Swan Gantz Catherter

and the Meaning of its

Readings
Justin Chandler
Surgical Critical Care Fellow
The Pulmonary Artery Catheter and
Its History
The Pulmonary Artery Catheter and
Its History
 Cardiac catheterization dates back to Claude
Bernard
 used it on animal models
 Clinical application begins with Werner
Forssmann in the 1930s
 inserted a catheter into his own forearm, guided it
fluoroscopically into his right atrium, and took an
X-ray picture of it
The Pulmonary Artery Catheter and
Its History
 The pulmonary artery catheter
introducted in 1972
 Frequently referred to as a
Swan-Ganz catheter, in honor
of its inventors Jeremy Swan and
William Ganz, from Cedars-
Sinai Medical Center
 The “sail” or balloon tip was a
modification of the simple portex
tubing method developed by
Ronald Bradley
 Ganz added the thermistor
 Indications
 Diagnostic indications:
 Shock states
 Differentiation of high vs low
pressure pulmonary edema
 Primary pulmonary
hypertension
 Valvular disease
 Intracardiac shunts
 Cardiac tamponade
 Pulmonary embolus
 Monitoring and management
of complicated acute
myocardial infarction
 Therapeutic indications:
 Assessing hemodynamic
response to therapies
 Management of multiorgan
failure
 Severe burns
 Hemodynamic instability after
cardiac surgery
 Assessment of response to
treatment in patients with
primary pulmonary
hypertension
 Aspiration of air emboli
 Placement
 Place an introducer
 R IJ > L SC > R SC > L IJ
 Femoral is an option
 Hand ports off to RN, inspect and have RN flush
catheter
 if CCO, leave tip in the holder to calibrate
 Place swandom on catheter
 Insert about 15cm and the inflate balloon
 Slowly and steadily advance catheter watching the
waveforms
 NB When wedged, not the volume required
Placement
 Typical Cather Insertion
Landmarks

Anatomic Structure Distance

Right atrium 20 to 25 cm

Right ventricle 30 to 35 cm

Pulmonary artery 40 to 45 cm

Pulmonary capillary wedge 45 to 55 cm

Conformation
Zones of West
 Insertion tips
Turn CVP off!


Once in the RV advance to PA quickly to




avoid coiling, ventricular arrhythmia.

Difficulty getting into PA


Valsava


Calciun iv


HOB up

 Basics to Remember
 Hemodynamic variables should not be
interpreted in isolation
 Integration of variables with the clinical situation
increases the accuracy of assessment
 Trends are generally more useful than isolated
variables at a single point in time
 What does a PAC tell us?
 Direct measurements  Calculated data
 CVP  Stroke volume (SV/SVI)
 Cardiac output (CO/CI)
 PA (systolic and
 Vascular resistance
diasotolic)
(SVR,PVR)
 PAOP (wedge)  Oxygen delivery
 SvO2 (mixed)  Extended calculations
 CCO
 Stroke work
 End diastolic volume, EF
 Variables of Hemodynamics
Variable Assessment

Stroke volume/index Pump performance

Cardiac output/index Blood flow

CVP/RAP R heart filling pressure

PAOP/Wedge L heart filling pressure

SvO2 Tissue oxygenation

 Normal Values
Variable Value

Stroke volume (SVI) 50-100 mL/beat (25-45)

Cardiac output (CI) 4-8 L/min(2.5-4.0)

CVP/RAP 2-6 mmHg

PAOP/Wedge 8-12 mmHg

SvO2 0.60 – 0.75

 Additional Values
Variable Value
SVR (SVRI) 900-1300 (1900-2400)dynes
sec/cm5

PVR 40-150 dynes sec/cm5

MAP 70-110 mmHg
 Equations to Remember
 CO = SV x HR or SV = CO / HR
 SV = EDV – ESV or EDV x EF
 C = ΔV/ΔP
 SVR = (MAP – CVP) x 80 / CO
 LSW = (MAP – LVEDP) x SV x 0.0136

