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The association of pulmonary artery catheterization utilization and surgical patients’ outcomes: a PRISMA-compliant systematic review and meta-analysis

Journal of Cardiothoracic Surgery volume 20, Article number: 227 (2025) Cite this article

Abstract

Background

The utilization of pulmonary artery catheterization (PAC) in surgical patients remains controversial. This study aims to assess the impact of PAC utilization on surgical patient outcomes.

Methods

Electronic databases were searched for studies comparing PAC with no-PAC in surgical patients. The primary outcome was short-term mortality. Secondary outcomes included the incidence of postoperative complications, postoperative recovery indicators, and hospitalization costs.

Results

Ten randomized controlled trials (n = 2,889) and sixteen observational studies (n = 2,221,917) were included. Among these studies, fifteen involved cardiac surgical patients (n = 2,217,736), and eleven involved non-cardiac surgical patients (n = 7,070). The present study demonstrated PAC utilization did not affect short-term mortality in cardiac surgical patients [odds ratio (OR) 1.20, 95% confidence interval (CI) 0.79–1.82, p 0.40], and was associated with a higher incidence of postoperative chronic heart failure, acute renal failure, cerebrovascular events, infectious complications, and longer length of stay (LOS) in intensive care unit (ICU) or hospital. Moreover, PAC utilization was not associated with short-term mortality (OR 0.40, 95% CI 0.16–1.02, p 0.06) and other outcomes for non-cardiac surgical patients.

Conclusions

This meta-analysis suggested PAC utilization was not associated with short-term mortality in surgical patients but with a higher incidence of major complications and longer LOS in the ICU or hospital in cardiac surgical patients.

Peer Review reports

Introduction

For five decades, pulmonary artery catheterization (PAC) has been used for preoperative hemodynamic optimization, intraoperative monitoring, and postoperative management in surgical patients [1,2,3,4,5,6,7,8,9]. PAC provides vital parameters, including cardiac output (CO), mixed venous oxygen saturation (SmvO2), pulmonary artery pressure (PAP), and pulmonary capillary wedge pressure (PCWP). Additional derived data could be calculated from these measurements, including pulmonary and systemic vascular resistance (PVR, SVR), cardiac index (CI), stroke volume (SV), right and left ventricular end-systolic and end-diastolic volume, right ventricular ejection fraction (RVEF), oxygen delivery, and oxygen consumption. PAC utilization could be valuable in guiding treatment in high-risk surgical patients.

Since the adoption of PAC into clinical practice, studies of PAC in surgical patients have yielded inconsistent results. Studies reported that PAC utilization in coronary artery bypass graft (CABG) [10] and in hip surgery [11] had reduced mortality; another study suggested that the benefit of PAC utilization outweighed the risk in cardiovascular surgical patients [12]. However, several studies found no benefit for PAC utilization [13,14,15,16] and reported that PAC utilization in cardiac surgical patients was associated with greater mortality, prolonged mechanical ventilation duration (MVD), and length of stay (LOS) in hospital [17]. These findings were consistent with an international prospective observational study in 5,065 patients undergoing CABG [18], and PAC’s benefit had not been reported in the most recent studies [5, 8, 19]. Therefore, the authors conducted the current study to investigate whether PAC utilization affects the outcomes of cardiac and non-cardiac surgical patients.

Methods

The current study sought to include all relevant studies based on recently published guidelines [20] and the Cochrane Handbook for Systematic Reviews of Interventions [21]. Findings were reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement [22] (Supplementary files Table 1). The study was registered on the International Prospective Register of Systematic Reviews PROSPERO: CRD42022374726.

Search strategy and study selection

Two authors (XCM and HLX) independently retrieved published studies [8] in PubMed, Embase, Cochrane Library, Web of Science, and Scopus databases from inception until 5 January 2025, using different combinations of search words as follows: (pulmonary artery catheter OR right heart catheter OR Swan-Ganz catheter) AND (surgery OR operation) AND clinical trial (Supplementary files Table 2). The language was restricted to English. Moreover, additional relevant studies were searched manually by checking references of the retrieved articles and relevant reviews.

