Cardiogenic Shock & Swan-Ganz/Pulmonary Artery Catheters

Mortality for patients in cardiogenic shock is finally improving to be less than 50%. It had been hovering at 50% for decades. Would floating a Swan Ganz catheter, also known as a Pulmonary Artery Catheter improve outcomes in Cardiogenic Shock? The ESCAPE trial took the winds out of the sails of the Swan-Ganz enthusiasts in Cardiogenic Shock back in 2006. Perhaps this was a bit too premature. Six observational studies from 2017 onward were included in a meta-analysis by Bertaina et al. revisiting this clinical question. They conducted their statistical jumping jacks and came to the following conclusions. This article is titled “Prognostic implications of pulmonary artery catheter monitoring in patients with cardiogenic shock: A systematic review and meta-analysis of observational studies”.

Comparing the cardiogenic shock patients who had a swan floated compared to those who didn’t, they found a 29% decreased odd of mortality in the short term. 36% of the patients in the swan group did not survive vs. 47% in the non-pulmonary artery catheter group. This give us a NNT of 9.1. By definition, this means that 9.1 patients with cardiogenic shock would need to have a swan versus not having a swan to save an additional life. We need to keep in mind all the limitations of the type of studies this is based on.

They also found that the patients who had cardiogenic shock with a swan were more likely to receive mechanical circulatory support. It was the opinion of the authors as well as my opinion that knowing the values of the PA catheter assisted in faster decision making. After all, slower escalation leads to increased death. We all have other technologies around our ICU’s that provide us with numbers. Technologies that are said to be equivalent to a swan. But what is the data behind these devices for the induction of Cardiogenic Shock?

Is Bioreactance as good as a Swan in Cardiogenic Shock?

Some might think that bioreactance can get the job done but Rali et al. found that “NICOM technology is not a reliable method of measuring CO in patients with decompensated heart failure and cardiogenic shock”. Authors stated that perhaps the pulmonary edema affected the ability for the device to function properly.

Is Pulse-Contour analysis as good as a Swan in Cardiogenic Shock?

Initial validation with a certain device vs. a swan was found to be favorable by Meyer et al. looking at just 27 patients in Cardiogenic Shock in 2006. Since then, Hattori et al. stated that “the degree of accuracy of the fourth-generation FloTrac/Vigileo in patients with low cardiac index was not acceptable”. In this study they compared the FloTrac to echocardiography. Phan et al. looked at two different pulse-contour devices in elective cardiac surgery patients. Here, they found that “in cardiac surgical patients, the (different devices) differ in their responses, do not always provide the same information as TD and therefore should not be used interchangeably to track CO changes”. This does not sound too convincing to me. Hadian et al. found that it was reliable in cardiac surgery patients, but this population is not the same as cardiogenic shock.

My Conclusions

To wrap this up, it is my opinion that if your patient is in cardiogenic shock, they need a swan. I personally do not like flying blind on their management. The mortality is already too high. Obtaining good windows are not always easy to perform serial echocardiograms. Sometimes, these patients also become vasoplegic, developing a distributive shock-type picture to accompany their cardiogenic shock. How else are you going to sort out their SVR? Also, those of us who use milrinone know that it usually brings its best friend norepinephrine to the party. That’s because of the vasodilatory properties of milrinone. So when you start the milrinone and the blood pressure begins to deteriorate, how will you easily know if it’s because the heart is getting worse or whether it is that they’re becoming vasoplegic due to the medication? I personally prefer for my cardiogenic shock patients to have a swan.

Let’s also not forget that you need a swan to appropriately calculate a Pulmonary Artery Pulsatility Index (PAPi) and Cardiac Power Output (CPO). These can help you determine whether a patient would benefit from mechanical circulatory support.

Citations for a Swan in Cardiogenic Shock

Binanay C, Califf RM, Hasselblad V, O’Connor CM, Shah MR, Sopko G, Stevenson LW, Francis GS, Leier CV, Miller LW; ESCAPE Investigators and ESCAPE Study Coordinators. Evaluation study of congestive heart failure and pulmonary artery catheterization effectiveness: the ESCAPE trial. JAMA. 2005 Oct 5;294(13):1625-33. doi: 10.1001/jama.294.13.1625. PMID: 16204662.
Link to Article and FULL FREE PDF

