ACC expert consensus document. Present use of bedside right heart catheterization in patients with cardiac disease. American College of Cardiology

The Role of Speckle Tracking Echocardiography in the Evaluation of Advanced-Heart-Failure Patients

Health care is currently showing a fall in heart failure (HF) incidence and prevalence, particularly in developed countries, but with only a subset receiving appropriate therapy to protect the heart against maladaptive processes such as fibrosis and hypertrophy. Appropriate markers of advanced HF remain unidentified, which would help in choosing the most suitable therapy and avoid major compliance problems. Speckle tracking echocardiography (STE) is a good choice, being a non-invasive imaging technique which is able to assess cardiac deformation in a variety of conditions. Several multicenter studies and meta-analyses have demonstrated the clinical application and accuracy of STE in early and late stages of HF, as well as its association with both left ventricular (LV) filling pressures and myocardial oxygen consumption. Furthermore, STE assists in assessing right ventricular free-wall longitudinal strain (RVFWLS), which is a solid predictor of right ventricle failure (RVF) following LV assist device (LVAD) implantation. However, STE is known for its limitations; despite these, it has been shown to explain symptoms and signs and also to be an accurate prognosticator. The aim of this review is to examine the advantages of STE in the early evaluation of myocardial dysfunction and its correlation with right heart catheterization (RHC) parameters, which should have significant clinical relevance in the management of HF patients.

Noninvasive echocardiographic cardiac power output predicts mortality in cardiac intensive care unit patients

BACKGROUND

Low cardiac power output (CPO), measured invasively, can identify critically ill patients at increased risk of adverse outcomes, including mortality. We sought to determine whether non-invasive, echocardiographic CPO measurement was associated with mortality in cardiac intensive care unit (CICU) patients.

METHODS

Patients admitted to CICU between 2007 and 2018 with echocardiography performed within one day (before or after) admission and who had available data necessary for calculation of CPO were evaluated. Multivariable logistic regression determined the relationship between CPO and adjusted hospital mortality.

RESULTS

A total of 5,585 patients (age of 68.3 ± 14.8 years, 36.7% female) were evaluated with admission diagnoses including acute coronary syndrome (ACS) in 56.7%, heart failure (HF) in 50.1%, cardiac arrest (CA) in 12.2%, shock in 15.5%, and cardiogenic shock (CS) in 12.8%. The mean left ventricular ejection fraction (LVEF) was 47.3 ± 16.2%, and the mean CPO was 1.04 ± 0.37 W. There were 419 in-hospital deaths (7.5%). CPO was inversely associated with the risk of hospital mortality, an association that was consistent among patients with ACS, HF, and CS. On multivariable analysis, higher CPO was associated with reduced hospital mortality (OR 0.960 per 0.1 W, 95CI 0.0.926-0.996, P = .03). Hospital mortality was particularly high in patients with low CPO coupled with reduced LVEF, increased vasopressor requirements, or higher admission lactate.

CONCLUSIONS

Echocardiographic CPO was inversely associated with hospital mortality in unselected CICU patients, particularly among patients with increased lactate and vasopressor requirements. Routine calculation and reporting of CPO should be considered for echocardiograms performed in CICU patients.

[Invasive hemodynamic monitoring by Swan-Ganz pulmonary artery catheter: concepts and utility]

Since its beginnings in the last century, pulmonary artery catheterization (PAC) has evolved into an invasive hemodynamic evaluation technique that can be performed at the patient's bedside through a Swan-Ganz catheter; this procedure has maintained an intermittent course in terms of its use; 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 hemodynamic variables directly or indirectly by means of established formulas and methods. This makes possible to perform an adequate hemodynamic evaluation and classification, perform specific tests (e.g. vasoreactivity test), which help to define the diagnosis, therapeutic , monitor the 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 concepts and usefulness of pulmonary artery catheterization.

Clinical utility of surveillance and clinically prompted right heart catheterization in patients listed for heart transplantation

BACKGROUND AND OBJECTIVES

The 2016 ISHLT guidelines recommend that patients listed for orthotopic heart transplantation (OHT) undergo periodic surveillance right heart catheterization (RHC) to re-assess hemodynamics (Class I, level of evidence C). However, the impact of RHC on management remains unclear. The aim of this study was to determine the utility of both surveillance and clinically prompted RHCs in patients listed for OHT.

