhythmias (most common- Ventricular/
– Misplacement
– Knotting
– Myocardial/valve/vessel rupture
• Related to maintenance and use of PAC:
– Pulmonary artery perforation
– Thromboembolism
– Infection

38. extravasation of contrast medium from the distal pulmonary
artery

39. Swan-Ganz
Cardiac Output
Principles
(Thermodilution)

40. Intermittent Cardiac Output Monitoring
With Swan Ganz

42. Bolus Thermodilution
 Injecting a solution that is colder
than blood through the right atrial
port of the catheter and
measuring the temperature
change distally with a built in
thermistor.
 The area under the time-
thermodilution curve is used to
calculate the cardiac output.
TIME
Conc.
Area under curve = CO

43. Cardiac Output Measurement

44. Continuous Cardiac
Output (CCO)
Principles & Benefits

46. PAC Volumetric Thermo-dilution Catheter
Thermal Filament
• 10 cm in length
• 14-25 cm from tip
• Rests between RA & RV
• Should be free floating
and avoid endocardial
surface
• Should NOT be in PA
Balloon Inflation
• Appropriate inflation
volume is 1.25-1.5 cc
Proximal Injectate Port
• 26 cm from tip
• Transduce RV waveform &
withdraw ~ 5cm
• Should be located in RA
• Should NOT be in RV

47. Continues Cardiac Output Monitoring
 Thermal filament in RA to provide
heat in specific, repetitive on-off
sequences, sensed by distal
thermistor.
 These “pulses” of energy replace the
traditional fluid bolus.
 Gives CCO value with a 30 sec
update.
 No need for calibration, bolus
injection.
 Correlates well with ‘gold standard’
bolus thermodilution.

48. ICO vs. CCO
 GOLD Standard for CO
 Area underneath washout curve
equates to CO
 Suffers from inexperienced users
 Misses information between
measurements
 Time consuming
 Still thermodilution technique
 Continuous monitoring
 Not time consuming
 Remove inaccuracies associated
with Bolus technique
 Continuous information to help
treat patient early
 Cuts down on nursing/doctors time
CCO
ICO

49. TYPES OF PAC
 Paceport – capable of providing cardiac pacing.
 Continuous Cardiac Output-- produces
thermodilution curve to determine cardiac output.
 Mixed venous O2 – can determine venous oxygen
Saturation.
 Heparin coated.

50. CONS
 PAC use in 5735 patients in first 24 hrs intensive care associated with
increased mortality, hospital stay and cost (Connors etal,1996)
 Three trials including 3468 patients showed no effect on mortality but
higher incidence of adverse effects (Harvey etal (PACMAN), 2005; The
ESCAPE Trial, 2005; Sandham etal, 2003)

51. …….Cardiac surgery patients
 National database analysis by Chiang et al., among 2,063,337
patients undergoing cardiac surgery (coronary and/or valve surgery)
in the US between 2000 and 2010, those who underwent pulmonary
artery catheterization were found to have a significantly higher
operative mortality.
 Database analysis by Brovman et al. found that among 116,333
patients undergoing coronary artery bypass graft (CABG) or valve
replacement surgeries in the US between 2010 and 2014, the
presence of PAC did not result in significant decreases in the odds of
cardiac arrest or death

52. Trend in pulmonary artery catheter use between 1993 and
2004 according to pre-identified diagnoses (Wiener RS, Welch HG
Trends in the use of the pulmonary artery catheter in the United States, 1993–2004. JAMA
2007;298:423–9)

54. PROS
 Pulmonary artery catheter use is associated with reduced mortality in
severely injured patients: a National Trauma Data Bank analysis of
53,312 patients. Friese RS, Shafi S, Gentilello LM - Crit. Care Med. - Jun
2006; 34(6); 1597-601
 Multi-center cohort analysis by Sotomi et al. in a population with
acute decompensated heart failure demonstrated that use of PAC
resulted in a decrease in all-cause mortality
 In mixed medical and surgical population with PAC use, APACHE scores
– <25 - Increased mortality
– >31 - Significant benefit (Chittock etal, 2004)

55. Sarkar M, Umbarkar S. Pulmonary artery catheter – Dilemma is still on?. Ann Card
Anaesth 2021;24:1-3

57. Summary
 PAC itself is not a therapeutic intervention.
 PAC can help to guide the therapy.
 High doses of ionotropes or vasoconstrictors are best
managed (choose & titrate)using all the data from a PAC
(SVR; PVR; SVO2).