Archivos Peruanos de Cardiología y Cirugía Cardiovascular

Arch Peru Cardiol Cir Cardiovasc. 2021;2(3):175-186.

Artículo de revisión

Invasive hemodynamic monitoring by Swan-Ganz pulmonary artery

catheter: concepts and utility
José María Carrasco Rueda 1,a, Giorgio André Gabino Gonzalez 1,a, José Luis Sánchez Cachi 1,b,
Roberto Pedro Pariona Canchiz 1,b, Anghella Fiorela Valdivia Gómez 1,b, Oscar Nelson Aguirre Zurita 1,a

Received: September 5, 2021

Accepted: September 29, 2021
ABSTRACT
Authors’ affiliation
1
Clinical Cardiology Service. Since its beginnings in the last century, pulmonary artery catheterization (PAC) has evolved into an
Instituto Nacional Cardiovascular
INCOR. Lima, Perú.
invasive hemodynamic evaluation technique that can be performed at the patient’s bedside through
a
Clinical cardiologist. a Swan-Ganz catheter; this procedure has maintained an intermittent course in terms of its use;
b
Cardiology Resident.
however, it has currently demonstrated relevance in specific scenarios. The PAC allows access to the
central venous circulation, the right heart and the pulmonary artery; it performs the calculation of
*Correspondence
José María Carrasco Rueda. Calle hemodynamic variables directly or indirectly by means of established formulas and methods. This in
Coronel Zegarra 417, Jesús María, turn provides proper hemodynamic evaluation and classification, additionally, PAC makes possible
Lima Perú
specific tests (e.g. vasoreactivity test), which help to define the diagnosis, treatment, monitor the
E-mail:
carruedajosemaria@gmail.com response to treatment, evaluation prior to advanced therapies (e.g. cardiac transplantation or
mechanical circulatory assistance devices), and prognosis in our patients. In this article we discuss the
Funding
Self-funded concepts and usefulness of pulmonary artery catheterization.

Conflicts of Interest
The authors declare that they have
no conflicts of interest. Keywords: Hypertension, pulmonary; Hemodynamic monitoring; Cardiogenic shock; Heart failure (source:
Cite as:
MeSH NLM).
Carrasco Rueda JM, Gabino Gonzalez
GA, Sánchez Cachi JL, Pariona Can-
chiz RP, Valdivia Gómez AF, Aguirre
Zurita ON. Monitoreo hemodiná-
mico invasivo por catéter de arteria
pulmonar Swan-Ganz: conceptos
y utilidad. Arch Peru Cardiol Cir
Cardiovasc. 2021;2(3):175-186. doi:
10.47487/apcyccv.v2i3.152.

Arch Peru Cardiol Cir Cardiovasc. 2021;2(3):175-186. doi: 10.47487/apcyccv.v2i3.152. EsSalud | 175
Invasive hemodynamic monitoring by Swan-Ganz Carrasco Rueda JM, et al.

- The distal lumen (yellow) is located at the distal end and

resides in the PA. It is used to monitor pressures and to obtain
Introduction a mixed venous sample.
- The red port is for inflating and deflating the balloon. Each
The first cardiac catheterization was performed in 1920 by
catheter is accompanied by a 1.5 mL syringe that is used to
Dr. Werner Forssmann by introducing a urological catheter in
inflate the balloon.
the antecubital vein up to the right atrium . Subsequently,
(1)
- The temperature sensor (thermistor) is used to measure the
catheterizations were routinely conducted with semi-rigid core temperature in the PA.
devices, and in 1953 Lategola and Rahn innovated, by animal
The objective of PAC is hemodynamic monitoring and its
experimentation, a balloon catheter system to facilitate the use
physiological parameters derived from the evaluation of left and
of right-sided and pulmonary catheterization without assisted
right ventricular function (1,8,9). The thermodilution technique that
fluoroscopy (2). In 1970, as a result of serendipity and based on
calculates cardiac output (CO) measures the blood temperature
the described antecedents, Harold James Swan and William Ganz
variability of the PA and that of the saline solution injected by
created the flexible catheter system with inflatable distal balloon
the RA, which produces a change in resistance and voltage,
for humans. They were motivated to develop a technique for the
generating a time-temperature curve from which the CO is
care and study of acute cardiac patients in whom fluoroscopy
estimated by means of the Stewart-Hamilton equation (10). If the
was not available or for those who were immobilized due to
area under the curve is small, the temperature equilibrates rapidly
hemodynamic instability or other causes (3,4).
with the ambient body temperature resulting in a high CO, and if
Pulmonary artery catheterization (PAC) by Swan- the area under the curve is large it implies a low CO (11,12).
Ganz catheter (SGC) was considered a revolutionary method
at the time; however, in subsequent years, with the advance Placement
of diagnostic and therapeutic techniques, its use declined. In
the past decade its use has regained prominence regarding Prior to the procedure, the indication for SGC placement must
invasive hemodynamic monitoring in patients with heart failure, be clear, any possible contraindication must be ruled out and

associated with a decrease in mortality and an increase in hospital the risk of complications must be assessed (Table 1) . The
(9,11)

stay . Likewise, its use has become relevant in patients with

(5-7) SCG introducer should be placed percutaneously via the inferior

cardiogenic shock (CS) hospitalized in intensive care units (8). vena cava through the femoral veins or via the superior vena cava
through the subclavian or internal jugular vein (interfascicular
The aim of this article is to review the current literature access); the latter accesses are of choice for bedside management.
on the concept, use, indications and usefulness of PAC by SGC, The right interfascicular approach via internal jugular vein is the
as well as the interpretation of cardiopulmonary hemodynamic preferred approach due to the easy and quick access to the RA.
parameters. Puncture should be performed with the patient in the supine or
Trendelenburg position with ultrasound guidance, confirming
adequate venous return, and dilating the access area through a
Concept dilator to facilitate entry of the venous introducer (13-15).

