1. The Swan-Ganz Catheter

2. What is a Swan?
• Full name: Swan-Ganz Catheter
• Pulmonary Artery (PA) Catheter = right heart catheter
• Used it to monitor a patient’s hemodynamics when we
cant answer the question using noninvasive/clinical
measures
• Useful to measure right atrial, pulmonary artery, right
ventricular pressures and indirectly measure left atrial
pressures, cardiac output and systemic vascular resistance

3. Why use a Swan?
• Differentiation between causes of shock>cardiogenic,
hypovolemic, septic
• Differentiation between causes of pulmonary
edema>cardiogenic versus noncardiogenic
• Diagnosis of pericardial tamponade
• Diagnosis of intracardiac shunt
• Evaluation/Management of pulmonary hypertension
• Diagnosis of lymphangitic spread of tumor and fat
embolism
• Management of complicated MI, HF
• Determine need for vasopressor/inotropic therapy
• Fluid Status>in GI bleed, renal failure, sepsis
• Ventilator management>determining the best PEEP

4. Some history…
• First pulm catheters were placed in 1940s
• 1970-William Ganz and Harold Swan introduced this
catheter. Pulmonary artery Catheter that is balloon-tipped
and flow directed, placed bedside
• Revolutionized catheters>moved from diagnosis only to
help in management. No clinical trials were done to see if
they improved mortality. Benefit was assumed
• 1987- nonrandomized trials:showed mortality was higher
in patients with an acute MI who had a Swan placed
• 1990s-Ontorio Intensive Care Group attempted a RCT for
use of Swans>not done b/c many clinicians felt unethical
to withhold Swan placement because accurate
diagnosis=accurate treatment=better prognosis????

5. Is it unethical to withhold Swan Placement?
And are they better at predicting clinical outcomes?
• 1996 observational study of RHC in first 24 hours said NO.
• Placement led to worse patient outcomes b/c of
complications of placement or misinterpretation of data
• Use of catheter might be a marker of more aggressive
care, which is associated with higher mortality
• Changes in therapy in response to the information might
have led to high mortality (i.e. using pressors)
• Study might not have adequately adjusted for
confounding factors
• Only looked at SGC placed in first 24 hours.
• Connors AF Jr, Speroff T, Dawson NV, et al. The effectiveness of right heart catheterization
in the initial care of critically ill patients. JAMA 1996;276:889-897

6. Randomized, Controlled Trial of the Use of Pulmonary-Artery
Catheters in High-Risk Surgical Patients. Sandman et al. NEJM-
Jan, 2003
• 1994 high-risk surgical patients underwent randomization
for PA catheters (RCT)
• Preop placement, for elective or urgent surgery
• Looked at 6mo and 12 mo mortality
• No difference b/t PA catheter group from placebo in terms
of mortality and length of hospitalization
• Increased risk of PE in the catheter group and thus, PA
catheters may be associated with increased morbidity

7. Escape Trial
• The value of Swan-Ganz catheterization to
guide tailored therapy in heart failure
patients is an area of controversy.
• The randomized ESCAPE trial showed no
benefit on a primary end point of the
number of days alive and out of the hospital
at six months
JAMA. 2005;294:1625-1633.

8. To Swan or Not to
Swan?
INDIVIDUALIZE CARE
Understanding Swan Ganz Catheters=
Understanding Hemodynamics

10. Basic Catheter Features
• Made of polyvinylchloride and has a
pliable shaft that softens at body
temperature
• Catheter is 110 cm and external diameter
is either 5 or 7 French (1
French=0.0335mm)
• Balloon is fastened 1-2mm from the tip
and when inflated it guides the catheter
(using fluid dynamic drag) from greater
intrathoracic veins through tight heart
into pulmonary artery
• Thermistor-4cm proximal to the tip,
measures temperature>important for
determining cardiac output

11. • Typically catheters have 4
ports:
2. White port with blue wire is the
proximal port> terminates at
30cm from tip of catheter and is
used to measure right atrium
pressures
3. White port, yellow wire is the
PAD distal port
4. White port with red wire is for
balloon inflation
5. Last port has the connection to
the thermodilution cardiac
output computer> contains the
electrical leads for thermistor.

