Comparison of goal-directed hemodynamic optimization using pulmonary artery catheter and transpulmonary thermodilution in combined valve repair: a randomized clinical trial

Abstract

Our aim was to compare the effects of goal-directed therapy guided either by pulmonary artery catheter (PAC) or by transpulmonary thermodilution (TTD) combined with monitoring of oxygen transport on perioperative hemodynamics and outcome after complex elective valve surgery. Measurements and Main Results. Forty patients were randomized into two equal groups: a PAC group and a TTD group. In the PAC group, therapy was guided by mean arterial pressure (MAP), cardiac index (CI) and pulmonary artery occlusion pressure (PAOP), whereas in the TTD group we additionally used global end-diastolic volume index (GEDVI), extravascular lung water index (EVLWI), and oxygen delivery index (DO(2)I). We observed a gradual increase in GEDVI, whereas EVLWI and PAOP decreased by 20-30% postoperatively (P < 0.05). The TTD group received 20% more fluid accompanied by increased stroke volume index and DO(2)I by 15-20% compared to the PAC group (P < 0.05). Duration of mechanical ventilation was increased by 5.2 hrs in the PAC group (P = 0.04). Conclusions. As compared to the PAC-guided algorithm, goal-directed therapy based on transpulmonary thermodilution and oxygen transport increases the volume of fluid therapy, improves hemodynamics and DO(2)I, and reduces the duration of respiratory support after complex valve surgery.

Figure 1

Flow diagram detailing the conduct of the study. PAC: pulmonary arterial catheter; TTD: transpulmonary thermodilution.

Figure 2

The algorithms of goal-directed hemodynamic optimization: (a) the PAC group, (b) the transpulmonary thermodilution (TTD) group. CPB: cardiopulmonary bypass; MAP: mean arterial pressure; PAOP: pulmonary artery occlusion pressure; CI: cardiac index; GEDVI: global end-diastolic volume index; EVLWI: extravascular lung water index; ScvO₂: central venous oxygen saturation; DO₂I: oxygen delivery index; Hb: hemoglobin concentration; RBC: red blood cells; HAES: hydroxyaethyl starch.

Figure 3

Changes in cardiac index, stroke volume index and oxygen delivery in the study groups. CI: cardiac index; SVI: stroke volume index; DO₂I: oxygen delivery index. *P < 0.05 between the groups; ^† P < 0.05 within the group compared with the preoperative value. Data are presented as mean ± SD.