The pulmonary artery catheter is a balloon-tipped flow-directed The SGC should be introduced up to approximately 15 cm

catheter that allows rapid access to the central venous circulation, to obtain RA pressure waves, after which the distal balloon will be

the right heart and the pulmonary artery (PA) . Its length is
(1,9) inflated and the catheter will continue to enter rapidly through the
right ventricle (RV), to avoid ventricular ectopy, until obtaining PA
approximately 110 cm, with a standard external diameter of 7
pressure waves. Then, it should slowly progress until a pulmonary
or 7.5 French. The balloon at the tip, when inflated, guides the
capillary pressure (PCP) curve is obtained, this happens 50 to 55 cm
catheter from the major intrathoracic veins through the right
after catheter entry (Figure 1) (15).
atrium (RA) and ventricular chambers into the PA (9,10). Most have
four separate lumens, each of which has individual functions (9,10): Zeroing the pressure system is important to obtain
an adequate PCP value and is carried out by positioning the
- The proximal lumen (blue) is located in the RA and measures transducer at the level of the RA (mid-axillary line, 4th intercostal
intra-atrial pressure. It can also be used to administer space). The SGC should be fixed with the protective cap to
medications. mitigate the risk of infections and the adequate position should

176 | EsSalud Arch Peru Cardiol Cir Cardiovasc. 2021;2(3):175-186. doi: 10.47487/apcyccv.v2i3.152.
Invasive hemodynamic monitoring by Swan-Ganz Carrasco Rueda JM, et al.

Table 1. Indications, contraindications and complications of the Swan-Ganz catheter.

INDICATIONS RL SOURCE
Patients with respiratory distress or altered systemic perfusion in the context of inadequate clinical I AHA 2013
management.
Heart failure (reduced or preserved ejection fraction). IIA AHA 2013
- Acute heart failure with persistent symptomatology not responding to empirical manage- AHA 2017
ment and/or uncertain hemodynamic status, acute renal failure and hypotension plus use of
vasopressors.
- Heart failure with organ dysfunction and absence of myocardial recovery, candidates for
circulatory support and cardiac transplantation. SCAI 2017

Cardiogenic shock IIA Ref.39,40

Cardiac transplant SCAI 2017

Mechanical circulatory support

- Initial acute management of patients on mechanical circulatory support. IIA SCAI 2017
- Persistent or recurrent heart failure after initiation of circulatory support. IB ISHLT 2013
- Right Ventricular Failure in Patients on Circulatory Support. IB ISHLT 2013
- Evaluation of circulatory support device dysfunction. IB
IIA ISHLT 2013
- Confirmation myocardial recovery associated with stepwise decrease in circulatory support ISHLT 2013
pump speed and weaning of the circulatory support pump.
- Monitoring during long-term circulatory support implantation IIA EACTS 2019
- Support in the management of fluid resuscitation and diagnosis of complications in patients IIA EACTS 2019
on long-term circulatory support.
-
Other scenarios:
- Cardiovascular postoperative monitoring.
- Cardiac tamponade, restrictive and constrictive heart disease.
- Pulmonary arterial hypertension.
- Intracardiac shunts (congenital heart disease).
- Acute pulmonary edema.
- Mechanical complication after myocardial infarction.
- Acute pulmonary thromboembolism.
- Etiological evaluation of severe hypotensive states (hypovolemic, septic, cardiogenic
shock).
- Assessment of volume status in renal or hepatic failure.
CONTRAINDICATIONS
Absolute:
Tricuspid or pulmonary mechanical valve prosthesis, intracavitary mass in right ventricle, right-sided endocarditis.
Relative:
Presence of endocardial pacing, tricuspid or pulmonary valvular biological prosthesis, respiratory distress syndrome due to pulmonary sepsis, com-
plete left bundle branch block, significant arrhythmias, infection of the puncture site..
COMPLICATIONS
Hemo/pneumothorax, arrhythmias, conduction disturbance, hematoma, hypotension, vasovagal event, lower respiratory tract bleeding, catheter
insertion site infection.
AHA: American heart association. SCAI: Society of Cardiovascular Angiography and Interventions. EACTS: Expert consensus on long-term mechanical circula-
tory support. ISHLT: International Society for Heart and Lung Transplantation. RL: Recommendation level.
Adapted from Hsu S, Fang JC, Borlaug BA. Hemodynamics for the Heart Failure Clinician: A State-of-the-Art Review [published online ahead of print, 2021
Aug 8]. J Card Fail. 2021;S1071-9164(21)00306-7. doi:10.1016/j.cardfail.2021.07.012 y Madias C and Kimmelstiel C. Right Heart Catheterization. Cardiology
Procedures. USA: Springer; 2017: 123 – 133.

be confirmed by radiologically locating the distal catheter in

West’s pulmonary zone III (9,14,15). Hemodynamic monitoring
CO by thermodilution is carried out by infusing 10 mL of
Right atrium
saline solution through the proximal lumen with a syringe in less
than 4 seconds. The modification of the CO calculation constant The RA pressure tracing shows different pressure curves (A-X-V-Y
sequence). The A-wave represents atrial contraction, the X-descent
depends on the infusion temperature, being 0.532 for 0 °C and
represents the pressure drop during early ventricular systole
0.586 for 24 °C (this may vary according to the brand and type of
and atrial relaxation, the V-wave represents atrial filling during
monitor). Hemodynamic calculations will be carried out with the ventricular systole and the Y-descent represents early diastole
obtained CO. It should be taken into account that the presence with rapid emptying of the RA. Thus, the X-descent and V-wave
of tricuspid insufficiency, low output states or intracardiac shunts are systolic events, whereas the Y-descent, A-wave and the V-wave
may alter the accuracy of the results (9,11,15). peak are diastolic events.

Arch Peru Cardiol Cir Cardiovasc. 2021;2(3):175-186. doi: 10.47487/apcyccv.v2i3.152. EsSalud | 177
Invasive hemodynamic monitoring by Swan-Ganz Carrasco Rueda JM, et al.