METHODS

A retrospective study was conducted in adult patients listed for OHT at our hospital from 2006 through 2014. Each patient included had at least one RHC after being listed for OHT. The primary outcome was management change: hospitalization, surgery (OHT or mechanical circulatory support [MCS]), change in United Network for Organ Sharing (UNOS) status, or initiation/modification of vasoactive drugs, diuretics or neurohormonal blockade.

RESULTS

Of the 194 patients included, 85 (43%) patients had more than one RHC. The median time between listing and transplantation was 115 days. Of the 376 RHCs performed, 187 (50%) were prompted by a clinical change; 189 (50%) were performed for surveillance. In 90.4% of clinically prompted RHCs and 42.9% of surveillance RHCs, a clinically important management change was implemented. Initiation/modification of vasoactive drugs, placement of MCS and/or change in UNOS transplant status occurred in 61 (33%) of the clinically prompted RHCs and 26 (14%) of the surveillance RHCs. Patients who underwent management change were more likely to receive a heart transplant (HR 1.58; CI 1.15-2.18) without an increased rate of death over the study period compared to those who did not have a management change. Multivariable analysis revealed that a hemoglobin level <12.2 g/dL (OR 2.96; CI 1.36-6.42) and a total bilirubin level >0.9 mg/dL (OR 5.07; CI 2.09-12.3) were predictors of management change.

CONCLUSIONS

In patients awaiting OHT, RHCs prompted by clinical instability or routine surveillance resulted in frequent management changes, including earlier heart transplant and MCS implant. Our study supports the Class I recommendation to perform surveillance RHC in patients listed for OHT and suggests that centers should consider maintaining a low threshold for repeat RHC during the formal waiting time.

[Infarct-related cardiogenic shock : Prognosis and treatment]

Patients with ST segment elevation myocardial infarction (STEMI) and non-ST segment elevation myocardial infarction (NSTEMI) experience cardiogenic shock in about 6-10% of cases during the hospital treatment. In recent years, the incidence seems to be decreasing due to invasive diagnostics and therapy after myocardial infarction. Early diagnosis is important to initiate immediate revascularization using percutaneous coronary intervention (PCI) with stent implantation as part of cardiogenic shock treatment. Thus, a significant improvement in survival can be achieved. Pharmacological and mechanical support is needed to maintain perfusion of the myocardium and organs. Drug therapy for infarct cardiogenic shock relies on dobutamine for inotropic agent and norepinephrine as a vasopressor. For further inotropic support, data on additional levosimendan treatment are available. The pharmacological therapy is supplemented by mechanical support systems such as Impella (ABIOMED, Danvers, MA, USA) or extracorporeal membrane oxygenation (ECMO). The intra-aortic balloon pump (IABP) is hardly used anymore. The majority of cardiogenic shock survivors have little functional cardiac impairment in the long term. This shows the transient damage component (stunning, inflammation), which underlines the need for a fast and effective cardiovascular supportive therapy.

Optimal Transducer Level for Atrial and Pulmonary Arterial Pressure Measurement in Patients with Functional Single Ventricle

This study aimed to investigate the optimal transducer level for accurate measurement of atrial and pulmonary arterial pressures in the supine position for patients with functional single ventricle. Contrast-enhanced chest computed tomographic images of 108 patients who underwent either the bidirectional cavopulmonary shunt (BCPS) placement or the Fontan procedure were reviewed. Vertical distances from the skin of the back to the uppermost levels of fluid in the single atrium or the pulmonary artery confluence and their ratios to the greatest anteroposterior (AP) diameter of the thoracic cage were determined. In patients who underwent BCPS, the ratios of the uppermost levels of blood in the atrium and pulmonary artery confluence to the greatest AP diameter of the thorax were 76.0 ± 8.1 and 56.3 ± 5.5 %, respectively. The distance (mm) between these two levels was calculated as 24.2 + 0.31 × age (years) (r ² = 0.08, P < 0.03). In patients who underwent the Fontan procedure, the ratios were 79.3 ± 10.0 and 58.3 ± 5.8 %, respectively. The distance (mm) between these two levels was calculated as 31.1 + 0.44 × age (years) (r ² = 0.05, P < 0.11). The optimal transducer levels for measuring atrial and pulmonary arterial pressures in the supine position are 75-80 and 55-60 % of the AP diameter of the thorax, respectively, in patients with functional single ventricle. We should consider the difference of the pressure when atrial and pulmonary arterial pressures were measured with the same level of transducers.

