REVIEW

C URRENT
OPINION Perioperative hemodynamic monitoring in
cardiac surgery
Michael C. Grant a, Rawn Salenger b and Kevin W. Lobdell c

Purpose of review
Cardiac surgery has traditionally relied upon invasive hemodynamic monitoring, including regular use of
pulmonary artery catheters. More recently, there has been advancement in our understanding as well as
broader adoption of less invasive alternatives. This review serves as an outline of the key perioperative
hemodynamic monitoring options for cardiac surgery.
Recent findings
Recent study has revealed that the use of invasive monitoring such as pulmonary artery catheters or
transesophageal echocardiography in low-risk patients undergoing low-risk cardiac surgery is of
questionable benefit. Lesser invasive approaches such a pulse contour analysis or ultrasound may provide a
useful alternative to assess patient hemodynamics and guide resuscitation therapy. A number of recent
studies have been published to support broader indication for these evolving technologies.
Summary
More selective use of indwelling catheters for cardiac surgery has coincided with greater application of
less invasive alternatives. Understanding the advantages and limitations of each tool allows the bedside
clinician to identify which hemodynamic monitoring modality is most suitable for which patient.
Keywords
cardiac surgery, hemodynamic monitoring, perioperative

INTRODUCTION facilitates both blood sampling (i.e., central and/

Perioperative hemodynamic monitoring in the car- or mixed venous blood gas) as well as direct meas-
diac surgical patient goes beyond the basic standard urement of central venous, right ventricular, pul-
American Society of Anesthesiologist (ASA) moni- monary arterial, and pulmonary arterial wedge
tors (i.e., oxygenation, ventilation, circulation, tem- pressures, along with the ability to utilize thermo-
perature) and often requires real-time assessment of dilution to quantify key hemodynamic parameters
advanced parameters to determine the adequacy of such as cardiac output (CO)/cardiac index (CI),
blood pressure, blood flow, intravascular volume stroke volume (SV)/stroke volume index (SVI),
status, vascular tone, and cardiac function. There and systemic vascular resistance (SVR). These
are a number of potential hemodynamic monitor- indwelling catheters theoretically assist providers
ing modalities, each with unique advantages and in the assessment, diagnosis and management of a
specific limitations, which also occupy a range of number of major cardiovascular conditions [1]
invasiveness (Table 1). The following review pro-
vides a brief synopsis of the recent literature assess-
ing the role of various hemodynamic monitoring a
Department of Anesthesiology and Critical Care Medicine, The Johns
modalities, introduced based on the degree of inva- Hopkins University School of Medicine, bDepartment of Surgery, Uni-
siveness (Fig. 1), in the cardiac surgical setting. versity of Maryland School of Medicine, Baltimore, Maryland and
c
Sanger Heart & Vascular Institute, Advocate Health, Charlotte, North
Carolina, USA
Pulmonary artery catheter
Correspondence to Michael C. Grant, MD, MSE Johns Hopkins Hos-
Since their introduction, pulmonary artery catheters pital, 1800 Orleans Street, Zayed 6208, Baltimore, MD 21287, USA.
(PACs) have represented a core component of peri- Tel: +1 410 955 7519; fax: +1 410 955 0994;
operative care for the cardiac surgical patient. PACs e-mail: [email protected]
are inserted through a large bore central venous Curr Opin Anesthesiol 2024, 37:1–9
introducer catheter and their unique design DOI:10.1097/ACO.0000000000001327

0952-7907 Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved. www.co-anesthesiology.com

Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.

Cardiovascular anesthesia

&&
decade. According to Brown et al. [6 ], patients were
KEY POINTS significantly more likely to receive a PAC for surgery
from 2010 to 2014 compared to those from 2015 to
 Despite their traditional role, recent study has revealed
2018. This may be due to the fact that previous study
that the use of invasive monitoring such as pulmonary
artery catheters in low-risk patients undergoing low-risk has suggested that more selective use of PACs may
cardiac surgery is of questionable benefit. translate to improved outcomes by targeting high-
risk patients (i.e., CHF, pulmonary artery hyperten-
 Transesophageal echocardiography (TEE) is a point-of- sion [PAH]) or high-risk procedures (i.e., multiple
care alternative that has been shown to guide decision-
valve operations, durable left ventricular assist
making in the OR and is associated with mortality &&

