Placement Of Pulmonary Artery Catheter Research Articles

Efficacy and safety of pulmonary artery catheterization with combined transesophageal echocardiography and pressure waveform: A prospective observational study

ObjectiveThis study investigated whether pulmonary artery catheter placement method with combined transesophageal echocardiography and pressure waveform measurement improve the placement success rate within 5 min and reduce the incidence of arrhythmia during pulmonary artery catheter placement compared to conventional pulmonary artery catheter placement with pressure waveform measurement only. MethodsThis single center prospective observational study included 129 patients scheduled for cardiac surgery. Patients were divided into two groups. In the conventional group, the pulmonary artery catheter was placed by monitoring the pressure waveform and the length of placement; in the combination group, not only were the pressure waveform and the length monitored but also the following transesophageal echocardiography images: “mid esophageal bicaval view,” " mid esophageal modified bicaval view,” a mirror image of “mid esophageal 4 chamber view,” “mid esophageal right ventricular inflow-outflow view,” and “mid esophageal ascending aortic short axis view." ResultsA 1:1 propensity score matching was used to adjust for confounding factors. The success rates of pulmonary artery catheter placement within 5 min in the conventional and combination groups were 85.5 % vs. 97.8 % (p = 0.032) before matching, and 73.7 % vs. 100 % (p = 0.001) after matching. The incidences of arrhythmias in the conventional and combination groups were 28.9 % vs. 17.4 % (p = 0.20) before matching, and 28.9 % vs. 18.4 % (p = 0.42) after matching. ConclusionPulmonary artery catheter placement with transesophageal echocardiography had a significantly higher rate of successful placement within 5 min, but no significant differences were observed in the incidences of arrhythmias.

Clinical Characteristics and Outcomes of Patients Suffering Acute Decompensated Heart Failure Complicated by Cardiogenic Shock.

Cardiogenic shock (CS) can stem from multiple causes and portends poor prognosis. Prior studies have focused on acute myocardial infarction-CS; however, acute decompensated heart failure (ADHF)-CS accounts for most cases. We studied patients suffering ADHF-CS to identify clinical factors, early in their trajectory, associated with a higher probability of successful outcomes. Consecutive patients with CS were evaluated (N=1162). We studied patients who developed ADHF-CS at our hospital (N=562). Primary end point was native heart survival (NHS), defined as survival to discharge without receiving advanced HF therapies. Secondary end points were adverse events, survival, major cardiac interventions, and hospital readmissions within 1 year following index hospitalization discharge. Association of clinical data with NHS was analyzed using logistic regression. Overall, 357 (63.5%) patients achieved NHS, 165 (29.2%) died, and 41 (7.3%) were discharged post advanced HF therapies. Of 398 discharged patients (70.8%), 303 (53.9%) were alive at 1 year. Patients with NHS less commonly suffered cardiac arrest, underwent intubation or pulmonary artery catheter placement, or received temporary mechanical circulatory support, had better hemodynamic and echocardiographic profiles, and had a lower vasoactive-inotropic score at shock onset. Bleeding, hemorrhagic stroke, hemolysis in patients with mechanical circulatory support, and acute kidney injury requiring renal replacement therapy were less common compared with patients who died or received advanced HF therapies. After multivariable adjustments, clinical variables associated with NHS likelihood included younger age, history of systemic hypertension, absence of cardiac arrest or acute kidney injury requiring renal replacement therapy, lower pulmonary capillary wedge pressure and vasoactive-inotropic score, and higher tricuspid annular plane systolic excursion at shock onset (all P<0.05). By studying contemporary patients with ADHF-CS, we identified clinical factors that can inform clinical management and provide future research targets. Right ventricular function, renal function, pulmonary artery catheter placement, and type and timing of temporary mechanical circulatory support warrant further investigation to improve outcomes of this devastating condition.