Noninvasive assessment of cardiac output by brachial occlusion-cuff technique: comparison with the open-circuit acetylene washin method

Cardiac output (CO) assessment as a basic hemodynamic parameter has been of interest in exercise physiology, cardiology, and anesthesiology. Noninvasive techniques available are technically challenging, and thus difficult to use outside of a clinical or laboratory setting. We propose a novel method of noninvasive CO assessment using a single, upper-arm cuff. The method uses the arterial pressure pulse wave signal acquired from the brachial artery during 20-s intervals of suprasystolic occlusion. This method was evaluated in a cohort of 12 healthy individuals (age, 27.7 ± 5.4 yr, 50% men) and compared with an established method for noninvasive CO assessment, the open-circuit acetylene method (OpCirc) at rest, and during low- to moderate-intensity exercise. CO increased from rest to exercise (rest, 7.4 ± 0.8 vs. 7.2 ± 0.8; low, 9.8 ± 1.8 vs. 9.9 ± 2.0; moderate, 14.1 ± 2.8 vs. 14.8 ± 3.2 l/min) as assessed by the cuff-occlusion and OpCirc techniques, respectively. The average error of experimental technique compared with OpCirc was -0.25 ± 1.02 l/min, Pearson's correlation coefficient of 0.96 (rest + exercise), and 0.21 ± 0.42 l/min with Pearson's correlation coefficient of 0.87 (rest only). Bland-Altman analysis demonstrated good agreement between methods (within 95% boundaries); the reproducibility coefficient (RPC) = 0.84 l/min with R² = 0.75 at rest and RPC = 2 l/min with R² = 0.92 at rest and during exercise, respectively. In comparison with an established method to quantify CO, the cuff-occlusion method provides similar measures at rest and with light to moderate exercise. Thus, we believe this method has the potential to be used as a new, noninvasive method for assessing CO during exercise.

Optimal level of the reference transducer for central venous pressure and pulmonary artery occlusion pressure monitoring in supine, prone, and sitting position

To guarantee accurate measurement of central venous pressure (CVP) or pulmonary artery occlusion pressure (PAOP), proper positioning of a reference transducer is a prerequisite. We investigated ideal transducer levels in supine, prone, and sitting position in adults. Chest computed tomography images of 113 patients, taken in supine or prone position were reviewed. For supine position, distances between the back and the uppermost blood level of both atria and their ratios to the largest anteroposterior (AP) diameter of thorax were calculated. For prone position, same distances and ratios were calculated from the anterior chest. For sitting position, distances between the mid-sternoclavicular joint and the most cephalad blood level of both atria and their ratios to the sternal length were calculated. The ratio of the uppermost blood level of right atrium (RA) and left atrium (LA) to the largest AP diameter of thorax was 0.81 ± 0.04 and 0.59 ± 0.03 from the back in supine position. That calculated from the anterior chest in prone position was 0.54 ± 0.03 and 0.46 ± 0.03. The ratio of the most cephalad blood level of RA and LA to the sternal length was 0.70 ± 0.10 and 0.68 ± 0.09 from the mid-sternoclavicular joint in sitting position, which corresponded to the upper border of 4th rib. Optimal CVP transducer levels are at four-fifths of the AP diameter of thorax in supine position, at a half of that in prone position, and at upper border of the 4th sternochondral joint in sitting position. PAOP transducer levels are similar in prone and sitting position, except for supine position which is at three-fifths of the AP diameter of thorax.