benefit among moderate and high-risk patients. device [LVAD] implantation) [7,8,9 ]. Interestingly,
a recently published study of the National Inpatient
 Pulse contour analysis technology has become Sample, which analyzed the outcomes associated
increasingly popularized, with versions of the with a subgroup of more than 320 000 cardiac sur-
monitoring technology spanning the full spectrum of
gical records of patients with CHF, PAH, mitral/
clinical invasiveness.
tricuspid disease or combined surgeries, found that
 Transthoracic echocardiography (TTE) and other point- after risk adjustment, although patients with PACs
of-care ultrasonography (POCUS), which is now experienced slightly shorter LOS, in-hospital deaths
included among the list of competencies for medical &&
were similar regardless of PAC use [10 ]. PAC use
training programs, is another alternative to more
varied as much by the institution as the patient or
invasive methods for quantifying advanced
hemodynamic parameters. surgery subgroup, further illustrating the degree to
which PAC use is influenced as much by local
 Goal-directed therapy (GDT), which protocolizes resources and culture as it is by clinical indication.
resuscitation to provide the appropriate combination of Whereas PACs appear to have a more selective
fluid, vasopressor and inotropes to maximize a
role in elective cardiac surgery, there has actually
patient’s hemodynamic response is a core aspect of
Enhanced Recovery Programs (ERPs). been broader application for management of end
stage heart failure and mechanical circulatory sup-
port over the last several years. This is largely the
result of a series of recent articles that showed an
(Fig. 2). Risks of PACs include vascular injury, infec- improvement in mortality among patients who
tion, difficulty with insertion, arrhythmia and car- received PACs as part of their heart failure manage-
diac valve or pulmonary artery injury, the relative ment, including higher likelihood of survival to
incidences of which are low, but relevant, given the durable left ventricular assist device (LVAD) or heart
& & &&
invasive nature of the catheter [2 ]. transplantation [11 ,12,13 ]. In addition, a recent
Despite the widespread application of PACs, nationwide analysis revealed an improved mortality
study has suggested that not all patients benefit rate among patients who received a PAC for manage-
from their use in cardiac surgery. Propensity- ment after ST-elevation myocardial infarction and
matched studies from the early and mid-2010s cardiogenic shock requiring temporary percutane-
&&
revealed patients with PACs were consistently likely ous LVAD support [14 ]. Given the immense com-
to receive more interventions (i.e., inotropic drugs, plexity of the management of end stage heart failure
fluid), experience longer length of stay (LOS; i.e., patients, there is greater recognition of the impor-
intensive care and hospital), yet have similar mortal- tance of standardization of right heart catheteriza-
ity rates compared to those who did not receive a tion to better define the role of advanced
&
PAC [3–5]. This is true of most recent study as well. hemodynamics in heart failure [15 ].
Based on the analysis of more than 3500 propensity-
&&
matched pairs, Brown et al. [6 ] found that PAC use
for cardiac surgery was associated with greater inten- Transesophageal echocardiography
sive care LOS and blood cell transfusion, but similar In contrast to the general trend of use of PACs in
overall postoperative outcomes, including stroke, cardiac surgery, TEE has become an increasingly
sepsis, new renal failure, and mortality compared ubiquitous monitoring device. TEE is widely consid-
to patients monitored with central venous pressures ered a standard for cardiac valve procedures [16,17],
alone. These findings were also similar among key and a recent study of more than 800 000 patients
subgroups, including patients with congestive heart undergoing cardiac valve or proximal aortic surgery
failure (CHF), mitral or tricuspid valve disease. analyzed from the Society of Thoracic Surgeons (STS)
Although PACs remain a common aspect of Adult Cardiac Surgery Database (ACSD) revealed that
perioperative care for the cardiac surgical patient, intraoperative TEE use was associated with a lower
their use has diminished somewhat over the last incidence of 30-day mortality compared to those who

2 www.co-anesthesiology.com Volume 37  Number 1  February 2024

Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.

 Hemodynamic monitoring in cardiac surgery Grant et al.

Table 1. Summary of perioperative hemodynamic monitoring modalities

Hemodynamic
Modality Device and mechanism parameters Advantages Disadvantages

Pulmonary artery Direct pressure transducer, Instantaneous: PAP Direct measurement of pressures, Invasive, requires large bore
catheter (PAC) thermodilution mediated (PASP, PADP, PAMP), ability to sample/analyze central vascular access,
algorithm for measurement PCWP, CVP blood from major blood vascular injury/arrhythmia/
of hemodynamic Calculated intermittently chambers, real-time infection risk, requires
parameters (by thermodilution): hemodynamic data, well experience to interpret data,
CO/CI, SV/SVI, studied and globally adopted questionable efficacy
SVR/SVRI, PVR/PVRI into practice particularly in low-risk patients
Transesophageal Moderate sized phase-array Instantaneous: HR, Real time hemodynamic data Requires sedation versus general
echocardiography ultrasound (2.5--7.5 MHz) distance, blood flow correlated with structural/ anesthesia, requires
(TEE) transducer; reproduces peak velocity, velocity functional information, specialized training and
2D/3D images, including time integral continuous monitoring, low credentialling, logistically
ability to discriminate Calculated intermittently incidence of major challenging, hemodynamic
tissue from fluid (by user): CO/CI, complications, numerous parameters largely calculated
SV/SVI, PASP, PADP, capabilities beyond (noncontinuous)
PCWP, CVP hemodynamics, increasing
popularity
Esophageal Doppler Small flexible esophageal Instantaneous: HR, Small, flexible device and Requires sedation versus general
ultrasound (4 MHz stroke distance, generally well tolerated, anesthesia, positioning error,
continuous or 5 MHz pulse maximum continuous monitoring inaccuracies related to
wave) transducer that acceleration, flow anatomical variations,
captures descending aortic time, peak velocity hemodynamic parameters
blood flow Calculated continuously largely calculated
(by algorithm): CO/
CI, SV/SVI
Pulse Contour analysis Arterial waveform pressure Instantaneous: SBP, DBP, Real-time hemodynamic data Invasive, recalibration necessary
(Invasive) signal (arterial catheter), MAP calibrated against after significant clinical
external calibration via Calculated continuously hemodynamic standard changes, unreliable in certain
thermodilution (by algorithm): CO/ clinical conditions, lack of
CI, SV/SVI, SVR/ recent cardiac surgery-specific
SVRI, PVR/PVRI data
Pulse Contour analysis Arterial waveform pressure Real-time hemodynamic data, Concordance with thermodilution
(minimally invasive) signal (arterial catheter), utilizes indwelling arterial line, standard is variable, unreliable
internal calibration user-friendly interface, minimal in certain clinical conditions
training to use
Pulse Contour analysis Arterial waveform pressure Noninvasive, user-friendly Unreliable in certain clinical
(non-invasive) signal via vascular interface, minimal training to conditions, particularly
unloading, radial artery use sensitive to hand/wrist
applanation tonometry, or movement, outcomes research
other method in cardiac surgery is lacking
Transthoracic Phase-array ultrasound Instantaneous: HR, Noninvasive, real time Requires training (sometimes
echocardiography (1--5 MHz) transducer; distance, blood flow hemodynamic data correlated credentialing), intermittent
(POCUS) reproduces 2D/3D peak velocity, velocity with structural/functional monitoring modality,
images, including ability to time integral information, numerous hemodynamic parameters
discriminate tissue from Calculated intermittently capabilities beyond largely calculated, imaging
fluid (by user): CO/CI, hemodynamics, increasing quality impacted by surgical
SV/SVI, CVP popularity dressing/incisions

