Pulmonary Artery Catheter Monitoring Research Articles

Haemodynamic effects of intra-aortic balloon pumps stratified by baseline pulmonary artery pulsatility index.

Intra-aortic balloon pump (IABP) devices are commonly used in patients with heart failure related cardiogenic shock (HF-CS), including those with out-of-proportion right ventricular (RV) dysfunction. Pulmonary artery pulsatility index (PAPi) is a haemodynamic surrogate for RV performance. We aimed to assess short-term haemodynamic changes in patients with HF-CS following IABP support stratified by baseline PAPi. This is a single-centre study of 67 consecutive patients with HF-CS who underwent IABP placement between 2020 and 2022. The primary aim was haemodynamic changes of specific variables on pulmonary artery catheter monitoring over 72h following IABP placement. Secondary aims were clinically significant changes in diuretic regimens, changes in inotropes or vasopressors at 72h following IABP, along with clinical outcomes. Prior to IABP placement, 57% of the total cohort (median age 59years [48, 69], 31% female) had Society of Cardiovascular Angiography and Interventions Stage C HF-CS. Thirty-eight (56%) patients had a PAPi <2.0. Following 72h of IABP support, the PAPi <2.0 group had an observed significant decrease in central venous pressure (CVP; 20 to 12mmHg, P<0.001) and mean pulmonary artery pressure (mPAP; 37.5 to 28.5mmHg, P=0.001), and an increase in PAPi (1 to 1.6, P=0.001). No significant change in cardiac index (CI; 2 to 2.1L/min/m2, P=0.31) was observed. The PAPi ≥2.0 group (N=29) had no observed significant change in CVP (10 to 8mmHg, P=0.47), or PAPi (2.6 to 2.8, P=0.92), but there was a significant improvement in CI (1.9 to 2.5L/min/m2, P=0.004) along with reduction in mPA (37 to 29mmHg, P=0.03). The PAPi <2.0 group had a significant increase in diuretic requirement (52.6% vs. 20.7%, P=0.01) and numerically greater addition of inotropes/vasopressors (47.3% vs. 34.4%, P=0.07) compared with the PAPi ≥2.0 group at 72h following IABP placement. Significantly more patients in the PAPi ≥2.0 group underwent left ventricular assist device (55.2% vs. 26.3%, P=0.02), with no overall significant differences observed in escalation to veno-arterial extracorporeal membrane oxygenation, 30-day mortality, renal replacement therapy post-IABP, or rates of heart transplantation. IABP devices in those with HF-CS and low or abnormal PAPi may provide modest short-term haemodynamic benefits without significant improvement in CI, along with greater need for adjustment in medical therapeutics to achieve haemodynamic optimization.

Pulmonary artery catheter monitoring versus arterial waveform-based monitoring during liver transplantation: a retrospective cohort study

Although pulmonary artery catheter (PAC) has been used during liver transplantation surgery, the usefulness of PAC has rarely been investigated. We evaluated whether the use of PAC is associated with better clinical outcomes compared to arterial waveform-based monitoring after liver transplantation. A total of 1565 cases undergoing liver transplantation were reviewed. We determined whether patients received PAC or not and divided our cohort into the PAC with hemodynamic monitoring using PAC and the non-PAC with arterial waveform-based monitoring using FloTrac-Vigileo. Propensity score matching was performed. Acute kidney injury (AKI), early allograft dysfunction (EAD) and 1-year all-cause mortality or graft failure were compared in the matched cohorts. Logistic regression analysis was performed in the inverse probability of treatment-weighted (IPTW) cohort for postoperative EAD and AKI, respectively. Five-year overall survival was compared between the two groups. In the matched cohort, there was no significant difference in the incidence of AKI, EAD, length of hospital or ICU stay, and 1-year all-cause mortality between the groups. In the IPTW cohort, the use of PAC was not a significant predictor for AKI or EAD (AKI: odds ratio (95% confidence interval) of 1.20 (0.47–1.56), p = 0.229; EAD: 0.99 (0.38–1.14), p = 0.323). There was no significant difference in the survival between groups after propensity score matching (Log-rank test p = 0.578). In conclusion, posttransplant clinical outcomes were not significantly different between the groups with and without PAC. Anesthetic management without the use of PAC may be possible in low-risk patients during liver transplantation. The risk should be carefully assessed by considering MELD scores, ischemic time, surgical history, previous treatment of underlying liver disease, and degree of portal and pulmonary hypertension.Registration: https://clinicaltrials.gov/ct2/show/NCT05457114 (registration date: July 15, 2022).