Diagnosis and Rescue of a Kinked Pulmonary Artery Catheter

Invasive hemodynamic monitoring with a pulmonary catheter has been relatively routine in cardiovascular and complex surgical operations as well as in the management of critical illnesses. However, due to multiple potential complications and its invasive nature, its use has decreased over the years and less invasive methods such as transesophageal echocardiography and hemodynamic sensors have gained widespread favor. Unlike these less invasive forms of hemodynamic monitoring, pulmonary artery catheters require an advanced understanding of cardiopulmonary physiology, anatomy, and the potential for complications in order to properly place, manage, and interpret the device. We describe a case wherein significant resistance was encountered during multiple unsuccessful attempts at removing a patient's catheter secondary to kinking and twisting of the catheter tip. These attempts to remove the catheter serve to demonstrate potential rescue options for such a situation. Ultimately, successful removal of the catheter was accomplished by simultaneous catheter retraction and sheath advancement while gently pulling both objects from the cannulation site. In addition to being skilled in catheter placement, it is imperative that providers comprehend the risks and complications of this invasive monitoring tool.

Variability in hemodynamic evaluation of pulmonary hypertension at large referral centers

Despite consensus guidelines for right heart catheterization (RHC) in the diagnosis of pulmonary arterial hypertension (PAH), considerable differences exist in the performance of RHC, interpretation of hemodynamic data, and frequency of RHC performance in patients with established disease. These differences may lead to variability in diagnosis or treatment of PAH. We sought to gather information on the standard practice of RHC for the diagnosis and management of PAH from experienced pulmonary vascular disease specialists. We developed a semiquantitative online survey of diagnosis and treatment patterns of pulmonary hypertension and distributed it to physicians at pulmonary hypertension centers in the United States. Thirty of 50 physicians completed the survey: 20 pulmonologists and 10 cardiologists, all of whom reported treating >100 patients with PAH in the past year. All respondents perform RHC in ≥90% of patients with suspected PAH. All physicians determine the pulmonary wedge pressure at end expiration; however, only half of respondents personally review tracings. Physicians differed in frequency of vasodilator testing (8 of 24 performed testing in >90% of patients with PAH), fluid challenge and exercise (19 of 30 performed testing in <25% of patients with PAH for both). Most physicians (70%) report repeating RHC between 6 months and 1 year after PAH treatment initiation. Variability exists in the interpretation of hemodynamic tracings and performance of vasodilator, fluid, and exercise challenges in the management of PAH by experienced physicians in the United States. Additional consensus guidelines delineating appropriate adjunctive testing to standardize the diagnosis of PAH are needed.

Assessment of cardiac output with transpulmonary thermodilution during exercise in humans

The accuracy and reproducibility of transpulmonary thermodilution (TPTd) to assess cardiac output (Q̇) in exercising men was determined using indocyanine green (ICG) dilution as a reference method. TPTd has been utilized for the assessment of Q̇ and preload indexes of global end-diastolic volume and intrathoracic blood volume, as well as extravascular lung water (EVLW) in resting humans. It remains unknown if this technique is also accurate and reproducible during exercise. Sixteen healthy men underwent catheterization of the right femoral vein (for iced saline injection), an antecubital vein (ICG injection), and femoral artery (thermistor) to determine their Q̇ by TPTd and ICG concentration during incremental one- and two-legged pedaling on a cycle ergometer and combined arm cranking with leg pedaling to exhaustion. There was a close relationship between TPTd-Q̇ and ICG-Q̇ ( r = 0.95, n = 151, standard error of the estimate: 1.452 l/min, P < 0.001; mean difference of 0.06 l/min; limits of agreement −2.98 to 2.86 l/min), and TPTd-Q̇ and ICG-Q̇ increased linearly with oxygen uptake with similar intercepts and slopes. Both methods had mean coefficients of variation close to 5% for Q̇, global end-diastolic volume, and intrathoracic blood volume. The mean coefficient of variation of EVLW, assessed with both indicators (ICG and thermal) was 17% and was sensitive enough to detect a reduction in EVLW of 107 ml when changing from resting supine to upright exercise. In summary, TPTd with bolus injection into the femoral vein is an accurate and reproducible method to assess Q̇ during exercise in humans.