The central venous pressure (CVP) reflects the right usually indicates decreased distensibility, as in patients with
intra-atrial pressure, it is preferably measured at the level of pulmonary hypertension (PHT), RV hypertrophy or volume
the Z-point and is represented by the correlation between the overload.
beginning of the QRS segment in the ECG and the intersection
Pulmonary artery distensibility (PAD), determined by
between the A and C wave. The CVP expresses the patient’s
the resistive and pulsatile components of RV load, represents
volume status and its direct relationship with the RV, it can be
the relationship between stroke volume and pulmonary pulse
interpreted as the filling pressures of the right side of the heart
pressure (PPP). It has been proven to be a strong prognostic
(Table 2) (16).
indicator of mortality and RV dysfunction in type II PHT and
heart failure with reduced ejection fraction (HFrEF); a value lower
Right ventricle
than 2.15 is associated with lower survival, even in patients with
normal pulmonary vascular resistance (PVR) (17,18).
RV tracings show a rapid pressure increase during ventricular
contraction and a rapid pressure decrease during relaxation, On the other hand, effective pulmonary artery elastance
with a diastolic phase characterized by an initially low pressure (PAE), a measure that relates PA systolic pressure (PAPs) to LV
that gradually increases. The RA pressure should be fairly close ejection volume, represents, like DAP, the RV afterload and
to the RV end-diastolic pressure, unless tricuspid stenosis is function and, therefore, is a more specific predictor of mortality
present. With atrial contraction, an A-wave may appear at the and RV dysfunction (independently of PVR and diastolic
end of ventricular diastole, which is an abnormal finding and pulmonary gradient) in patients with type II PHT and heart failure

Table 2. Direct measurement parameters in hemodynamic monitoring by Swan-Ganz catheter.

Name Normal range Description

Central venous pressure Represents right atrial pressure, and interprets right-sided filling pressures of the heart.
(CVP) 2 – 6 mmHg CVP > 15 mmHg indicates overloaded right-sided pressures.

RVSP: 15 – 30 mmHg Has a rapidly ascending and descending sinusoidal wave. The presence of an
RV pressure (RVP)
RVDP: 2 – 8 mmHg A-wave at the end of diastole usually indicates decreased distensibility.

It shows a rapid ascent and slow descent with a dicrotic notch, representing
SBP: 15 – 30 mmHg
pulmonary valve closure.
PA pressure (PAP) DAP: 8 – 15 mmHg
High PAPs associated with an elevated heart rate is indicative of right ventricular
MAP: 14 – 16 mmHg
dysfunction and high incidence of cardiac events.

The waveform is similar in appearance to the right atrial pressure wave with some
differences (greater variability with the ventilatory cycle and the magnitude of the
Capillary wedge
6 – 12 mmHg v-wave exceeds the a-wave in the tracing).
pressure (CWP)
CWP > 15 mmHg indicates hydrostatic edema, CWP should be corrected if PEEP is high
and >10mmHg.

Calculable by thermodilution using the Stewart-Hamilton equation and by the Fick

Cardiac output (CO) 4 – 8 L/min principle; calculation by thermodilution is preferable except in the presence of left-
to-right intracardiac shunt, where the use of Fick is recommended.
Cardiac index (CI) 2.5 – 4 L/min/m2 CO < 4 L/min indicates low cardiac output.
CI < 2.2 is a diagnostic criterion for cardiogenic shock.

Inversely related to left ventricular distensibility. CWP is directly associated with LA

Left atrium (LA) 5 – 10 mmHg
pressures and these in turn with LV end-diastolic pressure.

Oximetry analysis of a blood sample taken from the pulmonary artery (distal lumen).
Central venous saturation < 60 % in myocardial infarction is indicative of low output
Mixed venous 60 – 80 % state and cardiogenic shock.
saturation (SvO2) Mixed venous saturation < 60 % is an indicator of hypoperfusion, lactic acidosis
and poor prognosis.

PHT: pulmonary arterial hypertension. SBP: systolic blood pressure DAP: diastolic blood pressure. MAP: mean arterial pressure. PEEP: positive end-expira-
tory pressure. RV: right ventricle. RVDP: right ventricular diastolic pressure. RVSP: right ventricular systolic pressure. LV: left ventricle.

178 | EsSalud Arch Peru Cardiol Cir Cardiovasc. 2021;2(3):175-186. doi: 10.47487/apcyccv.v2i3.152.
Invasive hemodynamic monitoring by Swan-Ganz Carrasco Rueda JM, et al.

Figure 1. Hemodynamic monitoring by Swan-Ganz pulmonary artery catheter.

PAP: Pulmonary artery pressure. PEEP: Positive end-expiratory pressure.

(HF) even with HFrEF. Values greater than 1 support the need parameter that predicts severe RV dysfunction in the context
for therapy aimed at improving total RV load rather than the of inferior myocardial infarction and/or LV mechanical
precapillary component, and its use is recommended in patients circulatory support (MCS), developed with the aim of

with decompensated HF and PHT II, as well as RV failure (17,18). identifying patients requiring right mechanical assistance; it
also tends to be more predictive in patients with inotropic
The pulmonary arterial pulsatility index (PAPi) support and is useful as a prognostic indicator of survival of
determined by the relation between PPP and the RA, is a PHT when values are < 0.95 (19,20).

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Invasive hemodynamic monitoring by Swan-Ganz Carrasco Rueda JM, et al.

Tabla 3. Interpretation of the hemodynamic monitoring according to scenarios.

Scenario BP HR RA PCP CO SVR Actions

Stop acute decongestion.

Unclear volume,
perfusion and vascular Diuretic + vasodilator. Maintain CVP <
resistance status. 8mmHg, PCP < 15mmHg, SVR 1000 to 1200
dynas/s/cm-5 and MAP> 65mmHg.

Deterioration of Inotropics (MAP > 65mmHg and

renal function during CI > 2 L/min/m2)
decongestion.

Dyspnea and unclear Diagnostic suspicion and management of

volume status. RV infarction, PHT, pericarditis, PTE.

Diuretics

Hypotension of
IV Fluid (Probable Hypovolemic Shock)
undefined etiology..

IV fluid, vasopressor, etiologic management.

(Probable distributive shock)

Inotropic and vasopressor. Possibility of

MCS.

