Use of Pulmonary Arterial Catheters for Management of Acute Decompensated Heart Failure and Peri-Operative Monitoring in Children

Purpose Pulmonary arterial catheters (PAC) provide real-time hemodynamic data that has been used to tailor ICU therapies, aid in surgical decision making in adults with ADHF and in predicting right-heart failure (RHF) in adults undergoing LVAD evaluation. Approximately 1/3 of patients develop RVF after LVAD insertion. Patients who required rescue RVAD have increased mortality when compared to planned BiVAD implantation. Right ventricular stroke work index (RVSWI) has been demonstrated to predict RHF in adults. Prediction of RHF and data on use of PAC in children are limited. Methods Pediatric patients with ADHF and biventricular circulation undergoing PAC placement at Boston Children's Hospital from 2013 through 2018 were included in this retrospective cohort study. Data were collected as part of an ongoing QI project. Variables predictive of RVF in adults undergoing LVAD implantation were compared between patients with and without RHF. Pedimacs definition of RHF was used for post-VAD patients: RV dysfunction requiring inotropic support at 14 days. Results Thirteen PAC were placed in 11 patients, aged 2 to 18 years old, with biventricular circulation and ADHF. Eight patients had DCM, 2 had CHD and one RCM. Nine PAC were placed to aid in pre-VAD decision making. One to assess awake hemodynamics for transplant candidacy, and one was placed at the time of OHT. Nine PAC were placed by catheterization and 4 in the OR. Mean duration of PAC monitoring was 3.7 days (0.4 to 9.3 days). RVSWI alone was able to significantly predict post-LVAD RVF. All patients free from RVF post-LVAD implantation were discharged home before OHT, at an average or 27 +/-4 days. No patients with RVF reached discharge before transplantation. There were 2 AEs possibly related to the presence of a PAC, including one episode of hemodynamically well-tolerated EAT and one episode of slow VT. Conclusion PAC use in pediatrics is feasible with low rates of adverse events. Low pre-implantation RVSWI was associated with RHF after LVAD implantation. All patients undergoing LVAD implantation with no RHF were discharged home while every patient with RHF remained hospitalized until RVAD implantation or OHT. Arrhythmias occurred in two patients PACs. Though both were hemodynamically stable lines were removed, illustrating the opportunity for managing staff in optimum use of PACs.