Inclusion criteria: ① Study population: cardiac and non-cardiac surgical patients. ② Intervention measure: PAC utilization. ③ Control group: no-PAC utilization. ④ Outcomes: the primary outcome was short-term mortality; secondary outcomes included composite and individual incidences of postoperative complications, hospitalization costs, and postoperative recovery (MVD, LOS in ICU and hospital). ⑤ Study design: randomized controlled trials (RCTs), cohort studies, and case–control studies. Exclusion criteria: duplicate publications, reviews, case reports, abstracts, letters, comments, animal or cell studies, and studies lacking information about outcomes of interest.

Data abstraction

Three authors (CMX, MQS, LXH) independently extracted data from the selected articles strictly following the inclusion and exclusion criteria. The following information was recorded: (1) author, country and publication year, duration of included studies; (2) type of surgical procedure; (3) total number of patients, number of patients in PAC and no-PAC groups; (4) data regarding outcomes of interest in both groups. Disagreements were resolved by discussion among all authors during the process of data abstraction.

Outcome

The primary outcome was short-term mortality from any cause. Short-term mortality defined as in-hospital and 30-day post-operative mortality. Secondary outcomes included the incidence of postoperative complications, postoperative recovery indicators, and hospitalization costs. The composite postoperative outcomes consisted of fatal and nonfatal in-hospital outcomes classified as cardiac (arrhythmia, myocardial infarction, congestive heart failure), cerebrovascular events (stroke, encephalopathy), renal (dysfunction or failure), pulmonary complications, and infectious morbidities. The composite postoperative outcomes are mostly based on the data presented in the original study, rather than the authors simply adding up individual outcome measures.

In addition, the definition of individual outcomes, such as myocardial infarction or renal insufficiency, refers to the definition in the original study and the presented data.

Evaluation of the quality of studies

Two authors (CMX, MQS) independently assessed the quality of the included studies. The risk of bias assessment was conducted using the Cochrane Risk of Bias Tool [23]. Also, the modified 7-point Jadad score [24] was used to evaluate the methodological quality of included RCTs. Trials with 1–3 points were deemed low quality, and those with 4–7 points were deemed high quality. Additionally, the Newcastle–Ottawa Scale (NOS) was used to assess the methodological quality of included observational studies [25]. The NOS scale evaluated three aspects of study methods: selection of study groups (range 0–4), comparability of groups (range 0–2), and quality of outcome or exposure ascertainment (range 0–3). The total score ranged from 0 to 9, and a score > 5 reflected an acceptable methodological design.

Subgroup analysis

The present study assessed the effect of PAC utilization in different subgroups, including whether goal-directed therapy (GDT) was employed in the original article and whether the trial was conducted before/after the SUPPORT study (1996). The SUPPORT study involved medical and surgical patients and showed PAC utilization had increased mortality, LOS in ICU, and costs [2]. Hence, subsequent consensus statements recommended redoubled efforts at education regarding the use of pulmonary-artery catheters and randomized, controlled clinical trials of their service. Therefore, the current study conducted a subgroup analysis before/after the SUPPORT study (1996).

Statistical analyses

All data were analyzed using RevMan 5.4 (Cochrane Collaboration, Oxford, UK). Pooled odds ratio (OR) and 95% confidence interval (CI) were estimated for dichotomous data, and weighted mean difference (WMD) and 95% CI were for continuous data. Heterogeneity was assessed by I2 statistic, with statistics of < 25%, 25–50%, and > 50% as thresholds for low, moderate, and high heterogeneity, respectively [26, 27]. Each outcome was tested for heterogeneity, and a randomized-effects or fixed-effects model was used in the presence or absence of significant heterogeneity. Potential publication bias was explored through visual inspection of funnel plots of outcomes. Sensitivity analyses were done by examining the influence of the statistical model on estimated treatment effects, and analyses that adopted the fixed-effects model were repeated using the randomized-effects model and vice versa. In addition, it also evaluated the influence of individual studies on the overall effects. All p-values were two-sided, and statistical significance was defined as p < 0.05.