Hemodynamic monitoring in liver Transplantation patients in the third millennium

In patients undergoing orthotopic liver transplantation (OLTx) surgery, the intraoperative hemodynamic monitoring technique that is most utilized is still the pulmonary artery catheter (PAC). The popularity of transesophageal echocardiography (TEE) is increasing, so today's updated issue is the following: should the use of PAC and/or volumetric monitoring with transpulmonary thermodilution and/or advanced volumetric PAC be limited in clinical practice, only for some high risk patients? Could we use the TEE, if necessary, in less critical ill patients undergoing OLTx surgery? We can integrate all of the aforementioned monitoring techniques in an increasing modular step wise monitoring concept. But in an uncertain hemodynamic situation, transthoracic and/or transoesophageal echocardiographic evaluation represents a cornerstone. The use of echocardiography during OLTx is more and more common with several benefits demonstrated particularly by the TEE in this patient population. To achieve and maintain adequate tissue perfusion becomes difficult in case of major bleeding, an event quite possible to occur during OLTx, affecting the immediate and the late outcome. All the clinicians agree that bleeding interfere with the choice of hemodynamic monitoring and or vice versa. A reasonable compromise is to find a balance between the need to extend monitoring in high-risk surgical patients and the average consumption of blood products that characterizes each individual transplant center. This is also in line with what is shown in literature in terms of Maximum Surgical Blood Ordering Schedule (MSBOS).

Effectiveness of pulmonary artery catheter monitoring for patients with cardiogenic shock of various causes: a systematic review and meta-analysis.

Cardiogenic shock is associated with significant morbidity and mortality. Invasive hemodynamic monitoring with pulmonary artery catheterization (PAC) can be useful in the assessment of changes in cardiac function and hemodynamic status; however, the benefits of PAC in the management of cardiogenic shock are not known well. We performed a systematic review and meta-analysis of observational studies and randomized controlled trials, comparing in-hospital mortality between PAC and non-PAC groups of cardiogenic shock patients with various underlying causes. Articles were obtained from MEDLINE, Embase, and Cochrane CENTRAL. We reviewed titles, abstracts, and full articles and evaluated the quality of evidence using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) framework. We used a random-effects model to compare studies in terms of in-hospital mortality findings. We included twelve articles in our meta-analysis. Mortality among patients with cardiogenic shock was not significantly different between the PAC and the non-PAC groups [risk ratio (RR) 0.86, 95% confidence interval (CI): 0.73-1.02, I2=100%, P<0.01]. Two studies investigating cardiogenic shock caused by acute decompensated heart failure determined lower in-hospital mortality in the PAC group than in the non-PAC group (RR 0.49, 95% CI: 0.28-0.87, I2=45%, P=0.18). Six studies investigating cardiogenic shock of any cause determined lower in-hospital mortality in the PAC group than in the non-PAC group (RR 0.84, 95% CI: 0.72-0.97, I2=99%, P<0.01). There was no significant difference in in-hospital mortality between the PAC and non-PAC groups of patients with cardiogenic shock secondary to acute coronary syndrome (RR 1.01, 95% CI: 0.81-1.25, I2=99%, P<0.01). Overall, our meta-analysis demonstrated no significant association between PAC monitoring and in-hospital mortality among patients managed for cardiogenic shock. The use of PAC in the management of cardiogenic shock caused by acute decompensated heart failure was associated with lower in-hospital mortality, but there was no association between PAC monitoring and in-hospital mortality among patients with cardiogenic shock caused by acute coronary syndrome.

Hemodynamic and Respiratory Changes following Prone Position in Acute Respiratory Distress Syndrome Patients: A Clinical Study.

Limited data are available for the oxygenation changes following prone position in relation to hemodynamic and pulmonary vascular variations in acute respiratory distress syndrome (ARDS), using reliable invasive methods. We aimed to assess oxygenation and hemodynamic changes between the supine and prone posture in patients with ARDS and identify parameters associated with oxygenation improvement. Eighteen patients with ARDS under protective ventilation were assessed using advanced pulmonary artery catheter monitoring. Physiologic parameters were recorded at baseline supine position, 1 h and 18 h following prone position. The change in the Oxygenation Index (ΔOI) between supine and 18 h prone significantly correlated to the concurrent change in shunt fraction (r = 0.75, p = 0.0001), to the ΔOI between supine and 1 h prone (r = 0.73, p = 0.001), to the supine acute lung injury score and the OI (r = -0.73, p = 0.009 and r = 0.69, p = 0.002, respectively). Cardiac output did not change between supine and prone posture. Moreover, there was no change in pulmonary pressure, pulmonary vascular resistances, right ventricular (RV) volumes and the RV ejection fraction. The present investigation provides physiologic clinical data supporting that oxygenation improvement following prone position in ARDS is driven by the shunt fraction reduction and not by changes in hemodynamics. Moreover, oxygenation improvement was not correlated with RV or pulmonary circulation changes.

