The impact of pulmonary artery catheter use in cardiac surgery

Published:February 02, 2021DOI:



      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.


      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.


      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).


      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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        • Swan H.J.
        • Ganz W.
        • Forrester J.
        • Marcus H.
        • Diamond G.
        • Chonette D.
        Catheterization of the heart in man with use of a flow-directed balloon-tipped catheter.
        N Engl J Med. 1970; 283: 447-451
        • Harvey S.
        • Harrison D.A.
        • Singer M.
        • Ashcroft J.
        • Jones C.M.
        • Elbourne D.
        • et al.
        Assessment of the clinical effectiveness of pulmonary artery catheters in management of patients in intensive care (PAC-Man): a randomised controlled trial.
        Lancet. 2005; 366: 472-477
        • Connors A.F.
        • Speroff T.
        • Dawson N.V.
        • Thomas C.
        • Harrell F.E.
        • Wagner D.
        • et al.
        The effectiveness of right heart catheterization in the initial care of critically ill patients. SUPPORT Investigators.
        JAMA. 1996; 276: 889-897
        • Rajaram S.S.
        • Desai N.K.
        • Kalra A.
        • Gajera M.
        • Cavanaugh S.K.
        • Brampton W.
        • et al.
        Pulmonary artery catheters for adult patients in intensive care.
        Cochrane Database Syst Rev. 2013; 2013: CD003408
        • Polanczyk C.A.
        • Rohde L.E.
        • Goldman L.
        • Cook E.F.
        • Thomas E.J.
        • Marcantonio E.R.
        • et al.
        Right heart catheterization and cardiac complications in patients undergoing noncardiac surgery: an observational study.
        JAMA. 2001; 286: 309-314
        • Sandham J.D.
        • Hull R.D.
        • Brant R.F.
        • Knox L.
        • Pineo G.F.
        • Doig C.J.
        • et al.
        A randomized, controlled trial of the use of pulmonary-artery catheters in high-risk surgical patients.
        N Engl J Med. 2003; 348: 5-14
        • Binanay C.
        • Califf R.M.
        • Hasselblad V.
        • O'Connor C.M.
        • Shah M.R.
        • Sopko G.
        • et al.
        Evaluation study of congestive heart failure and pulmonary artery catheterization effectiveness: the ESCAPE trial.
        JAMA. 2005; 294: 1625-1633
        • Rhodes A.
        • Cusack R.J.
        • Newman P.J.
        • Grounds R.M.
        • Bennett E.D.
        A randomised, controlled trial of the pulmonary artery catheter in critically ill patients.
        Intensive Care Med. 2002; 28: 256-264
        • Richard C.
        • Warszawski J.
        • Anguel N.
        • Deye N.
        • Combes A.
        • Barnoud D.
        • et al.
        Early use of the pulmonary artery catheter and outcomes in patients with shock and acute respiratory distress syndrome: a randomized controlled trial.
        JAMA. 2003; 290: 2713-2720
        • Cohen M.G.
        • Kelly R.V.
        • Kong D.F.
        • Menon V.
        • Shah M.
        • Ferreira J.
        • et al.
        Pulmonary artery catheterization in acute coronary syndromes: insights from the GUSTO IIb and GUSTO III trials.
        Am J Med. 2005; 118: 482-488
        • Tuman K.J.
        • McCarthy R.J.
        • Spiess B.D.
        • DaValle M.
        • Hompland S.J.
        • Dabir R.
        • et al.
        Effect of pulmonary artery catheterization on outcome in patients undergoing coronary artery surgery.
        Anesthesiology. 1989; 70: 199-206
        • Schwann T.A.
        • Zacharias A.
        • Riordan C.J.
        • Durham S.J.
        • Engoren M.
        • Habib R.H.
        Safe, highly selective use of pulmonary artery catheters in coronary artery bypass grafting: an objective patient selection method.
        Ann Thorac Surg. 2002; 73: 1394-1401
        • Schwann N.M.
        • Hillel Z.
        • Hoeft A.
        • Barash P.
        • Möhnle P.
        • Miao Y.
        • et al.
        Lack of effectiveness of the pulmonary artery catheter in cardiac surgery.
        Anesth Analg. 2011; 113: 994-1002
        • Chiang Y.
        • Hosseinian L.
        • Rhee A.
        • Itagaki S.
        • Cavallaro P.
        • Chikwe J.
        Questionable benefit of the pulmonary artery catheter after cardiac surgery in high-risk patients.
        J Cardiothorac Vasc Anesth. 2015; 29: 76-81
        • Xu F.
        • Wang Q.
        • Zhang H.
        • Chen S.
        • Ao H.
        Use of pulmonary artery catheter in coronary artery bypass graft. costs and long-term outcomes.
        PLoS One. 2015; 10: e0117610
        • Ramsey S.D.
        • Saint S.
        • Sullivan S.D.
        • Dey L.
        • Kelley K.
        • Bowdle A.
        Clinical and economic effects of pulmonary artery catheterization in nonemergent coronary artery bypass graft surgery.
        J Cardiothorac Vasc Anesth. 2000; 14: 113-118
        • Wiener R.S.
        • Welch H.G.
        Trends in the use of the pulmonary artery catheter in the United States, 1993-2004.
        JAMA. 2007; 298: 423-429
        • Jacka M.J.
        • Cohen M.M.
        • To T.
        • Devitt J.H.
        • Byrick R.
        The use of and preferences for the transesophageal echocardiogram and pulmonary artery catheter among cardiovascular anesthesiologists.
        Anesth Analg. 2002; 94: 1065-1071
        • Judge O.
        • Ji F.
        • Fleming N.
        • Liu H.
        Current use of the pulmonary artery catheter in cardiac surgery: a survey study.
        J Cardiothorac Vasc Anesth. 2015; 29: 69-75
        • Brovman E.Y.
        • Gabriel R.A.
        • Dutton R.P.
        • Urman R.D.
        Pulmonary artery catheter use during cardiac surgery in the United States, 2010 to 2014.
        J Cardiothorac Vasc Anesth. 2016; 30: 579-584
        • Mahesh B.
        • Choong C.K.
        • Goldsmith K.
        • Gerrard C.
        • Nashef S.A.
        • Vuylsteke A.
        Prolonged stay in intensive care unit is a powerful predictor of adverse outcomes after cardiac operations.
        Ann Thorac Surg. 2012; 94: 109-116
        • Hein O.V.
        • Birnbaum J.
        • Wernecke K.
        • England M.
        • Konertz W.
        • Spies C.
        Prolonged intensive care unit stay in cardiac surgery: risk factors and long-term-survival.
        Ann Thorac Surg. 2006; 81: 880-885
        • Bianco V.
        • Kilic A.
        • Gleason T.G.
        • Aranda-Michel E.
        • Navid F.
        • Sultan I.
        Longitudinal outcomes of dialysis-dependent patients undergoing isolated coronary artery bypass grafting.
        J Card Surg. 2019; 34: 110-117
        • Seese L.
        • Sultan I.
        • Gleason T.G.
        • Wang Y.
        • Thoma F.
        • Navid F.
        • et al.
        Outcomes of conventional cardiac surgery in patients with severely reduced ejection fraction in the modern era.
        Ann Thorac Surg. 2020; 109: 1409-1418
        • Cigarroa R.G.
        • Lange R.A.
        • Williams R.H.
        • Bedotto J.B.
        • Hillis L.D.
        Underestimation of cardiac output by thermodilution in patients with tricuspid regurgitation.
        Am J Med. 1989; 86: 417-420

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