Results

Characteristics of included studies

The search initially retrieved 719 citations. Finally, twenty-six studies (n = 2,224,806) were included in qualitative synthesis (Fig. 1) [4,5,6,7,8,9,10,11, 13,14,15,16,17,18,19, 28,29,30,31,32,33,34,35,36,37,38]. One study did not report extractable outcomes and was not pooled for meta-analysis [30]. Characteristics of the included studies were summarized in Table 1 and Table 2, ten studies were RCTs (n = 2,889), and sixteen were observational cohort studies (n = 2,221,917). Also, fifteen involved cardiac surgical patients (only one was RCT [29]), and eleven studies included non-cardiac surgical patients (only two were cohort studies [8, 30]).

Fig. 1
figure 1

Flow diagram of study selection

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Table 1 Characteristics of the included studies
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Table 2 Summary of the effect of PAC utilization on outcomes of included studies
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Study quality and risk bias

The risk of bias analysis of the ten RCTs was shown in Supplementary files Fig. 1. Four RCTs [9, 15, 34, 37] scored as “high quality” according to the modified Jadad score, and the other RCTs as “low quality” (Supplementary files Table 3). Details of the methodological quality of the included observational cohort studies according to the NOS were provided in Supplementary files Table 3. The median NOS rating for the 16 studies reviewed was 6 (range: 5–8). Therefore, all were considered to be of high quality.

Short-term mortality

Data on the outcome of short-term mortality were available from twenty-four studies (three studies [6, 8, 28] reported 30-day mortality, seventeen reported in-hospital mortality, two [7, 16] reported zero death, one [33] reported overall mortality, and one did not provide available data). As shown in Fig. 2A, twelve observational cohort studies (n = 2,127,113) reported short-term mortality in cardiac surgical patients, and meta-analysis showed PAC was not associated with short-term mortality (OR 1.20, 95% CI 0.79–1.82, p 0.40) with high heterogeneity (I2 = 90%, p < 0.00001). The results of subgroup analysis (before/after the SUPPORT study) showed PAC did not affect short-term mortality (Supplementary files Fig. 2). As shown in Fig. 3A, eight RCTs (n = 2,711) and one observational cohort study (n = 200) reported short-term mortality in non-cardiac surgical patients, and meta-analysis results of RCTs showed PAC utilization was not associated with short-term mortality (OR 0.40, 95% CI 0.16–1.02, p 0.06) with high heterogeneity (I2 = 60%, p = 0.01). The results of the subgroup analysis (before/after the SUPPORT study) showed that PAC utilization did not affect short-term mortality (the group before the SUPPORT study) (Supplementary files Fig. 3). Another subgroup analysis was performed based on whether goal-directed therapy (GDT) was employed or not, and the results of the GDT group showed that PAC utilization did not affect short-term mortality (Supplementary files Fig. 4).

Fig. 2
figure 2

Meta-analysis results in cardiac surgical patients A Short-term mortality B The incidence of composite postoperative complications C LOS in ICU D LOS in hospital E. Hospitalization costs

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Fig. 3
figure 3

Meta-analysis results in non-cardiac surgical patient. A Short-term mortality B The incidence of composite postoperative complications C LOS in ICU D LOS in hospital E. Hospitalization costs

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The incidence of composite postoperative complications

As shown in Fig. 2B, three observational studies (n = 9,524) reported the incidence of composite postoperative complications in cardiac surgical patients, and meta-analysis showed PAC utilization did not affect the incidence of composite postoperative complications (OR 1.44, 95% CI 0.85–2.45, p 0.18) with high heterogeneity (I2 = 94%, p < 0.00001). Figure 3B showed that six RCTs (n = 577) and one observational study (n = 4,059) reported the incidence of composite postoperative complications in non-cardiac surgical patients. All the included RCTs performed goal-directed therapy, and meta-analysis results of RCTs showed PAC utilization did not affect the incidence of composite postoperative complications (OR 0.48, 95% CI 0.19–1.25, p 0.13) with high heterogeneity (I2 = 77%, p = 0.0007).

