2023, Number 1
Mexican College of Interventional Cardiology and Endovascular Therapy (COMECITE) international multidisciplinary consensus statement regarding catheter-based pulmonary artery monitoring
Full text
10.35366/110251
Language: English
References: 12
Page: 29-32
PDF size: 166.83 Kb.
ABSTRACT
The Swan-Ganz (SG) catheter is an indispensable tool for invasive hemodynamic monitoring but is underused due to controversy for misunderstandings after several confounding studies. The Mexican College of Interventional Cardiology and Endovascular Therapy (COMECITE) invited a select group of international specialists in interventional cardiology, critical cardiology care, and general intensive care for a consensus statement on SG catheter use, endorsed by COMECITE and the Mexican College of Critical Care (COMMEC). The consensus recommends the SG as a diagnostic tool in cardiogenic shock from any etiology and at any class and level, involving one ventricle or both; during worsening heart failure/hemodynamic instability, despite adequate treatment; for differential diagnosis during failed treatment for respiratory distress, hypotension, and or progressive renal failure; for simultaneous monitoring of the pulmonary artery and right atrial pressures during severe right heart-related shock. The consensus encourages centers with low SG utilization to include and master its hemodynamic monitoring benefits.INTRODUCTION
It has been more than fifty years since the Swan-Ganz (SG) catheter was first used for invasive hemodynamic monitoring and there has been ongoing controversy regarding benefits and risks of its use.1-4
The Mexican College of Interventional Cardiology and Endovascular Therapy (COMECITE: Colegio Mexicano de Cardiología Intervencionista y Terapia Endovascular) invited a select group of international specialists in interventional cardiology, critical cardiology care, and general intensive care, to discuss the current use of invasive pulmonary artery monitoring, its benefit/risk and to publish a consensus statement on SG catheter use, endorsed by COMECITE, the Mexican College of Critical Care (COMMEC: Colegio Mexicano de Medicina Crítica) through its cardiovascular care working group, plus other invited medical organizations.
MATERIAL AND METHODS
The consensus group emerged from members of COMECITE, COMMEC and SCAI plus international experts on cardiogenic shock (CS), further electing chair, co-chair, and the rest's specific functions.
The meetings took a nominal group technique format, which consisted of the face-to-face discussion on video conference, in which each member presents their proposal and their reasons, without a time limit. Delphi rounds finally solved disagreements.5-8
The consensus group defined the authors' nomination from the beginning of the consensus work and modified it during its process. According to the International Committee of Medical Journal Editors (ICMJE), were authors all the people who contributed and who strictly complied with every one of the following aspects:
- 1. Contributed substantially to the conception or design of the work; or the acquisition, analysis, or interpretation of data.
- 2. Wrote the work or critically reviewed it.
- 3. Approved the final version for publication.
- 4. Confirmed the accuracy and completeness concerning every part of the work.
The acknowledgments section mentions the contributors who have not complied with every one of the four points outlined above, but worth mentioning for relevant participation.
The magnitude of consensus' contribution ordered the authorship and the corresponding author designation, with a preponderance of the person who originated the idea and who presides and coordinates. In case of disagreement and dispute over the order, an anonymous vote in a ranking format of importance decides, and, in extreme cases, the consensus might call an internal or external judge.9
CURRENT KNOWLEDGE
The Society for Cardiac Angiography and Interventions (SCAI) stated on 2019, a classification of the CS (document endorsed by the American College of Cardiology [ACC], the American Heart Association [AHA], the Society of Critical Care Medicine [SCCM], and the Society of Thoracic Surgeons [STS]).10
This statement stresses the relevant accurate invasive hemodynamic information obtained by the utilization of the pulmonary artery catheterization during the monitorization for CS, measuring directly right atrial pressure (RA), pulmonary artery pressure (PA), pulmonary capillary wedge pressure (PCWP), mixed venous oxygen saturation and cardiac output (CO), which derives cardiac index (CI), systemic vascular resistance (SVR), pulmonary vascular resistance (PVR), pulmonary artery pulsatility index (PAPi), and cardiac power output (CPO).
This tool is essential for early recognition, differential diagnosis, phenotyping, therapeutic titration, escalation to mechanical circulatory support (MCS), weaning of therapies, prognosis, and identification of univentricular versus biventricular failure. This expert panel recommends invasive pulmonary artery monitoring in CS and recognizes the reluctance for its utilization based on currently unjustified controversy.