To convert to index: divide by BSA

BSA = [Ht + Wt-60]/100 (in cm & kg)
 Cardiac Output
 Major determinate of oxygenation delivery to
tissue
 Abnormalities are viewed in the context of
SV/SI and SvO2
 Remember: a normal CO/CI may be associated
with a low SV/SI in the presence of
tachycardia
 Factors Affecting CO
 Physiologic  Technical
 Dysrhythmias  Bolusing technique
 Septal defects  Themistor malfunction
 Tricuspid regurg  Factors not affecting
 Respirations CO:
 Iced vs room temp
 NSS vs D5
 Pt elevation (<45o)
 5 cc vs 10 cc
 CO Measurement
 Typically done with thermodilution method
 A cold solution of fixed volume is injected and a
thermsitor measures the change in temperature
 The area under the curve is integrated to calculate
the CO
 The waveform should be examined to determine if
the technique was good
 If the accuracy is in doubt, the Fick method
may be used
CO Waveforms
 Fick Method

 CO = VO2 / [CaO2 – CvO2] * 10

 SaO2 and SvO2 often substituted
 CO = VO2 / [SaO2 – SvO2] * Hgb * 1.34* 10
 VO2 is not usually measured
 Can use 3.5 mL/kg or 125 mL/m2
 If metabolic rate is abnormal, the calculation may be
incorrect
 Stroke volume
 If low
 Inadequate volume (hypovolemia)
 Impaired ventricular contraction
(ischemia/infarction)
 Increased SVR (drugs)

 Valve dysfunction (MVR)

 If high
 Low vascular resistance (sepsis, drugs)
 CVP
 Reflects R heart diastolic function and volume
status
 60-70% of blood volume is in venous system
 Abnormalities are viewed in the context of
SV/SI
 If high (>6) implies right ventricular dysfunction,
especially if SV is low
 If low (< 2) implies hypovolemia especially if SV
is low
 CVP
 High  Low
 Hypervolemia  Hypovolemia
 RV failure  Venodiliation
 Tricupid stenois/regurg
 Cardiac tamponade
 Cardiac pericarditis
 Pulm HTN
 Chronic LV failure
 PAOP
 Reflects left ventricular end
diastolic volume
 Assumes a static column
of blood from ventricle to
catheter during diastole and
consistent compliance
 Abnormalities are viewed in
the context of SV/SI
 If high (>18) implies left
ventricular dysfunction,
especially if SV is low
 If low (< 8) implies
hypovolemia especially if SV
is low
 PAOP
 High  Low
 Hypervolemia  Hypovolemia
 LV failure
 Cardiac tamponade  Aortic regurg
 Cardiac pericarditis  Elevated LVEDP
(>25mmHg) with
 Mitral stenosis/regurg decreased compliance
 Atrial myxoma
 Pulmonary diseases
 PAOP
 Conditions in Which PAD Does Not Equal
PAOP (1 – 4 mm Hg)
 Increased PVR
 Pulmonary hypertension

 Cor pulmonale

 Pulmonary embolus

 Eisenmenger’s syndrome
 Filling Pressures
 If low, but other parameters are normal may
only require observation
 If CO/CI are also low, treatment may be warranted
 If SvO2 and/or SV/SI are also low treatment is
needed
 Pulmonary congestion also warrants treatment
 S v O2
 Reflects the balance between oxygen delivery
and utilization
 The larger the abnormality, the greater the risk
of hypoxemia
 Remember: a normal or high SvO2 may
represent a threat to tissue oxygenation
 S v O2
 A low SvO2 usually warrants investigation
 Evaluate:
 SV/SI
 May require treatment, even if CVP/PAOP are normal
 Hb/Hct
 SaO2 (>90%)

 Reasons for oxygen consumption to be elevated

 Abnormally high SvO2 may be indicative of a

septal defect
 Continuous Cardiac Output
 Newer generation catheter
 Uses continuous cardiac output measurements
without need for bolusing
 Allows for right heart “volumetric” data
 RVEDV, RVEF, and RVSV
 RVSW and RVSWI

 Also provides continuous SvO2 measurements

 Additional Reference Numbers
(R)EDV (SV/EF) 100-160 ml
(R)EDVI 60-100 ml/m2
ESV (EDV-SV) 50-100 ml
ESVI 30-60 ml/m2 (*)
LVSWI 45-75 gm-m/m2/beat