The incidence of other major complications

Meta-analysis of the incidence of various complications was presented in Supplementary files Table 4, all the included studies in cardiac surgical patients were observational cohort studies, while all the included studies in non-cardiac surgical patients were RCTs. These results showed that PAC utilization was associated with higher incidence of postoperative chronic cardiac failure (CHF) (OR 3.14, 95% CI 0.99–10.00, p 0.05), acute renal failure (ARF) (OR 1.56, 95% CI 1.07–2.26, p 0.02), cerebrovascular events (OR 1.41, 95% CI 1.13–1.78, p 0.003), and infectious complications (OR 1.25, 95% CI 1.08–1.46, p 0.003) in cardiac surgical patients. The forest figures are shown in Supplementary files Fig. 5. Supplementary files Fig. 6 showed that six RCTs (n = 2,411) and one observational study (n = 4,059) reported the incidence of postoperative ARF in non-cardiac surgical patients, and meta-analysis result of 6 RCTs showed that PAC utilization was associated with lower incidence of postoperative ARF (OR 0.71, 95% CI 0.52–0.96, p 0.03).

LOS in ICU

As shown in Fig. 2C, seven observational studies (n = 28,071) reported LOS in ICU in cardiac surgical patients, and meta-analysis showed PAC utilization was associated with longer LOS in ICU (WMD 0.47, 95% CI 0.12–0.81, p 0.008) with high heterogeneity (I2 = 99%, p < 0.00001). Additionally, we conducted a subgroup analysis before/after the SUPPORT study, and the results of the group before the SUPPORT study showed PAC utilization did not affect LOS in the ICU (Supplementary files Fig. 7). Figure 3C showed that four RCTs (n = 351) and one observational study (n = 238) reported LOS in ICU in non-cardiac surgical patients. All the included RCTs performed GDT, and meta-analysis results of RCTs showed PAC utilization did not affect LOS in ICU (WMD − 0.92, 95% CI − 2.77–0.92, p 0.33) with high heterogeneity (I2 = 96%, p < 0.00001).

LOS in hospital

As shown in Fig. 2D, five observational studies (n = 28,071) reported hospital LOS in cardiac surgical patients, and meta-analysis showed PAC utilization was associated with longer LOS in hospital (WMD 0.75, 95% CI 0.00–1.50, p 0.05) with high heterogeneity (I2 = 99%, p < 0.00001). Figure 3D showed that seven RCTs (n = 2,566) and one observational study (n = 238) reported hospital LOS in non-cardiac surgical patients, and a meta-analysis of seven RCTs showed PAC did not affect hospital LOS (WMD 0.02, 95% CI − 0.67–0.70, p 0.96) with high heterogeneity (I2 = 79%, p < 0.0001). The subgroup analysis results (whether GDT was employed) showed PAC utilization did not affect hospital LOS (Supplementary files Fig. 8).

MVD

Three studies reported MVD, two observational cohort studies in cardiac surgical patients, and a meta-analysis showed PAC utilization did not affect MVD (OR 0.85, 95% CI 0.56–1.29, p 0.46) (Supplementary files Fig. 9). In non-cardiac surgical patients, only one study reported that PAC utilization did not influence MVD.