1121 USE OF IMPELLA 5.0 AS BRIDGE TO LVAD IN CARDIOGENIC SHOCK: REPORT OF TWO CASES

Abstract Background Left ventricle assist devices (LVAD) are an option in end stage heart failure (HF) as bridge to or alterative to heart transplantation. Adequate compensation of patient is key to obtain a good outcome. We report two cases of Impella 5.0 bridge to LVAD in patients with cardiogenic shock (CS) in which intra-aortic balloon pump (IABP) failed to obtain hemodynamic stability. Case series A) A 60 years old man developed CS after anterior myocardial infarction treated with primary PCI of left main coronary artery. At presentation patient was hypotensive with signs of hypoperfusion and pulmonary congestion: systemic blood pressure (SBP) 80/60 mmHg despite inotropic drugs, blood lactates 4 mmol/l, urine output of last 6 hours 0,4 ml/kg/h (INTERMACS 2). Echocardiography showed severe left ventricle disfunction with LVEF 15%, severe mitral regurgitation (MR) and sPAP 45 mmHg. Therefore, IABP was implanted. Right heart catheterization (RHC) showed pulmonary hypertension and high filling pressure with reduced cardiac output and increased pulmonary vascular resistance (mPAP 39 mmHg, CPWP 28 mmHg, CO 3 l/min, PVR 3.7 uW, PAPi 2.8); X-ray chest showed persistence of pulmonary congestion. After 9 days on IABP, patient underwent Impella 5.0 implant through right axillary artery as bridge to durable LVAD. Pulmonary artery catheter (PAC) monitoring showed reduction of pulmonary hypertension with mPAP 35 mmHg and CPWP 17 mmHg and chest X-ray documented improvement of lung congestion. Bedside rehabilitation was started. Two weeks later patient underwent LVAD HM3 implantation as destination therapy. The patient was discharge home on post-operative day 55. B) After subacute myocardial infarction with three-vessels disease, a 53 y.o. man developed severe congestive HF with severe left ventricular disfunction and was referred to our institution for evaluation. RHC showed pulmonary hypertension with pre-capillary component not reversible after enoximone test, contraindicating heart transplantation. Therefore, patient was candidate to receive LVAD as bridge strategy. Echocardiography at admission showed dilated and hypokinetic left ventricle (EDV 200 ml, LVEF 17% severe MR, sPAP 60 mmHg) and dilated and hypokinetic RV. During hospitalization the patient experienced CS with SBP 62/45 mmHg, 6-hours urine output of 1,4 ml/kg/h and blood lactates 8.3 mmol/l (INTERMACS 1) so femoral IABP was implanted. RHC was repeated both without IABP support (mPAP 37 mmHg, PCWP 28 mmHg, CO 1.4 l/min, CI 0.9 l/min/m2) and with IABP support (mPAP 32 mmHg, PCWP 18 mmHg, CO 2.15 l/min, CI 1.4 l/min/m2). During the following stay he developed S. Aureus sepsis requiring prolonged antibiotic therapy. Expecting a long time before LVAD, axillary Impella 5.0 was implanted in order to unload the LV and allow early patient mobilization. Subsequent PAC monitoring showed improvement of pulmonary hypertension and cardiac index (mPAP 24 mmHg, PCWP 9 mmHg, CO 5.1 l/min with Impella flow 4.2 l/min, CI 3.2 l/min/m2). After 11 days, patient received LVAD HVAD with uneventful course and was discharged on post-operative day 22. Conclusions Impella 5.0 is a surgically implanted intravascular microaxial blood pump that delivers up to 5 l/min of blood from LV to aorta, leading to improved perfusion and more efficient LV unloading. In patients with CS this can help to obtain better decongestion, RV recovery, and favorable preconditioning before LVAD implant. Moreover, axillary access allows better patient mobilization preventing cachexia after long time hospitalization.

