Review
Mexican College of Interventional Cardiology and Endovascular Therapy
(COMECITE) international multidisciplinary consensus statement regarding
catheter-based pulmonary artery monitoring
Declaración de consenso internacional y multidisciplinario del
Colegio Mexicano de Cardiología Intervencionista y Terapia Endovascular
(COMECITE) sobre la monitorización invasiva de la arteria
pulmonar
Rafael Moguel-Ancheita1
2
3
*
Rafael Olvera-Ruiz2
3
4
Pedro A Villablanca2
5
Enrique Monares-Zepeda6
7
Mir B Basir2
8
Alejandro Lemor9
Virendra K Arya10
Miguel Álvarez-Villela11
Rufino Iván Galván-Cerón7
12
Jorge A Morales-Álvarez13
Asisclo Villagómez-Ortiz7
14
1 The Clinics of the Heart/COSTAMED Cozumel,
Mexico.
2 Fellow of the Society for Cardiovascular
Angiography & Interventions (SCAI), USA.
3 Mexican College of Interventional Cardiology
and Endovascular Therapy (COMECITE: Colegio Mexicano de Cardiología
Intervencionista y Terapia Endovascular), México.
4 Clínica de Estudios Médicos. Guadalajara,
México.
5 Interventional Cardiology/Structural heart
disease, Henry Ford Hospital, USA.
6 Intensive Care Specialist. Obstetric Intensive
Unit, Hospital General de México «Dr. Eduardo Liceaga», México.
7 Mexican College of Critical Care (COMMEC:
Colegio Mexicano de Medicina Crítica), México.
8 Henry Ford Health Systems, USA.
9 Assistant Professor of Medicine. Department of
Cardiology, University of Mississippi Medical Center. Jackson, Mississippi,
USA.
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, USA.
12 Intensive Care Specialist. Colegio Mexicano de
Medicina Crítica, Unidad de Terapia Intensiva Cardiovascular, Centro Médico ABC,
Mexico City, México.
13 Director Médico, Sistema d’Emergències
Mèdiques de Catalunya, Spain.
14 Intensive Care Specialist/Internist.
Coordinador de Ciclos Clínicos Universidad Westhill, Mexico City,
México.
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.
Keywords: Swan-Ganz catheter; invasive pulmonary monitoring; cardiogenic shock; cardiac intensive care
Resumen:
El catéter de Swan-Ganz (SG) es una herramienta indispensable para la
monitorización hemodinámica invasiva, pero está subutilizado debido a la
controversia después de varios estudios con resultados que llevaron a
interpretaciones erróneas. El Colegio Mexicano de Cardiología Intervencionista y
Terapia Endovascular (COMECITE) invitó a un grupo selecto de especialistas
internacionales en cardiología intervencionista, cuidados cardiológicos críticos
y cuidados intensivos generales para una declaración de consenso sobre el uso
del catéter SG, avalada por COMECITE y el Colegio Mexicano de Cuidados Críticos
(COMMEC). El consenso recomienda el SG como herramienta diagnóstica en el choque
cardiogénico de cualquier etiología y de cualquier clase y nivel, con compromiso
de un ventrículo o de ambos; durante el empeoramiento de la insuficiencia
cardiaca e inestabilidad hemodinámica, a pesar del tratamiento adecuado; para el
diagnóstico diferencial durante el tratamiento fallido de dificultad
respiratoria, hipotensión o insuficiencia renal progresiva y para la
monitorización simultánea de las presiones de la arteria pulmonar y la aurícula
derecha durante un choque grave relacionado con el corazón derecho. El consenso
alienta a los centros con baja utilización de SG a incluir y dominar sus
beneficios en el monitoreo hemodinámico.
Palabras clave: catéter de Swan-Ganz; monitoreo invasivo de la arteria pulmonar; choque cardiogénico; cuidado intensivo cardiovascular
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:
Contributed substantially to the conception or design of the work; or the
acquisition, analysis, or interpretation of data.
Wrote the work or critically reviewed it.
Approved the final version for publication.