Hospitalization costs

As shown in Fig. 2E (the units shown were 1000 USD), five observational studies (n = 2,078,400) reported hospitalization costs in cardiac surgical patients, and meta-analysis results showed PAC utilization did not affect hospitalization costs (WMD − 0.59, 95% CI − 5.49–4.30, p 0.81) with high heterogeneity (I2 = 100%, p < 0.00001). The results of subgroup analysis (before/after the SUPPORT study) showed that PAC utilization was associated with higher hospitalization costs (the group before 1996) (Supplementary files Fig. 10). Figure 3E showed that four RCTs (n = 351) reported hospitalization costs in non-cardiac surgical patients, and meta-analysis showed PAC utilization did not affect hospitalization costs (WMD 1.33, 95% CI − 1.25–3.90, p 0.31) with high heterogeneity (I2 = 73%, p = 0.01).

Sensitivity analyses and publication bias

First, by examining the influence of the statistical model on estimated treatment effects, as shown in Supplementary files Table 5, results of short-term mortality in non-cardiac surgical patients, LOS in ICU of cardiac surgical patients, and postoperative cerebrovascular events, ARF, CHF, infectious complications in cardiac and non-cardiac surgical patients essentially did not change, indicating that these results were reliable. Second, sensitivity tests were performed by removal of each study to evaluate the influence of individual studies on the overall effects (Supplementary files Table 6). The meta-analysis results of short-term mortality and hospitalization costs in non-cardiac surgical patients, cerebrovascular events, ARF and LOS in hospital in cardiac surgical patients changed after the sensitivity test described above. Third, the funnel plot suggested moderate publication bias in studies reporting short-term mortality (Fig. 4).

Fig. 4
figure 4

Funnel plot of short-time mortality in cardiac and non-cardiac surgical patients

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Discussion

The invention of PAC has a long and distinguished history. Professor Werner Forssmann first performed the human right heart catheter in 1929. In the 1940s, Richards and colleagues [39] developed a catheter that could be inserted in the pulmonary artery to study hemodynamics in patients using fluoroscopy guidance. The introduction of PAC by professors Jeremy Swan and William Ganz in 1970 [1] allowed the insertion of the catheter at the bedside. Following the work of Swan/Ganz, PAC has begun to be routinely used in critically ill patients as a diagnostic tool and monitoring device, particularly for those with myocardial infarction, cardiogenic shock, and CHF. However, the SUPPORT trial conducted in 1996 revealed that PAC utilization was associated with increased 30-day mortality, LOS in the ICU, and costs [2]. These findings raised concerns regarding the risk–benefit profile of PAC utilization. Conversely, a study called PAC-man enrolled 1,041 ICU patients from the UK and reported no significant difference in in-hospital mortality between patients managed with or without PAC [40]. Several studies including high-risk surgical patients also showed that the benefit of PAC utilization was modest [4, 9, 18]. Concerns about the safety and efficacy of PAC, alternative less invasive or noninvasive hemodynamic monitoring devices emerged [41]. Although many technologies have sought to supplant PAC, none has been subjected to as much clinical use and scrutiny. PAC remains the gold standard for CO/CI, SmvO2, PAP, blood temperature, and all in one piece. Transesophageal echocardiography (TEE) has been increasingly used in non-cardiac and cardiac surgical patients. TEE could detect wall motion abnormalities, which are early signs of acute myocardial ischemia. Moreover, TEE could provide live information regarding valvular structures and function, and detect intracardiac air [42]. However, TEE use needs a skilled operator, and the standard TEE probes cannot be kept in the patient for too long. Therefore, TEE and PAC were complementary to each other. Combined use of PAC and TEE may be more helpful than alone.