RVSWI 5-10 gm-m/m2/beat

 Waveform Analysis
 Changes in pressure waveforms are due to:
 Blood entering or leaving a chamber
 Changes in wall tension (contraction/relaxation)

 Are always preceded by electrical stimulation

 Waveforms are also affected by changes in
intrathoracic pressure (present as rhythmic
changes)
The Waves
 The Waves - CVP/RA
 The a wave occurs with atrial contraction
 It occurs after the P wave in the PR-interval
 The c wave occurs with closure of the tricuspid valve
 It occurs at the end of the QRS (RST junction)
 The v wave occurs with filling of the atria with the tricupid valve closed
 Occurs after the T wave
 The mean of the a wave is the CVP
 The Waves - RV
 Has a sharp, rapid upstroke and a rapid down stroke
 Falls to near zero
 The Waves - PA
 Characteristics
 Rapid up stroke and
down stroke
 Dicrotic notch (closure
of pulmonic valve)
 Smooth runoff
 End systolic wave
occurs after the T wave
 End diastolic occurs
after the QRS
 The Waves - PAOP
 Characteristics
 May contain 3 waves
 a atrial contraction
 Found after the QRS
 c closure of mitral valve
(often absent)
 v filling of atria with
mitral valve closed
 Found well after the T
 Mean PAOP
 Average the a wave
 a Wave Differential
 Large  Absent
 Tricuspid or mitral  A-fib
regurg  Junctional rhythms
 Decreased ventricular  Paced rhythms
compliance  Ventricular rhythms
 Loss of A-V synchrony
 Junctional rhythms
 Tachycardia (>130)
 v Wave Differential
 Large  Absent
 Tricuspid or mitral  V-fib
regurg  Asystole
 Noncompliant atrium  PEA
 Ventricular
ischemia/failure
 Diagnosis by Waveform
 Mitral insuffiency
 Prominent v wave
 Proximity of v and a
waves
 Returns to a more
normal configuration
after afterload reduction
 Diagnosis by Waveform
 VSD
 Presents with increased
SvO2
 Note the delay in the v
wave
 May respond to afterload
reducers
 Diagnosis by Waveform
 Cardiac Tamponade
 As with constrictive
pericarditis, there is
equalization of diastolic
pressures
 Note the loss of the y
descent in cardiac
tamponade
 Diagnosis by Waveform
 Constrictive pericarditis
 Note the equalization of
the diastolic pressures
 Unlike tamponade, there
is an exaggeration of the
y descent due to a more
rigid pericardium
 Points to remember
 Intrathoracic pressure during inhalation and
exhalation cause pressures in the heart to vary
 Therefore all pressures should be measured at end-
expiration when intrathoracic pressure is closest to
zero
 Points to Remember
 Limitations in hemodynamic monitoring
 Ventricular filling pressures do not always accurately reflect
ventricular filling volume
 The pressure-volume relationship depends upon ventricular compliance
 If compliance changes, the pressure-volume relationship changes
 The PAOP is normally slightly (1-5 mm Hg) less than the PAD
pressure
 This relationship stills exists with pulm hypertension due to LV failure
 However, with an ↑ PVR or tachycardia (>125 bpm) this relationship may
breakdown and the PAD becomes significantly higher than the PAOP
 The PAOP may not equal LVEDP when