3D transesophageal echocardiographic visualization of the pulmonary artery catheter through the tricuspid valve and their position relative to the tricuspid valve leaflets

BackgroundThe tricuspid valve is an atrioventricular valve consisting of three lobes. We used the 3D transesophageal echocardiography to visualize position of the pulmonary artery catheter at the tricuspid valve annulus and examined where the catheter passed through at the level of the tricuspid annulus.MethodsIn this prospective and observational study, we monitored the pressure wave on patients undergoing cardiac surgery with the catheter placement by monitoring the pressure waveform for 8 months. We measured the time required for the catheter to pass through the tricuspid and pulmonary valves, respectively. We acquired the 3D image of the tricuspid valve by transesophageal echocardiography and determined the position of the pulmonary artery catheter at the level of the tricuspid annulus. The data were analyzed by Kruskal-Wallis test followed by Mann-Whitney test with Holm multiple comparisons. P < 0.05 was considered significant.ResultsOf the 116 cases, the pulmonary artery catheter passed through the tricuspid valve between antero-posterior leaflets in 78 cases (67.2 %), between septal-posterior leaflets in 25 cases (21.6 %), and between antero-septal leaflets in 2 cases (1.7 %) and the center in 11 cases (9.5 %), respectively. The time required for the catheter to pass through the pulmonary valves was significantly different among the catheter positions at the level of the tricuspid annulus.ConclusionThe pulmonary artery catheter location at the level of the tricuspid annulus can be identified using 3D transesophageal echocardiography. The location of the catheter significantly affects the pulmonary artery catheter placement time.

Serial invasive hemodynamics and clinical characteristics of patients with shock with and without invasive mechanical ventilation

Abstract Funding Acknowledgements None. Background Invasive mechanical ventilation (IMV) is commonly used in the Cardiac Intensive Care Unit (CICU) in patients with cardiogenic shock (CS). IMV causes hemodynamic changes that may impact outcomes based upon a patient’s profile. Our aim is to characterize the clinical profile and detailed serial hemodynamic parameters in the first 24-hours according to the use of IMV in patients with shock admitted to the CICU. Methods Retrospective analysis of consecutive patients with shock admitted to the CICU at Bellevue Hospital, undergoing pulmonary artery catheter (PAC) placement within the first 24 hours of admission, from February 2022 to June 2023. Clinical characteristics, as well as specific hemodynamic parameters collected and curated at times 0, 6, 12, 18 and 24 hours were from PAC placement compared between patients with and without IMV. Results A total of 101 patients were included (95% with cardiogenic shock), 59 receiving IMV (age 64 ± 15, 24% women) and 42 non-intubated (61 ± 13, 33% women). Non-intubated patients had higher prevalence of hypertension, prior coronary artery disease and heart failure with reduced ejection fraction (HFrEF), while acute coronary syndromes (44%) and cardiac arrest (12%) were more common causes of admission in patients undergoing IMV. Mixed shock predominated in IMV patients (51 vs 17%, p &amp;lt;0.001), whereas cardiogenic shock (CS) was more common in non-intubated patients (83 vs 41%, p &amp;lt;0.01). Patients with acute myocardial infarction CS (AMI-CS) were more likely to undergo IMV, while patients with heart failure CS (HF-CS) were more likely to be non-intubated. Patients undergoing IMV were more likely to have mechanical circulatory support (MCS) and ventricular dilatation compared to non-intubated patients (LVEDD 5.7 cm vs 4.9 cm, p 0.002). Patients undergoing IMV had a higher incidence of severe shock compared to the non-intubated group (31% vs 19% SCAI Shock D), higher lactate levels and greater use of vasoactive drugs (figure 1A). Patients undergoing IMV had significant improvements in cardiac power output (CPO), diastolic blood pressure and systemic vascular resistance (SVR) (figure 1B). Shock severity by SCAI SHOCK classification had a more notable improvement at 24 hours in patients with IMV compared to non-intubated patients (figure 1C), with a non-statistically significant improvement in lactate clearance in the first 24 hours (Figure 1D). Conclusions IMV in patients with CS is more commonly seen in patients with AMI-CS and among those with higher baseline shock severity and greater use of vasoactive medications. IMV is associated with significant improvements in shock severity, CPO and SVR at 24 hours when compared to patients with shock who are not intubated, which could be related to higher use of vasopressors. Further investigations are warranted to understand the impact of IMV on outcomes of patients with CS and how they might vary according to hemodynamic profile.

Carotid Flow Time Compared with Invasive Monitoring as a Predictor of Volume Responsiveness in ICU patients.

Objectives: Identifying patients who will have an increase in their cardiac output from volume administration is difficult to identify. We propose the use of carotid flow time, which is a non-invasive means to determine if a patient is volume responsive. Methods: Patients admitted to a critical care unit with a pulmonary artery catheter in place were enrolled. We perform a carotid flow time and pulmonary artery catheter measurement of cardiac output pre and post-passive leg raise and comparing the two. An increase of 10% change in the pre- vs. post-passive leg raise measurement would be indicative of a patient who is volume responsive. Results: We identified 8 patients who were volume responsive as determined by the gold standard pulmonary artery catheter. The sensitivity 87.5% and specificity 90.9%. Pearson correlation coefficient between PA-CO measurements and CFT was r=0.8316, indicative of strong correlation between the two measurements. Conclusion: In our patient sample of critically ill patients with pulmonary artery catheters, we found a strong correlation between corrected carotid flow times and cardiac output measurements from pulmonary artery catheters.

