Right heart catheterization

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mahmoud Sakr, M.D. [2]

Synonyms and keywords: Pulmonary artery catheterization, wedge, PA line, Swan Ganz catheterization, right heart cath

Overview

Pulmonary artery catheterization is the insertion of a catheter into a pulmonary artery. Its purpose is diagnostic; it is used to detect heart failure or sepsis, monitor therapy, and evaluate the effects of drugs. The pulmonary artery catheter allows direct, simultaneous measurement of pressures in the right atrium, right ventricle, pulmonary artery, and the filling pressure ("wedge" pressure) of the left atrium.

The pulmonary artery catheter is frequently referred to as a Swan-Ganz catheter, in honor of its inventors Jeremy Swan and William Ganz, from Cedars-Sinai Medical Center. The idea for this catheter (as later revealed by Dr. Swan) came about from the observation of sailboats on the water.

Indications

• Management of complicated myocardial infarction:
  • To differentiate hypovolemia vs cardiogenic shock
  • To differentiate ventricular septal defect (VSD) vs acute mitral regurgitation
  • To tailor therapy in severe left ventricular failure
  • To manage volume administration in right ventricular infarction

• Assessment of respiratory distress
  • To differentiate cardiogenic vs non-cardiogenic pulmonary edema
  • To differentiate primary vs secondary pulmonary hypertension

• Assessment of type of shock

• Assessment of response to therapy
  • Afterload reduction
  • Vasopressors
  • Beta blockers
  • Intra-aortic balloon counterpulsation

• Assessment of fluid requirement in critically ill patients with:
  • Hemorrhage
  • Sepsis
  • Acute renal failure
  • Burns

• Management of postoperative open heart surgical patients

• Assessment of valvular heart disease

• Assessment of cardiac tamponade / constriction

Current Indications for Use of the Swan-Ganz Catheter

• Indicated in patients with cardiogenic shock during supportive therapy

• Indicated in patients with discordant right and left ventricular failure

• Indicated in patients with severe chronic heart failure requiring inotropic, vasopressor, and vasodilator therapy

• Indicated in patients with suspected “pseudosepsis” (high cardiac output, low systemic vascular resistance, elevated right atrial and pulmonary capillary wedge pressures)

• Indicated in some patients with potentially reversible systolic heart failure such as fulminant myocarditis and peripartum cardiomyopathy

• Indicated for the hemodynamic differential diagnosis of pulmonary hypertension

• Indicated to assess response to therapy in patients with precapillary and mixed types of pulmonary hypertension

