Role of the PA Catheter in Managing Cardiogenic Shock

What is the role of the PA catheter (PAC) in managing cardiogenic shock? That’s the question A. Reshad Garan, MD, seeks to address in his recently published paper in JACC Heart Failure titled “Complete Hemodynamic Profiling With Pulmonary Artery Catheters in Cardiogenic Shock Is Associated With Lower In-Hospital Mortality.” Dr. Garan is section chief, advanced heart failure and mechanical circulatory support, at Beth Israel Deaconess Medical Center in Boston, MA.

In his paper, Dr. Garan and colleagues examined data from a large registry of patients encompassing multiple etiologies of shock managed with a variety of mechanical support devices. Patients were divided into 3 categories:

• Patients with complete PAC assessment
• Patients with incomplete PAC assessment (no right atrial pressure hemodynamic data)
• Patients who did not receive a PAC prior to initiation of mechanical circulatory support (MCS)

Dr. Garan explains that patients were divided into these 3 groups “because at the end of the day it matters how you use this catheter. It does not necessarily help the patient if you put the catheter in and then aren’t really using the full set of hemodynamic data that can be derived with the pulmonary artery catheter.”

“One thing is clear,” Garan states. “Even in a collection of centers where the PA catheter is used relatively frequently, there is variability in the use.” However, looking at usage by SCAI stages, he notes, “We did see that in patients that are what we would consider more advanced stages of shock, specifically stage D and stage E, there did seem to be a good representation of PA catheter use in those patients.”

Focusing on the central illustration in the paper, Dr. Garan explains that the benefit of PA catheter use becomes larger in patients with more advanced stages of shock. He also emphasizes, “because of the distinction between incomplete use of the PA catheter and complete use, it really underscores it’s not just about putting the catheter in. It’s about how you use the information that is derived from the catheter.” He notes the importance of using the information “to really guide, in real time, the decisions around ways to stabilize that patient.”

Dr. Garan concludes by explaining the importance of continuing to learn how to interpret and use PA catheter data. “We have to remember that the tool is only as good as how we use it… I think as we learn more and more about the optimal ways to manage this patient population, either medically or device based, I think we’re going to move towards understanding the proper timing of intervention for this patient population… I think hopefully this manuscript at least sets the stage for the next steps in trying to understand how to improve outcomes for this incredibly difficult and challenging patient population.”