When is a pulmonary artery catheter indicated

Clinical indications for PAC monitoring are shown in Table 1 [ 1 ]. The patient presented here had severe MR and pulmonary hypertension, and there was a possibility of resultant right-sided heart failure. Therefore, PAC monitoring was considered necessary in this case. Complications related to the PAC include arrhythmias [ 4 ], complete heart block [ 5 ], pulmonary infarction [ 6 ], catheter knotting and entrapment [ 7 , 8 ], valvular damage [ 9 , 10 ], thrombocytopenia [ 11 , 12 ], thrombus formation [ 13 ], balloon rupture [ 2 ], ventricular perforation [ 14 ], and incorrect placement [ 15 , 16 , 17 , 18 , 19 , 20 ].

Complete heart block is possible in patients with preexisting LBBB due to electrical irritability from the PAC tip causing transient right bundle branch block as it passes through the right ventricular outflow tract [ 5 ]. Mild thrombocytopenia is possible, and although heparin-coated PACs may reduce this risk, these catheters can trigger heparin-induced thrombocytopenia [ 11 , 12 ].

Misplacement of the PAC occurred in our patient. Spontaneous wedging of the catheter during CPB is the most frequent form of malposition [ 2 ]. Although there have been few case reports regarding PAC misplacement, abnormal sites such as the liver, coronary sinus, pulmonary vein, and right subclavian vein have been described [ 15 , 17 , 19 , 20 ].

In addition, looping of the PAC around an inferior vena cava filter and a left ventricular assist device has been described [ 16 , 18 ]. In patients with a persistent foramen ovale, or an atrial or ventricular septal defect, placement of the PAC in the left side of the heart is possible. Reports of PAC placement toward the cephalad direction are limited, but there have been reports of central venous catheters bent upward in the RIJV [ 21 , 22 ]. Catheter misplacement in the cephalad direction can lead to serious complications, including thrombosis and hemorrhage [ 23 ].

Early recognition and withdrawal of the PAC in our patient led to hospital discharge without complications. The balloon of the PAC tends to float to nondependent regions. Therefore, the position of the patient influences the passage of the PAC. In this case, the surgeon requested a head-up position to aid visualization of the surgical field. This position may have affected the balloon of the PAC, causing it to float toward the head.

In addition, the presence of a Hickman catheter in the RIJV may have served as an additional complicating factor. However, the tip of the introducer sheath was placed more distal from the heart than the insertion site of the Hickman catheter, as revealed by chest radiographs.

Therefore, the Hickman catheter may have interfered with passage of the PAC with the inflated balloon in this case. It has been documented that enlarged cardiac chambers, low cardiac output, pulmonary hypertension, and TR are related to difficult PAC positioning [ 2 , 3 ].

Our patient presented with enlarged cardiac chambers, pulmonary hypertension, and moderate TR at the time of this event. Therefore, unlike the previous surgery, successful PAC placement could not be achieved easily despite proper positioning of the patient after introducer sheath insertion.

Normally, placing the patient in a head-down position aids flotation from the RA to the RV, and repositioning the patient to achieve a right lateral tilt, with the head tilted slightly upward, aids flotation from the RV to the PA [ 2 , 3 ]. TEE or fluoroscopy can be used as alternatives to conventional waveform-based PAC placement with expertise hands [ 26 , 27 , 28 ]. Both adjunct methods have been shown efficacy in potentially difficult cases.

Many cardiac anesthesiologists prefer TEE because it is a routine monitoring method in cardiac surgery. Moreover, TEE has advantages over fluoroscopy in that the latter is not always readily available and involves exposure to radiation [ 27 , 28 ]. Three TEE views can aid advancement of the PAC; a midesophageal modified bicaval view when passing through the tricuspid valve; a midesophageal right ventricular inflow-outflow view when maneuvering through the RV and RV outflow tract; and a midesophageal ascending aortic short-axis view when confirming the final position of the PAC at the junction of the main PA and the right PA [ 27 , 28 ].