RA: right atrium. HR: heart rate. CO: cardiac output. PHT: pulmonary arterial hypertension. CI: cardiac index. IV: intravenous. BP: blood pressure. MAP: mean
arterial pressure. CVP: central venous pressure. PCP: pulmonary capillary pressure. SVR: systemic vascular resistance. PTE: pulmonary thromboembolism.
Adapted from: Hsu S, Fang JC, Borlaug BA. Hemodynamics for the Heart Failure Clinician: A State-of-the-Art Review [published online ahead of print, 2021 Aug
8]. J Card Fail. 2021;S1071-9164(21)00306-7. doi:10.1016/j.cardfail.2021.07.012

Pulmonary artery determines a greater consumption of oxygen by the RV in type I

PHT and, therefore, a greater risk of RV dysfunction (22).
The PA pressure tracing shows a rapid rise in pressure, a systolic
The measurement of mean pulmonary arterial pressure
peak, a decrease in pressure after peak ejection, and a well-
(mPAP) is relevant for the diagnosis and management of
defined dicrotic notch from pulmonary valve closure during
pulmonary hypertension. According to the latest consensus of
the pressure decrease. There should be no systolic pressure
the Sixth World Symposium on Pulmonary Hypertension (WSPH),
difference between the right ventricle and the PA unless stenosis
a value > 20 mmHg represents a cut-off point for the diagnosis
of the pulmonary artery or pulmonary valve exists.
of PHT, since adequate medical management from this value
The shape of the PA wave, like other right heart pressure upwards shows benefits in survival (23).
wave shapes, is subject to respiratory changes, thus patients
on mechanical ventilation, with severe lung disease, morbid
Pulmonary capillary pressure
obesity or respiratory distress, can create substantial changes in
intrathoracic pressure with noticeable differences in PA pressures
The PCP is measured directly in the absence of antegrade
during respiratory phases. Most experts consider that the end of
flow from the PA, so that it is transmitted from the left atrium,
expiration is the appropriate point to assess pulmonary artery
through the pulmonary veins and pulmonary capillary bed. It
(and other cardiac chamber) pressures because it is in this phase
is usually a few millimeters of mercury below left atrial pressure
that intrathoracic pressure is closest to zero (21).
(0 to 5 mmHg) (24,25). Characteristics of a good wave include the
The PAPs is produced at the same time as the T-wave presence of A- and V-waves, fluoroscopic confirmation of the
in the ECG and has been shown to be a parameter related to location of the catheter tip in distal PA with the balloon inflated,
major cardiac events. A PAPs associated with a high heart rate observation of a mPAP curve when the balloon is deflated or the

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Invasive hemodynamic monitoring by Swan-Ganz Carrasco Rueda JM, et al.

catheter is removed from position, and an oxygen saturation which represents the true left ventricular preload (29)
. With the
with the balloon inflated > 90%, the latter being the most help of PAC, CO and thus cardiac index (CI) can be calculated by
specific (Table 2). If the catheter tip is poorly positioned in a thermodilution and by Fick’s principle (10) (Figure 2). The presence
peripheral branch of the PA with the balloon over distended, an of a decreased CI is the main hemodynamic indicator for the
“overstacking” phenomenon occurs and a false PCP curve with diagnosis of CS. It can help to recognize a malfunction of MCS
an oscillating line without A- and V-waves is obtained, which devices and to assess myocardial recovery aimed at weaning.
can lead to abrupt rupture of the PA .
(25)
Together with systemic vascular resistance (SVR), the CI allows
differentiation of the various types of CS phenotypes (6). With
In patients with mechanical ventilation with positive
the values of CO, cardiac power (CP) can be calculated, which is
end-expiratory pressure (PEEP) >10 cmH2O, there is a significant
the strongest independent hemodynamic marker of in-hospital
increase in alveolar pressure, which reduces the proportion of
mortality; the Shock trial reported CP within the risk stratification
WEST’s pulmonary zone 3, directly affecting the pressures of the
of patients with myocardial infarction, a value < 0.6 Watts is
right side, causing an overestimation of PCP (25). Direct correction
indicative of severe LV dysfunction (10,29).
of PCP due to elevated PEEP is carried out by subtracting the
esophageal pressure measured with an intraesophageal balloon On the other hand, the LV transmural filling pressure
from the PCP; however, there are other practical methods such represents LV preload, as well as the difference between
as subtracting 2 to 3 mmHg of PCP for each 5 cmH2O increase in pulmonary capillary pressure (PCP) and pericardial pressure (PP),
PEEP or arguing that the corrected PCP is equal to the measured using CVP instead of PP for calculation. PCP varies with changes in
PCP minus half the quotient of PEEP divided by 1.36 (16,25,26). LV transmural pressure and PP, so in a patient with HF it shows the
pericardial restrictive effect on the LV preload (11,30).
If the PCP is high, the increase in the ratio between RA
and PCP serves as an indicator of RV dysfunction and increased There is also a biventricular assessment measure called
complications in advanced HF; its value is associated with systolic work index (SWI).This parameter evaluates ventricular work
increased pulmonary resistance and in-hospital mortality (26). (energy) and has shown that its decrease in the LV is a predictor of
poor prognosis and the need for greater hemodynamic support;
To assess whether the increase in PA pressure is due
in addition, the SWI of the RV is a predictor of RV failure in MCS
to an isolated elevation of pulmonary wedge pressure, the
and mortality in post-lung transplant patients (31) (Figure 2).
transpulmonary arterial pressure gradient was traditionally used,
the value of which varies according to mPAP flow and LV filling
Intracardiac shunt (IS)
pressures; currently, it is notably less relevant. However, the
diastolic pulmonary arterial pressure gradient is a more accurate
PA oxygen saturation greater than 75% may indicate the presence
marker that allows adequate classification of PHT according
of a left-to-right IS, so it is recommended to measure the superior
to its pre- and post-capillary component; in addition, a high
and inferior vena cava, RA (middle, high and low), RV and PA.
value is considered a predictor of mortality, poor prognosis and
Increased oxygen saturation ≥ 7% may be indicative of a left-to-
hospitalization for heart failure (24,27).
right atrial shunt, whereas ≥ 5% may indicate a shunt at the level
Finally, pulmonary vascular resistance (PVR) is a of the RV or the PA. The direct Fick method is the preferred means
marker that has gained prominence since the sixth WSPH; and of CO measurement when a left-to-right IS is suspected (32).
determines the presence of pulmonary vascular disease by being
a better indicator of precapillary PHT, in contrast to the diastolic
pulmonary gradient (DPG) (3). It is also used as a therapeutic Indications and usefulness
parameter in patients with congenital heart disease and in
Cardiogenic Shock
patients awaiting cardiac transplantation (Figure 1) (24,27,28).