 there is high alveolar pressures
 when the catheter tip is above the left atrium
 severe hypovolemia
 tachycardia (130 bpm)
 in mitral stenosis.
 Points to remember
 Calculated variables (e.g. SVR, PVR & SV/SI)
are limited in value due to assumptions made
in their calculations
 Complications
 Air embolism
 S&S: hypoxemia, cyanosis, hypotension/syncope,
“machinery murmur”, elevated CVP, arrest
 Tx: place in left lateral trendelenburg, FiO2 of 100%,
attempt aspiration of air, CPR
 Arrhythmias
 Prevention: keep balloon inflated, minimize insertion time
 Tx: removal of catheter, ACLS
 Heart blocks
 Typically RBBB occurs, so avoid PACs in LBBB
 Tx: transvenous/transcutaneous pacers, PACs with pacer
 Complications
 Knotting
 Prevention: minimize insertion time, avoid pushing agaist
resistance, verify RA to RV transition
 Tx: check CXR, attempt to unknot
 Pulmonary artery rupture
 S&S: hypoxemia, hemoptysis, circ collapse
 Prevention: withdraw PAC if spontaneously wedges or
wedges with < 1.25 cc of air
 Tx: stop anti-coagulation, affected side down, selective
bronchial intubation, PEEP, surgical repair (CPB or
ECMO)
 Complications
 Pulmonary infarction
 Prevention
 Avoid distal positioning of catheter
 Check CXR
 Monitor PA EDP instead of PAOP
 Pull back if spontaneous wedge occurs
 Limit air in cuff (pull back if < 1.25 cc)
 Tx
 CXR
 Check cath position, deflate and withdraw
 Observe
 Complications
 Infection
 Prevention!
 Aseptic technique
 Dead-end caps
 Sterile sleeve (swandom)
 Minimize entry into system
 Avoid glucose containing fluid
 Avoid over changing of tubing, etc (72-96 hr)
 Remove catheter ASAP
 Thrombus
 Prevention – continuous flush +/- heparin
 Tx – lytic agent ; remove catheter
 Emerging Technology
 Devices exist that use arterial pressure waveform to
continuously measure cardiac output
 Variations of the arterial pressure are proportional to stroke
volume
 Several studies demonstrate that SVV has a high sensitivity
and specificity in determining if a patient will respond
(increasing SV) when given volume (“preload
responsiveness”)
 Limitations
 Only used in mechanically ventilated pts
 Wildly inaccurate when arrhythmias are present
 Emerging Technology
 Impedance Cardiography (ICG)
 Converts changes in thoracic
impedance to changes in volume
over time
 ICG offers noninvasive, continuous,
beat-by-beat measurements of:
 Stroke Volume/Index (SV/SVI)
 Cardiac Output/Index (CO/CI)
 Systemic Vascular Resistance/Index
(SVR/SVRI)
 Velocity Index (VI)
 Thoracic Fluid Content (TFC)
 Systolic Time Ratio (STR)
 Left Ventricular Ejection Time
(LVET)
 Pre-Ejection Period (PEP)
 Left Cardiac Work/Index
(LCW/LCWI)
 Heart Rate
 In a Nutshell
 Right heart failure  Hypotension
 Low CI, high PVR  Hypovolemia
 Left heart failure  Low CVP, PAOP, CI
 High SVR
 High PAOP, low CI,
high SVR
 Cardiogenic
 High CVP,PAOP, SVR
 Tamponade  Low CI
 High PAOP, low CI,  Sepsis
CVP ≈ POAP  Low CVP, PAOP, SVR
 High CI
 References
 Pulmonary Artery Catheter Education Project
 http://www.pacep.org

