Approach to Right heart Catheterization (Swan-Ganz catheterization, PA Catheterization)
Many of our CCU patients have Swan-Ganz/PA catheters in place. They provide extremely valuable diagnostic and prognostic information and can be a critical tool for guiding management in critically ill patients. However, the sheer amount of data can sometimes be overwhelming. This infographic aims to help with 1) Learning the normal intracardiac pressures. 2) Utilization of these variables to derive important hemodynamic parameters. 3) Understanding some of the diagnostic and/or prognostic significance of these parameters, and how to use them in clinical practice.
RHC Infographic by Dr. Ahmed Ghoneem
RHC infographic: References
“PVR is the recommended parameter for differentiating subtypes of PH.”
Galiè N, McLaughlin VV, Rubin LJ, Simonneau G. An overview of the 6th World Symposium on Pulmonary Hypertension. Eur Respir J. 2019 Jan 24;53(1):1802148. doi: 10.1183/13993003.02148-2018. PMID: 30552088; PMCID: PMC6351332.
“PAPi ≤ 0.9 predicts RV failure and in-hospital mortality in inferior MI.”
Korabathina R, Heffernan KS, Paruchuri V, Patel AR, Mudd JO, Prutkin JM, Orr NM, Weintraub A, Kimmelstiel CD, Kapur NK. The pulmonary artery pulsatility index identifies severe right ventricular dysfunction in acute inferior myocardial infarction. Catheter Cardiovasc Interv. 2012 Oct 1;80(4):593-600. doi: 10.1002/ccd.23309. Epub 2012 Jan 10. PMID: 21954053.
“PAPi < 1.85 predicts RV failure in patients with LVADs.”
Morine KJ, Kiernan MS, Pham DT, Paruchuri V, Denofrio D, Kapur NK. Pulmonary Artery Pulsatility Index Is Associated With Right Ventricular Failure After Left Ventricular Assist Device Surgery. J Card Fail. 2016 Feb;22(2):110-6. doi: 10.1016/j.cardfail.2015.10.019. Epub 2015 Nov 10. PMID: 26564619.
“RA/PCWP > 0.54 predicted RV dysfunction in patients with LVADs.”
Soliman OII, Akin S, Muslem R, Boersma E, Manintveld OC, Krabatsch T, Gummert JF, de By TMMH, Bogers AJJC, Zijlstra F, Mohacsi P, Caliskan K; EUROMACS Investigators. Derivation and Validation of a Novel Right-Sided Heart Failure Model After Implantation of Continuous Flow Left Ventricular Assist Devices: The EUROMACS (European Registry for Patients with Mechanical Circulatory Support) Right-Sided Heart Failure Risk Score. Circulation. 2018 Feb 27;137(9):891-906. doi: 10.1161/CIRCULATIONAHA.117.030543. Epub 2017 Aug 27. PMID: 28847897.
“RA/PCWP >0.63 predicted RV dysfunction in patients with LVADs.”
Kormos RL, Teuteberg JJ, Pagani FD, Russell SD, John R, Miller LW, Massey T, Milano CA, Moazami N, Sundareswaran KS, Farrar DJ; HeartMate II Clinical Investigators. Right ventricular failure in patients with the HeartMate II continuous-flow left ventricular assist device: incidence, risk factors, and effect on outcomes. J Thorac Cardiovasc Surg. 2010 May;139(5):1316-24. doi: 10.1016/j.jtcvs.2009.11.020. Epub 2010 Feb 4. PMID: 20132950.
“CPO of <0.6 was the strongest independent hemodynamic correlate in the SHOCK trial registry for in-hospital mortality in patients with cardiogenic shock.”
Fincke R, Hochman JS, Lowe AM, Menon V, Slater JN, Webb JG, LeJemtel TH, Cotter G; SHOCK Investigators. Cardiac power is the strongest hemodynamic correlate of mortality in cardiogenic shock: a report from the SHOCK trial registry. J Am Coll Cardiol. 2004 Jul 21;44(2):340-8. doi: 10.1016/j.jacc.2004.03.060. PMID: 15261929.
