Hemodynamic monitoring strategies in cardiac surgery: an update systematic review

Hemodynamic monitoring is a cornerstone of perioperative care in cardiac surgery, where patients are at high risk of cardiovascular instability and organ hypoperfusion. In recent years, goal-directed therapy (GDT) protocols have increasingly incorporated advanced monitoring technologies to optimize perfusion and improve outcomes. This systematic review aims to critically appraise contemporary hemodynamic monitoring strategies and their integration into GDT protocols in adult patients undergoing cardiac surgery. A systematic review of studies published between January 2015 and May 2025 was conducted using PubMed, Embase, Scopus, and the Cochrane Library. The last search was conducted on 17 May 2025 in all databases. Eligible studies included adult cardiac surgical patients managed with perioperative hemodynamic monitoring strategies that incorporated cardiac output assessment and structured GDT protocols. A qualitative synthesis of monitoring modalities, targeted hemodynamic endpoints, and reported clinical outcomes was performed. Our analysis included 15 studies comprising 4,224 patients. Monitoring strategies ranged from pulmonary artery catheters to minimally invasive and noninvasive tools such as FloTrac/EV1000 and esophageal Doppler. Cardiac index and stroke volume variation were the most frequently targeted parameters, often in combination with perfusion markers such as mean arterial pressure or central venous oxygen saturation. GDT protocols were associated with reductions in AKI, duration of mechanical ventilation, and ICU/hospital stay. Mortality benefits were inconsistently reported and not predefined in most studies. Current evidence supports the physiological rationale for GDT guided by advanced hemodynamic monitoring in cardiac surgery. Nonetheless, substantial heterogeneity in strategies and outcomes highlights the need for standardized protocols and high-quality multicenter trials to determine the most effective, patient-centered approaches.Trial registration: PROSPERO registration number: CRD420251102582, retrospectively registered on 11 July 2025.