Historical Vignettes in Heart Failure

Authors


Hemodynamics and Heart Failure

“To meet the requirements for clinical and therapeutic evaluation of seriously ill patients admitted to the Myocardial Infarction Research Unit, three major criteria for acceptable placement of catheters within the pulmonary artery were established. No standard procedures fulfilled these criteria, which comprised placement without associated ventricular arrhythmias, prompt and reliable passage to the pulmonary artery[,] and passage without fluoroscopy . . . accordingly, we developed a flow-guided balloon catheter of flexible construction to meet these criteria . . .”

“The catheter was inserted through an antecubital vein cutdown and advanced 35 cm. If it did not traverse the veins of the shoulder with ease[,] the balloon was inflated with 0.4 to 0.6 mL of air, and the catheter withdrawn slightly before advancement. In all but three cases[,] the catheter passed into the superior vena cava and right atrium with pressure and electrocardiographic monitoring. The balloon was then inflated to a total volume of 0.8 mL. When the catheter passed into the right ventricle and pulmonary artery[,] it was allowed to proceed downstream until pressure resembling the pulmonary artery was obtained. The balloon was then deflated, and the catheter advanced 1 to 3 cm. When a wedge pressure was required[,] the balloon was reinflated without further manipulation. An adequate frequency response, with minimal motion artifact, characterized the system.”

“. . . the initial stimulus to the development of the catheter was for the care and study of acutely ill patients in whom fluoroscopy was not readily available . . . we now use the system for the accurate management of fluid volume control in patients with a wide variety of serious illnesses including . . . bacteremia, acute pancreatitis, and severe blood loss . . . we use it routinely in catheterization of the right side of the heart and pulmonary artery in the diagnostic laboratory. . . the balloon catheter appears to be an ideal vehicle for one of the most important applications in the management of acute[ly] ill patients[,] specifically the effective and prompt placement of pacing electrodes in the right ventricle without the use of fluoroscopy . . .”

Commentary

In 1968, Harold James Charles “Jeremy” Swan (1922–2005) designed with his colleague William Ganz (1919–2009) at Cedars Sinai Medical Center in Los Angeles, California, the pulmonary artery balloon catheter that bears their names. It brought cardiac catheterization to the bedside and revolutionized the management of myocardial infarction, critically ill patients, open heart surgery, and acute respiratory failure.

This classic manuscript reports the clinical experience of the use of the newly developed balloon-tipped catheter to measure hemodynamic parameters at the bedside and without fluoroscopic guidance.1 The clinical development of cardiac catheterization at the patient bedside by these investigators introduced a new era in the understanding and treatment of heart failure.

First, the authors described why they devised the catheter and why the properties of this new catheter were suited to achieve bedside hemodynamic monitoring for critically ill patients:

“ . . . No standard procedures fulfilled these criteria, which comprised placement without associated ventricular arrhythmias, prompt and reliable passage to the pulmonary artery[,] and passage without fluoroscopy . . . accordingly, we developed a flow-guided balloon catheter of flexible construction to meet these criteria . . . ”

Second, the authors explained the technique for the placement of the catheter:

“The balloon was then inflated to a total volume of 0.8 mL. When the catheter passed into the right ventricle and pulmonary artery[,] it was allowed to proceed downstream until pressure resembling the pulmonary artery was obtained. The balloon was then deflated, and the catheter advanced 1 to 3 cm. When a wedge pressure was required[,] the balloon was reinflated without further manipulation. An adequate frequency response, with minimal motion artifact, characterized the system.”

In addition, the authors described clearly the successes and the complications of the placement of the catheter, listing the average passage time, 36 seconds, the percentage passed to the pulmonary artery and wedge (92% and 80%, respectively), and the percentage of patients with premature ventricular contractions (13%). They also listed the development of venous thrombus around the catheter and protruding into the right atrium, with pulmonary emboli especially in a patient with cardiogenic shock in whom the balloon was kept more than 14 days. Balloon rupture was also a problem in 10 cases; however, there was no harm to the patients.

Finally, the authors described other possible uses of the catheter:

“. . . The balloon catheter appears to be an ideal vehicle for one of the most important applications in the management of acute[ly] ill patients[,] specifically the effective and prompt placement of pacing electrodes in the right ventricle without the use of fluoroscopy . . .”

The Swan-Ganz catheter is utilized today with some modifications and some controversy, but it remains a tool for diagnosis and for evaluating response to treatment in a variety of disease states including heart failure.

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