CI, cardiac index; CO, cardiac output; CVP, central venous pressure; HR, heart rate; PADP, pulmonary arterial diastolic pressure; PAMP, pulmonary arterial mean
pressure; PAP, pulmonary arterial pressure; PASP, pulmonary arterial systolic pressure; PCWP, pulmonary capillary wedge pressure; PVR, pulmonary vascular
resistance; PVRI, pulmonary vascular resistance index; SV, stroke volume; SVI, stroke volume index; SVR, systemic vascular resistance; SVRI, systemic vascular
resistance index.

FIGURE 1. Relative invasiveness of hemodynamic monitoring modalities.

0952-7907 Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved. www.co-anesthesiology.com 3

Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.

Cardiovascular anesthesia

FIGURE 2. Clinical conditions and their associated advanced hemodynamic parameters.

&& && &

did not receive the modality [18 ]. TEE use is a can predispose patients to complications [26 ,27 ].
growing part of coronary artery bypass graft (CABG) As a recent multicenter randomized controlled trial
as well. A study of 1.3 million patients undergoing showed, video laryngoscope assisted probe insertion
isolated CABG also derived from the STS ACSD can reduce both the number of placement attempts
showed that the percentage of patients who received and subsequent likelihood of oropharyngeal injury
&
intraoperative TEE increased from 39.9% in 2011 to [28 ].
&&
62.1% in 2019 [19 ]. After risk adjustment, the study
also found that patients who received intraoperative
TEE had a lower overall odds of mortality, a finding Esophageal doppler
weighted in particular by a significant reduction in More simplified ultrasound technology is available
mortality among medium (STS risk 4–8%) and high- in the form of esophageal Doppler, which involves
risk (>8%), but not low-risk (<4%) patients. Recent the insertion of a small device, comparable to an
guidelines have summarized the available literature esophageal temperature probe, into the portion of
[20,21] to suggest that TEE plays an important role in the esophagus overlying the descending aorta,
coronary, valvular and other structural cardiac pro- where it estimates CO based on measured blood flow
cedures as a tool to assess for regional wall motion velocity. Although reasonably well studied in non-
&&
abnormality or structural abnormalities [9 ]. cardiac surgery [29], the application of esophageal
There is rationale to conclude that the mortality Doppler to cardiac surgery has been limited, likely
benefit associated with TEE is mediated by more due to evidence of poor correlation with PACs
than assessment of the fidelity of valvular repair [30,31] and challenges in achieving adequate data
or identification of occult structural abnormalities. capture with cardiac manipulation, particularly dur-
Similar to PACs, TEE can provide real-time feedback ing off-pump CABG procedures [32]. This, coupled
regarding the nature and severity of hemodynamic with its relative invasiveness compared to other
instability. TEE-derived parameters provide surro- modalities, make esophageal Doppler less applicable
gates for virtually all of the data derived from PACs, to the cardiac surgical population.
including CO/CI, SV/index as well as functional
correlation to guide perioperative resuscitation
&
[22,23 ] (Fig. 3). Despite the theoretical benefits of Pulse contour analysis
TEE, there still remains a great deal of institutional Monitoring technology has evolved to include
&&
variation in its use [24 ], likely owing to the fact modalities based on pulse contour analysis, where
that it typically requires certification and can be blood pressure waveform signals are translated using
logistically challenging to harmonize, validate and proprietary algorithms to estimate key advanced
& &&
maintain local clinical practice [25 ]. Finally, there is hemodynamic parameters [33 ]. Modalities utiliz-
greater recognition of the potential complications ing pulse contour analysis range in degree of inva-
associated with TEE. Recent reviews highlighted the siveness, largely dictated by their calibration
low (typically < 1%), but important risk of gastro- methods. Invasive technologies base their analysis
intestinal and oropharyngeal injury that can result on arterial waveforms (i.e., measurement from
from placement and manipulation of the TEE probe radial or femoral artery line) and externally calibrate
and providers are encouraged to assess for preexist- results using central venous catheter mediated ther-
ing oropharyngeal or esophageal abnormalities that modilution (i.e., cold indicator solution, lithium

4 www.co-anesthesiology.com Volume 37  Number 1  February 2024

Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.

 Hemodynamic monitoring in cardiac surgery Grant et al.