As many cardiac surgery patients present with risk factors for difficult PAC placement, cardiac anesthesiologists should be experienced in the practice of placing the PAC with TEE. Practice guidelines for pulmonary artery catheterization: an updated report by the American Society of Anesthesiologists Task Force on Pulmonary Artery Catheterization. Pulmonary artery catheter. Best Pract Res Clin Anaesthesiol. Article Google Scholar.

Vincent JL. The pulmonary artery catheter. J Clin Monit Comput. A review of pulmonary artery catheterization in 6, patients. Risk of developing complete heart block during bedside pulmonary artery catheterization in patients with left bundle-branch block. Arch Intern Med. Pulmonary complications of the flow-directed balloon-tipped catheter. N Engl J Med. Pulmonary artery catheter complications: report on a case of a knot accident and literature review.

Knot in the cava--an unusual complication of swan-ganz catheters. Eur J Vasc Endovasc Surg. Pulmonary-valve injury and insufficiency during pulmonary-artery catheterization. Boscoe MJ, de Lange S. Damage to the tricuspid valve with a Swann-Ganz catheter.

Thrombocytopenia associated with swan-Ganz catheterization in patients. Heparin-induced thrombocytopenia: a possible complication of heparin-coated pulmonary artery catheters. J Cardiothorac Anesth. Thrombus formation on the balloon of heparin-bonded pulmonary artery catheters: an ultrastructural scanning electron microscope study. Healthcare providers always weigh the benefits and risks of the procedure for specific people.

Risks may be higher for some people. These include older adults and people who have higher pressure in the vessels of the lungs. Ask your healthcare provider how to get ready for this procedure. You may need to avoid eating and drinking for 6 hours or more beforehand. You may also need to stop taking certain medicines, as directed by your healthcare provider.

Talk with your healthcare provider about exactly what will happen. A healthcare provider and a special team of nurses will do the procedure. It will often take place at the bedside in an intensive care unit. Or it may occur in a special catheterization lab. In general:. Health Home Treatments, Tests and Therapies. Why might I need pulmonary artery catheterization? These include: Shock. Pulmonary edema.

The test helps find the cause of fluid buildup in the lungs. Heart failure. This test evaluated heart pressures and blood flow in a weak heart. Congenital heart disease. This test may help understand the flow of blood within the heart affected by a birth defect. High blood pressure in the lungs pulmonary hypertension Fat embolism clot that is blocking a blood vessel Pulmonary artery catheterization can help guide treatment. For example, it can help with: Complicated heart attacks Being unstable before or after surgery High blood pressure during the latter part of pregnancy severe preeclampsia Drug therapy Fluid levels in the blood vessels Burns Kidney failure Heart failure Sepsis Ventilator management What are the risks of pulmonary artery catheterization?

Possible risks include: Abnormal heart rhythms, some of which can be life threatening Right bundle branch block, which is often temporary Knotting of the catheter Rupture of the pulmonary artery Severely reduced blood flow to part of the lung Blood clots, which can cause a stroke Infection of the heart valves endocarditis Infections of the catheter Bleeding at the insertion site There is also a risk of inaccurate catheter placement.

How do I get ready for pulmonary artery catheterization? Your healthcare provider may want some other tests before the procedure. These might include: Chest X-ray Electrocardiogram, to look at heart rhythm Blood tests, to check general health Echocardiogram, to see blood flow through the heart and to view the fluid around the heart What happens during a pulmonary artery catheterization?

In general: You will be awake. You may be given medicine to make you sleepy before the procedure starts. This measurement is an indirect way to determine pressure in the left atrium. Blood samples can be taken through the catheter, so that the oxygen and carbon dioxide levels in the blood can be measured.

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Common Health Topics. Commonly searched drugs. How pulmonary artery catheterization is done. Diagnosis of Heart and Blood Vessel Disorders. Test your knowledge. Postprandial hypotension is an excessive decline in blood pressure after a meal.