Current studies suggest that the use of PAC in CS is associated

Left ventricle (LV) with a benefit in patient morbidity and mortality; the American
Heart Association (AHA) recommends the early use of PAC in
LV pressure has a rapid acceleration during initial systole, followed the management of CS, especially in cases of refractoriness
by a rapid decline. The initial diastolic pressure is low, while the final to treatment and/or therapeutic uncertainty (1,8,33,34)
. A large
diastolic pressure increases slowly until the left atrium contracts, retrospective study found that the use of PAC in CS was associated

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182 | EsSalud
Invasive hemodynamic monitoring by Swan-Ganz

Figure 2. Hemodynamic calculations by Swan-Ganz pulmonary arterial catheter.

RA: right atrium. CS: cardiogenic shock. PAD: pulmonary artery distensibility. PEAE: Pulmonary effective arterial elastance. HR: heart rate. CO, cardiac output. PDG: pulmonary diastolic gradient. TPG: transpulmonary gradient. CI: cardiac index.
MI: myocardial infarction. RVSWI: Right ventricular systolic work index. LVSWI: Left ventricular systolic work index. CPi: Cardiac power index. SEVi: Systolic ejection volume index. SEV: Systolic ejection volume. PAP: Pulmonary artery pressure.
dPAP: Diastolic pulmonary artery pressure. PAPi: Pulmonary artery pulsatility index. mPAP: Mean pulmonary artery pressure. sPAP: Systolic pulmonary artery pressure. mSBP: Mean systemic blood pressure. CP: cardiac power. PCP: Pulmonary
capillary pressure. PEEP: Positive end-expiratory pressure. CVP: central venous pressure. SVR: Systemic vascular resistance. PVR: Pulmonary vascular resistance. BSA: Body surface area. NV: Normal values.

Arch Peru Cardiol Cir Cardiovasc. 2021;2(3):175-186. doi: 10.47487/apcyccv.v2i3.152.

Carrasco Rueda JM, et al.
Invasive hemodynamic monitoring by Swan-Ganz Carrasco Rueda JM, et al.

with lower mortality and lower incidence of in-hospital cardiac large retrospective study found an association between the
arrest compared to those under conventional management .
(35) use of hemodynamic monitoring in patients with HF without
Another multicenter study of similar characteristics demonstrated CS and elevated mortality; however, the same study describes
that PAC-guided management offers greater in-hospital survival a significant decrease in the mortality rate over time associated
in the various CS scenarios before the onset of MCS, because it with increased use of advanced therapies and MCS, where the
allows recognition of the type of scenario, the need for drug use of SGC proves to have a greater benefit . Its usefulness
(37)

titration, and the time of onset of MCS .

(8,36) becomes important in patients with HF whose perfusion or
volume status is uncertain, especially in cases of advanced HF
The recognition of the scenario and hemodynamic or CS, since literature describes benefit in its use by improving
phenotype of the CS by PAC based on the assessment of survival, decreasing complications and encouraging the timely
CP, PAPi and LVEFP, has an important role in guiding the use of advanced support (1,36,41).
management strategy until patient recovery or the use of
On the other hand, approximately half of patients with HF
MCS; in addition, it helps to prevent the hemometabolic
have preserved ejection fraction (HFpEF), its diagnosis is based
consequences of the hypoperfusion status and organ failure
on the use of non-invasive parameters; however, according to
produced by CS (Table 3) (1,8,34).
the new ESC HF 2021 guideline, the confirmatory diagnostic test
Within these presentation phenotypes, CS due to RV consists of the invasive evaluation of PCP at rest (>15 mmHg)
failure is reported to account for 30% of all clinical presentations. and at exercise (>25 mmHg), although its use is limited and does
In contexts such as this, the European Society of Cardiology (ESC) not have a routine indication; PAC offers a relevant benefit when
recommends the use of PAC in patients who do not respond noninvasive markers provide low diagnostic sensitivity; moreover,
to initial therapies (IIb C) or in case of diagnostic or therapeutic it plays an important role in the approach to differential diagnoses,
doubt. The usefulness of the PAC is essential for correct decision as well as additional information on the possible entities causing
making in the preservation of an optimal euvolemic state and the HFpEF (42,43). Hemodynamic monitoring on exertion is useful since
decision of inotropic management and/or the use of MCS (36,37). it directly assesses pressure variability and provides predictive
value by calculating the PCP/CO slope. In hospitalized patients,
On the other hand, a substudy of the Shock trial reported an increase in PCP with the leg raise test is a good indicator of
that in patients with CS, SIRS is an important predictor of death HFrEF and non-cardiac dyspnea (1,42).
and is associated with a non-significant increase in deaths with
In cases of acute mechanical complications, frequently
low SVR values, so PAC can be important for identifying this type
due to myocardial infarction, PAC is usually not required, except
of scenario, allowing early and appropriate management and
in the context of a patient with hemodynamic instability, post-
follow-up (38).
infarction heart failure progression or the diagnostic suspicion
There is benefit in measuring hemodynamic parameters of an IS due to rupture of the interventricular septum when
by PAC in CS because they are useful predictors of mortality, as obtaining oxygen saturation between cardiac chambers (RA,
reported by the CardShock study, a prospective, multicenter PA, RV); likewise, PAC can serve as a confirmatory diagnostic
registry that showed that HF, CPi, and indexed SV are strong tool for IS by calculating the ratio of systemic and pulmonary
predictors of 30-day mortality; likewise, PAC-guided management flow (44).
of CS is associated with more aggressive treatment without
compromising 30-day survival . Finally, a contemporary
(25) Pulmonary hypertension
retrospective study reported a lower incidence of mortality,
stroke, and hospital readmission associated with greater use of The PAC is useful in PHT because it directly determines PA
MCS and cardiac transplantation. Therefore, it is concluded that pressures. It was shown that patients who were in an apparent
PAC in CS is associated with greater clinical benefit and greater gray zone (mPAP: 21-24 mmHg) presented an increase in

use of advanced therapies (39,40). mortality, which is why the 6th WSPH proposed a change in the
cut-off points for the diagnosis of PHT (mPAP > 20 mmHg) (5,45).