Unfortunately, the controversy about the invasive right heart monitoring currently provokes its underuse, surely with a significantly negative impact on CS patients, because the old studies did not include a significant volume of patients with CS or those treated with MCS, while there is indeed a significantly lower mortality in CS under SG monitoring (29.7% versus 38.1%). This kind of monitoring, when properly managed and interpreted, may help to identify worsening heart failure and CS and will help to guide treatment in clinically conflicting and mixed shock conditions.4
Finally, severe right ventricle dysfunction may require continuous right heart monitoring, particularly during intense bi-ventricular failures, such as right coronary-related myocardial infarction with significant right ventricle involvement, in which the simultaneous monitoring of the pulmonary artery and right atrial pressures, is valuable to determine the diastolic relationships between both.11
Several medical organizations wrote current guidelines for invasive right heart monitoring (American College of Cardiology Foundation, American Heart Association, European Society of Cardiology, Heart Failure Society of America, International Society of Heart and Lung Transplantation), as follows:12
- 1. On anesthesia induction on CS patients for coronary bypass graft surgery (class I; level of evidence C).
- 2. To estimate intracardiac filling pressures on respiratory distress or impaired perfusion with clinical discrepancy (class I; level of evidence C).
- 3. On heart failure persistence despite therapeutic adjust and any of the following (class IIa; level of evidence C):
- a. Uncertain systemic or pulmonary vascular resistance, fluid or perfusion status.
- b. Unresponsive hypotension.
- c. Worsening renal function.
- d. Need for vasopressors.
- e. On candidates for mechanical circulatory support or heart transplantation.
- 4. On patients with mechanical circulatory support (class I; level of evidence B).
- 5. On hemodynamic instability due to unknown worsening mechanism or refractory heart failure (class IIb; level of evidence C).
- 6. To withdraw mechanical circulatory or pharmacologic support.
RECOMMENDATIONS
Regarding the utilization of the Swan-Ganz catheter for continuous right heart monitoring, this consensus recommends:
- 1. The SG catheter is a hemodynamic diagnostic tool; it is not a device for treatment.
- 2. Do not utilize the SG catheter to monitor respiratory insufficiency without heart failure.
- 3. Indicate the SG catheter on any cardiogenic shock from any etiology and at any class and level, involving one ventricle or both.
- 4. Consider the SG catheter:
- a. During worsening heart failure/hemodynamic instability, despite adequate treatment.
- b. For differential diagnosis during failed treatment for respiratory distress, hypotension, and or progressive renal failure.
- 5. Consider simultaneous monitoring of the pulmonary artery and right atrial pressures during severe right heart-related shock.
- 6. Encourage centers with low SG utilization to include and master its hemodynamic monitoring benefits.
REFERENCES
Baran DA, Grines CL, Bailey S, Burkhoff D, Hall SA, Henry TD et al. SCAI clinical expert consensus statement on the classification of cardiogenic shock: This document was endorsed by the American College of Cardiology (ACC), the American Heart Association (AHA), the Society of Critical Care Medicine (SCCM), and the Society of Thoracic Surgeons (STS) in April 2019. Catheter Cardiovasc Interv. 2019; 94 (1): 29-37. doi: 10.1002/ccd.28329.
AFFILIATIONS
1 The Clinics of the Heart/COSTAMED Cozumel, Mexico.
2 Fellow of the Society for Cardiovascular Angiography & Interventions (SCAI).
3 Mexican College of Interventional Cardiology and Endovascular Therapy (COMECITE: Colegio Mexicano de Cardiología Intervencionista y Terapia Endovascular).
4 Clínica de Estudios Médicos. Guadalajara, México.
5 Interventional Cardiology/Structural heart disease, Henry Ford Hospital.
6 Intensive Care Specialist. Obstetric Intensive Unit, Hospital General de México "Dr. Eduardo Liceaga".
7 Mexican College of Critical Care (COMMEC: Colegio Mexicano de Medicina Crítica).
8 Henry Ford Health Systems.
9 Assistant Professor of Medicine. Department of Cardiology, University of Mississippi Medical Center. Jackson, Mississippi.
10 Fellow of Royal College of Physicians of Canada (FRCPC). Professor of Anesthesiology. Department of Anesthesiology/Perioperative and Pain Medicine, Max Rady College of Medicine, University of Manitoba. Winnipeg, Canada.
11 Assistant Professor of Cardiology. Zucker School of Medicine Northwell Health. New York, NY.
12 Intensive Care Specialist. Colegio Mexicano de Medicina Crítica, Unidad de Terapia Intensiva Cardiovascular, Centro Médico ABC, Mexico City.
13 Director Médico, Sistema d'Emergències Mèdiques de Catalunya.
14 Intensive Care Specialist/Internist. Coordinador de Ciclos Clínicos Universidad Westhill, Mexico City.
Funding/support: the authors did not receive any funding for the present consensus statement.
Conflict of interest: the authors do not have any conflict of interest regarding this consensus statement.
CORRESPONDENCE
Rafael Moguel-Ancheita, MD, FSCAI. E-mail: cathboss@gmail.comReceived: 02/24/2023. Accepted: 03/15/2023.