The present study demonstrated PAC utilization did not affect short-term mortality in cardiac surgical patients and was associated with a higher incidence of postoperative CHF, ARF, cerebrovascular events, infectious complications, and LOS in the ICU or hospital. It is plausible to hypothesize that this observation results reflect the practice of escalating monitoring to include PAC placement in the face of clinical deterioration in patients who ultimately suffer a complication could be reasonable. To our knowledge, many factors may affect surgical patients’ outcomes, for example, patients’ pre-operative conditions, comorbidities, surgery risks, etc. As far as PAC is concerned, the indications of PAC utilization, clinicians’ proficiency and experience, whether GDT was employed, and the timing of PAC insertion could all affect the patients’ outcomes. However, early PAC insertion was not associated with survival benefits in critically ill patients with cardiac diseases, either in surgical or non-surgical patients [43].

In 2003, the American Society of Anesthesiologists (ASA) updated the practice guidelines for PAC utilization, recommending that appropriate PAC use should be determined based on three key factors: patient characteristics, surgical considerations, and clinical practice variables [44]. Firstly, PAC utilization was appropriate in high-risk surgical patients (ASA grade 4/5, hemodynamic disturbances with high possibility of organ dysfunction or death) undergoing high-risk procedures (a great chance of fluid change or hemodynamic disturbances or other factors with high risk of morbidity and mortality). Secondly, the low-risk practice settings (good catheter-use skills and technical support, training, and experience of nursing staff in the recovery room and ICU, technical support for ancillary services, and availability of specialists and equipment to manage complications), as well as the proficiency and experience of clinicians in PAC utilization, must be taken into account. Finally, the risk degree of patients and the risk posed by the procedure itself should influence the decision whether or not a PAC is used [44]. It is noteworthy that this latest PAC guideline was published 20 years ago. One non-cardiac surgery study (liver transplantation) and seven cardiac surgery studies included in the present study were conducted after 2003. However, the enrolled patients did not reach ASA grade 4/5 and mainly underwent CABG or VS. In 2021, the Chinese Society of Anesthesiology (CSA) issued recommendations for utilizing PAC in cardiac surgical patients with specific conditions such as left ventricular systolic dysfunction (ejection fraction < 30%), right ventricular systolic dysfunction, left ventricular diastolic dysfunction, acute ventricular septal perforation and left ventricular assist device. Consequently, judicious employment of PAC in this patient population is advised primarily for individuals experiencing persistent hemodynamic instability or at high risk of developing such circumstances intraoperatively or shortly after surgery.

The clinicians’ expertise and extensive experience with PAC are indispensable. Professor Jeremy Swan, the pioneer of PAC, recommended that physicians should perform a minimum of 50 PAC procedures annually to uphold their proficiency [45]. The latest review concluded that a thorough understanding of measurements (e.g., CO, PAWP, SmvO2) obtained from PAC was the first step in the successful application of PAC in clinical practice [46]. In some patients, CO measurement was indicated as an aid to diagnosis, to monitor the adequacy of therapy, and to prognosis [47]. Critically-ill patients who could not sustain a CI in excess of 2 L/min/m2, despite aggressive therapy, had a very high mortality rate [48]. For CHF patients, PCWP < 15 mmHg was an indicator of remission of HF [49]. Maintaining SmvO2 > 70% during cardiac surgery correlates with a better postoperative outcome [50]. Pinsky and colleagues pointed out that the monitoring device could only improve outcomes if coupled with a specific treatment plan known to improve outcomes [51]. However, several surveys [52,53,54,55] identified that many physicians and nurses could not correctly measure or interpret even the most basic information provided by PAC. If future generations of physicians and nurses receive less training in PAC than their predecessors, these deficiencies will likely worsen, which may further decrease the effectiveness of PAC utilization in clinical situations. Correspondingly, educational modalities for learning PAC would like to be relied upon more broadly, such as simulation, similar to the high-fidelity mannequins in central venous catheter insertion [56]. Expansion of high-fidelity simulation to include waveform interpretation and identification and management of complications of PAC (e.g., arrhythmias) could supplement hands-on training [57].