Characteristics of pulmonary artery catheter use in multicenter ICUs in Japan and the association with mortality: a multicenter cohort study using the Japanese Intensive care PAtient Database

BackgroundIt has been 50 years since the pulmonary artery catheter was introduced, but the actual use of pulmonary artery catheters in recent years is unknown. Some randomized controlled trials have reported no causality with mortality, but some observational studies have been published showing an association with mortality for patients with cardiogenic shock, and the association with a pulmonary artery catheter and mortality is unknown. The aim of this study was to investigate the utilization of pulmonary artery catheters (PACs) in the intensive care unit (ICU) and to examine their association with mortality, taking into account differences between hospitals.MethodsThis is a retrospective analysis using the Japanese Intensive care PAtient Database, a multicenter, prospective, observational registry in Japanese ICUs. We included patients aged 16 years or older who were admitted to the ICU for reasons other than procedures. We excluded patients who were discharged within 24 h or had missing values. We compared the prognosis of patients with and without PAC. The primary outcome was hospital mortality. We performed propensity score analysis to adjust for baseline characteristics and hospital characteristics.ResultsAmong 184,705 patients in this registry from April 2015 to December 2020, 59,922 patients were included in the analysis. Most patients (94.0%) with a PAC in place had cardiovascular disease. There was a wide variation in the frequency of PAC use between hospitals, from 0 to 60.3% (median 14.4%, interquartile range 2.2–28.6%). Hospital mortality was not significantly different between the PAC use group and the non-PAC use group in patients after adjustment for propensity score analysis (3.9% vs 4.3%; difference, − 0.4%; 95% CI − 1.1 to 0.3; p = 0.32). Among patients with cardiac disease, those with post-open-heart surgery and those in shock, hospital mortality was also not significantly different between the two groups (3.4% vs 3.7%, p = 0.45, 1.7% vs 1.7%, p = 0.93, 4.8% vs 4.9%, p = 0.87).ConclusionsThe frequency of PAC use varied among hospitals. PAC use for ICU patients was not associated with lower hospital mortality after adjusting for differences between hospitals.

Pulmonary Artery Catheter Use and Outcomes in Patients With ST-Elevation Myocardial Infarction and Cardiogenic Shock Treated With Impella (a Nationwide Analysis from the United States)

The role of continuous hemodynamic assessment with pulmonary artery (PA) catheter placement in cardiogenic shock (CS) remains debated. We aimed to assess the association between PA catheter placement and clinical outcomes in patients with CS secondary to ST-elevation myocardial infarction (STEMI) treated with an intravascular microaxial flow pump. We identified patients hospitalized with STEMI complicated by CS on mechanical circulatory support with an intravascular microaxial flow pump (Impella, Abiomed, Danvers, Massachusetts) using the National Inpatient Sample database and compared the outcomes in those treated with and without PA catheters. The primary outcome was in-hospital mortality. The secondary outcomes included in-hospital complications, hospital length of stay, inpatient costs, and temporal trends. The total cohort included 14,635 hospitalizations for STEMI complicated by CS treated with Impella between 2016 and 2020, of whom 5,505 (37.6%) received PA catheters. Over the study period, the use of PA catheters increased significantly from 25.9% to 41.8% (ptrend <0.01). Similarly, the use of Impella increased from 9.9% to 18.9% (ptrend <0.01). After adjustment for baseline characteristics using a multivariate logistic regression analysis, PA catheter use was associated with lower in-hospital mortality (adjusted odds ratio 0.80, 95% confidence interval 0.67 to 0.96, p=0.01) and similar cardiovascular, neurologic, renal, and hematologic complications; length of stay; and inpatient costs compared with no PA catheter use. In conclusion, PA catheter use in patients with STEMI complicated by CS treated with Impella is associated with reduced in-hospital mortality and similar complication rates. Given the mortality benefit, further research is necessary to optimize PA catheter use in patients with STEMI with CS.