Evaluation and Management of ST-elevation Myocardial Infarction and Shock

Cardiogenic shock is the deadliest complication of acute ST-elevation myocardial infarction. Prompt recognition and intervention are critical for patient survival. The diagnosis of cardiogenic shock is primarily a clinical one based on signs and symptoms of low cardiac output and heart failure, and can be confirmed with placement of a pulmonary arterial catheter. Vasopressor and inotropic therapies are typically required, and in severe cases, an intra-aortic balloon pump can provide additional haemodynamic support. Although mortality for cardiogenic shock associated with ST-elevation myocardial infarction remains high, early reperfusion strategies primarily via percutaneous coronary intervention or coronary artery bypass graft surgery have led to improved outcomes.

Gender- and race-based utilization and outcomes of pulmonary artery catheterization in the setting of full-time intensivist staffing

BACKGROUND

Little is known regarding gender- or race-based differences in critical care. We investigated whether gender or race was associated with pulmonary artery catheter (PAC) utilization or with in-hospital death among patients with a PAC. A particular focus was patients with cardiogenic shock (CS), in whom guidelines recommend PAC use.

METHODS

This was a retrospective cohort analysis from the coronary care unit of a large tertiary-care hospital staffed with full-time cardiac intensivists.

RESULTS

We analyzed 8845 consecutive adult patients, of whom 42.1% were women and 40.8% were black. PAC use rates were 11.3% in women and 11.5% in men (P = 0.79), and 11.3% in blacks and 11.5% in whites (P = 0.76). In CS patients, PAC use rates in women and men were 50.3% and 49.1% (P = 0.85) and in blacks and whites were 43.7% and 53.3% (P = 0.05). There was no independent association between gender or race and PAC use overall or in those with CS. Neither gender nor race was a predictor of in-hospital death in patients undergoing PAC.

CONCLUSIONS

PAC use and in-hospital death were determined not by gender or race but by disease severity. Full-time intensivist staffing and the presence of definitive guidelines may reduce gender- and race-based treatment disparities.

Post myocardial infarction cardiogenic shock: a review of current therapies

Cardiogenic shock is often a devastating consequence of acute myocardial infarction (MI) and portends to significant mortality and morbidity. Despite improvements in expediting the time to treatment and enhancements in available medical therapy and reperfusion techniques, cardiogenic shock remains the most common cause of mortality following MI. Post-MI cardiogenic shock most commonly occurs as a consequence of severe left ventricular dysfunction. Right ventricular (RV) MI must also be considered. Mechanical complications including acute mitral regurgitation, ventricular septal rupture, and ventricular free-wall rupture can also lead to cardiogenic shock. Rapid diagnosis of cardiogenic shock and its underlying cause is pivotal to delivering definitive therapy. Intravenous vasoactive agents and mechanical support devices may temporize the patient's hemodynamic status until definitive therapy by percutaneous or surgical intervention can be performed. Despite prompt management, post-MI cardiogenic shock mortality remains high.

S3 guidelines for intensive care in cardiac surgery patients: hemodynamic monitoring and cardiocirculary system

Hemodynamic monitoring and adequate volume-therapy, as well as the treatment with positive inotropic drugs and vasopressors are the basic principles of the postoperative intensive care treatment of patient after cardiothoracic surgery. The goal of these S3 guidelines is to evaluate the recommendations in regard to evidence based medicine and to define therapy goals for monitoring and therapy. In context with the clinical situation the evaluation of the different hemodynamic parameters allows the development of a therapeutic concept and the definition of goal criteria to evaluate the effect of treatment. Up to now there are only guidelines for subareas of postoperative treatment of cardiothoracic surgical patients, like the use of a pulmonary artery catheter or the transesophageal echocardiography. The German Society for Thoracic and Cardiovascular Surgery (Deutsche Gesellschaft für Thorax-, Herz- und Gefässchirurgie, DGTHG) and the German Society for Anaesthesiology and Intensive Care Medicine (Deutsche Gesellschaft für Anästhesiologie und lntensivmedizin, DGAI) made an approach to ensure and improve the quality of the postoperative intensive care medicine after cardiothoracic surgery by the development of S3 consensus-based treatment guidelines. Goal of this guideline is to assess the available monitoring methods with regard to indication, procedures, predication, limits, contraindications and risks for use. The differentiated therapy of volume-replacement, positive inotropic support and vasoactive drugs, the therapy with vasodilatators, inodilatators and calcium sensitizers and the use of intra-aortic balloon pumps will also be addressed. The guideline has been developed following the recommendations for the development of guidelines by the Association of the Scientific Medical Societies in Germany (AWMF). The presented key messages of the guidelines were approved after two consensus meetings under the moderation of the Association of the Scientific Medical Societies in Germany (AWMF).