 Chatterjee, The Swan-Ganz Catheters: Past, Present, and Future: A Viewpoint.

Circulation 2009;119;147-152

 Edwards Scientific
 http://ht.edwards.com/presentationvideos/powerpoint/strokevolumevariation/st
rokevolumevariation.pdf
 Question #1
 Which one of the following statements is
most correct?
A) A CVP <2 mmHg usually reflects
hypovolemia if the SVI is>45 mL/beat/M2
B) A CVP >6 mmHg usually reflects RV
failure if the SVI is <25 mL/beat/M2
C) A PAOP >18 mmHg usually reflects LV
failure if the SVI is >45 mL/beat/M2
D) A PAOP <8 mmHg usually reflects
hypovolemia if the SVI is >25 mL/beat/M2
 Answer #1
 Which one of the following statements is
most correct?
A) A CVP <2 mmHg usually reflects
hypovolemia if the SVI is>45 mL/beat/M2
B) A CVP >6 mmHg usually reflects RV
failure if the SVI is <25 mL/beat/M2
C) A PAOP >18 mmHg usually reflects LV
failure if the SVI is >45 mL/beat/M2
D) A PAOP <8 mmHg usually reflects
hypovolemia if the SVI is >25 mL/beat/M2
 Question #2
 Identify the condition most consistent with
the following hemodynamic profile:
SvO2 ... 0.50 ... PAOP ... 21 mmHg
CI ... 2.2 L/min/M2 ...CVP/RA ... 4 mmHg
SVI ... 23 ml/beat M2 ... HR ... 98
A) Hypovolemia
B) Hypervolemia
C) LV dysfunction/failure
D) Bilateral ventricular failure
 Answer #2
 Identify the condition most consistent with
the following hemodynamic profile:
SvO2 ... 0.50 ... PAOP ... 21 mmHg
CI ... 2.2 L/min/M2 ...CVP/RA ... 4 mmHg
SVI ... 23 ml/beat M2 ... HR ... 98
A) Hypovolemia
B) Hypervolemia
C) LV dysfunction/failure
D) Bilateral ventricular failure
 Question #3
 Identify the condition most consistent with
the following hemodynamic profile: SvO2 ...
0.47 ... PAOP ... 4 mm Hg
CI ... 2.0 L/min/M2 ... CVP/RA ... 2 mm Hg
SVI ... 19 ml/beat/M2 ... HR ... 111
A) Hypovolemia
B) Hypervolemia
C) LV dysfunction/failure
D) Bilateral ventricular failure
 Answer #3
 Identify the condition most consistent with
the following hemodynamic profile: SvO2 ...
0.47 ... PAOP ... 4 mm Hg
CI ... 2.0 L/min/M2 ... CVP/RA ... 2 mm Hg
SVI ... 19 ml/beat/M2 ... HR ... 111
A) Hypovolemia
B) Hypervolemia
C) LV dysfunction/failure
D) Bilateral ventricular failure
 Question #4
 Which of the combined set of hemodynamic values is of
greatest concern?
A) CO = 6.9 L/min; CI = 3.8 L/min/M2 SV = 63 mL/beat; SVI
= 34 mL/beat/M2 BP = 102/52 mm Hg SvO2 = 0.83

 B) CO = 4.3 L/min; CI = 2.5 L/min/M2 SV = 43 mL/beat; SVI

= 25 mL/beat/M2 BP = 94/62 mm Hg SvO2 = 0.64

 C) CO = 6.3 L/min; CI = 3.7 L/min/M2 SV = 64 mL/beat; SVI

= 37 mL/beat/M2 BP = 90/56 mm Hg SvO2 = 0.75
 D) CO = 3.8 L/min; CI =2.3 L/min/M2 SV = 73 mL/beat; SVI
= 43 mL/beat/M2 BP = 100/58 mm Hg SvO2 = 0.72
 Answer #4
 Which of the combined set of hemodynamic values is of
greatest concern?
A) CO = 6.9 L/min; CI = 3.8 L/min/M2 SV = 63 mL/beat; SVI
= 34 mL/beat/M2 BP = 102/52 mm Hg SvO2 = 0.83

 B) CO = 4.3 L/min; CI = 2.5 L/min/M2 SV = 43 mL/beat; SVI

= 25 mL/beat/M2 BP = 94/62 mm Hg SvO2 = 0.64

 C) CO = 6.3 L/min; CI = 3.7 L/min/M2 SV = 64 mL/beat; SVI

= 37 mL/beat/M2 BP = 90/56 mm Hg SvO2 = 0.75
 D) CO = 3.8 L/min; CI =2.3 L/min/M2 SV = 73 mL/beat; SVI
= 43 mL/beat/M2 BP = 100/58 mm Hg SvO2 = 0.72
 Question #5
 Immediate treatment of pulmonary artery
rupture may include all of the following
except:
A) Discontinuation of anticoagulation
B) Placing patient in lateral position with
unaffected side down.
C) Selective bronchial intubation
D) PEEP
 Answer #5
 Immediate treatment of pulmonary artery
rupture may include all of the following
except:
A) Discontinuation of anticoagulation
B) Placing patient in lateral position with
unaffected side down.
C) Selective bronchial intubation
D) PEEP
 E) Hire a lawyer