FIGURE 3. Comparison of advanced hemodynamic parameters derived from pulmonary artery catheters and transesophageal
echocardiography.

dilution techniques). More minimally invasive central venous access to apply thermodilution and
alternatives also base their analysis on arterial wave- providers must regularly calibrate the device after
forms, but utilize various algorithms to internally significant changes to vasomotor tone [37,38]. In
calibrate results and therefore do not require central addition, a number of randomized trials comparing
venous access. There are also a number of noninva- pulse contour hemodynamics derived from an arte-
sive alternatives which obviate the need for arterial rial catheter to thermodilution reference found a
catheter insertion, relying upon the concept of vas- wide and sometimes discouraging range of overall
cular unloading or arterial applanation tonometry concordance [39–42]. This is also true among cer-
to calculate CO using either a finger cuff or radial tain patients monitored via noninvasive pulse con-
artery pressure dressing [34], which have been tour analysis. A recent systematic review and meta-
shown to positively correlate with thermodilution analysis of studies comparing noninvasive finger-
or other clinical standards [35,36]. The theoretical cuff derived hemodynamic measures to reference
benefits of applying pulse contour analysis monitor- invasive indices found that although several studies
ing to the cardiac surgical setting are clear, as the suggested a strong correlation, the two methods
majority of patients are routinely monitored via were not interchangeable in surgical or critically
arterial line and/or central venous access. As care ill patients [43]. Regardless of the degree of invasive-
is de-escalated in the postoperative setting, the use ness, limitations to pulse contour analysis include
of a continuous noninvasive alternative is appealing atrial or ventricular arrhythmia, significant aortic
to guide resuscitative and diuresis decision-making. regurgitation, intra-aortic balloon counter-pulsa-
A stated advantage to most of these technologies is a tion, or the presence of other mechanical circulatory
simplified user interface and algorithmic approach support [44,45], all of which are problematic in the
to care, which may mitigate the necessary experi- cardiac surgical setting, where each of these scenar-
ence required to interpret PAC data or credentialing ios are common.
associated with TEE.
Despite the variety of potential applications,
there are still limitations to the use of pulse contour Transthoracic ultrasound
analysis technology. Externally calibrated versions There is growing enthusiasm for transthoracic echo-
can commonly require cannulation of a central cardiography (TTE) and other point-of-care ultraso-
artery (i.e., brachial, femoral, axillary), necessitate nography (POCUS), which can provide assessment of

0952-7907 Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved. www.co-anesthesiology.com 5

Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.

Cardiovascular anesthesia

cardiovascular structures and translate blood flow concordance with more conventional methods
&
velocity into key hemodynamic parameters in a fash- [56 ,57,58]. Finally, devices that utilize bioimpe-
ion similar to TEE. Previous study has shown a mod- dance and/or bioreactance rely upon assessment of
erate to strong degree of correlation between TTE and electrical resistance in the blood stream that accom-
thermodilution among critically ill surgical and non- pany changes in fluid volume. Widespread use of this
surgical populations [46,47]. A recent study also com- technology has been hampered either by the need for
pared TTE-derived stroke volume measurement endotracheal intubation and variable concordance
techniques to gold standard cardiac magnetic reso- with thermodilution (bioimpedance) or excessive
&
nance imaging and found a strong agreement [48 ]. sensitivity of the device to environmental factors
Although POCUS requires education on the part of including mode of ventilation, humidity, electrocau-
user in order to obtain high-quality images and tery, and temperature (bioreductance) [1,59].
adequately interpret findings (i.e., certification is
offered as part of the CCEeXAM Examination of
Special Competence in Critical Care Echocardiogra- ENHANCED RECOVERY AFTER CARDIAC
&&
phy [49 ]), a recent study shows that when utilized to SURGERY
assess key hemodynamic parameters on healthy vol- Enhanced Recovery Programs (ERPs) have become
unteers, SV, CO, and inferior vena cava diameter popularized as a means to provide phase-specific
&
showed a high degree of repeatability [50 ]. Others evidence-based care to lessen surgical insult, hasten
have shown POCUS can be useful for assessment of recovery and reduce rates of perioperative compli-
more dynamic clinical scenarios including fluid cation [60]. Within the context of ERPs, there is a
responsiveness, though repeat measurements are growing recognition of the value of goal-directed
often required to ensure adequate precision, partic- therapy (GDT), which protocolizes resuscitation to
ularly among patients with atrial fibrillation [51]. provide the appropriate combination of fluid, vaso-
Research on application to the cardiac surgical pop- pressor and inotropes to maximize a patient’s hemo-
ulation is lacking, but POCUS may be advantageous dynamic response to surgical insult as means to
as a real-time bedside assessment tool to determine avoid iatrogenic injury from the inappropriate use
adequacy of cardiac output in lieu of more invasive any one of those therapies [61]. GDT is commonly
alternatives, particularly given the increasingly endorsed as part of a comprehensive ERP and fre-
widespread availability of ultrasound equipment quently recommended within surgical subspeciality
and greater emphasis on the skillset in national guidelines including those put forward by the
and international medical training (i.e., Accredita- Enhanced Recovery After Surgery Cardiac Society
tion Council for Graduate Medical Education [62–64]. All of the various hemodynamic monitor-
[ACGME], European Society of Intensive Care Med- ing options can theoretically inform an institutional
&
icine [ESICM]) [52 ,53]. GDT protocol, and versions of those approaches are
likely incorporated in the studies investigating the
outcomes associated with more established modal-
Other modalities ities such as PACs and TEE.
Several alternative modalities have been employed A number of studies have more directly assessed
to determine advanced hemodynamic parameters. the impact of GDT in the setting of cardiac surgery,
These include partial carbon dioxide (CO2) rebreath- where not only has it been shown to be feasible to
ing, which is most useful in mechanically ventilated derive a GDT protocol from less invasive hemody-
patient, involves noninvasive CO2 and airflow sen- namic options [65]. Based on several trials, GDT has
sors and relies upon the Fick equation to provide a been shown to reduce composite postoperative com-
continuous measurement of CO. Studies devoted to plications, including acute kidney injury, infection,
its use in cardiac surgery are available, but generally low-cardiac output syndrome, and LOS compared to
limited to the 2000s and its use has fallen out of usual care [66–68]. These results mirror those of an
favor due to the need for specialized equipment as accompanying meta-analysis, which reinforced GDT
well as limitations in assessment in patients with as a vehicle to reduce postoperative complications
pulmonary disease or those with spontaneous res- and LOS, albeit without appreciably impacting over-
pirations [54,55]. Pulse wave transit time (PWTT) all survival [68]. Esophageal Doppler has also been
systems provide CO based on the time it takes for a popularized as a tool to guide GDT, most notably in
pulse pressure waveform to travel between two sites noncardiac surgery, where a meta-analysis of
of capture, typically the electrocardiogram and randomized trials revealed that its use was associated
pulse oximetry. Despite being both inexpensive with fewer overall complications, but similar rates of
and noninvasive, recent studies, including those cardiac, renal, infectious and gastrointestinal com-
respective to cardiac surgery, have shown variable plications, as well as similar rates of mortality