Heart failure According to the ESC, the PAC is the gold standard to
confirm the diagnosis of PHT because it allows defining the
Routine hemodynamic monitoring by PAC is not recommended hemodynamic profile, severity, classification, and the approach
in patients with HFrEF because, according to the ESCAPE study, for differential diagnoses (43)
. Likewise, it allows additional
it has not shown benefit on mortality during its initial routine evaluations such as the vasoreactivity test or hemodynamic
use in patients with acute decompensated HF . In 2019, a
(25)
monitoring on exertion, parameters with great relevance

Arch Peru Cardiol Cir Cardiovasc. 2021;2(3):175-186. doi: 10.47487/apcyccv.v2i3.152. EsSalud | 183
Invasive hemodynamic monitoring by Swan-Ganz Carrasco Rueda JM, et al.

during the assessment of prognosis, therapeutic orientation, Other pathologies

and response to therapy.
PAC can be useful in patients with congenital and/or valvular
Furthermore, PAC is useful in the diagnosis of exercise-
heart disease when noninvasive evaluations are inconclusive and
induced PHT and is necessary to distinguish it from HFpEF. for the differential diagnosis between constrictive pericarditis
Recent studies have shown that these patients have worse and restrictive cardiomyopathy (1,9).
clinical prognosis; however, early diagnosis and early initiation of
treatment may improve survival (1).
Conclusions
Left ventricular assist devices (LVADs) and cardiac
transplantation (CT) The SGC has currently proven to be useful in the management
of various scenarios for both patients with cardiogenic shock
The role of the PAC is fundamental in both scenarios. In the and advanced heart failure as well as for patients with PHT, HF
pre-CT evaluation, the assessment of the hemodynamic status and even HFpEF due to its diagnostic utility and therapeutic
of patients influences the presence of complications such support.
as acute HF or post-CT death; the presence of precapillary SCG monitoring and the interpretation of hemodynamic
component (PVR > 3.5 UW) is a relative contraindication, and parameters are a relevant tool in patient management, capable
its evaluation through a reversibility test stratifies the risk of supporting the decision to provide advanced care, MCS and CT,
profile .
(1,16)
and therefore it is regaining prominence in the cardiovascular area.

During LVAD consideration, a comprehensive RV Contribution of the authors

assessment with hemodynamic predictors using PAC is
All authors participated in the preparation, writing and correction
important to assess the risk of RV dysfunction (42% of cases),
of the manuscript, as well as in the elaboration of figures and tables.
as it has important repercussions on morbidity and mortality.
Additionaly, during post-implantation management, it
Acknowledgement
allows faster optimization of the device compared to clinical-
echocardiographic follow-up; likewise, it provides better Acknowledgement and credits to Dr. Carlos Manuel Pereda Joh
diagnostic accuracy when device-associated complications for his contribution to the preparation and editing of the main
occur (9,32,46). graph of this article.

References

1. Hsu S, Fang JC, Borlaug BA. Hemodynamics for the Heart Failure 7. Doshi R, Patel H, Shah P. Pulmonary artery catheterization use and
Clinician: A State-of-the-Art Review. J Card Fail. 2021;S1071- mortality in hospitalizations with HFrEF and HFpEF: A nationally
9164(21)00306-7. doi:10.1016/j.cardfail.2021.07.012 representative trend analysis from 2005 to 2014. Int J Cardiol.
2018;269:289-291. doi:10.1016/j.ijcard.2018.07.069
2. Lategola M, Rahn H. A self-guiding catheter for cardiac and
pulmonary arterial catheterization and occlusion. Proc Soc Exp Biol 8. Saxena A, Garan AR, Kapur NK, O’Neill WW, Lindenfeld J, Pinney S, et
Med. 1953;84(3):667-668. doi:10.3181/00379727-84-20745 al. Value of Hemodynamic Monitoring in Patients With Cardiogenic
Shock Undergoing Mechanical Circulatory Support. Circulation.
3. Swan HJ, Ganz W, Forrester J, Marcus H, Diamond G, Chonette D.
2020;141(14):1184-1197. doi:10.1161/CIRCULATIONAHA.119.043080
Catheterization of the heart in man with use of a flow-directed
balloon-tipped catheter. N Engl J Med. 1970;283(9):447–51. 9. Zipes DP, Libby P, Bonow RO, Mann DL, Tomaselli GF, Braunwald E.
doi:10.1056/NEJM197008272830902. Braunwald’s heart disease, a textbook of cardiovascular medicine.
11th ed. Philadelphia: Elsevier Inc; 2019.
4. Forrester JS. A Tale of Serendipity, Ingenuity, and Chance: 50th
Anniversary of Creation of the Swan-Ganz Catheter. J Am Coll Cardiol. 10. García X, Mateu L, Maynar J, Mercadal J, Ochagavía A, Ferrandiz
2019;74(1):100-103. doi:10.1016/j.jacc.2019.04.050. A. Estimación del gasto cardíaco. Utilidad en la práctica clínica.
Monitorización disponible invasiva y no invasiva. Medicina Intensiva.
5. Binanay C, Califf RM, Hasselblad V, O’Connor CM, Shah MR, Sopko
2011; 35(9): 552 - 561. Available at: http://scielo.isciii.es/scielo.
G, et al. Evaluation study of congestive heart failure and pulmonary
php?script=sci_arttext&pid=S0210-56912011000900004&lng=es
artery catheterization effectiveness: the ESCAPE trial. JAMA.
2005;294(13):1625–33. doi:10.1001/jama.294.13.1625. 11. Madias C, Kimmelstiel C. (2017) Right Heart Catheterization. In:
Hendel R., Kimmelstiel C. (eds) Cardiology Procedures. Springer,
6. Isseh IN, Lee R, Khedraki R, Hoffman K. A Critical Review of
London. doi: 10.1007/978-1-4471-7290-1_14.
Hemodynamically Guided Therapy for Cardiogenic Shock: Old
Habits Die Hard. Curr Treat Options Cardiovasc Med. 2021;23(5):29. 12. Mueller HS, Chatterjee K, Davis KB, Fifer MA, Franklin C, Greenberg
doi:10.1007/s11936-021-00903-8. MA, et al. ACC expert consensus document. Present use of bedside