Pulmonary Artery Catheter Use and Risk of In-hospital Death in Heart Failure Cardiogenic Shock

BackgroundPulmonary artery catheters (PACs) are increasingly used to guide management decisions in cardiogenic shock (CS). The goal of this study was to determine if PAC use was associated with a lower risk of in-hospital mortality in CS owing to acute heart failure (HF-CS). Methods and ResultsThis multicenter, retrospective, observational study included patients with CS hospitalized between 2019 and 2021 at 15 US hospitals participating in the Cardiogenic Shock Working Group registry. The primary end point was in-hospital mortality. Inverse probability of treatment-weighted logistic regression models were used to estimate odds ratios (ORs) and corresponding 95% confidence intervals (CI), accounting for multiple variables at admission. The association between the timing of PAC placement and in-hospital death was also analyzed. A total of 1055 patients with HF-CS were included, of whom 834 (79%) received a PAC during their hospitalization. In-hospital mortality risk for the cohort was 24.7% (n = 261). PAC use was associated with lower adjusted in-hospital mortality risk (22.2% vs 29.8%, OR 0.68, 95% CI 0.50–0.94). Similar associations were found across SCAI stages of shock, both at admission and at maximum SCAI stage during hospitalization. Early PAC use (≤6 hours of admission) was observed in 220 PAC recipients (26%) and associated with a lower adjusted risk of in-hospital mortality compared with delayed (≥48 hours) or no PAC use (17.3% vs 27.7%, OR 0.54, 95% CI 0.37–0.81). ConclusionsThis observational study supports PAC use, because it was associated with decreased in-hospital mortality in HF-CS, especially if performed within 6 hours of hospital admission. Condensed AbstractAn observational study from the Cardiogenic Shock Working Group registry of 1055 patients with HF-CS showed that pulmonary artery catheter (PAC) use was associated with a lower adjusted in-hospital mortality risk (22.2% vs 29.8%, odds ratio 0.68, 95% confidence interval 0.50–0.94) compared with outcomes in patients managed without PAC. Early PAC use (≤6 hours of admission) was associated with a lower adjusted risk of in-hospital mortality compared with delayed (≥48 hours) or no PAC use (17.3% vs 27.7%, odds ratio 0.54, 95% confidence interval 0.37–0.81).

Oxygen Consumption Predicts Long-Term Outcome of Patients with Left Ventricular Assist Devices.

Reduced oxygen consumption (VO2), either due to insufficient oxygen delivery (DO2), microcirculatory hypoperfusion and/or mitochondrial dysfunction, has an impact on the adverse short- and long-term survival of patients after cardiac surgery. However, it is still unclear whether VO2 remains an efficient predictive marker in a population in which cardiac output (CO) and consequently DO2 is determined by a left ventricular assist device (LVAD). We enrolled 93 consecutive patients who received an LVAD with a pulmonary artery catheter in place to monitor CO and venous oxygen saturation. VO2 and DO2 of in-hospital survivors and non-survivors were calculated over the first 4 days. Furthermore, we plotted receiver-operating curves (ROC) and performed a cox-regression analysis. VO2 predicted in-hospital, 1- and 6-year survival with the highest area under the curve of 0.77 (95%CI: 0.6-0.9; p = 0.0004). A cut-off value of 210 mL/min VO2 stratified patients regarding mortality with a sensitivity of 70% and a specificity of 81%. Reduced VO2 was an independent predictor for in-hospital, 1- and 6-year mortality with a hazard ratio of 5.1 (p = 0.006), 3.2 (p = 0.003) and 1.9 (p = 0.0021). In non-survivors, VO2 was significantly lower within the first 3 days (p = 0.010, p < 0.001, p < 0.001 and p = 0.015); DO2 was reduced on days 2 and 3 (p = 0.007 and p = 0.003). In LVAD patients, impaired VO2 impacts short- and long-term outcomes. Perioperative and intensive care medicine must, therefore, shift their focus from solely guaranteeing sufficient oxygen supply to restoring microcirculatory perfusion and mitochondrial functioning.