In the present study, PAC-guided GDT was employed in only two cardiac surgical studies, one described PAC-guided GDT reduced mortality [10], and another study described PAC-guided GDT did not affect mortality and morbidity [29]. PAC was inserted and guided for GDT in eight non-cardiac surgical studies, and four studies showed benefit [11, 14, 34, 37], three studies showed no effect [16, 28, 36], and one study showed harm [9]. As shown in Table 2, four GDT parameters (CI, PCWP, SVR, oxygen delivery) were used in seven [9, 10, 14, 16, 28, 34, 36], six [9, 14, 16, 28, 36, 37], five [10, 14, 16, 28, 36], and four [9, 16, 34, 37] included PAC-guided GDT studies in the current study, respectively. However, there were few definitive data to support the use of any hemodynamic target. The benefit of GDT seemed to rely on the use of vasoactive agents, and the mortality was not statistically significant in cardiac surgical patients. Nonetheless, the results were relevant to anesthetic practice, the performance of intra-operatively initiated GDT still yielded clinically important benefit [58].

In the present study, two [15, 18], five [8, 14, 15, 28, 36], four [9, 14,15,16] non-cardiac surgical studies showed that PAC utilization did not affect MVD, LOS in ICU, and hospital LOS, respectively. For cardiac surgical patients, four [7, 17, 18, 35], seven [5, 7, 17,18,19, 31, 35], four [5, 7, 31, 35] studies showed that PAC utilization was associated with longer MVD, LOS in ICU, and hospital LOS, respectively. And two [29, 32], three [13, 29, 32], one [32] studies showed no effect on MVD, LOS in ICU, and hospital LOS, respectively. Only one study showed that PAC utilization was associated with shorter hospital LOS. As mentioned above, many factors affected the mortality and morbidity of surgical patients using PAC. Similarly, postoperative recovery was also influenced by many factors (patients’ condition, doctors’ preferences, and institutions’ clinical routines).

The results showed that PAC utilization did not affect hospitalization costs in cardiac and non-cardiac surgical patients in the current study. In the original studies, four non-cardiac surgical studies [14, 15, 28, 34, 36] and one cardiac surgical study [17] showed that PAC utilization did not affect hospitalization costs, and one non-cardiac surgical study [34] showed PAC utilization had reduced costs. On the contrary, four cardiac surgical studies [29, 31, 35, 38] showed higher hospitalization costs with PAC utilization. Hospitalization costs were also influenced by many factors. Clermont et al. reported that PAC utilization had increased costs for routine PAC utilization in acute lung injury patients [59]. A retrospective cohort study reported that PAC utilization had increased hospitalization costs in HF patients [60]. When PAC utilization reduced mortality and improved outcomes, it was a benefit despite the increased costs. An economic calculating model-based study [61] reported that for an acute care hospital with 500 procedures/year and 34% PAC adoption (It is based PAC utilization was approximately 34% of the US cardiac surgical procedures), annualized savings were $61,806 versus no PAC utilization, and for an integrated payer-provider health system with the base-case scenario of 3845 procedures/year and 34% PAC adoption, estimated savings were $596,637 for the combined surgical index admission and treatment for related complications over the following year.

In general, the evidence of effectiveness and safety for PAC utilization was still lacking, and it wasn’t easy to draw definitive conclusions from accumulated evidence. PAC, while a valuable diagnostic and monitoring tool, is not without risks. Common complications include arrhythmias, rare but severe complications include pulmonary artery rupture and catheter-related infections. Thrombotic complications, mechanical complications such as catheter knotting, can lead to significant morbidity. The overall mortality rate associated with PAC, these potential adverse outcomes underscore the importance of careful patient selection, skilled catheter placement, and judicious use of this invasive monitoring technique. Based on the current study’s findings, routine use of PAC in low-risk patients had not reduced mortality or hospital LOS. For patients with relative contraindications, the harm of PAC utilization may outweigh its benefit, and for patients with indications, PAC utilization may improve prognosis. Although clinical trials could not reach consistent conclusions, there were a large number of patients in clinical practice who needed PAC utilization and benefited from it. Future studies should focus on defining subgroups of patients who might benefit from PAC utilization and defining effective therapeutic interventions according to the hemodynamic information gained from PAC.

