🫀Invasive monitoring is not dead. It was misunderstood For years Pulmonary artery catheters were abandoned “Too invasive” “No outcome benefit” But maybe the problem was not the tool...It was how we used it 🧐 *Hemodynamics is not a number. It is a trajectory This review reframes the concept Not a snapshot But a dynamic evolution After initial therapy The hemodynamic trajectory predicts outcomes 🫀 Clinical implication If you are not reassessing You are treating blindly *Phenotyping shock. The real power of invasive monitoring Cardiogenic shock is not one entity Cold and wet Cold and dry Warm and wet (SIRS-driven) Mixed shock 🫀 Clinical implication Same blood pressure Different physiology Different treatment *Normotensive shock. The silent killer One of the most important concepts Patients can have: Normal BP Normal lactate But low cardiac output 🫀 Clinical implication SvO₂ ↓ is often more sensitive than lactate Perfusion can be impaired before hypotension appears *PAC is not for everyone. But essential for some Routine use? No Targeted use? Absolutely Indications: • Overt cardiogenic shock • Unclear hemodynamics • Failure of initial therapy • Mechanical circulatory support 🫀 Clinical implication Use PAC when decisions matter most *Cardiac power output. The strongest prognostic marker CPO = MAP × CO / 451 It integrates pressure + flow 🫀 Clinical implication Low CPO = high mortality Better than CO alone *Right ventricle. The forgotten determinant RV failure changes everything Key markers: • CVP/PAWP ratio • PAPi • Pulmonary compliance 🫀 Clinical implication If you treat LV and ignore RV You will fail *Monitoring during mechanical support tMCS is not “set and forget” You need continuous adjustment Flow Preload Afterload RV-LV interaction 🫀 Clinical implication PAC transforms tMCS from support Into precision therapy *AI is coming. But physiology remains the foundation Hypotension prediction Shock phenotyping Outcome prediction But Garbage data → garbage AI 🫀 Clinical implication Good monitoring is the prerequisite for good AI 🤓Final reflection We moved from: Clinical exam → Non-invasive tools Now we must integrate Invasive + non-invasive + physiology Because monitoring does not save patients, Understanding does 🤓 📚 Baldetti L et al. Rev. Cardiovasc. Med. 2025; 26(6): 27034 doi.org/10.31083/RCM27034