Ventricular fibrillation during pulmonary artery catheter placement in a patient with Stanford type A aortic dissection: a case report

Ventricular fibrillation during pulmonary artery catheter placement in a patient with Stanford type A aortic dissection: a case report

Factors Affecting Pulmonary Artery Catheterisation in Patients Undergoing Coronary Artery Bypass Grafting: A Cross-sectional Study

Introduction: The Pulmonary Artery (PA) catheter continues to be used for monitoring haemodynamic parameters in the majority of patients undergoing Coronary Artery Bypass Grafting (CABG) surgeries, despite concerns raised regarding costeffectiveness and safety issues. Sometimes, placement takes longer or is difficult just by looking at the pressure waves. There are several factors that may influence the duration of Pulmonary Artery Catheter (PAC) insertion. Aim: To determine the factors affecting PAC in anaesthetised patients undergoing elective CABG. Materials and Methods: A single-centred, cross-sectional study was conducted in the Cardiothoracic and Vascular Surgery operation theartre at IPGME&amp;R and SSKM Hospital, Kolkata, India including 138 patients aged 35-65 years of either sex undergoing elective CABG surgery in a tertiary care hospital in Eastern India. The attempt to perform successful first-time catheterisation or failure of the PAC done by a resident cardioanaesthesiologist was noted, as well as whether catheterisation was successfully done within a specified time or not. This time was obtained as the 75th percentile of the time taken for catheter placement for the first 30 cases catheterised in the first attempt. For ease of analysis, all first attempt successful cases were considered as Group A (n=125), and all first attempt failure cases as Group B (n=13). The study data on various parameters were recorded on a proforma and summarised as the mean and standard deviation for normally distributed numerical variables, median and interquartile range for skewed numerical variables, and counts and percentages for categorical variables. A p-value &lt;0.05 was considered statistically significant. Results: A total of 138 patients were analysed during the entire study. There was a predominance of male patients (82.6%) with a male-to-female ratio of 114:24. The first attempt failure rate of successful PAC was 13 out of 138, i.e., 9.42% (95% confidence interval 4.55% to 14.29%). The cut-off time for the procedure as the 75th percentile of the first 30 successful cases is 269 seconds. The number of cases in which it was done within this time was 109 cases, i.e., 78.99%. There was a significant difference (p&lt;0.05) in terms of body weight, body surface area, and neck length between the two groups. Conclusion: Increased body weight and increased body surface area are significant factors associated with difficult PAC placement. On the other hand, short neck length is a significant factor for taking more time in the placement of the catheter.

Abstract 13997: What is the Role of Pulmonary Artery Catheterization in Patients With Acute Myocardial Infarction Complicated With Cardiogenic Shock?

Background: Acute myocardial infarction (AMI) remains one of the most common cause for cardiogenic shock (CS). Emergent revascularization with and without mechanical support demonstrated the benefit in patients with AMI-CS, but data on the utility of pulmonary artery catheter (PAC) in patients with AMI-CS is lacking. Methods: We performed a retrospective study from a large healthcare system (11 hospitals) from October 1 st 2014 to October 2021. We divided the patients with AMI-CS, into two groups those who received PAC and those who did not. Propensity matched analysis was performed for baseline characteristics, comorbidities, and laboratory values to account for the underlying cofounders. The in-hospital outcome was recorded for both groups Results The total cohort included 2585 patients (STEMI: 797; NSTEMI: 1788). Of these 517 patients underwent PAC placement: 19.7 % of the patients in the STEMI group, and 20.4% of patients in the NSTEMI group. Mean age was similar among the PAC and the non-PAC groups (68.87 years vs 67.12 years respectively. Patients who underwent PAC had more diabetes (59.4% vs 53.1%, p=0.011), chronic kidney disease (50.9% vs45.2%, p=0.020), and coronary artery disease (77.8% vs 71.9%, p = 0.007). Overall, in-hospital mortality was lower in patients who underwent PAC and higher in patients who did not receive PAC (25.9% vs 35.9%, p&lt;0.001) and these results remained significant after propensity matching as shown in Figure 1. Similar results were seen across all SCAI stages with improved mortality in PAC group. Overall mechanical circulatory device utilization was higher in the PAC group. Conclusion Our study shows that the use of PAC patients with AMI-CS was associated with improved mortality. If proven in randomized clinical trials PAC should be routinely used for all patients presenting with AMI-CS.