Dynamic Invasive Hemodynamic Congestion Profile Impacts Acute Myocardial Infarction Complicated by Cardiogenic Shock Outcomes: A Real-World Single-Center Study

Cardiogenic shock (CS) commonly complicates the management of acute myocardial infarction (AMI), and it results in high mortality rates. Pulmonary artery catheter (PAC) monitoring can be valuable for personalizing critical-care interventions. We hypothesized that patients with AMI-CS experiencing persistent congestion measures during the first 24 hours of the PAC installment would exhibit worse in-hospital survival rates. We studied 295 patients with AMI-CS between January 2006 and December 2021. The first 24-hour PAC-derived hemodynamic measures were divided by the congestion profiling and the proposed 2022 Cardiovascular Angiography and Interventions (SCAI) classification. Biventricular congestion was the most common profile and was associated with the highest patient mortality rates at all time points (mean 56.6%). A persistent congestive profile was associated with increased mortality rates (hazard ratio [HR] = 1.85; P = 0.002) compared with patients who achieved decongestive profiles. Patients with SCAI stages D/E had higher levels of right atrial pressure (RAP): 14-15 mmHg) and pulmonary capillary wedge pressure (PCWP): 18-20 mmHg) compared with stage C (RAP, 10-11 mmHg, mean difference 3-5 mmHg; P < 0.001; PCWP 14-17 mmHg; mean difference 1.56-4 mmHg; P = 0.011). In SCAI stages D/E, the pulmonary artery pulsatility index (0.8-1.19) was lower than in those with grade C (1.29-1.63; mean difference 0.21-0.73; P < 0.001). Continuous congestion profiling using the SCAI classification matched the grade of hemodynamic severity and the increased risk of in-hospital death. Early decongestion appears to be an important prognostic and therapeutic goal in patients with AMI-CS and warrants further study.

Prognostic implications of pulmonary artery catheter monitoring in patients with cardiogenic shock: A systematic review and meta-analysis of observational studies.

To investigate the impact of pulmonary artery catheter (PAC) monitoring on survival of cardiogenic shock(CS), in the light of the controversies in available evidence. MEDLINE, EMBASE, Cochrane library and Web of Science were systematically screened to identify most relevant studies on patients with CS comparing PAC use to non-use during hospital stay. Short-term mortality was the primary endpoint and the use of Mechanical Circulatory Support (MCS) devices was the secondary one. Six observational studies including 1,166,762 patients were selected. The most frequent etiology of CS was post-myocardial infarction (75% [95% CI 55-89%] in PAC-group and 81%[95% CI 47-95%] in non-PAC group). Overall, PAC was used in 33%(95% CI 24-44%) of cases. Pooling data adjusted for confounders, a significant association between the PAC-group and a reduction in short-term mortality emerged when compared to the non-PAC group (36%[95% CI 27-45%] vs 47%[95% CI 35-59%];AdjustedOR 0.71, 95% CI 0.59-0.87, p < 0.01). MCS use was significantly higher in PAC vs non-PAC group (59% [95% CI 54-65%]) vs 48% [95% CI 43-53%]);OR 1.60 [95% CI 1.27-2.02, p < 0.01]). PAC was associated with lower incidence of short-term mortality in CS pooling adjusted observational studies. Prospective studies are needed to confirm our hypothesis and better clarify the mechanisms of this potential prognostic benefit.

Pulmonary Artery Catheter Monitoring in Patients with Cardiogenic Shock: Time for a Reappraisal?

Cardiogenic shock represents one of the most dramatic scenarios to deal with in intensive cardiology care and is burdened by substantial short-term mortality. An integrated approach, including timely diagnosis and phenotyping, along with a well-established shock team and management protocol, may improve survival. The use of the Swan-Ganz catheter could play a pivotal role in various phases of cardiogenic shock management, encompassing diagnosis and haemodynamic characterisation to treatment selection, titration and weaning. Moreover, it is essential in the evaluation of patients who might be candidates for long-term heart-replacement strategies. This review provides a historical background on the use of the Swan-Ganz catheter in the intensive care unit and an analysis of the available evidence in terms of potential prognostic implications in this setting.