184 | EsSalud Arch Peru Cardiol Cir Cardiovasc. 2021;2(3):175-186. doi: 10.47487/apcyccv.v2i3.152.
Invasive hemodynamic monitoring by Swan-Ganz Carrasco Rueda JM, et al.

right heart catheterization in patients with cardiac disease. American 28. Simonneau G, Montani D, Celermajer DS, Denton CP, Gatzoulis MA,
College of Cardiology. J Am Coll Cardiol. 1998;32(3):840-864. Krowka M, et al. Haemodynamic definitions and updated clinical
doi:10.1016/s0735-1097(98)00327-1 classification of pulmonary hypertension. Eur Respir J 2019; 53:
1801913.
13. Griffin BP, Topol EJ, editors. Manual of cardiovascular medicine. 5th
ed. Philadelphia: Lippincott Williams and Wilkins; 2018. 29. Arman T. Askari, Adrian W. Messerli. Cardiovascular Hemodynamics.
USA: Human Press, 2019.
14. Moscucci M. Grossman & Baim’s Cardiac catheterization, angiography
and intervention. Philadelphia Lippincott Williams and Wilkins 9th 30. Iyad N, Ran L, Rola K, Hoffman K. A Critical Review of Hemodynamically
ed. 2020. Guided Therapy for Cardiogenic Shock: Old Habits Die Hard. Curr
Treat Options Cardio Med. 2021; 23: 29.
15. Sorajja P, Lim MJ, Kern MJ. Kern’s cardiac catheterization handbook.
7th ed. Oxford, Elsevier Health Sciences, 2019. 31. Siddiqi UA, Belkin M, Kalantari S, Kanelidis A, Miller T, Sarswat N, et al.
16. Kapur NK, Esposito ML, Bader Y, Morine KJ, Kiernan MS, Pham Prognostic Role of Simultaneous Assessment of Biventricular Function
DT, et al. Mechanical Circulatory Support Devices for Acute Right Using Left Ventricular Stroke Work Index and Right Ventricular Stroke
Ventricular Failure. Circulation. 2017;136(3):314-326. doi:10.1161/ Work Index.J Heart Lung Transplant. 2021;40(4):S262. doi: 10.1016/j.
CIRCULATIONAHA.116.025290 healun.2021.01.747

17. Pellegrini P, Rossi A, Pasotti M, Raineri C, Cicoira M, Bonapace S, 32. Rosenkranz S, Preston IR. Right heart catheterization: best
et al. Prognostic relevance of pulmonary arterial compliance in practice and pitfalls in pulmonary hypertension. Eur Respir Rev.
patients with chronic heart failure. Chest. 2014;145(5):1064-1070. 2015;24(138):642-652. doi:10.1183/16000617.0062-2015
doi:10.1378/chest.13-1510 33. Van Diepen S, Katz JN, Albert NM, Henry TD, Jacobs AK, Kapur NK, et al.
18. Tampakakis E, Shah SJ, Borlaug BA, Leavy PJ, Patel HH, Miller Contemporary Management of Cardiogenic Shock: A Scientific
WL, et al. Pulmonary Effective Arterial Elastance as a Measure Statement From the American Heart Association. Circulation.
of Right Ventricular Afterload and Its Prognostic Value in 2017;136(16):e232-e268. doi:10.1161/CIR.0000000000000525.
Pulmonary Hypertension Due to Left Heart Disease. Circ Heart Fail. 34. Tehrani BN, Truesdell AG, Sherwood MW, Desai S, Tran HA, Epps KC,
2018;11(4):e004436. doi:10.1161/CIRCHEARTFAILURE.117.004436. et al. Standardized Team-Based Care for Cardiogenic Shock. J Am
19. Mazimba S, Welch TS, Mwansa H, Breathett KK, Kennedy JL, Mihalek Coll Cardiol. 2019;73(13):1659-1669. doi:10.1016/j.jacc.2018.12.084.
AD, et al. Haemodynamically Derived Pulmonary Artery Pulsatility
35. Hernandez GA, Lemor A, Blumer V, et al. Trends in Utilization
Index Predicts Mortality in Pulmonary Arterial Hypertension. Heart
and Outcomes of Pulmonary Artery Catheterization in PH With
Lung Circ. 2019;28(5):752-760. doi:10.1016/j.hlc.2018.04.280
and Without Cardiogenic Shock. Journal of Cardiac Failure.
20. Kang G, Ha R, Banerjee D. Pulmonary artery pulsatility index 2019;25(5):364-371. doi:10.1016/j.cardfail.2019.03.004.
predicts right ventricular failure after left ventricular assist
36. Garan AR, Kanwar M, Thayer KL, Whitehead E, Zweck E, Hernandez-
device implantation. J Heart Lung Transplant. 2016;35(1):67-73.
Montfort J, et al. Complete Hemodynamic Profiling With Pulmonary
doi:10.1016/j.healun.2015.06.009.
Artery Catheters in Cardiogenic Shock Is Associated With Lower In-
21. D’Alto M, Dimopoulos K, Coghlan JG, Kovacs G, Rosenkranz S, Naeije Hospital Mortality. JACC Heart Fail. 2020;8(11):903-913. doi:10.1016/j.
R. Right Heart Catheterization for the Diagnosis of Pulmonary jchf.2020.08.012.
Hypertension: Controversies and Practical Issues. Heart Fail Clin.
2018;14(3):467-477. doi:10.1016/j.hfc.2018.03.011 36. Ponikowski P, Voors AA, Anker SD, Bueno H, Cleland JGF, Coats AJS, et
al. 2016 ESC Guidelines for the Diagnosis and Treatment of Acute and
22. Aschauer S, Kammerlander AA, Zotter-Tufaro C, Ristl R, Pfaffenberger Chronic Heart Failure. Rev Esp Cardiol (Engl Ed). 2016;69(12):1167.
S, Bachmann A, et al. The right heart in heart failure with preserved doi:10.1016/j.rec.2016.11.005
ejection fraction: insights from cardiac magnetic resonance imaging
and invasive haemodynamics. Eur J Heart Fail. 2016;18(1):71-80. 37. Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE, Drazner MH, et
doi:10.1002/ejhf.418. al. 2013 ACCF/AHA guideline for the management of heart failure: a
report of the American College of Cardiology Foundation/American
23. Condon DF, Nickel NP, Anderson R, Mirza S, de Jesus Perez VA. The 6th Heart Association Task Force on practice guidelines. Circulation.
World Symposium on Pulmonary Hypertension: what’s old is new. 2013;128(16):e240-e327. doi:10.1161/CIR.0b013e31829e8776
F1000Res. 2019;8:F1000 Faculty Rev-888. Published 2019 Jun 19.
doi:10.12688/f1000research.18811.1 38. Kohsaka, S, Menon V, Lowe AP, Lange M, Dzavik V, Sleeper LA, et
al. (2005). Systemic Inflammatory Response Syndrome After Acute
24. Galiè N, Humbert M, Vachiery JL, Gibbs S, Lang I, Torbicki A, Myocardial Infarction Complicated by Cardiogenic Shock. Archives
Simonneau G, et al. 2015 ESC/ERS Guidelines for the diagnosis and of Internal Medicine, 165(14), 1643. https://doi.org/10.1001/
treatment of pulmonary hypertension: The Joint Task Force for archinte.165.14.1643
the Diagnosis and Treatment of Pulmonary Hypertension of the
European Society of Cardiology (ESC) and the European Respiratory 39. Ranka S, Mastoris I, Kapur NK, Tedford R, Rali A, Acharya P, et al.
Society (ERS): Endorsed by: Association for European Paediatric Right Heart Catheterization in Cardiogenic Shock Is Associated With
and Congenital Cardiology (AEPC), International Society for Heart Improved Outcomes: Insights From the Nationwide Readmissions
and Lung Transplantation (ISHLT). Eur Heart J. 2016;37(1):67-119. Database. J Am Heart Assoc. 2021;e019843. doi:10.1161/
doi:10.1093/eurheartj/ehv317 JAHA.120.019843.

