Con: pulmonary artery catheters are not routinely indicated in patients undergoing elective abdominal aortic reconstruction.

N THE PAST MONTH, I have had two patients suffer cardiac arrest as a direct result of pulmonary artery catheters (PACs). One occurred as a result of heart block during insertion, and the other occurred during catheter removal, presumably from pulmonary embolization of thrombus on the catheter. A few months before, another patient whose severe left ventricular dysfunction was man- aged with a PAC died on the fourth day following lower extremity revascularization after PA rupture. When con- fronted with a monitoring tool that has such risks, we should seek evidence that its use improves outcome in our patients. It is important to focus on patient outcome when evaluating new.and existing technologies rather than inter- mediate variables, especially given the growing pressures for cost containment in the American health care system. Various factors may result in changes in physician prac- tice patterns. Properly performed randomized clinical tri- als, when published in the literature, may alter practice.’ The results of multiple studies may be synthesized using metaanalysis.2 Increasingly, the federal government has sponsored expert panels to try to develop practice guide- lines, such as those developed for the treatment of acute pain.3 Recently, the American Society of Anesthesiologists has published guidelines for the perioperative use of pulmonary artery catheters by anesthesiologists.4 It also appears that reimbursement patterns5 and physi- cian availability6 affect how services are provided. Whereas previous reimbursement patterns may have encouraged the use of PACs by anesthesiologists, future reimbursement formulas may pay a hxed amount for a patient’s anesthetic care, or even for his or her entire hospitalization. Reimburse- ment schemes that are not based on time or the complexity of monitoring may result in decreased numbers of PACs inserted by anesthesiologists. Would patients suffer as a result? In most cases, I suspect not. It is my impression that over the past decade the preparation of patients coming to the operating room for aortic reconstruction has improved. These improvements are multifactorial and include improved and more wide- spread antianginal and antihypertensive therapy, more precise preoperative risk assessment by noninvasive testing, and preoperative myocardial revascularization in those with the highest cardiac risk. Cardiac management has improved to the point where cardiac complications may no longer be the leading cause of death in surgical patients with coronary disease.’ Successful therapy of chronic of hypertension results in a more stable induction of general anesthesia, presumably by increasing plasma volumes and reduces left ventricular hypertrophy.9 Such improvements in preoperative preparation and pharmacologic therapy make it difficult to use historical controls to prove that PACs improve outcome, as purported by Rao et al.1° In addition to improvements in preoperative therapy, preoperative cardiac assessment is more common in my practice. This evaluation typically consists of standard echocardiography to document left ventricular function and may include dipyridamole thallium scanning (DTS) or dobutamine stress echocardiography (DSE) a screening device for coronary artery disease. For these last two tests, there is a significant literature suggesting that patients with normal tests have very low rates of perioperative cardiac morbidity or mortality. Before entering the operating room, then, we have already identified a subset of patients (albeit it at a cost higher than that of a PAC, but with less risk) in whom the risk of a perioperative cardiac event is low (1.6% in patients with a normal dipyridamole thallium scanning” and 0% in those with a normal dobutamine echocardio- gram’*) and in whom the risk/benefit ratio of PA catheter- ization is presumably higher. In the 1990s PA catheteriza- tion should be limited to those at highest risk, or to those about whose cardiac reserve little is known. Cardiac evaluation before abdominal aortic reconstruc- tive (AAR) surgery may detect coronary artery disease amenable to treatment by PTCA or CABG surgery. Preop- erative coronary revascularization, in selected patients, improves long-term survival after vascular surgery.13 Most studies have also suggested relatively low rates of periopera- tive cardiac morbidity after noncardiac surgery in patients with recent myocardial revascularization.14J5 One pre- sumes that many patients in Attia et al’si famous study documenting cardiac decompensation at the time of tempo- rary aortic occlusion (“cross-clamping”) would, in the 1990s have undergone myocardial revascularization before AAR surgery. Even in patients at highest risk, however, there is little in the literature to conclusively persuade me that PA catheterization will benefit my patients. The complications of pulmonary artery catheterization are legion and well known. *’ The most common include arrhythmias, arterial damage, endocardial and valvular damage, pulmonary infarct, pulmonary hemorrhage, cath- eter knotting, and line sepsis. These complications probably occur less frequently, and the risk/benefit ratio is probably lower in environments where use of PACs is common. No matter how skillfully and at low risk the catheter is placed, if the intensive care environment is not one in which the information is used effectively and in which dangers (such as a wedged PA trace) are quickly recognized, then the risks are magnified. Ibertils has shown that many clinicians are not skillful in interpreting the result of PA catheterization, potentially resulting in inappropriate inter- ventions. In this study, the frequency of physicians’ use of