Impact of pulmonary artery catheter hemodynamic monitoring on post-operative morbidity and mortality in elective bentall procedures

Introduction Because of debated effectiveness and safety, the perioperative use of pulmonary artery catheter (PAC) has decreased in cardiac surgery (1). However, PAC keeps some specifics indications in high risk cardiac surgery (2). This study evaluates the impact of perioperative PAC monitoring on postoperative morbidity and mortality after Bentall procedures. Methods We designed a single center retrospective observational study comparing patients undergoing Bentall procedure with or without perioperative CAP monitoring. Patients included had no major risk of hemodynamic complications (Left ventricular ejection fractions (LVEF) > 40%, no pulmonary arterial hypertension, no history of cardiac surgery). Primary endpoint was a composite criteria of postoperative morbidities and mortality defined by the occurrence of any the following: death in hospital, cardiac dysfunction (myocardial infarction or congestive heart failure), cerebral dysfunction (stroke or encephalopathy), renal dysfunction (acute kidney injury or dialysis), or pulmonary dysfunction (acute respiratory distress syndrome). Epidemiology of CAP use, others postoperative complications, biological markers (lactates, troponin), hemodynamic management and length of stay in intensive care unit (ICU) and hospital were also assessed. Results Among the 134 patients enrolled between 2012 and 2019, the primary endpoint occurred in 29 of 59 PAC patients vs. 17 of 75 patients without PAC (49.2%, 95% confidence interval (CI), 37-62, vs 22.7%, 95% CI, 15-33; P The PAC group had an increased risk of cardiac (22% vs 2.7%, P In multivariate logistic regression analysis, with independent factors (CAP use, length of cardiopulmonary bypass, EuroSCORE 2), CAP use was not associated with the occurrence of primary endpoint (adjusted odds ratio 2.07, 95% CI [0.9-4.7], P=0.08). Discussion In our study, a PAC was used in a highest risk group. The use of PAC was associated with increased postoperative mortality and morbidity in univariate but not in multivariate analysis. A randomized clinical trial is needed to clarify the link between CAP use and postoperative complications.

Value of Hemodynamic Monitoring in Patients With Cardiogenic Shock Undergoing Mechanical Circulatory Support.

The recent widespread availability and use of mechanical circulatory support is transforming the management and outcomes of cardiogenic shock (CS). Clinical decision-making regarding the optimization of therapies for patients with CS can be guided effectively by hemodynamic monitoring with a pulmonary artery catheter (PAC). Because several studies regarding the benefit of PACs are ambiguous, the use of PACs is variable among clinicians treating patients with CS. More notable is that PAC use has not been studied as part of a randomized, controlled trial in patients with CS with or without mechanical circulatory support. Standardized approaches to hemodynamic monitoring in these patients can improve decision-making and outcomes. In this review, we summarize the hemodynamics of CS and mechanical circulatory support with PAC-derived measurements, and provide a compelling rationale for the use of PAC monitoring in patients with CS receiving mechanical circulatory support.

Influence of Intraoperative Transesophageal Echocardiography and Pulmonary Artery Catheter Monitoring on Outcomes in Liver Transplantation

Background.Anesthetic management of orthotopic liver transplantation (OLT) can be challenging. Management involves responding to sudden hemodynamic shifts, addressing instability, and performing ongoing volume assessment. To best prepare for these perturbations, various monitors are used intraoperatively. We sought to explore the impact of transesophageal echocardiography (TEE) and pulmonary artery catheter (PAC) use on outcomes of patients undergoing OLT.Methods.We retrospectively reviewed records of patients who underwent OLT at a single institution and included all who were monitored intraoperatively with TEE alone, PAC alone, or both methods concurrently (TEE + PAC). We determined whether these groups had differences in length of hospitalization (primary outcome), 30-day mortality rate, and other outcomes.Results.Three hundred eighteen liver transplant operations were included in the study. Patients in the TEE + PAC group had the shortest median length of hospitalization (TEE + PAC, 8.6 days; TEE, 10.3; PAC, 9.1; P = 0.04). The TEE + PAC group also had the lowest 30-day mortality rate (TEE + PAC, n = 1 [1.3%]; TEE, n = 5 [12.8%]; PAC, n = 7 [3.5%]; P = 0.009). However, the TEE + PAC group also had the highest rate of a new postoperative need for dialysis (TEE + PAC, n = 8 [10.3%]; TEE, n = 2 [5.1%]; PAC, n = 1 [0.5%]; P < 0.001).Conclusions.Compared with either TEE alone or PAC alone, intraoperative monitoring with TEE + PAC during OLT was associated with the shortest length of hospitalization and lowest 30-day mortality rate. Transplant anesthesiologists should be aware of the potential benefit on patient mortality and hospital length of stay with concurrent intraoperative TEE + PAC monitoring and the increased need for new postoperative dialysis.