• Indicated for the transplantation workup

Recommendations for Use of Bedside Right Heart Catheterization

Heart Failure
Conditions In Which RHC is Warranted	Conditions in Which Differences of Opinion Exist	Conditions in Which RHC Is Not Warranted
Differentiation between hemodynamic and permeability pulmonary edema or dyspnea (or determination of contribution of left heart failure to respiratory insufficiency in patients with concurrent cardiac and pulmonary disease) when a trial of diuretic and/or vasodilator therapy has failed or is associated with high risk Differentiation between cardiogenic and noncardiogenic shock when a trial of intravascular volume expansion has failed or is associated with high risk; guidance of pharmacologic and/or mechanical support Guidance of therapy in patients with concomitant manifestations of “forward” (hypotension, oliguria, and/or azotemia) and “backward” (dyspnea and/or hypoxemia) heart failure Determination of whether pericardial tamponade is present when clinical assessment is inconclusive and echocardiography is unavailable, technically inadequate or nondiagnostic Guidance of perioperative management in selected patients with decompensated heart failure undergoing intermediate or high risk noncardiac surgery Detection of presence of pulmonary vasoconstriction and determination of its reversibility in patients being considered for heart transplantation	Differentiation between hemodynamic and permeability pulmonary edema or dyspnea (or determination of the contribution of left heart failure to respiratory insufficiency in patients with concurrent cardiac and pulmonary disease) when a trial of diuretic and/or vasodilator therapy is associated with low or intermediate risk Differentiation between cardiogenic and noncardiogenic shock when a trial of intravascular volume expansion is associated with intermediate risk Facilitation of titration of diuretic, vasodilator and inotropic therapy in patients with severe heart failure Guidance of perioperative management in patients with compensated heart failure undergoing intermediate or high risk noncardiac surgery	Routine management of pulmonary edema, even if endotracheal intubation and mechanical ventilation have been necessary Differentiation between cardiogenic and noncardiogenic shock before a trial of intravascular volume expansion, when such a trial is associated with low risk Institution or titration of diuretic and/or vasodilator therapy in patients with mild or moderate heart failure Marked hemodynamic instability in patients in whom pericardial tamponade is certain or probable by clinical and/or echocardiographic criteria and RHC would delay treatment Guidance of perioperative management in patients with compensated heart failure undergoing low risk noncardiac surgery
Acute Myocardial Infarction
Conditions In Which RHC is Warranted	Conditions in Which Differences of Opinion Exist	Conditions in Which RHC Is Not Warranted
Differentiation between cardiogenic and hypovolemic shock when initial therapy with intravascular volume expansion and low doses of inotropic drugs has failed Guidance of management of cardiogenic shock with pharmacologic and/or mechanical support in patients with and without coronary reperfusion therapy Short-term guidance of pharmacologic and/or mechanical management of acute mitral regurgitation (with or without disruption of the mitral valve) before surgical correction Establishment of severity of left to right shunting and short-term guidance of pharmacologic and/or mechanical management of ventricular septal rupture before surgical correction Guidance of management of right ventricular infarction with hypotension and/or signs of low cardiac output not responding to intravascular volume expansion, low doses of inotropic drugs and/ or restoration of heart rate and atrioventricular synchrony Guidance of management of acute pulmonary edema not responding to treatment with diuretic drugs, nitroglycerin, other vasodilator agents and low doses of inotropic drugs	Guidance of ongoing management of hypotension, after response to initial therapy with intravascular volume expansion and/or low doses of inotropic drugs Short-term guidance of pharmacologic and/or mechanical management of acute mitral regurgitation if operation is delayed or not contemplated Establishment of severity of left to right shunting and short-term guidance of pharmacologic and/or mechanical management of ventricular septal rupture if operation is delayed or not contemplated Guidance of management of right ventricular infarction, after correction of hypotension and/or signs of low cardiac output by intravascular volume expansion, low doses of inotropic drugs and/or restoration of heart rate and atrioventricular synchrony Guidance of management of acute pulmonary edema with vasodilators and/or inotropic drugs, after initial treatment with diuretic drugs and nitroglycerin has failed Confirmation of diagnosis of pericardial tamponade subsequent to subacute myocardial rupture when clinical and echocardiographic assessments are inconclusive	Guidance of management of postinfarction angina Guidance of ongoing management of pulmonary edema responding promptly to treatment with diuretic drugs and nitroglycerin Pericardial tamponade with marked hemodynamic instability, when the diagnosis is certain or likely by clinical and/ or echocardiographic criteria and RHC would delay treatment
Perioperative Use in Cardiac Surgery
Conditions In Which RHC is Warranted	Conditions in Which Differences of Opinion Exist	Conditions in Which RHC Is Not Warranted
Differentiation between causes of low cardiac output (hypovolemia vs. ventricular dysfunction), when clinical and/or echocardiographic assessment is inconclusive Differentiation between right and left ventricular dysfunction and pericardial tamponade, when clinical and/or echocardiographic assessment is inconclusive Guidance of management of severe low cardiac output syndrome Diagnosis and guidance of management of pulmonary hypertension in patients with systemic hypotension and evidence of inadequate organ perfusion	Guidance of inotropic and/or vasopressor therapy, after patients with significant cardiac dysfunction have achieved hemodynamic stability Guidance of management of hypotension and evidence of inadequate organ perfusion when a therapeutic trial of intravascular volume expansion and/or vasoactive agents is associated with moderate risk	Routine management of uncomplicated cardiac surgical patients with good ventricular function and hemodynamic stability Initial management of postoperative hypotension when a therapeutic trial of volume expansion and/or vasoactive agents is associated with low risk
Primary Pulmonary Hypertension
Conditions In Which RHC is Warranted	Conditions in Which Differences of Opinion Exist	Conditions in Which RHC Is Not Warranted
Exclusion of postcapillary (elevated PAOP) causes of pulmonary hypertension Establishment of diagnosis and assessment of severity of precapillary (normal PAOP) pulmonary hypertension Selection and establishment of safety and efficacy of long-term vasodilator therapy based on acute hemodynamic response Assessment of hemodynamic variables before lung transplantation	Evaluation of long-term efficacy of vasodilator therapy, particularly prostacyclin Exclusion of significant left to right or right to left intracardiac shunt	None

Procedure

• The catheter is introduced through a large vein—often the internal jugular, subclavian, or femoral veins. From this entry site, it is threaded, often with the aid of fluoroscopy, through the right atrium of the heart, the right ventricle, and subsequently into the pulmonary artery.

• The standard pulmonary artery catheter is equipped with an inflatable balloon at the tip, which facilitates its placement into the pulmonary artery through the flow of blood. The balloon, when inflated, causes the catheter to "wedge" in a small pulmonary blood vessel. So wedged, the catheter can provide a measurement of the pressure in the left atrium of the heart.

Complications

• Arrhythmias
• Bleeding
• Infection
• Pneumothorax
• Rupture of the pulmonary artery
• Thrombosis

Controversy

Evidence of Benefit

The benefit of the use of this type of catheter has been controversial. Therefore many clinicians minimize its use. Several studies in the 1980s seemed to show a benefit of the increase in physiological information. Many reports showing benefit of the PA catheter are from anesthestic and surgical settings. In these settings cardiovascular performance was optimized thinking patients would have supranormal metabolic requirements.

Evidence of Harm or Lack of Benefit

Contrary to earlier studies there is growing evidence the use of a PA catheter (PAC) does not necessarily lead to improved outcome. For example, see [3]. The following explanations have been advanced. One explanation could be that nurses and physicians were insufficiently knowledgeable to adequately interpret the PA catheter measurements. Also, the benefits might be reduced by the complications from the use of the PAC. Furthermore, using information from the PAC might result in a more aggressive therapy causing the detrimental effect. Or, it could give rise to more harmful therapies (i.e. achieving supranormal values could be associated with increased mortality).