What is a Swan-Ganz catheterization?
A Swan-Ganz catheterization is a type of pulmonary artery catheterization procedure.
It’s a diagnostic test used to determine whether any hemodynamic, or blood flow-related, abnormalities exist in the heart and lungs. It can be a useful test for people who have recently had heart problems, such as a heart attack.
The procedure involves the insertion of a pulmonary artery catheter (PAC) into the right side of the heart and into the arteries that lead to the lungs. The PAC has a balloon tip. The balloon allows the catheter to be carried by the flow of your blood to the place in your heart where it’ll be used.
Because your blood takes the catheter where it’s needed, imaging isn’t needed to help guide it. Therefore, the procedure can be done at your bedside. The PAC is also known as a Swan-Ganz catheter, or right heart catheter.
The procedure itself is sometimes called right heart catheterization. This is because it can measure the pressure of your blood as it flows through the right side of your heart. It measures the pressure at three different places:
- right atrium
- pulmonary artery
- pulmonary capillaries
These measurements can be used to figure out the amount of oxygen in the blood of the right portion of your heart. It’s also used to figure out how much blood flows out of your heart overall.
A PAC is a long, thin tube with a balloon tip on the end. The balloon tip helps the catheter move smoothly through the blood vessels and into the right chamber of the heart. The PAC has been in clinical use for more than 30 years. According to recent literature, it’s not known how often PACs are currently used in the United States.
The PAC is a diagnostic tool used to monitor heart and lung function. It also evaluates the effectiveness of medications. It’s generally inserted into one of three veins:
- Right internal jugular vein (RIJ). This is located in the neck and is the shortest, most direct path to the heart.
- Left subclavian vein. This is located under the clavicle, or collarbone. It’s a large vein on the left side of the upper chest area.
- Femoral veins. These are located in the groin.
In a Swan-Ganz catheterization, the PAC is inserted into one of these access points and guided into the vessels and chambers of the right heart and lung.
A right heart catheterization evaluates the hemodynamics as it circulates through the heart and lungs and into the body. It’s often used to check for complications in the heart, lungs, or kidneys.
The procedure is also used to evaluate:
It’s sometimes used in conjunction with an IV. Heart medications can be delivered through the IV and the effects of this medication can be tested and monitored by the Swan-Ganz.
Swan-Ganz catheterization can also be performed in combination with an endocardial biopsy to prepare for a heart transplant. The endocardial biopsy focuses on the heart muscle. Pulmonary heart pressure must be as low as possible for heart transplant recipients. The Swan-Ganz can help determine whether medications are needed to lower blood pressure.
You’ll probably be asked to avoid eating or drinking anything for at least eight hours before the procedure. Some people will be required to sleep in the hospital the night before the test.
Tell your doctor if any of the following apply to you:
You’ll have to remove any jewelry prior to the procedure.
You’ll also have to sign a consent form before the procedure to show that you understand the risks. Your healthcare provider will tell you exactly what to expect during the procedure.
The PAC may be inserted while you’re in an intensive care unit or a special lab area. The procedure generally follows several steps:
- You’ll be given a sedative to help you relax, but not put you to sleep.
- The area where the PAC will be inserted will be shaved, cleaned, and numbed with local anesthesia so you don’t feel any pain. It’s usually inserted in the neck or groin.
- The doctor will make a small cut to allow the PAC to enter through a vein.
- An introducer sheath, or hollow tube, will be placed into the vein first. This allows for the catheter to enter your body more easily.
- The catheter is then directed through the veins and into the right side of the heart.
- The doctor will then measure the blood pressure in the pulmonary artery.
- A blood sample may be taken to check blood oxygen levels, or heart medications may be administered to check your heart’s response.
- When all the tests are complete, the equipment will be removed and the incision wound will be closed with stitches.
During the procedure, your heartbeat will be closely monitored using an electrocardiogram (EKG) machine. You’ll be awake during the procedure, but you shouldn’t feel pain. You may feel a slight pressure where the catheter is inserted.
The amount of time the PAC stays in the heart depends on the person. For very ill people who require more intense monitoring, the PAC may need to stay in place for a few days.
