What is the efficacy of pulmonary artery catheterization (PAC)?

Updated: Dec 22, 2017
  • Author: Bojan Paunovic, MD; Chief Editor: Karlheinz Peter, MD, PhD  more...
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Answer

Data from the Acute Decompensated Heart Failure Syndromes (ATTEND) Registry involving 4842 patients showed appropriate PAC use reduced in-hospital mortality in patients with acute heart failure syndromes, particularly those with lower systolic blood pressure or who received inotropic therapy. [19] In the study, 16.8% patients (n = 813) were managed with PACs, of which 502 were propensity score-matched with 502 control subjects. Patients in the PAC group had lower all-cause mortality than those in the control group. [19]

Overall, the literature does not show a positive effect on patient outcome with PAC use. However, a criticism of the current available research is that patient groups potentially benefit from the use of a PAC but this effect is lost in studies that also include patient groups that gain little or no benefit. Chittock et al published an observational cohort study showing that PAC use was associated with increased mortality in less acutely ill patients but associated with decreased mortality in more acutely ill patients. [20]

As well, the use of a monitoring tool such as the PAC itself is unlikely to show a significant treatment effect. Some criticize the current literature because a number of studies did not use a predefined treatment protocol. The lack of defined specific treatment based on measured PAC-derived variables could contribute more to patient outcome than merely the presence or absence of a PAC.

Contention also exists that PACs do not harm people; people harm people. In other words, operator competence may be the root cause of the mortality difference. Reviews have shown deficiencies in both nursing-dependent information derived from the PAC as well as physician-dependent interpretation and subsequent management.

Nevertheless, the growing evidence of the limitations of PACs may be affecting clinical practice. A time-trend analysis on national estimates of PAC use in the United States from 1993–2004, using data from the Nationwide Inpatient Sample, found a 65% decrease in PAC use during that period; the most prominent decline, by 81%, was in use of PACs for myocardial infarction. [21] Canadian authors also found more than a 50% reduction in PAC use. [22]

The advent of newer noninvasive imaging modalities may also be making inroads into PAC use. For example, noninvasive devices have been developed that measure cardiac output using ultrasound. [23] As well, the measurement of arterial pressure waveforms have shown good correlation when compared to the PAC thermodilution technique. [24]

The increased availability of bedside echocardiography is likely contributing to the decline in PAC use, as was postulated in a recent observational study in patients with acute coronary syndromes. [25]

More recent reviews agree on the importance of a measured approach to PAC use; PACs remain an important tool, but they should be used only in selected patients and only by well-trained physicians. [26, 27, 28, 29, 30]

A concise review by Chatterjee offers some reasonable indications for ongoing PAC use; however, these unfortunately lack empiric evidence at present. [26]


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