The Current Role of the Pulmonary Artery Catheter in Critical Care: A Case Report and Review of the Literature

The clinical use of the pulmonary artery catheter (PAC) has changed the modern practice of intensive care medicine. However, the effect of invasive haemodynamic monitoring on patient outcome remains uncertain. We report an unusual case of malposition of a PAC in the left internal mammary vein and we discuss the role of this monitor in the intensive care setting. Overall, the literature does not suggest a positive effect of PAC use on patient outcome. It has been suggested that PAC insertion may be of little benefit unless linked to specific therapies which may alter outcome. It is essential to understand the capabilities and limitations of the PAC in order to minimise potential complications and maximise benefits.

Comparison of pulmonary artery and aortic transpulmonary thermodilution for monitoring of cardiac output in patients with severe heart failure: validation of a novel method

OBJECTIVE

Hemodynamic monitoring with the pulmonary artery catheter is frequently used in the management of severe heart failure. For measurement of cardiac output (CO), transpulmonary thermodilution (TPTD) has recently been adopted into clinical practice as an alternative to pulmonary artery thermodilution. However, no data have been published on the comparability of the two methods for patients with severely reduced left ventricular function. Our objective was to evaluate the correlation between these two methods of CO determination in patients with severe left ventricular dysfunction.

DESIGN

Prospective observational clinical study.

SETTING

Cardiological intermediate care unit and medical intensive care unit of a university hospital.

PATIENTS

Twenty-nine patients with left ventricular ejection fraction <35% and symptoms of heart failure (New York Heart Association class III-IV).

INTERVENTION

None.

MEASUREMENTS AND MAIN RESULTS

The two methods of intermittent CO measurement were compared by simultaneously recording the results of pulmonary artery thermodilution and TPTD after injection of a cold saline bolus. Measurements were performed when clinically necessary. A total of 325 data pairs were analyzed. Mean CO of both methods was 4.4 L/min with a bias of 0.45 L/min (2 SD 1.20 L/min), resulting in a percentage error of 27.3%.

CONCLUSION

In patients with severely impaired left ventricular function, measurement of CO by TPTD provides valid results.

The evaluation and management of cardiogenic shock

Cardiogenic shock (CS) continues to be the leading cause of death in patients who present to the hospital with acute myocardial infarction (AMI). Mortality in patients with AMI complicated by CS remains extremely high, with 1-month mortality rates ranging from 40% to 60%. Although pump failure is the dominant etiologic feature of CS after AMI, the inflammatory system has been implicated in its pathogenesis. The dominant therapy for treatment of CS is early mechanical revascularization with either percutaneous coronary intervention or coronary artery bypass graft surgery. Supportive measures such as intravenous vasopressors or intra-aortic balloon counterpulsation can complement the benefit of definitive revascularization. Newer therapies are directed at mitigating the inflammatory response or supporting cardiovascular function until either patient recovery or until other destination therapy is available. The strategies in this critical pathway outline the general approach in treating CS after AMI at our institution.

Canadian Cardiovascular Society Consensus Conference recommendations on heart failure update 2007: Prevention, management during intercurrent illness or acute decompensation, and use of biomarkers