More common risks of a PAC procedure include:
Pneumothorax, or lung collapse, can also occur as a result of a puncture to the lung. This is more common when the catheter is inserted into the neck or chest veins.
Less common complications include:
The most dangerous risk of a PAC procedure is pulmonary artery rupture, which has a 50 percent mortality rate, according to one study. This is a rare complication that most often affects women over 60 years old who have PAH. It’s also more of a risk for people receiving anticoagulation, or blood-thinning, therapy.
Swan-Ganz catheterization and other PACs have been the subject of controversy over the years. This is in part because of a 1996 study led by Alfred F. Connors, Jr. of Case Western Reserve University. According to the study, the PAC procedure might increase the risk of death for people who are critically ill.
Additional studies have since questioned the usefulness of the Swan-Ganz catheterization as unreliable, inaccurate, and poorly understood and misinterpreted by medical personnel. More recent technologies offer less invasive and reliable results. They include:
- Transesophageal echocardiography. This is a type of echocardiogram. A small transducer is guided down the throat to behind the heart to view any problems.
- Pulse contour technology. This is a noninvasive system that continuously and comprehensively monitors cardiac output using an arterial line, or catheter.
- Dynamic assessment of fluid responsiveness. This is a continuous assessment of how responsive the body will be to adding IV fluid to increase cardiac output. Sometimes giving fluids won’t help increase cardiac output.
Despite these controversies, PAC still has a role in the diagnosis and management of PAH and acute right-ventricular failure.
Pulmonary artery catheterization is a diagnostic procedure in which an intravascular catheter is inserted through a central vein, such as the femoral, jugular, antecubital or brachial vein, to connect to the right side of the heart and advance towards the pulmonary artery. Pulmonary artery catheterization remains an excellent tool for the assessment of patients with pulmonary hypertension, cardiogenic shock, or unexplained dyspnea. It can be used to assess right-sided cardiac chamber filling pressures, to estimate cardiac output, to evaluate intracardiac shunts, to evaluate cardiac valves, or to assess vascular resistance. This activity describes the indications and techniques involved in pulmonary artery catheterization and highlights the role of the interprofessional team in the care of patients undergoing this procedure.
Objectives:
Identify the anatomical structures pertinent to pulmonary artery catheterization.
Summarize the indications for pulmonary artery catheterization.
Review the complications associated with pulmonary artery catheterization.
Explain interprofessional team strategies for improving care coordination and communication to advance the safe use of pulmonary artery catheters to minimize complications and improve patient outcomes.
Pulmonary artery catheterization (PAC) is a procedure in which an intravascular catheter is inserted through a central vein (femoral, jugular, antecubital or brachial) to connect to the right side of the heart and advance towards the pulmonary artery. This diagnostic procedure can be utilized to assess right sided cardiac chamber filling pressures, estimation of cardiac output, intracardiac shunt evaluation, valvular studies, and vascular resistance. Despite the decrease in the use of pulmonary artery catheterization for evaluation and management of critically ill patients, it still remains an excellent tool for assessment of patients with pulmonary hypertension, cardiogenic shock, and unexplained dyspnea[1].
Insertion of the catheter from one of the main central veins (subclavian, internal jugular, femoral) traverses into the superior or inferior vena cava and reach the right atrium. From the right atrium through the tricuspid valve, the catheter reaches the right ventricle. From here the catheter is advanced to the right ventricular outflow tract and then to the pulmonary artery after getting across the pulmonary valve. The tip of the catheter lays into the main pulmonary artery, where the balloon can be inflated and deflated for measurement of pressures. Balloon can be inflated here to obtain pulmonary capillary wedge (or occlusive) pressure which gives an indirect assessment of left sided filling pressures.
During the placement of the catheter, due to the transducer that is in the catheter, a pressure waveform can be seen in the monitor. Each section of the right heart anatomy has a distinctive pattern that can help to assist or helps to determine where is the catheter tips.