Non-invasive assessment of right ventricular function and pulmonary pressures in cardiogenic shock remains challenging: don't pack away the PAC just yet

Abstract Background Cardiogenic shock (CS) is associated with high levels of morbidity and mortality despite advances in treatment. Patients with right ventricle (RV) dysfunction have been shown to have poorer outcomes. It is suggested that invasive monitoring through pulmonary artery catheter (PAC) placement can assist in guiding management to improve survival, though they are associated with adverse events. Purpose This study assessed the utility of non-invasive, echocardiographic assessment of RV performance and pulmonary artery pressures (PAP) in patients with CS. Methods Consecutive patients admitted to a North American quaternary cardiac intensive care unit who had PAC placement were recruited into this study. Invasive haemodynamic assessment was followed by transthoracic echocardiography (TTE) performed by a critical care cardiologist, blinded to the invasive measurements. TTE images were later reported by a second cardiologist, blinded to the invasive measurements and the patient. Correlations between RV and pulmonary invasive and non-invasive parameters were evaluated using Pearson's correlation. Results Overall, 96 assessments of 60 patients were compared. Patients were predominantly male (73%), aged 58±14 years and SCAI stage C (55%) and D (22%) at the time of assessment. Invasive measurements of right heart and pulmonary function was possible in all patients. Mean RAP was 8.5±4.7 mmHg, systolic PAP 37.5±9.9 mmHg, diastolic PAP 18.1±6.5 mmHg, mean PAP 25.1±7.2 mmHg, pulmonary capillary wedge pressure (PCWP) 16.0±16.4 mmHg, pulmonary vascular resistance (PVR) 157±99dyn s cm–5, RV stroke work index (RVSWI) 7.0±3.9 g min/m2 and PAP index (PAPi) 2.9±4.2. When compared to non-invasive echocardiographic parameters, there was little correlation with invasive values (Table). RVSWI moderately correlated with peak tricuspid regurgitation (TR) velocity, tricuspid annular plane systolic excursion (TAPSE) and estimated systolic PAP; while peak TR velocity was mild-moderately correlated with PAP and PCWP. No single non-invasive parameter demonstrated strong prediction of invasive values. Conclusion Non-invasive assessment of right heart and pulmonary haemodynamic parameters is of limited validity when compared with invasive monitoring through PAC in patients with CS. PAC remains the most reliable method of assessing the RV haemodynamic profile in CS. Future studies should evaluate the clinical benefit of invasive haemodynamic monitoring in this population. Funding Acknowledgement Type of funding sources: None.

Early pulmonary artery catheterization is not associated with survival benefits in critically ill patients with cardiac disease: An analysis of the MIMIC-IV database

BackgroundMany studies demonstrated no improved survival in patients with pulmonary artery catheter placement. However, no consistent conclusions have been drawn regarding the impact of pulmonary artery catheter in critically ill patients with heart disease. This study aimed to investigate the association of early pulmonary artery catheter use with 28-day mortality in that population. MethodsThe Multiparameter Intelligent Monitoring in Intensive Care IV (MIMIC-IV) database, a single-center critical care database, was employed to investigate this issue. This study enrolled a total of 11,887 critically ill patients with cardiac disease with or without pulmonary artery catheter insertion. The primary outcome was 28-day mortality. The multivariate regression was modeled to examine the association between pulmonary artery catheter and outcomes. Additionally, we examined the effect modification by cardiac surgeries. Propensity score matching was conducted to validate our findings. ResultsNo improvement in 28-day mortality was observed among the pulmonary artery catheter group compared to the non–pulmonary artery catheter group (odds ratio 95% confidence interval: 1.18 [1.00–1.38], P = .049). When stratified by cardiac surgeries, the results were consistent. The patients in the pulmonary artery catheter group had fewer ventilation-free days and vasopressor-free days than those in the nonpulmonary artery catheter group after surgery stratification. In the surgical patients, pulmonary artery catheter insertion was not associated with the occurrence of acute kidney injury, and it was associated with a higher daily fluid input (mean difference 95% confidence interval: 0.13 [0.05–0.20], P = .001). In nonsurgical patients, the pulmonary artery catheter group had a higher risk of acute kidney injury occurrence (odds ratio 95% confidence interval: 1.94 [1.32–2.84], P = .001). ConclusionEarly pulmonary artery catheter placement is not associated with survival benefits in critically ill patients with cardiac diseases, either in surgical or nonsurgical patients.

Anticoagulation on Extracorporeal Support: An Alternative Strategy.