Heart failure is common, yet it is difficult to treat. It presents in many different guises and circumstances in which therapy needs to be individualized. The Canadian Cardiovascular Society published a comprehensive set of recommendations in January 2006 on the diagnosis and management of heart failure, and the present update builds on those core recommendations. Based on feedback obtained through a national program of heart failure workshops during 2006, several topics were identified as priorities because of the challenges they pose to health care professionals. New evidence-based recommendations were developed using the structured approach for the review and assessment of evidence adopted and previously described by the Society. Specific recommendations and practical tips were written for the prevention of heart failure, the management of heart failure during intercurrent illness, the treatment of acute heart failure, and the current and future roles of biomarkers in heart failure care. Specific clinical questions that are addressed include: which patients should be identified as being at high risk of developing heart failure and which interventions should be used? What complications can occur in heart failure patients during an intercurrent illness, how should these patients be monitored and which medications may require a dose adjustment or discontinuation? What are the best therapeutic, both drug and nondrug, strategies for patients with acute heart failure? How can new biomarkers help in the treatment of heart failure, and when and how should BNP be measured in heart failure patients? The goals of the present update are to translate best evidence into practice, to apply clinical wisdom where evidence for specific strategies is weaker, and to aid physicians and other health care providers to optimally treat heart failure patients to result in a measurable impact on patient health and clinical outcomes in Canada.

Rupture de l'artère pulmonaire par cathéter de Swan-Ganz au cours de la chirurgie cardiaque : conduite à tenir et stratégie

Pulmonary artery catheterization is almost uniformly used nowadays in cardiac surgery. Although rare, rupture of the pulmonary artery following catheterization is highly lethal. This review examines ways of avoiding its occurrence and means of improving outcomes in case of rupture.

Patent foramen ovale and migraine--bringing closure to the subject

There is increasing interest in the relationship between migraine and patent foramen ovale (PFO). PFO is more common in migraineurs with aura, and migraine with aura is more prevalent in patients with PFO. Retrospective analyses of PFO closure for stroke prevention and decompression illness in divers have suggested that migraineurs with and without aura may derive significant benefit from PFO closure, but to date no prospective, randomized, sham-controlled study to confirm this has been completed. Herein we review published data regarding the relationship between migraine and PFO and discuss the rationale, justification, and important factors to consider in the conduct of prospective, controlled, clinical trials designed to evaluate the efficacy and safety of percutaneous device closure of PFO for migraine prevention.

The Pulmonary Artery Catheter: Gold Standard or Redundant Relic

Pulmonary artery catheter (PAC) technology has changed significantly and use has decreased over the last 20 years. Barriers to use include: (a) increased patient risk with placement; (b) ability to measure similar variables via less invasive measures; (c) increased cost; (d) inaccurate measurement leading to misuse of PAC-derived variables; (e) incorrect interpretation and clinical application; and (f) lack of proven benefit for patient management. Advances in technology have allowed for continuous trending of hemodynamic parameters measured via the PAC. Patient risk is similar to that of central line placement; however risks associated with pulmonary artery infarction and rupture are inherent to the PAC. Less invasive assessment of cardiac output equals that of the PAC, whereas pulmonary capillary wedge pressure and mixed venous oxygen saturation monitoring are unique features of the PAC. Effective use of PAC data will require ongoing standardized education. More studies are needed on the cost-effectiveness of PAC monitoring as well as outcome benefits. Much of the data available from the PAC can be obtained via less invasive methods. However, the PAC continues to be useful in specific situations and remains the gold standard for comparison of new technologies. This paper discusses use of the PAC during the past 2 decades and reviews studies affecting its use in clinical practice.

Complications of invasive monitoring

Invasive monitoring in anesthesiology is relatively safe. Arterial catheterization in particular has an extremely low rate of serious complications. Radial, brachial, and femoral artery catheterization sites appear to have similar and low complication rates. CVP and PA catheters are more dangerous and entail potentially fatal complications. The most troublesome complication with CVP catheters is perforation of the heart or cava, which should be avoidable under most circumstances if care is taken to position the catheter properly, outside the heart. Chest radiography should be used to specifically ascertain that the catheter is not in a dangerous location. The most troublesome complication with PA catheters is perforation of the pulmonary artery. This is probably a sporadic problem, and it is not necessarily avoidable by adherence to particular techniques. It should be assumed that hemoptysis in a patient with a PA catheter is caused by perforation of the pulmonary artery until proven otherwise, and it should be treated aggressively.