The most frequent indications for placement of a pulmonary artery catheter are the following[2][3]:
Evaluation or diagnosis of pulmonary hypertension
Distinduishing etiology of shock based on mixed venous oxygen saturation (SvO2) measurement such as in septic or cardiogenic shock[4]
Assessment of volume status in severe shock[5]
Evaluation of pericardial illnesses such as cardiac tamponade or constricitve pericarditis
Assessment of right-sided valvular disease, congenital heart disease, cardiac shunts, when surgical repair is planned
Contraindications for placement of right heart catheterization are[6]:
Insertion of the catheter through a site where is an active infection
Presence of a Right sided ventricular assist device
Lack of consent
A relative contraindication is the presence of left bundle branch block. If this is the case, due to the risk of right bundle branch block during catheter insertion, external or transvenous pacer should be placed at the moment of the procedure to prevent complete heart block.
A Swan-Ganz catheter or right heart catheter is a quadruple-lumen catheter with a thermodilution sensor that is attached to a pressure transducer outside the body, with this transducer, is possible to determine the central vein pressure, right atrial pressure, right ventricular pressure, and pulmonary artery pressure[7].
The catheters size range from 60 to 110 cm in length and 4F to 8F in caliber
Each of the 4-lumen is placed in a specific distance through the length of the catheter, and each of them has a specific function, as explained[7]:
The blue lumen or CVP port represent the right atrial lumen. Ii is at 30 cm from the tip of the catheter and rests within the right atrium. It is the proximal port and can be used for infusion. This port can assess central venous pressure (CVP) and right atrial pressure.
The white or clear lumen terminates close to the prior lumen, at 31 cm from the tip of the catheter and lies in the right atrium. This port is used for infusion.
The yellow lumen or PA distal is the pulmonary artery lumen is the distal port at the tip of the catheter. This port does the measurement of the pulmonary artery pressure. Mixed venous can be drawn from this port too.
The thermistor is a red/white connector that consists a temperature-sensitive wire that terminates 4 cm proximal to the tip of the catheter. The terminal portion of the wire is called the thermistor bead, and it rests in a main pulmonary artery when the catheter tip is positioned correctly. The connection of the thermistor port to cardiac output (CO) monitor allows determination of a CO using thermodilution.
The red port is the balloon port. Air is introduced to inflate the balloon and removed when needs to be deflated.
The pulmonary artery catheter has a balloon that can be inflated and helps the clinician place the tip of the catheter in the pulmonary artery.
Within the catheter, there are black lines that help to measure the length of the catheter. One thin line is 10 cm, and a thick black line indicated 50 cm.
Preparation for the pulmonary artery catheter is similar for the placement of every invasive procedure.
Verbal consent is necessary before the procedure. Detail explanation of the procedure, risk, and benefits need to be done before starting the procedure.
Selection of the site of insertion of the catheter needs to be selected before starting the procedure. Especial consideration needs to be taken when selecting the site of insertion as skin or site infection, prior vein thrombosis or anatomical abnormalities to prevent complications. Proper catheter selection according to the insertion site is necessary.
Sterile barriers and techniques need to be done during the procedure. Proper cleaning of the site of insertion and draping of the patient is necessary. Also, the person doing the procedure needs to be wearing protective equipment and sterile barrier as sterile gloves, mask, and surgical gown.
Pulmonary artery catheterization can be done under fluoroscopy (most common) or at the bedside with use of ultrasound and echocardiography for catheter placement.
Complications related to catheter placement are similar to the placement of central catheter placement[8]. Infection of the site of insertion can occur.
Pneumothorax or hemothorax can be a complication after insertion when the catheter is placed in the subclavian vein.
Air embolism caused by entrainment of air from the infusion ports.
Complications related to catheter insertion include the occurrences of atrial or ventricular arrhythmias due to irritation or contact of the catheter with the cardiac walls[9].
Valve rupture or cardiac wall perforation can occur but it is rare.
Misplacement of the catheter can occur due to looping of the catheter in the right chambers. This can be prevented with the placement of the catheter under fluoroscopy and paying attention to the waveforms in the monitor.
Vessel rupture can happen at the moment of balloon inflation into the pulmonary artery. Pulmonary artery perforation, pseudoaneurysm formation, and rupture can develop and has a 30% to 70% mortality[10].
Pulmonary infarction can occur when the balloon is inflated for long period or migration to the catheter to the distal branches.
