pulmonary artery catheter evidence and data

The randomized ESCAPE trial is often cited as evidence that PAC does not change outcomes in patients with heart failure, but that trial excluded patients with recent inotropic therapy and so would not apply in cases such as this. In fact, several prospective series have reported improved outcomes, including decreased in-hospital mortality, when pulmonary artery catheters are used in patients with cardiogenic shock. Failure to respond to empiric inotropic therapy and uncertainty about intravascular volume status are very good reasons to consider invasive hemodynamic assessment, as it might allow titration of diuretics and vasoactive agents to maximize cardiac output while minimizing arrhythmias and myocardial oxygen consumption. Measurement of mixed venous SpO2, something that can be done only with a catheter in the pulmonary artery, can also inform the adequacy of cardiac output. Furthermore, the use of PAC to obtain complete hemodynamic data before initiation of temporary mechanical circulatory support is associated with decreased mortality from all-cause cardiogenic shock.

The Cardiogenic Shock Working Group is an academic research consortium with a national registry that began in 2016. The registry includes data in patients with cardiogenic shock in the contemporary era of mechanical circulatory support devices. Kanwar et al analyzed this registry data from 15 US hospitals between the years of 2019 and 2021, excluded patients with acute coronary syndromes, and included 1,055 patients with cardiogenic shock from acute decompensated heart failure. In this study, PAC use compared with no PAC use was associated with lower adjusted in-hospital mortality (22.2% vs 30%), and early PAC use (<6 h of hospitalization) compared with no or delayed PAC use (≥48 h) was associated with decreased in-hospital mortality (17.3% vs 27.7%). A meta-analysis comparing in-hospital mortality between PAC and non-PAC use in patients with cardiogenic shock found PAC use in patients with cardiogenic shock from acute decompensated heart failure was associated with decreased in-hospital mortality, whereas the use of PAC in patients with cardiogenic shock from acute coronary syndrome was not associated with in-hospital mortality. Randomized controlled trials are needed to confirm (or refute) findings from observational real-world registry studies in the modern age of mechanical circulatory support. These trials should address optimal timing of PAC and investigate whether this diagnostic tool improves survival and informs goal-directed care and/or use of mechanical circulatory support.

A meta-analysis of randomized controlled trials and propensity score-matched studies of mechanical circulatory support for cardiogenic shock included 38 studies in nearly 49,000 participants with advanced cardiogenic shock. This meta-analysis found that, compared with no mechanical circulatory support, IABP use was not associated with a reduction in mortality. In this study, only venoarterial extracorporeal membrane oxygenation plus IABP was associated with favorable outcomes compared with no mechanical support (OR of mortality, 0.54; 95% CI, 0.33-0.86).

Continuous renal replacement therapy can be useful in achieving a negative volume balance in patients with cardiogenic shock, volume overload, and low BP. However, this patient continues to respond to IV diuretics and does not meet other indications to initiate renal replacement therapy. Although this patient has had several episodes of asymptomatic nonsustained ventricular tachycardia, this was likely an adverse effect of the dobutamine infusion, and antiarrhythmic drugs are not indicated.1234567

Footnotes

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  2. Binanay C, Califf RM, Hasselblad V, et al; ESCAPE Investigators and ESCAPE Study Coordinators. Evaluation study of congestive heart failure and pulmonary artery catheterization effectiveness: the ESCAPE trial. JAMA. 2005;294(13):1625-1633. PubMed ↩

  3. Garan AR, Kanwar M, Thayer KL, et al. Complete hemodynamic profiling with pulmonary artery catheters in cardiogenic shock is associated with lower in-hospital mortality. JACC Heart Fail. 2020;8(11):903-913. PubMed ↩

  4. Kanwar MK, Blumer V, Zhang Y, et al. Pulmonary artery catheter use and risk of in-hospital death in heart failure cardiogenic shock. J Card Fail. 2023;29(9):1234-1244. PubMed ↩

  5. Lee J, Lee JB, Kim AR, et al. Effectiveness of pulmonary artery catheter monitoring for patients with cardiogenic shock of various causes: a systematic review and meta-analysis. J Thorac Dis. 2023;15(3):1115-1123. PubMed ↩

  6. Low CJW, Ling RR, Lau MPXL, et al. Mechanical circulatory support for cardiogenic shock: a network meta-analysis of randomized controlled trials and propensity score-matched studies. Intensive Care Med. 2024;50(2):209-221. PubMed ↩

  7. Ranka S, Mastoris I, Kapur NK, et al. Right heart catheterization in cardiogenic shock is associated with improved outcomes: insights from the Nationwide Readmissions Database. J Am Heart Assoc. 2021;10(17):e019843. PubMed ↩