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
On anesthesia induction on CS patients for coronary bypass graft surgery
(class I; level of evidence C).
To estimate intracardiac filling pressures on respiratory distress or
impaired perfusion with clinical discrepancy (class I; level of evidence
C).
On heart failure persistence despite therapeutic adjust and any of the
following (class IIa; level of evidence C):
Uncertain systemic or pulmonary vascular resistance, fluid or
perfusion status.
Unresponsive hypotension.
Worsening renal function.
Need for vasopressors.
On candidates for mechanical circulatory support or heart
transplantation.
On patients with mechanical circulatory support (class I; level of
evidence B).
On hemodynamic instability due to unknown worsening mechanism or
refractory heart failure (class IIb; level of evidence C).
To withdraw mechanical circulatory or pharmacologic support.
Recommendations
Regarding the utilization of the Swan-Ganz catheter for continuous right heart
monitoring, this consensus recommends:
The SG catheter is a hemodynamic diagnostic tool; it is not a device for
treatment.
Do not utilize the SG catheter to monitor respiratory insufficiency
without heart failure.
Indicate the SG catheter on any cardiogenic shock from any etiology and
at any class and level, involving one ventricle or both.
Consider the SG catheter:
During worsening heart failure/hemodynamic instability,
despite adequate treatment.
For differential diagnosis during failed treatment for
respiratory distress, hypotension, and or progressive renal
failure.
Consider simultaneous monitoring of the pulmonary artery and right atrial
pressures during severe right heart-related shock.
Encourage centers with low SG utilization to include and master its
hemodynamic monitoring benefits.
References
1. Frazier SK, Skinner GJ. Pulmonary artery catheters: state of the
controversy. J Cardiovasc Nurs. 2008; 23 (2): 113-121; quiz 122-123. doi:
10.1097/01.JCN.0000305073.49613.db.
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2. Carrillo-López A, Fiol-Sala M, Rodríguez-Salgado A. El papel del
catéter de Swan-Ganz en la actualidad. Med Intensiva. 2010; 34 (3):
203-214.
[ Links ]
3. Hadian M, Pinsky MR. Evidence-based review of the use of the
pulmonary artery catheter: impact data and complications. Crit Care. 2006; 10
Suppl3: S8. doi: 10.1186/cc4834.
[ Links ]
4. Isseh IN, Lee R, Khedraki R, Hoffman K. A critical review of
hemodynamically guided therapy for cardiogenic shock: old habits die hard. Curr
Treat Options Cardiovasc Med. 2021; 23 (5): 29. doi:
10.1007/s11936-021-00903-8.
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5. American Society for Quality. Available in: https://asq.org/quality-resources/nominal-group-technique
[ Links ]
6. Delphi Technique a Step-by-Step Guide. 2021. Available in:
https://www.projectsmart.co.uk/delphi-technique-a-step-by-step-guide.php
[ Links ]
7. Sample JA. Nominal group technique: an alternative to
brainstorming. J Ext March. 1984; 22 (2).
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8. Thangaritam S, Redman CWE. The Delphi technique. Obstet Gynaecol.
2005; 7 (2): 120-125.
[ Links ]
9. International Committee of Medical Journal Editors. Defining the
role of authors and contributors. Available in: http://www.icmje.org/recommendations/browse/roles-and-responsibilities/defining-the-role-of-authors-and-contributors.html
[ Links ]
10. 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.
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11. Hrymak C, Strumpher J, Jacobsohn E. Acute right ventricle
failure in the intensive care unit: assessment and management. Can J Cardiol.
2017; 33 (1): 61-71. doi: 10.1016/j.cjca.2016.10.030.
[ Links ]
12. Ponamgi SP, Maqsood MH, Sundaragiri PR, DelCore MG,
Kanmanthareddy A, Jaber WA et al. Pulmonary artery catheterization in acute
myocardial infarction complicated by cardiogenic shock: A review of contemporary
literature. World J Cardiol. 2021; 13 (12): 720-732. doi:
10.4330/wjc.v13.i12.720.
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