6 www.co-anesthesiology.com Volume 37  Number 1  February 2024

Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.

 Hemodynamic monitoring in cardiac surgery Grant et al.

2. Fox WE, Marshall M, Walters SM, et al. Bedside clinician’s guide to pulmonary
compared with conventional care [29]. Pulse contour & artery catheters. Crit Care Nurse 2023; 43:9–18.
analysis has even been coupled with artificial intelli- Overview of the practical aspects of PACs, including device characteristics,
measurement parameters, placement troubleshooting, and complications.
gence and machine learning to anticipate hemody- 3. Schwann NM, Hillel Z, Hoeft A, et al. Lack of effectiveness of the pulmonary
namic instability in cardiac surgery with a high artery catheter in cardiac surgery. Anesth Analg 2011; 113:994–1002.
& 4. Chiang Y, Hosseinian L, Rhee A, et al. Questionable benefit of the pulmonary
degree of accuracy [69 ]. A recent multiinstitutional artery catheter after cardiac surgery in high-risk patients. J Cardiothorac Vasc
quality improvement initiative found that hemody- Anesth 2015; 29:76–81.
5. Shaw AD, Mythen MG, Shook D, et al. Pulmonary artery catheter use in adult
namic management supported a GDT algorithm was patients undergoing cardiac surgery: a retrospective, cohort study. Perioper
associated with a significant reduction in postoper- Med (Lond) 2018; 7:24.
6. Brown JA, Aranda-Michel E, Kilic A, et al. The impact of pulmonary artery
ative acute kidney injury and intensive care LOS && catheter use in cardiac surgery. J Thorac Cardiovasc Surg 2022;
&
[70 ]. As data are forthcoming which favorably com- 164:1965–1973; e6.
Large observational, propensity-matched analysis analyzing the association be-
pares less invasive options to current invasive stand- tween PAC use and outcomes in cardiac surgery.
ards, it is likely there will be a concomitant shift 7. Schwann TA, Zacharias A, Riordan CJ, et al. Safe, highly selective use of
pulmonary artery catheters in coronary artery bypass grafting: an objective
toward those modes of hemodynamic monitoring. patient selection method. Ann Thorac Surg 2002; 73:1394–1401; discus-
sion 1401-1402.
8. Schwann NM, Mangano DT; Multicenter Study of Perioperative Ischemia
CONCLUSION Research Group. Pulmonary-artery catheters in high-risk surgical patients. N
Engl J Med 2003; 348:2035–2037; author reply 2035-2037.
9. Writing Committee Members. Lawton JS, Tamis-Holland JE, Bangalore S,
Recent study has revealed that the use of invasive && et al. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization:
monitoring such as PACs or TEE in low-risk patients a report of the American College of Cardiology/American Heart Association
Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2022; 79:
undergoing low-risk cardiac surgery is of question- e21–e129.
able benefit. More selective use of indwelling cath- Updated guideline for coronary revascularization, which includes periprocedural
considerations, including the use PACs and TEE.
eters for cardiac surgery has also coincided with 10. Beydoun HA, Beydoun MA, Eid SM, Zonderman AB. Association of pulmon-
greater application of less invasive alternatives. && ary artery catheter with in-hospital outcomes after cardiac surgery in the
United States: National Inpatient Sample 1999–2019. Sci Rep 2023;
These modalities, which include pulse contour anal- 13:13541.
ysis, ultrasound, and others, may provide useful Large database-derived analysis of outcomes associated with PAC use in the
United States.
alternatives to assess and derive advanced cardiac 11. Ranka S, Mastoris I, Kapur NK, et al. Right heart catheterization in cardiogenic
hemodynamics as well as guide perioperative resus- & shock is associated with improved outcomes: insights from the Nationwide
Readmissions Database. J Am Heart Assoc 2021; 10:e019843.
citation therapy. Understanding the advantages and Large retrospective analysis of outcomes associated with PAC use in patients with
limitations of each tool allows the bedside clinician cardiogenic shock.
12. Garan AR, Kanwar M, Thayer KL, et al. Complete hemodynamic profiling with
to identify which hemodynamic monitoring modal- pulmonary artery catheters in cardiogenic shock is associated with lower in-
ity is most suitable for which clinical scenario. hospital mortality. JACC Heart Fail 2020; 8:903–913.
13. Kadosh BS, Berg DD, Bohula EA, et al. Pulmonary artery catheter use and
&& mortality in the cardiac intensive care unit. JACC Heart Fail 2023;
Acknowledgements 11:903–914.
Retrospective analysis of outcomes associated with PAC use among patients
None. admitted to the cardiac ICU, including those who ultimately required mechanical
circulatory support, durable left ventricular assist devices or transplantation.
14. Ismayl M, Hussain Y, Aboeata A, et al. Pulmonary artery catheter use and
Financial support and sponsorship && outcomes in patients with ST-elevation myocardial infarction and cardiogenic
None. shock treated with Impella (a nationwide analysis from the United States). Am
J Cardiol 2023; 203:304–314.
Retrospective analysis of outcome associated with PAC use among patients with
Conflicts of interest ST-elevation myocardial infarction, including those who ultimately required tem-
porary mechanical circulatory support.
Drs. Grant, Salenger, and Lobdell are nonremunerated 15. Grinstein J, Houston BA, Nguyen AB, et al. Standardization of the right heart
& catheterization and the emerging role of advanced hemodynamics in heart
Executive Board Members of the Enhanced Recovery failure. J Card Fail 2023.
After Surgery Cardiac Society. Dr Grant reports no finan- Overview of summary of the approach to assessment and management of patients
with heart failure, including the role of advanced hemodynamics as part of their
cial disclosures. Dr Salenger reports a financial relation- care.
ship with Terumo, Encare, La Jolla, Atricure, Zimmer 16. MacKay EJ, Neuman MD, Fleisher LA, et al. Transesophageal echocardio-
graphy, mortality, and length of hospitalization after cardiac valve surgery. J
Biomet, and JACE Medical. Dr Lobdell reports a finan- Am Soc Echocardiogr 2020; 33:756–762; e1.
cial relationship with Abiomed, Alexion Pharmaceuti- 17. Nicoara A, Skubas N, Ad N, et al. Guidelines for the use of transesophageal
echocardiography to assist with surgical decision-making in the operating
cals, Medela, Medtronic, and Renibus Therapeutics. room: a surgery-based approach: from the American Society of Echocardio-
graphy in Collaboration with the Society of Cardiovascular Anesthesiologists
and the Society of Thoracic Surgeons. J Am Soc Echocardiogr 2020;
REFERENCES AND RECOMMENDED 33:692–734.
18. MacKay EJ, Zhang B, Augoustides JG, et al. Association of intraoperative
READING && transesophageal echocardiography and clinical outcomes after open cardiac
Papers of particular interest, published within the annual period of review, have valve or proximal aortic surgery. JAMA Netw Open 2022; 5:e2147820.
been highlighted as: Large observational study analyzing the association between intraoperative TEE
& of special interest and outcomes following cardiac valve and aortic surgery.
&& of outstanding interest 19. Metkus TS, Thibault D, Grant MC, et al. Transesophageal echocardiography
&& in patients undergoing coronary artery bypass graft surgery. J Am Coll Cardiol
1. Recco DP, Roy N, Gregory AJ, Lobdell KW. Invasive and noninvasive 2021; 78:112–122.
cardiovascular monitoring options for cardiac surgery. JTCVS Open 2022; Large observational study analyzing the association between intraoperative TEE
10:256–263. and outcomes following isolated coronary artery bypass surgery.