25. Ragosta, Michael. Textbook of Clinical Hemodynamics E-Book. 40. Osman M, Syed M, Patel B, Munir MB, Kheiri B, Caccamo M, et al. Invasive
Elsevier Health Sciences, 2017. Hemodynamic Monitoring in Cardiogenic Shock Is Associated With
Lower In-Hospital Mortality. J Am Heart Assoc. 2021;10(18):e021808.
26. Drazner MH, Velez-Martinez M, Ayers CR, Reimold SC, Thibodeau
doi:10.1161/JAHA.121.021808.
JT, Mishkin JD, et al. Relationship of right- to left-sided ventricular
filling pressures in advanced heart failure: insights from the 41. Khera R, Pandey A, Kumar N, Singh R, Bano S, Golwala H, et al. Variation
ESCAPE trial. Circ Heart Fail. 2013;6(2):264-270. doi:10.1161/ in Hospital Use and Outcomes Associated With Pulmonary Artery
CIRCHEARTFAILURE.112.000204. Catheterization in Heart Failure in the United States. Circ Heart
Fail.2016;9(11):e003226. doi:10.1161/CIRCHEARTFAILURE.116.003226
27. Vachiéry J-L, Tedford RJ, Rosenkranz S, Palazzini M, Lang I, Guazzi M,
et al. Pulmonary hypertension due to left heart disease. Eur Respir J 42. Borlaug BA. Evaluation and management of HFpEF. Nat Rev Cardiol.
2019; 53: 1801897. 2020;17(9):559-573. doi:10.1038/s41569-020-0363-2.

Arch Peru Cardiol Cir Cardiovasc. 2021;2(3):175-186. doi: 10.47487/apcyccv.v2i3.152. EsSalud | 185
Invasive hemodynamic monitoring by Swan-Ganz Carrasco Rueda JM, et al.

43. McDonagh TA, Metra M, Adamo M, Gardner RS, Baumbach A, Böhm 45. Ikuta K, Wang Y, Robinson A, Ahmad T, Krumholz HM, Desai
M, Burri H, et al. 2021 ESC Guidelines for the diagnosis and treatment NR. National trends in use and outcomes of pulmonary artery
of acute and chronic heart failure. Eur Heart J. 2021;ehab368. catheters among Medicare beneficiaries, 1999–2013. JAMA Cardiol.
doi:10.1093/eurheartj/ehab368. 2017;2(8):908–13. doi:10.1001/jamacardio.2017.1670.
44. Wang W, Cheung A, Watson TJ, Ong PJ, Tcheng JE. Mechanical 46. Potapov EV, Antonides C, Crespo-Leiro MG, Combes A, Färber
Complications of Acute Myocardial Infraction. In: Watson TJ, Ong PJL, G, Hannan MM, et al. 2019 EACTS Expert Consensus on long-
Tcheng JE, eds. Primary Angioplasty: A Practical Guide. Singapore: term mechanical circulatory support. Eur J Cardiothorac Surg.
Springer; July 14, 2018.275-287. 2019;56(2):230-270. doi:10.1093/ejcts/ezz098.

186 | EsSalud Arch Peru Cardiol Cir Cardiovasc. 2021;2(3):175-186. doi: 10.47487/apcyccv.v2i3.152.