Limitations

The limitations of this study should be acknowledged, which are characteristics of all aggregate data meta-analyses [62, 63]. First, the authors included several studies performed in different settings with different aims, and simultaneously these data were not suitable for subgroup analysis, which may be the source of heterogeneity [64]. Second, the present study included both RCTs and observational studies, the period of inclusion was large, and the sample size of four RCTs was less than 100, therefore may reduce the quality of evidence of the present study. Third, the authors focused on surgical patients, which did not include studies of PAC utilization in other settings such as in HF patients and coronary care units. Fourth, the current study had limitations in analyzing the secondary outcomes (complications, LOS in ICU and hospital, hospitalization costs), because only some of the included studies reported these outcomes. In addition, the diagnostic criteria of complications in each study were not unified. Finally, the postoperative recovery of surgical patients was complex and could be affected by many factors, however, the present study only analyzed the effect of PAC utilization.

Conclusions

This meta-analysis suggested that PAC utilization was not associated with short-term mortality in surgical patients but with a higher incidence of major complications and longer LOS in the ICU or hospital in cardiac surgical patients.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author upon reasonable request.

Abbreviations

PAC:

Pulmonary artery catheterization

OR:

Odds ratio

CI:

Confidence interval

LOS:

Length of stay

ICU:

Intensive care unit

CO:

Cardiac output

SmvO2 :

Mixed venous oxygen saturation

PAP:

Pulmonary artery pressure

PCWP:

Pulmonary capillary wedge pressure

PVR:

Pulmonary vascular resistance

SVR:

Systemic vascular resistance

CI:

Cardiac index

SV:

Stroke volume

RVEF:

Right ventricular ejection fraction

CABG:

Coronary artery bypass graft

MVD:

Mechanical ventilation duration

RCTs:

Randomized controlled trials

NOS:

Newcastle–Ottawa scale

GDT:

Goal-directed therapy

WMD:

Weighted mean difference

CHF:

Chronic cardiac failure

ARF:

Acute renal failure

PiCCO:

Pulse index continuous cardiac output

LiDCO:

Lithium dilution cardiac output

NICO:

Noninvasive cardiac output

TEE:

Transesophageal echocardiography

HF:

Heart failure

SCA:

Society of cardiovascular anesthesiologists

ASA:

American society of anesthesiologists

CSA:

Chinese society of anesthesiology

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Funding

This work was supported by the National Key Research and Development Program (2022YFC2503400), the Yunnan Provincial Clinical Medicine Research Special Program (202405AJ310003), and the Major Science and Technology Special Plan Project of Yunnan Province (202302AA310045).

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  1. Department of Anesthesiology, Fuwai Yunnan Hospital, Chinese Academy of Medical Sciences, Affiliated Cardiovascular Hospital of Kunming Medical University, Kunming, 650102, China

    Chun-mei Xie, Li-xian He & Meng-qi Shen

  2. Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100037, China

    Yun-tai Yao

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Chun-Mei Xie, Li-Xian He: conceptualization, software, methodology, data collection, data analysis/interpretation, statistics, and writing-original draft. Meng-Qi Shen: data collection, formal analysis, software, and critical revision of the article. Yun-Tai Yao: conceptualization, data collection, data analysis/interpretation, statistics, formal analysis, supervision, and critical revision of the article.

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Xie, Cm., He, Lx., Shen, Mq. et al. The association of pulmonary artery catheterization utilization and surgical patients’ outcomes: a PRISMA-compliant systematic review and meta-analysis. J Cardiothorac Surg 20, 227 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s13019-025-03416-8

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Journal of Cardiothoracic Surgery

ISSN: 1749-8090

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