Thromboembolism can also occur secondary to inflammation or infection of the catheter that acts as a nidus for thrombus.
As mentioned before, placement of the PAC helps for diagnosis of multiple conditions[2][3].
PAC can help to determine causes of shock, as cardiogenic versus other causes as septic shock or distributive shock by obtaining SvO2
PAC is used to determine the cause of pulmonary hypertension for proper treatment after classification in the different groups of pulmonary hypertension.
PAC can help to determine the intracardiac pressurea and valvular abnormalities.
PAC also helps to determine intracardiac shunts and to determine hemodynamic state before the procedure.
PAC is an important procedure for diagnosis and management of different conditions and despite the underuse of this procedure, still useful.
PAC can be used to estimate pulmonary capillary wedge pressure to give indirect assessment of left sided filling pressures.
Pulmonary artery catheterization was once frequently done in ICU patients for various reasons. While a good technique for some patients, pulmonary artery catheterization is now being replaced by echocardiography, which has a lower morbidity than the pulmonary catheter. Pulmonary artery catheterization requires ICU nurses as part of the interprofessional team for insertion and monitoring. The technique is also associated with complications. Echo can be done at the bedside without the need for X-ray or fluoroscopy.
Review Questions
1.
Pulmonary Artery Catheter Consensus Conference: consensus statement. New Horiz. 1997 Aug;5(3):175-94. [PubMed: 9259329]
2.Rapoport J, Teres D, Steingrub J, Higgins T, McGee W, Lemeshow S. Patient characteristics and ICU organizational factors that influence frequency of pulmonary artery catheterization. JAMA. 2000 May 17;283(19):2559-67. [PubMed: 10815120]
3.Koo KK, Sun JC, Zhou Q, Guyatt G, Cook DJ, Walter SD, Meade MO. Pulmonary artery catheters: evolving rates and reasons for use. Crit Care Med. 2011 Jul;39(7):1613-8. [PubMed: 21494107]
4.Connors AF, Speroff T, Dawson NV, Thomas C, Harrell FE, Wagner D, Desbiens N, Goldman L, Wu AW, Califf RM, Fulkerson WJ, Vidaillet H, Broste S, Bellamy P, Lynn J, Knaus WA. The effectiveness of right heart catheterization in the initial care of critically ill patients. SUPPORT Investigators. JAMA. 1996 Sep 18;276(11):889-97. [PubMed: 8782638]
5.Chittock DR, Dhingra VK, Ronco JJ, Russell JA, Forrest DM, Tweeddale M, Fenwick JC. Severity of illness and risk of death associated with pulmonary artery catheter use. Crit Care Med. 2004 Apr;32(4):911-5. [PubMed: 15071376]
6.Evans DC, Doraiswamy VA, Prosciak MP, Silviera M, Seamon MJ, Rodriguez Funes V, Cipolla J, Wang CF, Kavuturu S, Torigian DA, Cook CH, Lindsey DE, Steinberg SM, Stawicki SP. Complications associated with pulmonary artery catheters: a comprehensive clinical review. Scand J Surg. 2009;98(4):199-208. [PubMed: 20218415]
7.Swan HJ, Ganz W, Forrester J, Marcus H, Diamond G, Chonette D. Catheterization of the heart in man with use of a flow-directed balloon-tipped catheter. N Engl J Med. 1970 Aug 27;283(9):447-51. [PubMed: 5434111]
8.Lopes MC, de Cleva R, Zilberstein B, Gama-Rodrigues JJ. Pulmonary artery catheter complications: report on a case of a knot accident and literature review. Rev Hosp Clin Fac Med Sao Paulo. 2004 Apr;59(2):77-85. [PubMed: 15122422]
9.Sprung CL, Pozen RG, Rozanski JJ, Pinero JR, Eisler BR, Castellanos A. Advanced ventricular arrhythmias during bedside pulmonary artery catheterization. Am J Med. 1982 Feb;72(2):203-8. [PubMed: 7058832]
10.Ducatman BS, McMichan JC, Edwards WD. Catheter-induced lesions of the right side of the heart. A one-year prospective study of 141 autopsies. JAMA. 1985 Feb 08;253(6):791-5. [PubMed: 3968816]