Table 6.6. Recommendations for pulmonary artery catheter use in patients with advanced HF.

Recommendations	Class	LE	Comments	Table 2018	Ref.
In patients with advanced HF, heart transplantation candidates or receiving mechanical circulatory support.	I	B	2018 recommendation remains current.	Item 2.2.6. (page 495)	See 2018
To help treatment and hemodynamic support for patients with HF refractory to standard treatment or patients with cardiogenic shock.	IIa	B	MODIFIED:New evidence supports the change in class of recommendation.	Item 2.2.6. (page 495)	60–61
The use of a pulmonary artery catheter (PAC) in hemodynamic monitoring for patients hospitalized for refractory HF remains controversial.62,63 In 2005, the ESCAPE (Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness) trial found no benefits from the routine use of PACs in managing decompensated HF patients without CS.64 However, recent advances in the field of mechanical circulatory support devices (MCSDs) have prompted the development of algorithms to manage CS guided by PAC parameters. Early recognition, identification of the shock subtype and understanding of the expected impact of each type of device on hemodynamic parameters such as cardiac output, pulmonary capillary wedge pressure (PCWP), central venous pressure (CVP), and mean arterial pressure (MAP) allow choosing the most suitable MCSD for each stage of CS (Figure 6.1). In addition, the information obtained via PAC assist the phenotype characterization of CS into predominantly left ventricular shock (CPO < 0.6 W, PAPi > 1, CVP < 15 mm Hg and PCWP > 15 mm Hg), right ventricular shock (CPO < 0.6 W, PAPi <1, CVP > 15 mm Hg and PCWP < 15 mm Hg) or biventricular shock (CPO < 0.6 W, PAPi < 1, CVP > 15 mm Hg and PCWP > 15 mm Hg).60,65–68 Recently, in one of the first studies by the Cardiogenic Shock Working Group (CSWG), Garan et al.61 evaluated the association between CS management guided by CAP parameters and hospital mortality in 1,414 patients with CS, most with indication for MCSD use and in stage D of the SCAI classification. CS management guided by PAC parameters obtained before implanting a MCSD was associated with a significant decrease in mortality, especially in the more advanced stages of CS (stages D or E of the SCAI classification).61 It should be emphasized that the PAC is a diagnostic tool, not a therapeutic one, and its effectiveness depends on clinical decisions taken by the team involved in managing the CS.

CPO: cardiac power output; CS: cardiogenic shock; CVP: central venous pressure; HF: heart failure; MAP: mean arterial pressure; MCSD: mechanical circulatory support device; PAC: pulmonary artery catheter; PAPi: pulmonary artery pulsatility index; PCWP: pulmonary capillary wedge pressure.