“LV Transmural Filling Pressure.”
Borlaug BA, Reddy YNV. The Role of the Pericardium in Heart Failure: Implications for Pathophysiology and Treatment. JACC Heart Fail. 2019 Jul;7(7):574-585. doi: 10.1016/j.jchf.2019.03.021. PMID: 31248569; PMCID: PMC6601642.
“Studies have shown good correlation between TD and Direct Fick in severe TR and extremes of CO.”
Hoeper MM, Maier R, Tongers J, Niedermeyer J, Hohlfeld JM, Hamm M, Fabel H. Determination of cardiac output by the Fick method, thermodilution, and acetylene rebreathing in pulmonary hypertension. Am J Respir Crit Care Med. 1999 Aug;160(2):535-41. doi: 10.1164/ajrccm.160.2.9811062. PMID: 10430725.
Yung GL, Fedullo PF, Kinninger K, Johnson W, Channick RN. Comparison of impedance cardiography to direct Fick and thermodilution cardiac output determination in pulmonary arterial hypertension. Congest Heart Fail. 2004 Mar-Apr;10(2 Suppl 2):7-10. doi: 10.1111/j.1527-5299.2004.03406.x. PMID: 15073478.
“Central venous pressure (CVP) was shown as one of the predictors of SCAI profile and mortality in the Cardiogenic Shock Working Group registry.”
Thayer KL, Zweck E, Ayouty M, Garan AR, Hernandez-Montfort J, Mahr C, Morine KJ, Newman S, Jorde L, Haywood JL, Harwani NM, Esposito ML, Davila CD, Wencker D, Sinha SS, Vorovich E, Abraham J, O’Neill W, Udelson J, Burkhoff D, Kapur NK. Invasive Hemodynamic Assessment and Classification of In-Hospital Mortality Risk Among Patients With Cardiogenic Shock. Circ Heart Fail. 2020 Sep;13(9):e007099. doi: 10.1161/CIRCHEARTFAILURE.120.007099. Epub 2020 Sep 9. PMID: 32900234.
Other references used to create this infographic:
Eric L. Bonno, Michael C. Viray, Gregory R. Jackson, Brian A. Houston, Ryan J. Tedford; Modern Right Heart Catheterization: Beyond Simple Hemodynamics. Advances in Pulmonary Hypertension 1 January 2020; 19 (1): 6–15.
Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine. Tenth edition. Philadelphia, PA: Elsevier/Saunders, 2015.
Anwaruddin S, Martin JM, Stephens JC, Askari AT. Cardiovascular Hemodynamics: An Introductory Guide: Humana Press; 2012
About Right Heart Catherization InfoGrpahic Creator
Dr. Ahmed Ghoneem is an internal medicine resident at Lahey Hospital and Medical Center in Burlington, Massachusetts. He received his medical degree from Alexandria University in Egypt, where he also completed a 4-year cardiology residency and one year as a junior faculty member. In 2018, he joined the Cardiovascular Imaging Research Center at the Massachusetts General Hospital in Boston as a clinical research fellow up until he started his residency last July. His interests include cardiac PET imaging, mechanical circulatory support and interventional cardiology, with a special passion for structural interventions. Outside the hospital, he is quite the movie buff ; a huge fan of Quentin Tarantino and “everything Batman”.
Dr. Steven Hsu, Assistant Professor of Medicine, Advanced Heart Failure Cardiologist and Medical Director of the Mechanical Circulatory Support program at The Johns Hopkins Hospital. See Cardionerds episode 15. HF part 4: LVAD 101 with Dr. Steve Hsu.
Dr. Sachin Shah, Advanced Heart Failure Cardiologist at Beth Israel Lahey Health and Assistant professor of Medicine, Tufts University School of Medicine.