To the Editor, We read with extreme interest the updated Extracorporeal Life Support (ELSO) guidelines for anticoagulation during extracorporeal membrane anticoagulation (ECMO)1 and would like to integrate this valuable document with a potential alternative therapeutic anticoagulation strategy for patients requiring veno-venous ECMO. This approach is based on subcutaneous administration of low-molecular-weight heparin (LMWH) 3 times a day, paired with antifactor Xa (anti-Xa) assay monitoring, 3 times a day, each sample equidistant between two administrations of LMWH. Anticoagulation monitoring is integrated on a regular schedule with additional blood tests, including hemoglobin and hematocrit, platelets count, Fibrinogen, D-dimers, haptoglobin levels, and with full coagulation tests and point-of-care viscoelastic testing on an as needed basis. We designed and started implementing an algorithmic protocol (detailed in Figure, Supplemental Digital Content 1, https://links.lww.com/ASAIO/A838) to standardize dosage adjustment based on anti-Xa value, potential evidence of clinically significant bleeding or prothrombotic states, and eventual need for surgical interventions or other invasive procedures. Despite paucity of literature related to anticoagulation management based on LMWH only during ECMO support,2–4 we decided to introduce this approach since the second wave of Coronavirus disease 2019 (COVID-19) pandemic, to simplify and standardize anticoagulation management, reducing the strain on the team members, particularly on most recently recruited, and less experienced ones, involved to expand ECMO capacity. The rationale for the off-label three-daily dosing (despite the commonly recommended once/twice daily dosing) is to achieve and constantly maintain a therapeutic level of anticoagulation, avoiding excessive peaks and minimizing peak-to-trough variability, with the aim of effective prevention of thrombosis without increasing bleeding risk.5 The rationale for anti-Xa assessment 4 hours after LMWH administration is to thoroughly evaluate its effect, including peak, occurring 3–5 hours after subcutaneous administration, being able to properly adapt subsequent dosing. During the run, the protocol anticipates some conditions which demand to modify LMWH administration (dose or timing): need for invasive elective or emergent procedures; we do not consider percutaneuos central venous catheter, pulmonary artery catheter and arterial line placement, nor percutaneous tracheostomy among procedures requiring dosing adjustment; evidence of clinically significant bleeding defined (as per ELSO Registry definition); evidence of thrombotic complications (both intracircuit or patient complications). Since the implementation of this protocol, we did not notice increased ratio of thrombotic events; no patient required the circuit to be replaced more than once during the run (mean duration 19 days [6–52]). No cannula thrombosis, nor thrombosis involving the cannula or cannulated vessels have been observed, despite the high risk profile of this patient population. No brain hemorrhages, nor GI or cannulation site bleedings requiring more than medical approach were observed; and increased incidence of pulmonary hemorrhages was noticed: clinical evidence suggested these as presumably disease, rather than anticoagulation, related. We recognize that such an algorithm significantly deviates from conventional clinical practice and from guidelines, but in our limited, single center experience, its application in a population of COVID-19 patients requiring V-V ECMO was feasible and safe (unpublished data, manuscript in preparation), and easy to be implemented at bedside, in selected settings.

Hemodynamic Effects of COVID-19 Vaccination in Hospitalized Patients Awaiting Heart Transplantation

PurposeThe American Society of Transplantation and the International Society of Heart and Lung Transplantation recommend COVID-19 vaccination of transplant candidates to maximize immunity, as vaccination after initiation of immunosuppression may confer only partial immunity. However, there are concerns about the impact of vaccine-induced systemic inflammatory responses in critically ill patients with variable hemodynamic states. We aim to explore the safety of pre-transplant vaccination by examining the immediate impact of COVID-19 vaccination on the hemodynamics of hospitalized patients awaiting transplant.MethodsA retrospective chart review at a major transplant center was conducted among all heart transplant recipients from January 2021 through September 2021 who were hospitalized and listed or under consideration for listing for transplant at the time of COVID-19 vaccination. Primary outcomes included vital signs, hemodynamic parameters from pulmonary artery catheter-derived measurements, and changes in inotrope/vasopressor infusion rates. Data were extracted at fixed time points 24 hours before and up to 72 hours after vaccination. Given the small sample size and exploratory study nature, only univariate analysis was performed.ResultsOf the 50 patients who received heart transplants at our center from January 2021 through September 2021, 37 patients were vaccinated against COVID-19. 13 of those patients were vaccinated before transplant while hospitalized, and 10 of those 13 patients had a pulmonary artery catheter in place at the time of immunization. No significant changes in vital signs (blood pressure, heart rate), hemodynamics (cardiac index, pulmonary artery pressures, systemic vascular resistance), or vasopressor/inotrope infusion rates were observed after vaccination.ConclusionIn this exploratory review of COVID-19 vaccination in heart transplant candidates, we did not detect any notable changes to hemodynamics in the first 72 hours after immunization. Although further investigative research is needed to assess COVID-19 vaccine safety comprehensively in patients with advanced heart failure, the absence of notable hemodynamic changes in this cohort of heart transplant candidates encourages the continued use of COVID-19 vaccination among hospitalized patients with advanced heart failure who are awaiting transplant.