Perioperative management of obstetrical surgeries in women having coexisting cardiovascular disease: our experience

Background and aim: Coexisting cardiovascular disease in pregnancy is associated with high maternal morbidity and mortality. These patients pose a great challenge to both anesthesiologist and obstetrician. Present study was aimed at reviewing the perioperative management and outcome of obstetrical surgeries in women who had coexisting cardiovascular disease in a tertiary care teaching institute. Materials and Methods: Departmental database of all pregnant patients with coexisting cardiovascular diseases who underwent obstetrical surgeries during January 2011 to August 2016 were reviewed. Patients functional status, obstetrical history, stage of labor, type of anaesthesia, monitoring, hemodynamics, post operative care and baby outcome were noted. Data are expressed in absolute number and percentage scale and INSTAT software was used for measuring central tendencies and dispersion. Results: A total of 22 women (mean + Standard deviation: SD age 26.18 + 4.78 years) were found eligible and included for analysis. 21(95.45%) patients underwent cesarean section and one medical termination of pregnancy. 68.18% cases were done under subarachnoid block. Most of the patient needed post operative high dependant unit care, one patient developed mild pulmonary edema and no maternal and fetal deaths were noted. All the babies were born with APGAR > 7 at 1 min. No patient was managed using pulmonary artery catheter or continuous cardiac output monitoring. Conclusion: Pregnant patients with coexisting cardiovascular disease need multidisciplinary approach, timely delivery and intensive therapy in perioperative period. They can be safely delivered under subarachnoid blocks. Pulmonary artery catheterization is probably not an essential for hemodynamics management of such patients in perioperative management.

Current use of the pulmonary artery catheter in cardiac surgery: a survey study.

Because of its invasive nature, debated effect on patient outcome, and the development of alternative hemodynamic monitoring technologies, the intraoperative use of the pulmonary artery catheter (PAC) has significantly decreased. The authors conducted a survey of the members of the Society of Cardiovascular Anesthesiologists (SCA) to assess current use of the PAC and alternative hemodynamic monitoring technologies in patients undergoing cardiac surgery. A survey study. Hospitals in North America, Europe, Asia, Australia, New Zealand, and South America. SCA members in North America, Europe, Asia, Australia, New Zealand, and South America. The survey was e-mailed by the SCA to roughly 6,000 of its members. The survey was left open for 30 days. Respondents accessed the survey via a secured web-based database. A total of 854 questionnaires were completed. A total of 705 (82.6%) were from North American members. Four hundred twelve of the respondents (48.1%) worked in a private practice setting, while 350 (40.9%) were from an academic practice. A majority of the respondents (57.9%) were from hospitals that performed more than 400 cardiac surgeries a year, a subset of which (29.6%) did more than 800 cases annually. For cases using cardiopulmonary bypass, 583 (68.2%) of the respondents used a PAC more than 75% of the time, while 30 (3.5%) did not use the PAC at all. Ninety-four percent of respondents used transesophageal echocardiography (TEE) as part of the intraoperative monitoring. When not using a PAC, FloTrac/Vigileo was the alternative cardiac monitoring modality in 15.2% of the responses. Similar trends in monitor preferences were seen in off-pump coronary artery bypass grafting and minimally invasive/robotic heart surgery. The results of this study suggested that a majority of the respondents still prefer to use the PAC for most cardiac surgeries. Subgroup analysis of the data revealed that geographical location, type of practice, and surgeon support played a significant role in the decision to use a PAC. Although most respondents prefer to use TEE as a complimentary tool, TEE also remains the most popular supplemental/alternative hemodynamic monitoring technology.

Postresuscitation hemodynamics during therapeutic hypothermia after out-of-hospital cardiac arrest with ventricular fibrillation: A retrospective study