0952-7907 Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved. www.co-anesthesiology.com 7

Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.

Cardiovascular anesthesia

20. Eltzschig HK, Rosenberger P, Loffler M, et al. Impact of intraoperative 41. Saugel B, Heeschen J, Hapfelmeier A, et al. Cardiac output estimation using
transesophageal echocardiography on surgical decisions in 12,566 patients multibeat analysis of the radial arterial blood pressure waveform: a method
undergoing cardiac surgery. Ann Thorac Surg 2008; 85:845–852. comparison study in patients having off-pump coronary artery bypass surgery
21. Qaddoura FE, Abel MD, Mecklenburg KL, et al. Role of intraoperative using intermittent pulmonary artery thermodilution as the reference method. J
transesophageal echocardiography in patients having coronary artery bypass Clin Monit Comput 2020; 34:649–654.
graft surgery. Ann Thorac Surg 2004; 78:1586–1590. 42. Greiwe G, Luehsen K, Hapfelmeier A, et al. Cardiac output estimation by pulse
22. Suehiro K, Tanaka K, Yamada T, et al. The utility of intra-operative three- wave analysis using the pressure recording analytical method and intermittent
dimensional transoesophageal echocardiography for dynamic measurement pulmonary artery thermodilution: a method comparison study after off-pump
of stroke volume. Anaesthesia 2015; 70:150–159. coronary artery bypass surgery. Eur J Anaesthesiol 2020; 37:920–925.
23. Nyhan SM, Steppan J. Con: it is not necessary to use a pulmonary artery 43. Saugel B, Hoppe P, Nicklas JY, et al. Continuous noninvasive pulse wave
& catheter in cardiac surgery. J Cardiothorac Vasc Anesth 2023; 37:663–665. analysis using finger cuff technologies for arterial blood pressure and cardiac
Editorial that outlines the surrogate variables for PAC parameters that can be output monitoring in perioperative and intensive care medicine: a systematic
obtained via cardiac ultrasound. review and meta-analysis. Br J Anaesth 2020; 125:25–37.
24. MacKay EJ, Zhang B, Shah RM, et al. Predictors of intraoperative echocar- 44. Barile L, Landoni G, Pieri M, et al. Cardiac index assessment by the pressure
&& diography: analysis of The Society of Thoracic Surgeons Database. Ann recording analytic method in critically ill unstable patients after cardiac
Thorac Surg 2023; 115:1289–1295. surgery. J Cardiothorac Vasc Anesth 2013; 27:1108–1113.
Large observational study that details the incidence and predictors of intraopera- 45. Romagnoli S, Romano SM, Bevilacqua S, et al. Cardiac output by arterial
tive TEE use in the United States. pulse contour: reliability under hemodynamic derangements. Interact Cardi-
25. Call CM, Onyeukwu JO, Trzcinka A, et al. Iatrogenic injury during intraopera- ovasc Thorac Surg 2009; 8:642–646.
& tive transesophageal echocardiography: implications for medical equipment 46. Olivieri PP, Patel R, Kolb S, et al. Echo is a good, not perfect, measure of
storage. Jt Comm J Qual Patient Saf 2023. cardiac output in critically ill surgical patients. J Trauma Acute Care Surg
Observational study and review of the necessary systems level requirements, 2019; 87:379–385.
including data and equipment management, associated with an intraoperative TEE 47. Mercado P, Maizel J, Beyls C, et al. Transthoracic echocardiography: an
program. accurate and precise method for estimating cardiac output in the critically ill
26. Patel KM, Desai RG, Trivedi K, et al. Complications of transesophageal patient. Crit Care 2017; 21:136.
&& echocardiography: a review of injuries, risk factors, and management. J 48. Cowie B, Wright L, Costello B, et al. Measurement of stroke volume with
Cardiothorac Vasc Anesth 2022; 36(8 Pt B):3292–3302. & echocardiography compared to gold standard cardiac magnetic resonance
Review and summary of the incidence of oropharyngeal and gastrointestinal imaging: an observational study. J Cardiothorac Vasc Anesth 2023;
complications associated with TEE. 37:1639–1645.
27. Khoche S, Ellis J, Poorsattar SP, et al. The year in perioperative echocardio- Observational study examining the concordance between TTE derived stroke
& graphy: selected highlights from 2022. J Cardiothorac Vasc Anesth 2023; volume measurement and cardiac MRI.
37:1537–1549. 49. CCEeXAM1 Examination of Special Competence in Critical Care Echocar-
Review and summary of the relevant published literature regarding TEE, including && diography. https://www.echoboards.org/examination/cceexam/. [Accessed
more detailed information regarding complications associated with its use. 1 September 2023].
28. Borde D, Jasapara A, Shetty V, et al. Use of a video laryngoscope to reduce Updated curriculum, which include point-of-care cardiac ultrasound, for the critical
& complications of transesophageal echocardiography probe insertion: a multi- care echocardiography board examination.
center randomized study. J Cardiothorac Vasc Anesth 2022; 36:4289–4295. 50. Blanca D, Schwarz EC, Olgers TJ, et al. Intra-and inter-observer variability of
Randomized trial establishing the benefit of video laryngoscope assisted transe- & point of care ultrasound measurements to evaluate hemodynamic parameters
sophageal echocardiogram to prevent placement-associated oropharyngeal com- in healthy volunteers. Ultrasound J 2023; 15:22.
plications. Observational study evaluating the intra-observer and inter-observer variability in
