|LETTER TO THE EDITOR
|Year : 2021 | Volume
| Issue : 4 | Page : 272-273
Pulmonary artery catheter in left pulmonary artery: Should we worry
Kunal Sarin1, Vikas Kumar Shankhyan1, Paul Varghese2
1 Department of Anesthesia and Critical Care, Army Hospital (Research and Referral), New Delhi, India
2 Department of Cardio Thoracic Surgery, Army Hospital (Research and Referral), New Delhi, India
|Date of Submission||27-Jun-2021|
|Date of Acceptance||22-Jul-2021|
|Date of Web Publication||20-Oct-2021|
Dr. Kunal Sarin
Department of Anesthesia and Critical Care (Cardiac Anaesthesia), Army Hospital (Research and Referral), New Delhi - 110 010
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Sarin K, Shankhyan VK, Varghese P. Pulmonary artery catheter in left pulmonary artery: Should we worry. APIK J Int Med 2021;9:272-3
|How to cite this URL:|
Sarin K, Shankhyan VK, Varghese P. Pulmonary artery catheter in left pulmonary artery: Should we worry. APIK J Int Med [serial online] 2021 [cited 2022 Aug 17];9:272-3. Available from: https://www.ajim.in/text.asp?2021/9/4/272/328679
Pulmonary artery (PA) catheter based on the principle of flow direction through balloon flotation was introduced by Swan et al., in 1970 for hemodynamic assessment of the patients with acute myocardial infarction. During cardiac and noncardiac surgeries, various cardiorespiratory indices can be monitored by the polyvinyl chloride PA catheters.
We present a case of a 78-year-old male with a history of hypertension and diabetes mellitus presented with the New York Heart Association Class III chest pain, diagnosed to have triple vessel disease with ejection fraction of 40% and inferior wall hypokinesia, scheduled for coronary artery bypass graft surgery (CABG). The patient was taking beta-blockers, aspirin, oral hypoglycemics, atorvastatin, and angiotensin-converting enzyme inhibitors preoperatively. After an uneventful induction, the right internal jugular vein was cannulated and a PA catheter 7.5 F (Edwards Lifesciences Swan Ganz, CA, USA) was introduced through the 8.5 F introducer sheath (Edwards Lifesciences Introflex, CA, USA). The distal port was attached to the transducer and the catheter was guided into the PA using the waveform technique. After obtaining the PA catheter wedge position, the balloon was deflated and the catheter was fixed. PA catheter was used during the surgery to guide fluid therapy and titrate the ionotropic and vasopressor support post-CABG. After shifting the patient to the intensive care unit, a routine chest X-ray was ordered as per the protocols. It was on chest X-ray that the position of the PA catheter in the left PA (LPA) was noticed [Figure 1]. After this, till extubation, hemodynamic indices, and PA Catheter observations were recorded for any variation from the clinical profile of the patient. The patient was extubated the next day and the PA catheter was removed 6 h thereafter.
In cardiac surgery, placement of PA catheters is generally indicated in major procedures involving large fluid shifts or blood loss in patients with: Right-sided heart failure, pulmonary hypertension • Severe left-sided heart failure not responsive to therapy • Cardiogenic or septic shock or with multiple-organ failure • Orthotopic heart transplantation • Left ventricular assist device implantation and common perioperative scenarios such as acute and chronic pulmonary hypertension and pulmonary thromboembolism, cardiopulmonary bypass weaning failure intraoperatively, postcardiac surgery vasopressor or ionotrope weaning failure.
Various studies have researched on potential differences between pressures in the LPA and right pulmonary artery (RPA). These are based on the geometrical anatomical differences, differences in flow velocities, and pulmonary valve dysfunction. Muster et al. in their study stated that significantly different pressures in the RPA and LPA PA were observed at catheterization in patients with pulmonary valve stenosis and no branch stenosis. Burman et al. measured cine cardiovascular magnetic resonance main and branch PA diameters and cross-sectional areas in diastole and systole to establish normal ranges and the effects on them of age, gender, and body surface area. They observed consistent differences in their findings.
Due to anatomical factors such as a straighter course of the larger-sized RPA receiving more blood flow as compared to LPA, the catheter tends to localize more commonly in the RPA than in the LPA, as it floats with the blood flow. Tempe et al. in their study on the incidence of the PA catheter placement in patients undergoing cardiac surgery; observed a significantly higher probability of the PA catheter entering the RPA than LPA (96% vs. 3%, P < 0.001). Benumof et al. using radiograph reported that the majority of the PA catheters are located in the RPA. The PA catheter passing through the pulmonary valve can lead to some pulmonary dysfunction and flow across it.
None of the studies have brought out the clinical impact and management of patients based on findings of the RPA or LPA pressure readings. Ninety-six percent of times the PA catheter floats to the RPA. In our case, the PA catheter incidentally entered LPA. This did not have any impact on patient management. Hence, the study supports the finding that there should be no advantage in placing the catheter in the RPA over LPA and should not be attempted.
To conclude, review of literature and our experience indicates that clinical management based on hemodynamic data derived from the PA catheter does not change with the location of the PA catheter. Patient management is not affected in the left-sided PA Catheter.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Stocking JE, Lake CL. The role of the pulmonary artery catheter in the year 2000 and beyond. J Cardiothorac Vasc Anesth 2000;14:111-2.
Alexander JC. Mittnach, David L. Reich, Michael Sander, Joel A. Kaplan. Monitoring of the Heart and Vascular System. Kaplan's Textbook of Cardiac Anesthesia for Cardiac and Noncardiac Surgery. 7th ed. pg 408.
Muster AJ, van Grondelle A, Paul MH. Unequal pressures in the central pulmonary arterial branches in patients with pulmonary stenosis. The influence of blood velocity and anatomy. Pediatr Cardiol 1982;2:7-14.
Burman ED, Keegan J, Kilner PJ. Pulmonary artery diameters, cross sectional areas and area changes measured by cine cardiovascular magnetic resonance in healthy volunteers. J Cardiovasc Magn Reson 2016;18:12.
Tripathi M, Pandey M. Intrathoracic pulmonary artery catheter allocation in the background of left atrial dilatation. J Cardiovasc Surg (Torino) 2003;44:719-24.
Tempe DK, Batra UB, Datt V, Tomar AS, Virmani S. Where does the pulmonary artery catheter float: Transesophageal echocardiography evaluation. Ann Card Anaesth 2015;18:491-4.
] [Full text]
Benumof JL, Saidman LJ, Arkin DB, Diamant M. Where pulmonary arterial catheters go: Intrathoracic distribution. Anesthesiology 1977;46:336-8.