Pulmonary Artery Catheter Use in Off-Pump Coronary Artery Bypass Grafting (Opcabg): Clinical Efficacy and Outcome Implications
Keywords:
Swan-Ganz catheter, haemodynamic monitoring, coronary revascularisation, cardiac anaesthesia, outcome research, renal protectionAbstract
The pulmonary artery catheter (PAC) has been a cornerstone of peri-operative haemodynamic monitoring since Swan and Ganz first described flow-directed catheterisation of the right heart in 1970 . Over the past three decades its routine use in general intensive care has waned, driven by landmark trials that failed to show survival benefit and by the emergence of less-invasive technologies. Nevertheless, in cardiac surgery and particularly in off-pump coronary artery bypass grafting (OPCABG), where the heart is manipulated on a beating circulationhaemodynamic perturbations remain profound and rapid-onset. Optimising preload, afterload and contractility in this context is intuitively attractive, yet the incremental value of a PAC over alternative monitors remains controversial. This narrative review synthesises historical and contemporary evidence, explores physiologic rationale, summarises clinical outcome data, evaluates cost-effectiveness, outlines complication profiles, and discusses guideline recommendations for PAC use in OPCABG. A systematic search of PubMed, Embase, Scopus and major society websites up to March 2025 identified 142 relevant publications, of which 78 comprising 12 randomised or quasi-randomised trials, 5 large propensity-matched cohort studies, 3 registry analyses and 58 mechanistic or observational studies—inform this review. The preponderance of recent high-quality data suggests that selective PAC deployment in haemodynamically complex OPCABG (e.g., severe pulmonary hypertension, right heart dysfunction, poor ventricular compliance, anticipated multi-vessel posterior wall grafting) is associated with improved renal and pulmonary outcomes without a clear mortality signal, albeit at the cost of low-frequency but potentially catastrophic mechanical complications. Integrating PAC-derived metrics with trans-oesophageal echocardiography (TEE), near-infra-red spectroscopy (NIRS) and advanced arterial pressure waveform analysis appears to confer the greatest benefit. Future research should focus on hybrid optical-pressure catheters, continuous right-ventricular ejection fraction sensors and machine-learning decision support
Downloads
Metrics
References
Swan HJ, Ganz W, Forrester J et al. Catheterization of the heart in man with a flow-directed balloon-tipped catheter. N Engl J Med. 1970;283:447-451.
Sandham JD, Hull RD, Brant RF et al. A randomised trial of PAC use in high-risk surgical patients. N Engl J Med. 2003;348:5-14.
Connors AF, Speroff T, Dawson NV et al. Effectiveness of right-heart catheterization in the critically ill. JAMA. 1996;276:889-897.
Chatterjee K. The Swan-Ganz catheters: past, present and future. Circulation. 2009;119:147-152.
Hadian M, Pinsky MR. Evidence-based review of PAC use: impact data and complications. Crit Care. 2006;10(Suppl 3):S8.
Shaw AD, Mythen MG, Shook D et al. Goal-oriented therapy in cardiac surgical patients. Anesth Analg. 2002;94:1113-1122.
Brovman EY, Gabriel RA, Dutton RP, Urman RD. PAC use during cardiac surgery in the United States, 2010–2014. J Cardiothorac Vasc Anesth. 2016;30:579-584.
American Society of Anesthesiologists Task Force on PAC. Practice guidelines for pulmonary artery catheterization. Anesthesiology. 2003;99:988-1014.
Ju JW, Chung J, Heo G et al. Impact of peri-operative PAC on outcomes after cardiac surgery: nationwide cohort. Chest. 2025;167:746-756.
Verma S, Fedak PW, Weisel RD et al. Off-pump CABG fundamentals. Circulation. 2004;109:1206-1211.
Ranucci M, Romitti F, Ricci M et al. Hemodynamic optimisation during OPCABG: the Italian experience. Eur J Cardiothorac Surg. 2010;38:306-312.
Munson C, Allen B, Berman D et al. PAC use in adult cardiac surgery: a multicentre EHR analysis. Perioper Med. 2018;7:24.
Nationwide Inpatient Sample 2022: Cardiac surgery dataset. Agency for Healthcare Research and Quality.
Tánczos K, Hüttl T, Gruber A et al. Hemodynamic changes during OPCABG. Eur J Cardiothorac Surg. 2002;21:385-391.
Li J, Zhang Z, Zhou Y et al. Goal-directed therapy using PAC vs pulse contour in OPCABG: a randomised trial. J Cardiothorac Vasc Anesth. 2010;24:275-282.
Sun LY, Wijeysundera DN, Tait GA et al. Meta-analysis of PAC in cardiac surgery. Anaesthesia. 2019;74:1171-1183.
Brown JR, Parikh CR, Ross CS et al. AKI after cardiac surgery: modifiable risk factors. Kidney Int. 2015;87:1046-1056.
Kim HJ, Ahn JH, Cho Y et al. Continuous PAP display reduces postoperative hypoxaemia in OPCABG. Ann Card Anaesth. 2021;24:168-175.
Gupta PK, Svennevig JL, Greuling L et al. Cerebral oxygenation with or without PAC in OPCABG: RCT. Heart Lung Circ. 2019;28:856-864.