29. Ripoll es-Melchor J, Casans-Frances R, Espinosa A, et al., EAR Group, Evidence point of care cardiac ultrasound.
Anesthesia Review Group. Goal directed hemodynamic therapy based in 51. Jozwiak M, Mercado P, Teboul JL, et al. What is the lowest change in cardiac
esophageal Doppler flow parameters: a systematic review, meta-analysis and output that transthoracic echocardiography can detect? Crit Care 2019;
trial sequential analysis. Rev Esp Anestesiol Reanim 2016; 63:384–405. 23:116.
30. Collins S, Girard F, Boudreault D, et al. Esophageal Doppler and thermo- 52. ACGME program requirements for graduate medical education in anesthe-
dilution are not interchangeable for determination of cardiac output. Can J & siology. https://www.acgme.org/globalassets/pfassets/programrequire-
Anaesth 2005; 52:978–985. ments/040_anesthesiology_2022.pdf. [Accessed 1 September 2023].
31. Sharma J, Bhise M, Singh A, et al. Hemodynamic measurements after cardiac Updated objectives and expectations of competency to satisfy training in the field
surgery: transesophageal Doppler versus pulmonary artery catheter. J Car- of anesthesiology.
diothorac Vasc Anesth 2005; 19:746–750. 53. Expert Round Table on Ultrasound in ICU. International expert statement on
32. Missant C, Rex S, Wouters PF. Accuracy of cardiac output measurements with training standards for critical care ultrasonography. Intensive Care Med 2011;
pulse contour analysis (PulseCO) and Doppler echocardiography during off- 37:1077–1083.
pump coronary artery bypass grafting. Eur J Anaesthesiol 2008; 25:243–248. 54. Young BP, Low LL. Noninvasive monitoring cardiac output using partial CO
33. Saugel B, Kouz K, Scheeren TWL, et al. Cardiac output estimation using pulse (2) rebreathing. Crit Care Clin 2010; 26:383–392.
&& wave analysis-physiology, algorithms, and technologies: a narrative review. Br 55. Tachibana K, Imanaka H, Takeuchi M, et al. Noninvasive cardiac output
J Anaesth 2021; 126:67–76. measurement using partial carbon dioxide rebreathing is less accurate at
Review of the various pulse wave derived cardiac output modalities that are settings of reduced minute ventilation and when spontaneous breathing is
currently available. present. Anesthesiology 2003; 98:830–837.
34. Saugel B, Cecconi M, Hajjar LA. Noninvasive cardiac output monitoring in 56. Fot EV, Smetkin AA, Volkov DA, et al. The validation of cardiac index and stroke-
cardiothoracic surgery patients: available methods and future directions. J & volume variation measured by the pulse-wave transit time-analysis versus
Cardiothorac Vasc Anesth 2019; 33:1742–1752. conventional pulse-contour analysis after off-pump coronary artery bypass
35. Maass SW, Roekaerts PM, Lanc e MD. Cardiac output measurement by grafting: observational study. J Cardiothorac Vasc Anesth 2023; 37:919–926.
bioimpedance and noninvasive pulse contour analysis compared with the Recent evaluation of concordance between pulse wave transit time and pulse-
continuous pulmonary artery thermodilution technique. J Cardiothorac Vasc contour analysis in coronary artery bypass graft surgery.
Anesth 2014; 28:534–539. 57. Ehlers U, Erlebach R, Brandi G, et al. Continuous estimation of cardiac output
36. Wagner JY, Sarwari H, Schon G, et al. Radial artery applanation tonometry for in critical care: a noninvasive method based on pulse wave transit time
continuous noninvasive cardiac output measurement: a comparison with compared with transpulmonary thermodilution. Crit Care Res Pract 2020;
intermittent pulmonary artery thermodilution in patients after cardiothoracic 2020:8956372.
surgery. Crit Care Med 2015; 43:1423–1428. 58. Terada T, Oiwa A, Maemura Y, et al. Comparison of the ability of two
37. Yamashita K, Nishiyama T, Yokoyama T, et al. The effects of vasodilation on continuous cardiac output monitors to measure trends in cardiac output:
cardiac output measured by PiCCO. J Cardiothorac Vasc Anesth 2008; estimated continuous cardiac output measured by modified pulse wave transit
22:688–692. time and an arterial pulse contour-based cardiac output device. J Clin Monit
38. Hamzaoui O, Monnet X, Richard C, et al. Effects of changes in vascular tone Comput 2016; 30:621–627.
on the agreement between pulse contour and transpulmonary thermodilution 59. Peyton PJ, Chong SW. Minimally invasive measurement of cardiac output
cardiac output measurements within an up to 6-h calibration-free period. Crit during surgery and critical care: a meta-analysis of accuracy and precision.
Care Med 2008; 36:434–440. Anesthesiology 2010; 113:1220–1235.
39. Asamoto M, Orii R, Otsuji M, et al. Reliability of cardiac output measurements 60. Ljungqvist O, Scott M, Fearon KC. Enhanced recovery after surgery: a review.
using LiDCOrapidTM and FloTrac/VigileoTM across broad ranges of cardiac JAMA Surg 2017; 152:292–298.
output values. J Clin Monit Comput 2017; 31:709–716. 61. Lobdell KW, Chatterjee S, Sander M. Goal-directed therapy for cardiac
40. Maeda T, Hamaguchi E, Kubo N, et al. The accuracy and trending ability of surgery. Crit Care Clin 2020; 36:653–662.
cardiac index measured by the fourth-generation FloTrac/Vigileo systemTM 62. Scott MJ, Baldini G, Fearon KC, et al. Enhanced Recovery After Surgery
and the Fick method in cardiac surgery patients. J Clin Monit Comput 2019; (ERAS) for gastrointestinal surgery, part 1: pathophysiological considera-
33:767–776. tions. Acta Anaesthesiol Scand 2015; 59:1212–1231.

