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The impact of pulmonary artery catheter use in cardiac surgery

Published:February 02, 2021DOI:https://doi.org/10.1016/j.jtcvs.2021.01.086

      Abstract

      Objective

      Pulmonary artery catheterization provides continuous monitoring of hemodynamic parameters that may aid in the perioperative management of patients undergoing cardiac surgery. However, prior data suggest that pulmonary artery catheterization has limited benefit in intensive care and surgical settings. Thus, this study sought to determine the impact of pulmonary artery catheter insertion on short-term postoperative outcomes in a large, contemporaneous cohort of patients undergoing open cardiac surgery compared with standard central venous pressure monitoring.

      Methods

      This was an observational study of open cardiac surgeries from 2010 to 2018. Patients with pulmonary artery catheter insertion were identified and matched against patients without pulmonary artery catheter insertion via 1:1 nearest neighbor propensity matching. Multivariable analysis was performed to assess the impact of pulmonary artery catheterization on operative mortality in the overall cohort, as well as recent heart failure, mitral valve disease, and tricuspid insufficiency subgroups.

      Results

      Of the 11,820 patients undergoing (Society of Thoracic Surgeons indexed) coronary or valvular surgery, 4605 (39.0%) had pulmonary artery catheter insertion. Propensity score matching yielded 3519 evenly balanced pairs. Compared with central venous pressure monitoring, pulmonary artery catheter use was not associated with improved operative mortality in the overall cohort or in the recent heart failure, mitral valve disease, or tricuspid insufficiency subgroups. Intensive care unit length of stay was longer (P < .001), and there were more packed red blood cell transfusions in the pulmonary artery catheterization group (P < .001); however, postoperative outcomes were otherwise similar, including stroke, sepsis, and new renal failure (P > .05).

      Conclusions

      These findings suggest that pulmonary artery catheterization may have limited benefit in cardiac surgery.

      Graphical abstract

      Key Words

      Abbreviations and Acronyms:

      CABG (coronary artery bypass grafting), CHF (congestive heart failure), CI (confidence interval), CVP (central venous pressure), ICU (intensive care unit), IQR (interquartile range), LOS (length of stay), OR (odds ratio), PAC (pulmonary artery catheter (catheterization)), pRBC (packed red blood cells), SMD (standardized mean difference), STS (Society of Thoracic Surgeons)
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      Linked Article

      • Commentary: Has pulmonary artery catheter ship sailed?
        The Journal of Thoracic and Cardiovascular SurgeryVol. 164Issue 6
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          There appears to be a persistent enthusiasm for a continual investigation into whether the use of pulmonary artery catheter (PAC) leads to reduced morbidity and mortality in critically ill patients. Perhaps no other monitoring tool enjoys being consistently trendy for several decades. A wide spectrum of opinions can be found in the literature. Some authors already have written an obituary to PAC,1 some argue that PAC is immortal,2 and others believe that “in medio virtus,” finding PAC more alive than dead.
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      • Commentary: The uncertain fate of the pulmonary artery catheter in cardiac surgery: The difference is in the exceptions
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          Since its introduction in the 1970s, use of the flow-directed balloon-tipped pulmonary artery catheter (PAC) has become the gold standard for guiding therapy in critically ill patients and those undergoing complex surgical procedures. These invasive catheters allow real-time measurement of cardiac output, pulmonary arterial pressure, pulmonary capillary wedge pressure, and mixed venous oxygen saturation—frequently used hemodynamic parameters to discern between different physiologic states. However, large-scale studies and meta-analyses have failed to show an outcome benefit in noncardiac critical care patients.
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      • Commentary: To Swan or not to Swan in cardiac surgery? Narrowing the window of benefit
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          The development of the flow-directed pulmonary artery catheter (PAC) allowing for bedside placement, originally by Swan and colleagues in 1970,1 revolutionized the care and study of hemodynamics in the intensive care unit (ICU) and operating room settings. The PAC or Swan-Ganz catheter was crucial to define and differentiate the different types of shock with objective and real-time hemodynamic data, serving as a diagnostic tool and monitor response to treatment at a time when echocardiography was in its infancy.
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