Correlation Between Venous Oxygen Saturations Obtained From Pulmonary Artery Catheter And Peripherally Inserted Central Catheter In Patients Receiving Inotrope Support

Correlation Between Venous Oxygen Saturations Obtained From Pulmonary Artery Catheter And Peripherally Inserted Central Catheter In Patients Receiving Inotrope Support

Inadvertent placement of pulmonary artery catheter in persistent left superior vena cava, detected by transesophageal echocardiography

肺動脈カテーテル（pulmonary artery catheterization, PAC）は重症患者のモニタリングに有用とされている。しかし，左上大静脈遺残（persistent left superior vena cava, PLSVC）へのカテーテル留置は，重篤な合併症との関連が指摘されている。今回，僧帽弁形成術においてPACが冠静脈洞を経由してPLSVCに迷入し，ICUで行った経食道心エコー図検査（transesophageal echocardiography, TEE）で診断された1例を経験した。PLSVCと心拡大が併存する場合や経皮的心肺補助装置管理中の場合，胸部単純X線写真や圧波形のみではPAC が適切な位置にあるか診断するのは困難である。PACの適切な位置への留置にはTEEの併用が有用である可能性がある。

Hemodynamic Monitoring Using a Pulmonary Artery Catheter Versus the Vigileo/FloTrac System during Elective Cardiac Surgery Based on Real-world Data in Japan.

The controversy concerning the benefits of pulmonary artery catheter (PAC)-based hemodynamic monitoring in cardiac surgeries has not been adequately addressed. This study aims to compare the all-cause mortality between the PAC with venous oxygen saturation monitoring and the Vigileo/FloTrac (FloTrac) system with central venous oxygen saturation monitoring in cardiac surgeries. This nationwide retrospective study includes adult patients who underwent elective cardiac surgeries between April 2010 and October 2014, based on the Japanese health insurance claims database. The main outcome was 30-day all-cause mortality. Propensity scores (PS) were used to adjust for the confounding factors. Treatment effects were estimated using multivariable logistic regression analysis, including PS. A total of 5,838 patients were included in this study. The crude 30-day mortality rates were 2.4% (8/334) and 1.7% (96/5,504) in the FloTrac and PAC groups, respectively. After PS matching, the ORs for 30-day all-cause mortality, in-hospital mortality after PAC placement (vs. FloTrac) were 0.36 (95% CI: 0.05-2.37; p = 0.28) and 0.59 (95% CI: 0.16-2.20; p = 0.43), respectively. The amount of dobutamine was larger in the PAC group (281 ± 31 mg vs 155 ± 19 mg; p < 0.001). There were no significant differences in the amounts of other inotropes, the volume of fluids, or blood transfusions. The association between PAC (with venous oxygen saturation monitoring) and mortality in patients who underwent elective cardiac surgeries was unclear compared to FloTrac (with central venous oxygen saturation monitoring). Additional investigation is needed to evaluate the benefits of PAC-specific hemodynamic parameters in this population.

Adult liver transplant anesthesiology practice patterns and resource utilization in the United States: Survey results from the society for the advancement of transplant anesthesia.

Liver transplant anesthesiology is an evolving and expanding subspecialty, and programs have, in the past, exhibited significant variations of practice at transplant centers across the United States. In order to explore current practice patterns, the Quality & Standards Committee from the Society for the Advancement of Transplant Anesthesia (SATA) undertook a survey of liver transplant anesthesiology program directors. Program directors were invited to participate in an online questionnaire. A total of 110 program directors were identified from the 2018 Scientific Registry of Transplant Recipients (SRTR) database. Replies were received from 65 programs (response rate of 59%). Our results indicate an increase in transplant anesthesia fellowship training and advanced training in transesophageal echocardiography (TEE). We also find that the use of intraoperative TEE and viscoelastic testing is more common. However, there has been a reduction in the use of veno-venous bypass, routine placement of pulmonary artery catheters and the intraoperative use of anti-fibrinolytics when compared to prior surveys. The results show considerable heterogeneity in practice patterns across the country that continues to evolve. However, there appears to be a movement towards the adoption of specific structural and clinical practices.