8 www.co-anesthesiology.com Volume 37  Number 1  February 2024

Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.

 Hemodynamic monitoring in cardiac surgery Grant et al.

63. Nelson G, Bakkum-Gamez J, Kalogera E, et al. Guidelines for perioperative care 68. Osawa EA, Rhodes A, Landoni G, et al. Effect of perioperative goal-directed
in gynecologic/oncology: Enhanced Recovery After Surgery (ERAS) Society hemodynamic resuscitation therapy on outcomes following cardiac surgery: a
recommendations-2019 update. Int J Gynecol Cancer 2019; 29:651–668. randomized clinical trial and systematic review. Crit Care Med 2016;
64. Engelman DT, Ben Ali W, Williams JB, et al. Guidelines for perioperative care 44:724–733.
in cardiac surgery: Enhanced Recovery After Surgery Society Recommenda- 69. Shin B, Maler SA, Reddy K, Fleming NW. Use of the hypotension prediction
tions. JAMA Surg 2019; 154:755–766. & index during cardiac surgery. J Cardiothorac Vasc Anesth 2021; 35:
65. Parke RL, McGuinness SP, Gilder E, et al. A randomised feasibility study to 1769–1775.
assess a novel strategy to rationalise fluid in patients after cardiac surgery. Br J Observational study that established a strong correlation between hypotension
Anaesth 2015; 115:45–52. prediction index algorithm and subsequent hemodynamic instability in cardiac
66. Ramsingh D, Hu H, Yan M, et al. Perioperative individualized goal directed surgery.
therapy for cardiac surgery: a historical-prospective, comparative effective- 70. Reddy S, Stout D, Fletcher R, et al. Advanced AI-guided hemodynamic
ness study. J Clin Med 2021; 10:400. & management within cardiac ERAS pathways: a multiinstitution quality im-
67. Johnston LE, Thiele RH, Hawkins RB, et al., Virginia Interdisciplinary Cardi- provement review. 2023. JTCVS Open. https://www.jtcvsopen.org/article/
othoracic Outcomes Research Center. Goal-directed resuscitation following S2666-2736(23)00209-7/pdf
cardiac surgery reduces acute kidney injury: A quality initiative prepost Multicenter observational trial evaluating the outcomes associated with the
analysis. J Thorac Cardiovasc Surg 2020; 159:1868–1877; e1. use of hypotension prediction index and acute kidney injury following cardiac surgery.

0952-7907 Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved. www.co-anesthesiology.com 9

Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.