12. Insertion Techniques
• Average time from decision to use PA catheter
until onset of catheter based treatment is 120
minutes
• Goal: get the catheter to the pulmonary artery
• Cordis into right internal jugular vein or left
subclavian allows easiest passage
• Swan should be oriented ex-vivo to approximate
the course in the body
• Catheter goes through an introducer and into the
vein. The balloon stays closed until we reach
the right atrium.
• When we reach the right atrium (20cm), balloon
should be inflated to reduce possibility of injury
to the myocardium.
• Then the balloon should be moved quickly
through the right ventricle (30cm)> and then
pulmonary artery (40cm) and PCWP (50cm)
FROM SUBCLAVIAN/IJ APPROACH

13. How do you know you are in the Right
Atrium?>>20 cm
Normal right atrial presssure is 0-6mmHg.
Normal oxygen content 15%
Normal O2 saturation 75%
a=atrial contraction.
c=sudden motion of the AV ring toward
the right atrium
x descent=atrial relaxation
v=pressure generated by venous filling
of the right atrium
y descent=rapid emptying of the RA
into RV

14. What Elevates the Right Atrial Pressure?
• RV infarct
• Pulmonary hypertension
• Pulmonary stenosis
• Left to right shunt
• Tricuspid valvular disease
• Left heart failure

15. Prominent RA pulsations
• Prominent a wave:
• Tricuspid stenosis
• Cannon a wave:
• AV dissociation or Ventricular tachycardia
• Prominent v wave:
• Tricuspid regurgitation or VSD

16. How do you know you are in the right ventricle?
30cm
RV systolic=17-30
RV diastolic=0-6
RV O2 content=15%
RV O2 saturation 75%

17. What Increases RV Pressures?
• RV failure
• Pulmonary hypertension
• Pulmonary stenosis
• Pulmonary Embolism
• Cardiomyopathy
• Cardiac tamponade
• Cardiac constriction

18. How do you know you are in the pulmonary artery?
Normal PA pressure,
systolic 15-30
Normal PA pressure,
diastolic 5-13
O2 content 15%
O2 saturation 75%

19. What Elevates PA pressure?
• Volume Overload (backflow)
• Primary lung disease
• Primary pulmonary hypertension
• Pulmonary Embolism
• Left to right shunt
• Mitral Valve Disease

20. THE WEDGE:
What is the Pulmonary Artery Wedge Pressure?
The measurement is obtained when the inflated balloon impacts into a slightly
smaller branch of the pulmonary artery. This is where the arterial pressure exceeds
the venous pressure and the venous pressure exceeds the alveolar pressure, thereby
creating a continuous column of blood from the catheter tip to the left atrium
when the balloon is inflated. Pulmonary venous pressure is the best indicator of
left atrial pressure except when there is venoocclusive disease. AND ONLY
WHEN THE PA CATHETER IS IN ZONE 3 of the lung.

21. Inflation of the Balloon for PCWP Tracing
Pulmonary artery wedge 2-12 PCWP tracing looks like RA tracing
Pulmonary vein O2 content 20% except that the v wave is slightly higher
Pulmonary vein O2 sat 98% than the a wave (opposite of RA).
Also, b/c of the time required for LA
mechanical events, PAWP waveforms are
further delayed when recorded by EKG

22. What Increases PCWP?
• PEEP (minimally)
• LV failure
• Cardiac tamponade
• Aortic Insufficiency
• Mitral regurgitation
• VSD

23. Prominent PCWP Tracings
• Prominent a waves:
-mitral stenosis
-LV systolic dysfunction
-LV overload
-Decreased LV compliance
• Prominent v waves
-mitral regurgitation
-VSD

25. Calculation of Cardiac
Output
Thermodilution versus Ficks method
•Thermodilution: Add an indicator substance (5ml of dextrose or
saline) that is cooler than blood. Indicator in injected through the
proximal port of the PA catheter and mixes with the blood in the
RV. The mixing lowers the temperature of the flowing blood which
is carried to the distal thermistor port. The thermistor records the
temperature change and electronically displays a temperature/time
curve. The area under the curve is inversely proportional to the
flow rate in the pulmonary artery which equals the cardiac output
in absence of intracardiac shunt
-sources of error with thermodilution are seen with tricuspid
regurgitation and intracardiac shunts

26. Fick’s Method
• General principle: the release or uptake of a substance by
an organ equals the product of the bloodflow through that
organ times the difference of arteriovenous concentrations
of that substance.
• CO= O2 consumption (ml/min)
---------------------------------------------------------------
arterial O2 content(PCWP)-mixed venous (PA) O2 content
• O2 consumption varies according to individual, by age and
sex. Usually estimated as being 250mL for a 70kg male.
Generally estimated at 130mL x BSA
• Blood O2 content=% saturation X Hb x 1.39 ml O2/gm Hb
• Errors: assumptions of O2 consumption, wont work at all
with intracardiac shunts. But works better with TR