The semi-elective use of the pulmonary artery flotation catheter in children with progressive pulmonary hypertension or left ventricular dysfunction

OBJECTIVE: To describe the experience with the semi-elective use of the pulmonary artery flotation catheter in pediatric patients with progressive pulmonary hypertension or left ventricular dysfunction. DESIGN: Prospective study. SETTING: Pediatric intensive care unit in a tertiary care center. PATIENTS: Seven consecutive children with pulmonary hypertension and ten children with left ventricular dysfunction. INTERVENTIONS: Drug-response studies were performed using a pulmonary artery flotation catheter. Cardiac index, systemic and pulmonary blood pressure, and occlusion pressure were measured during incremental doses of calcium channel blocker (diltiazem) that were administered to children with pulmonary hypertension and during incremental doses of nitroglycerine and angiotensin-converting enzyme-inhibitor (captopril) that were administered to patients with left ventricular dysfunction. MAIN RESULTS: Four patients (60%) with pulmonary hypertension were identified as responders to calcium channel blockers, resulting in maintenance therapy with high-dose diltiazem in three of them. Nine patients (90%) with left ventricular dysfunction showed a >15% increase in cardiac index with vasodilator therapy. Eleven patients (65%) developed fever during the procedure. Nine patients (53%) had a high probability of bacterial infection. Seven patients (40%) died within 3.5 months after the procedure. Fever, infection, and mortality appeared to occur more frequently in patients in New York Heart Association classes III and IV. CONCLUSIONS: The use of a pulmonary artery flotation catheter enables us to optimize medical treatment strategies in the individual child with progressive pulmonary hypertension or left ventricular dysfunction. Children with left ventricular dysfunction in poor clinical condition showed a high mortality rate post or propter the procedure. In our opinion, drug-response studies using pulmonary artery flotation catheters in patients with left ventricular dysfunction should be performed in a relatively early stage of the disease.

Management of acute heart failure exacerbation

Patients with decompensated heart failure should be managed in an aggressive and proactive manner, using predominantly hemodynamic and end-organ function goals. This management is in contrast to the chronic maintenance therapy of patients with heart failure, where a neuroendocrine approach is indicated. Underlying anatomic targets for intervention should be sought aggressively and addressed. Patients who prove resistant to standard measures should be considered for early referral to heart transplant centers for more definitive measures, including evaluation for heart transplantation and mechanical circulatory support if necessary.

Hemodynamic classification in acute myocardial infarction

OBJECTIVE

Current mortality (M(1)) in hemodynamic subgroups of patients with acute myocardial infarction (AMI) was compared to that observed 30 years ago (M(0)), when hemodynamic classification was established. The prognostic value of oxyhemodynamic indexes in predicting M(1) for patients receiving right heart catheterization (RHC) was investigated.

PATIENTS AND METHODS

We assigned 393 patients with AMI (mean age, 72 +/- 10 years) to four Killip categories. A fiberoptic reflectance catheter was inserted in the pulmonary artery (PA) in 136 patients. Cardiac index (CI), PA wedge pressure (PWP), PA mixed venous blood oxygen saturation (SvO(2)), oxygen extraction ratio (O(2)ER), and normalized CI (NCI; CI/O(2)ER) were measured. Catheterized patients were classified into four Forrester groups, and M(1) and M(0) were compared. Survivors (group S) were compared to nonsurvivors (group NS), and the prognostic value of oxyhemodynamic parameters in predicting M(1) was estimated.

RESULTS

A significant decline in total mortality was observed (M(1) of 8% vs M(0) of 34%; p < 0.0001). In catheterized patients, total M(1) was also decreased (M(1) of 15% vs M(0) of 26%; p < 0.05). Compared with group S, group NS had lower (mean +/- SD) CI (1.8 +/- 0.4 L/min/m(2) vs 2.4 +/- 0.6 L/min/m(2); p < 0.01), SvO(2) (46.1 +/- 10.6% vs 59.9 +/- 10.0%; p < 0.01), NCI (4.2 +/- 1.4 vs 7.4 +/- 4.1 L/min/m(2); p < 0.01), and higher PWP (22.7 +/- 6.8 mm Hg vs 14. 4 +/- 4.7 mm Hg; p < 0.01). NCI presented the best sensitivity (81%), specificity (78%), and predictive value (40%), in predicting M(1).

CONCLUSIONS

The historical AMI hemodynamic classification has lost its semiquantitative value, since mortality has decreased. RHC does not compromise the outcome. NCI has a high prognostic value in predicting early mortality.