Bertaina M, Galluzzo A, Rossello X, Sbarra P, Petitti E, Prever SB, Boccuzzi G, D’Ascenzo F, Frea S, Pidello S, Morici N, Sacco A, Oliva F, Valente S, De Ferrari GM, Ugo F, Rametta F, Attisani M, Zanini P, Noussan P, Iannaccone M. Prognostic implications of pulmonary artery catheter monitoring in patients with cardiogenic shock: A systematic review and meta-analysis of observational studies. J Crit Care. 2022 Jun;69:154024. doi: 10.1016/j.jcrc.2022.154024. Epub 2022 Mar 25. PMID: 35344825.
Link to (NOT FREE) Article

Rali AS, Buechler T, Van Gotten B, Waters A, Shah Z, Haglund N, Sauer A. Non-Invasive Cardiac Output Monitoring in Cardiogenic Shock: The NICOM Study. J Card Fail. 2020 Feb;26(2):160-165. doi: 10.1016/j.cardfail.2019.11.015. Epub 2019 Nov 18. PMID: 31751786.
Link to (NOT FREE) Article

Meyer B, Delle Karth G, Bartok A, Hülsmann M, Heinz G. Monitoring of cardiac output in cardiogenic shock and low-output heart failure: LiDCO vs pulmonary artery catheter thermodilution. Crit Care. 2006;10(Suppl 1):P337. doi: 10.1186/cc4684. Epub 2006 Mar 21. PMCID: PMC4092712.
Link to Article

Hattori K, Maeda T, Masubuchi T, Yoshikawa A, Ebuchi K, Morishima K, Kamei M, Yoshitani K, Ohnishi Y. Accuracy and Trending Ability of the Fourth-Generation FloTrac/Vigileo System in Patients With Low Cardiac Index. J Cardiothorac Vasc Anesth. 2017 Feb;31(1):99-104. doi: 10.1053/j.jvca.2016.06.016. Epub 2016 Jun 21. PMID: 27612931.
Link to (NOT FREE) Article

Phan TD, Kluger R, Wan C, Wong D, Padayachee A. A comparison of three minimally invasive cardiac output devices with thermodilution in elective cardiac surgery. Anaesth Intensive Care. 2011 Nov;39(6):1014-21. doi: 10.1177/0310057X1103900606. PMID: 22165352.
Link to Article

Hadian M, Kim HK, Severyn DA, Pinsky MR. Cross-comparison of cardiac output trending accuracy of LiDCO, PiCCO, FloTrac and pulmonary artery catheters. Crit Care. 2010;14(6):R212. doi: 10.1186/cc9335. Epub 2010 Nov 23. PMID: 21092290; PMCID: PMC3220011.
Link to Article

Sotomi Y, Sato N, Kajimoto K, Sakata Y, Mizuno M, Minami Y, Fujii K, Takano T; investigators of the Acute Decompensated Heart Failure Syndromes (ATTEND) Registry. Impact of pulmonary artery catheter on outcome in patients with acute heart failure syndromes with hypotension or receiving inotropes: from the ATTEND Registry. Int J Cardiol. 2014 Mar 1;172(1):165-72. doi: 10.1016/j.ijcard.2013.12.174. Epub 2014 Jan 9. PMID: 24447746.
Link to NOT FREE Article

New Article Shared on 10/2/22

Garan AR, Kanwar M, Thayer KL, Whitehead E, Zweck E, Hernandez-Montfort J, Mahr C, Haywood JL, Harwani NM, Wencker D, Sinha SS, Vorovich E, Abraham J, O’Neill W, Burkhoff D, Kapur NK. Complete Hemodynamic Profiling With Pulmonary Artery Catheters in Cardiogenic Shock Is Associated With Lower In-Hospital Mortality. JACC Heart Fail. 2020 Nov;8(11):903-913. doi: 10.1016/j.jchf.2020.08.012. PMID: 33121702.
Link to Article

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Reel Transcript

Your patient is in cardiogenic shock.
My bias is to float a Swan aka pulmonary artery catheters.
But this is not medical advice.
The ESCAPE trial found no benefit to floating a swan in patients with cardiogenic shock.
But does that data from 2006 still apply in 2022?
A more recent systematic review and meta-analysis revisited this concept.
They analyzed over 1 million patients from 6 recent observational trials.
They found a mortality benefit.
Historically, 50% of patients with cardiogenic shock do not make it.
Here, 64% of the patients with a PA catheter survived
Compare this to 53% of those without a PA catheter surviving.
This gives us a NNT of 9.1.
Not to mention that more patients who had a swan placed ended up with mechanical circulatory support.
This is likely because a swan helps facilitate the calculation of cardiac power output and pulmonary artery pulsatility index.
Are our other technologies such as bioreactance and pulse contour analysis strongly validated in this population?
I personally do not float a swan in every cardiogenic shock patient, but it could be more useful than some of us think.
Are swans making a comeback in your ICU?