Aims of the studyTo evaluate the incidence of postresuscitation myocardial depression (PRMD) and hemodynamical parameters associated with PRMD in patients treated with therapeutic hypothermia (TH) after out-of-hospital cardiac arrest with ventricular fibrillation (OHCA-VF). MethodsAnalysis of hemodynamical data from computerized clinical databases of two academic ICUs during two year period. We analyzed hemodynamical data from a subgroup of patients with pulmonary artery catheter (PAC). We defined PRMD as a cardiac index (CI) less than 1.5l/(minm2) any time during the first 12h and compared clinical variables and hemodynamical parameters in patients with or without PRMD. ResultsOf 120 included patients PAC monitoring was used in 47 (39%). Of 47, 31 (66%, 95% CI 52% to 80%) developed PRMD. There was no difference in urinary output, lactate, mean arterial or central venous pressures or mixed venous saturation between patients with or without PRMD. Low CI was reversed with dobutamine infusion. Presence or absence PRMD was not associated with 6-month neurological outcome. ConclusionTwo-thirds of the OHCA-VF patients develops transient postresuscitation myocardial depression not easily detected without monitoring of CI during therapeutic hypothermia. Further controlled studies are warranted to evaluate the value of different hemodynamic targets and monitoring after cardiac arrest in terms of outcome.

Lobar Lung Transplantation for High Risk Patients – Lessons from the Initial Experience

Purpose Since development of a cadaveric lobar lung transplantation (CLLTx) protocol as a surgical option for critically ill patients, our CLLTx number has expanded to 17% of all LTx cases this year. While many challenging patients have been saved by this novel approach, major complications and management issues have also been experienced, resulting in our protocolized management of CLLTx patients for successful outcomes. Methods and Materials Critically ill patients with end-stage lung disease who were considered to be unlikely to survive the long wait for size-matching lungs underwent CLLTx between 2009 and 2012. Based on their short-term outcomes and major complications, the intra- and post-surgical management has been protocolized at our institution. Results Indications for CLLTx included those who were on the ventilator, on ECMO, and LAS above 60 with size restrictions. Total 32 patients received an anatomic lobectomy with individual ligation techniques at back-table followed by double lung transplantation. There were 3 in-hospital deaths. One early bronchial stump dehiscence (3.1%) was experienced. Atypical progression of PGD with significantly elevated pulmonary artery pressures was also experienced in 3 cases (9.3%). Because of this experience, our current management for CLLTx patients includes prolonged use of inhaled nitric oxide, pulmonary artery catheter monitoring and strict negative fluid balance management. Conclusions Our experience has demonstrated that protocolized management is critical for success. Thus, we have adopted a systematic approach that has allowed us to adovocate for CLLTx as a viable option for critically ill patients with small chests who may not have exhausted all options. [ figure 1 ]

Assessing Pulmonary Arterial Hypertension in Infants With Severe Chronic Lung Disease of Infancy: A Role for a Pulmonary Artery Catheter?

The treatment of pulmonary arterial hypertension (PAH) associated with chronic lung disease of infancy (CLDI) is becoming commonplace. However, an optimal approach to the monitoring of this treatment has not been clearly established, and data suggest that such therapy may not be without risk. This study assessed the feasibility and safety of pulmonary artery catheter (PAC) placement and its role in the management of PAH associated with CLDI. The medical records of 12 infants with CLDI requiring chronic mechanical ventilation who underwent PAC monitoring were reviewed. Data analyzed included demographics, hemodynamic data, PAH pharmacological therapy, respiratory support, echocardiographic data, sedation level, complications related to PAC use, and mortality. In this analysis, PAC placement and monitoring was found to be feasible, appeared safe, and was associated with the ability to wean inspired oxygen, decrease sedation, and titrate PAH therapy without untoward effect. However, no definitive conclusions can be drawn from this report given its small sample size and uncontrolled, retrospective design. It is hoped that these data will renew interest in PAC monitoring for CLDI and foster prospective study where its true value can be ascertained.

Hämodynamisches Monitoring - Gibt es Indikationen für den perioperativen Einsatz des pulmonal-arteriellen Katheters?

The benefit of the pulmonary-artery catheter (PAC) is a matter of discussion since years. The development of alternative monitoring techniques especially for measurement of volume parameters has decreased routine use of the PAC. Several investigations verified advantages of therapy attempting to optimize circulation parameters regardless of the used technique. Nonetheless, patients with a higher peri-operative risk, especially in cardiovascular surgery, may benefit from PAC monitoring intra- or postoperatively.The concerns about the available monitoring techniques bear mainly on the fear being too invasive. Up to now, there is no technique complying with all requirements of an ideal monitoring system.