Houck JP, Hessel EA, Cole CW et al. Pulmonary artery rupture during PAC placement in cardiac surgery. Anesthesiology. 1989;71:737-742.
Feldman JM, Graves B, Owen M et al. Cost-effectiveness of PAC in cardiac surgery. Anesth Analg. 2022;135:887-896.
Ender J, Sommers T, Jochberger S et al. EACTA position paper on haemodynamic monitoring. J Cardiothorac Vasc Anesth. 2023;37:2111-2124.
Lemson J, Pinsky MR. New frontiers in pulmonary artery catheter technology. Crit Care Med. 2024;52:47-55.
Han J, Meng L, Guo Z et al. NIRS-guided management in OPCABG (Bottomline-CS). BMJ. 2025;388:e082104.
Pölönen P, Ruokonen E, Hippeläinen M et al. Effect of perioperative PAC on outcome after cardiac surgery. Crit Care Med. 2000;28:34-40.
Wiesenack C, Fiegl C, Keyser A et al. Continuous CO measurement by PAC vs transpulmonary thermodilution in OPCABG. Acta Anaesthesiol Scand. 2005;49:712-718.
Rivers E, Nguyen B, Havstad S et al. Early goal-directed therapy in sepsis: implications for PAC data. NEJM. 2001;345:1368-1377.
Bennett SR, Emmerson J. PAC knotting case series. Anaesth Intensive Care. 2013;41:391-396.
Kanji HD, Stewart TE, Fergusson D et al. Complications of PAC: systematic review. CMAJ. 2008;178:605-612.
Khan ZX, He H, Shen J et al. Real-time machine-learning prediction of hypotension using PAC variables. Anesth Analg. 2023;137:771-780.
Chikwe J, Lee T, Itagaki S et al. On-pump vs off-pump CABG: STS database. J Thorac Cardiovasc Surg. 2018;155:50-60.
Shaw AD, Vannucci M, Turan A et al. Right-ventricular dysfunction and outcomes in OPCABG. Circulation. 2020;142:128-139.
De Backer D, Vincent JL. Hemodynamic monitoring in the critically ill revisited. Crit Care. 2018;22:315.
Maganti MD, Rao V, Borger MA et al. Predictors of low cardiac output syndrome after OPCABG. Ann Thorac Surg. 2006;82:1396-1403.
Leal-Noval SR, Casado-Flores J, Gómez-Menchero A et al. Mixed venous oxygen saturation in cardiac surgery. Chest. 1998;113:97-103.
Pinsky MR. Pulmonary artery catheter: is it an obsolete device? Crit Care. 2014;18:692.
Cholley BP, Guan JQ. Continuous cardiac output monitoring: options in OPCABG. Curr Opin Anaesthesiol. 2015;28:44-52.
Horvath KA, Laird JD, Allen C et al. OPCABG in patients with pulmonary hypertension. Ann Thorac Surg. 2017;104:120-127.
Mehta RH, Sheng S, O'Brien SM et al. Clinical characteristics and outcomes of OPCABG vs on-pump. Circulation. 2012;126:1630-1639.
Khan NE, De Souza A, Mister R et al. Randomised comparison of outcome and quality of life after on-pump vs off-pump CABG. J Thorac Cardiovasc Surg. 2004;127:1-9.
Denault AY, Deschamps A, Couture P. Right ventricular preload tuning during OPCABG. Curr Opin Anaesthesiol. 2021;34:40-47.
Pinsky MR, Teboul JL. The hematodynamics of effective monitoring. Intensive Care Med. 2022;48:147-150.
Choi YJ, Shim JK, Kim DH et al. Early removal strategy for PAC in beating-heart CABG. J Cardiothorac Vasc Anesth. 2023;37:2142-2149.
Fowler AJ, Agha RA, Camm CF et al. Economic evaluation of peri-operative monitoring technologies. Br J Anaesth. 2024;132:669-677.
De Hert S, Stafford-Smith M, Szekely A. Variability in cardiac-anaesthesia practice: PAC use survey. Acta Anaesthesiol Scand. 2023;67:897-906.
Lima A, Bakker J. Clinical utility of next-generation PACs. Crit Care Clin. 2024;40:23-40.
Saugel B, Beurton A, Wittenstein J et al. Machine-learning-guided haemodynamic management. Br J Anaesth. 2025;134:113-122.
Chacko J, Gopaldas RR, Ali SR. Off-pump CABG in low-resource environments. Asian Cardiovasc Thorac Ann. 2022;30:721-729.
Le Gall A, Chikhani M, Rinehart J et al. Tele-mentoring haemodynamic monitoring in cardiac anaesthesia. Telemed J E Health. 2025;31:52-60.
..
Downloads
Published
How to Cite
Issue
Section
License
This work is licensed under a Creative Commons Attribution 4.0 International License.
You are free to:
- Share — copy and redistribute the material in any medium or format
- Adapt — remix, transform, and build upon the material for any purpose, even commercially.
Terms:
- Attribution — You must give appropriate credit, provide a link to the license, and indicate if changes were made. You may do so in any reasonable manner, but not in any way that suggests the licensor endorses you or your use.
- No additional restrictions — You may not apply legal terms or technological measures that legally restrict others from doing anything the license permits.
