Invasive Hemodynamic Monitoring in Acute Heart Failure and Cardiogenic Shock

Abstract

Invasive hemodynamic monitoring provides essential information for managing acute heart failure (AHF) and cardiogenic shock (CS) patients, aiding circulatory shock phenotyping and in individualized and hemodynamically-based therapeutic management. The hemodynamic trajectory after the initial care bundle has been provided refines prognostication and anticipates hospital outcomes. Invasive hemodynamic monitoring also tracks the clinical response to supportive measures, providing objective background for therapeutic escalation/de-escalation, facilitating titration of vasoactive/temporary mechanical circulatory support (tMCS) to achieve an optimal balance between native heart function and device assistance, and allowing for a repeated reassessment of hemodynamics during the support weaning phase. Therefore, complete hemodynamic assessment (i.e., arterial line, central venous catheter, and pulmonary artery catheter) is recommended for any patient in overt CS; however, we also provide some pragmatic clinical, imaging, and laboratory criteria to identify patients with beginning stages of CS, which could also benefit from complete invasive hemodynamic assessment. The specific hemodynamic phenotypes that can be applied in clinical practice and case-based examples of how the invasive hemodynamic phenotype can change following therapeutic actions are presented to provide pragmatic guidance on invasive hemodynamic monitoring. This review also aims to summarize the available monitoring technologies, describing the current limitations of each one and the perspective for future developments in the era of artificial intelligence. The gaps in evidence that still characterize pulmonary catheter use, i.e., lack of a robust positive randomized clinical trial in CS, are discussed, along with the wide background of non-randomized studies currently supporting its use in the CS field. The reappraisal of invasive hemodynamic monitoring, closely linked to the advent and increasing adoption of tMCS, sets the stage for greater adoption of this clinical tool in the future, as it remains a fundamental tool for the intensive care cardiologist.

Keywords: acute heart failure; cardiogenic shock; hemodynamic monitoring; hemodynamics; intensive care; mechanical circulatory support; pulmonary artery catheter; right heart catheterization.

Fig. 1.

Common pitfalls in invasive hemodynamic monitoring and pressure waveform analysis. (A) An optimally damped pressure line: the waveform responds with 1–2 oscillations after line flushing. This ensures accurate estimation of pressure values. (B) An underdamped pressure line: the waveform responds with $>$2 oscillations after line flushing, leading to systolic pressure overestimation and diastolic pressure underestimation (mean pressure value is usually unaffected). This suggests insufficient density of the line filling fluid: changing the fluid with more viscous solutions (e.g., saline over glucose) should be considered. (C) An overdamped pressure line: the waveform responds with no oscillations after line flushing, leading to systolic pressure underestimation and diastolic pressure overestimation (mean pressure value is usually unaffected). This suggests obstruction of the pressure line: changing catheter position, repeated manual flushing with a syringe and deairing of the line should be considered to fix this problem.

Fig. 2.

Pragmatic algorithm for patient and hemodynamic monitoring selection based on the AHF/CS etiology. Select criteria that warrant consideration for hemodynamic monitoring are summarized, based on the CS etiology. In case of AHF and beginning CS (SCAI B), presence of two or more of the proposed criteria warrant insertion of ABP line and CVC; if poor SvCO₂ or high Pv-aCO₂ gap are measured on the central venous blood sample, PiCCO or PAC insertion should also be evaluated. Notably, PiCCO would not be accurate if tMCS are instituted. In case of over CS (SCAI C or higher) a complete hemodynamic monitoring with ABP line, CVC and PAC is warranted. If PAC has a limited availability, PiCCO offers an alternative, provided that no tMCS are used. ABP, arterial blood pressure; AMI, acute myocardial infarction; ADHF, acute decompensated heart failure; CS, cardiogenic shock; CVC, central venous catheter; HR, heart rate; LVEDP, left ventricular end-diastolic pressure; LVOT, left ventricular outflow tract; PAC, pulmonary artery catheter; Pv-aCO₂ gap, veno-arterial CO₂ pressure gap; RAP, right atrial pressure; SCAI, Society for Cardiovascular Angiography & Interventions; s’-TDI, s’ wave on tissue Doppler imaging; sPAP, systolic pulmonary artery pressure; SvcO₂, central venous oxygen saturation; TAPSE, tricuspid annular plane systolic excursion; tMCS, temporary mechanical circulatory support; VA, ventricular arrhythmia; VTI, velocity-time integral; AHF, acute heart failure; CS, cardiogenic shock; HR, heart rate; ECG, electrocardiogram; ECHO, echocardiography; LABS, laboratory tests; LVEF, left ventricular ejection fraction; VA, ventricular arrhythmias. Fig. 2 was created with Biorender.com.

Fig. 3.

The spectrum of goals of invasive hemodynamic monitoring in the AHF patient. AMI, acute myocardial infarction; ADHF, acute decompensated heart failure; CS, cardiogenic shock; LV, left ventricular; LVAD, left ventricular assist device; MS, mixed shock; RV, right ventricular; tMCS, temporary mechanical circulatory support; HRT, heart replacement therapies; HF, heart failure.

Fig. 4.

Summary of common CS classifications and framework of supportive measures according to CS phenotypes. AHF, acute heart failure; CPR, cardiopulmonary resuscitation; CI, cardiac index; CS, cardiogenic shock; CSWG, Cardiogenic Shock Working Group; CVP, central venous pressure; IABP, intra-aortic balloon pump; LV, left ventricular; MS, mixed shock; OMT, optimal medical therapy; PAWP, pulmonary artery wedge pressure; RV, right ventricular; SCAI, Society for Cardiovascular Angiography and Interventions; tMCS, temporary mechanical circulatory support; V-A ECMO, veno-arterial extracorporeal membrane oxygenation; V-P ECMO, veno-pulmonary extracorporeal membrane oxygenation; ECPella, ECMO combined with Impella; BiPella, biventricular support with pVAD.