Effect of external counterpulsation on cardiac work following cardiac surgery: Implications of the mechanism responsible for clinical benefits

External counterpulsation (ECP) has been recognized as a non-invasive treatment for chronic refractory angina or heart failure. However, the mechanisms responsible for the clinical benefits of ECP therapy remain elusive. Moreover, the clinical significance of ECP therapy for postoperative patients has not been established yet. Six adult patients received ECP therapy for 60 min under pulmonary artery catheter monitoring after cardiac surgery. Hemodynamic data were obtained before ECP therapy (pre-ECP), 20 min after ECP was commenced (20-min-ECP), 40 min after ECP was commenced (40-min-ECP), and after ECP therapy (post-ECP). The mean right atrial pressure (pre-ECP: 9 ± 4 mmHg; 20-min-ECP: 12 ± 5 mmHg; 40-min-ECP: 12 ± 4 mmHg; and post-ECP: 9 ± 4 mmHg), pulmonary wedge pressure (16 ± 6 mmHg, 20 ± 7 mmHg, 20 ± 7 mmHg, and 17 ± 7 mmHg, respectively), cardiac index (2.4 ± 0.4 l/min/m(2), 2.8 ± 0.6 l/min/m(2), 2.7 ± 0.5 l/min/m(2), and 2.5 ± 0.4 l/min/m(2), respectively), cardiac work index (2.5 ± 0.4 kgm/m(2), 3.3 ± 0.8 kgm/m(2), 3.1 ± 0.8 kgm/m(2), and 2.6 ± 0.5 kgm/m(2), respectively), and left ventricular stroke work index (32 ± 7 gm/m(2), 41 ± 12 gm/m(2), 39 ± 12 gm/m(2), and 33 ± 8 gm/m(2), respectively) significantly (p<0.05) increased after ECP was commenced (pre-ECP vs. 20-min-ECP) and decreased after ECP was discontinued (40-min-ECP vs. post-ECP). Significant (p<0.001) diastolic augmentation (20-min-ECP: 24 ± 6%, 40-min-ECP: 23 ± 5%) and systolic unloading (3 ± 1%, and 3 ± 1%, respectively) were obtained. No clinical adverse effects were observed. ECP increases venous return, cardiac output, and cardiac work in addition to diastolic augmentation and systolic unloading. These actions may play important roles in the clinical benefits of ECP therapy. Our data also suggest that ECP is beneficial for patients undergoing cardiac surgery.

3D Echocardiography to Evaluate Right Atrial Pressure in Acutely Decompensated Heart Failure: Correlation With Invasive Hemodynamics

This study examined the utility of 3-dimensional right atrial volume index (3D-RAVi), combined with 2-dimensional echocardiographic (2DE) parameters, for the identification of elevated right atrial pressure (RAP) in patients with heart failure. Accurate noninvasive determination of RAP is clinically important for the management of patients with heart failure. Although 2DE methods have been used to noninvasively estimate RAP, the accuracy of these parameters has limitations when estimating RAP in an individual patient. Three-dimensional echocardiography (3DE) provides tomographic imaging of right atrial volume that may be helpful in refining the noninvasive assessment of hemodynamics in patients with heart failure. 2DE and 3DE studies were examined in 40 initial patients who were admitted for acutely decompensated heart failure. Simultaneous pulmonary artery catheter monitoring was performed. The relationship between echocardiographic parameters and RAP was examined in this derivation group. The findings from the derivation group were then prospectively tested in a validation group of 40 additional patients. Mean RAP was 11 ± 5 mm Hg (range 2 to 22 mm Hg). 3D-RAVi correlated with RAP (r = 0.51, p < 0.001), whereas 2-dimensional right atrial volume index did not. Inferior vena cava (IVC) diameter ≥2 cm and IVC respirophasic collapse <40% also correlated with RAP (p < 0.001 and p = 0.028, respectively). Based on receiver-operator characteristic curve analysis, 3D-RAVi ≥35 ml/m(2) was the optimal 3D-RAVi cutpoint for identifying RAP >10 mm Hg. The value of 3D-RAVi ≥35 ml/m(2), combined with IVC measures, for predicting RAP >10 mm Hg was prospectively tested in the validation group. 3D-RAVi ≥35 ml/m(2) in combination with IVC ≥2 cm had a high accuracy (88%) for identifying RAP >10 mm Hg and had a higher accuracy than the combination of IVC ≥2 cm and IVC collapse <40% (accuracy: 68%, p = 0.038). In patients with heart failure, 3D-RAVi in conjunction with IVC parameters has a high accuracy for detection of elevated RAP. The addition of 3D-RAVi to 2DE methods may be helpful in the noninvasive estimation of right atrial pressure.