27. Cardiac Output/Index
• What is cardiac output?
• What is normal cardiac output?
• What is normal cardiac index?

28. Effects of PEEP
• Effects of positive end-expiratory pressure —
Alveolar pressure will not return to atmospheric
pressure at end-expiration in the presence of
positive end-expiratory pressure (PEEP), a change
that can affect the measurement of intravascular
pressures.
• The effects of PEEP are generally felt not to be
clinically significant.
• PEEP does affect right sided pressures (i.e. RA or
CVP).

29. Systemic Vascular Resistance (SVR)
• Refers to the resistance to blood flow offered by all of the
systemic vascular resistance, excluding the pulmonary
vasculature.
• This is sometimes referred as total peripheral resistance
(TPR).
• Mechanisms that cause vasoconstriction increase SVR, and
those mechanisms that cause vasodilation decrease SVR.
• SVR can be calculated if cardiac output (CO), mean arterial
pressure (MAP), and central venous pressure (CVP) are
known.
• SVR = 80 X (MAP - CVP) ÷ CO
• Normal Systemic Vascular Resistance is 800-1200
(dyne*sec)/cm5

30. Zeroing is performed by opening the system to air to establish atmospheric
pressure as zero.
Referencing (or leveling) is accomplished by placing the air-fluid
interface of the catheter (or the transducer) at a specific point to negate the
effects of the weight of the catheter tubing and fluid column

31. Not an Entirely Benign Lign…
•Insertion of an introducer to provide venous access>Pntx, bleeding,
infection
•Passage of the Swan through the introducer>minimized by inflating
the balloon tip after entering the right atrium
-Sustained ventricular arrythmias, occur in 0-3% pts
-RBBB develops in about 5% of catheter insertions, placing
pts with a preexisting LBBB in complete heart block. RBBB
is usually temporary.
-Knotting catheter-can occur during insertion if loops are
allowed to form in one of the cardiac chambers. When knotting
occurs, can usually remove transvenously but some require
venotomy or surgical extraction.
•Maintenance of the catheter>Inflating balloon when catheter has
moved distally>causing pulmonary artery perforation. Mortality
>30%, usu requires thoracotomy

32. Not Without Risks???
•Don’t leave balloon inflated in wedge position for extended
period of time>can cause pulmonary infarction
• Thromboembolic events can occur with the catheter acting as a
nidus for thrombus formation. Less common with heparin
bonded catheters
•Misinterpretation of the data
•Mural thrombi can be induced by inflammation of infection of a
vessel wall, seen in 33% of patients at autopsy
•Sterile vegetations, seen in 90% of patients
•Endocarditis of the pulmonic valve
•Rupture of the catheter balloon and consequent air embolism

33. THINK HARD BEFORE YOU STICK

34. Sample Questions
• BP 80/40 HR 120
• RA 20
• RV 50/23
• PA 70/30
• PCWP 28
• CO 2.0
• SVR 1600

35. • BP 80/40 HR 120
• RA 20
• PA 70/33
• PCWP 12
• CO 2.0
• SVR 1200

36. • BP 80/40 HR 120
• RA 5
• RV 18/5
• PA 25/15
• PCWP 10
• CO 2.0
• SVR 1600

37. • BP 80/40 HR 120
• RA 12
• PA 25/12
• PCWP 14
• CO 9
• SVR 500

38. Case Scenario
•55 yo male comes into the ED.
•

41. Cath showed 100% RCA occlusion. Treated with O2,
heparin, MSO4 and his condition improves.
48 hours later, he becomes pale, diaphoretic and oliguric.
Vitals: HR 120bpm, RR 24/min and BP 88/55.
PE: JVP+ angle of jaw, +RUQ tenderness, lungs clear.
+S3, Grade ¼ holosystolic murmur at LLSB. +LE edema

42. EKG: unchanged
Right heart cath placed which showed:
RA 20 mmHg
RV 40/18 mmHg
PAP 25/15 mmHg
PCWP 12 mmHg
CO 2L/min
RA tracing:

43. WHAT DOES THIS PT HAVE?
c. Papillary muscle rupture
d. Massive PE
e. Cardiac Tamponade
f. Rupture of the IV septum
g. RV infarct

46. Ngorogoro Crater, Tanzania