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Reiter T, Kerzner J, Fette G, Frantz S, Voelker W, Ertl G, Bauer W, Morbach C, Störk S, Güder G. Accuracy of VO 2 estimation according to the widely used Krakau formula for the prediction of cardiac output. Herz 2024; 49:50-59. [PMID: 37439804 PMCID: PMC10830659 DOI: 10.1007/s00059-023-05196-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 05/21/2023] [Accepted: 06/01/2023] [Indexed: 07/14/2023]
Abstract
BACKGROUND Invasive cardiac output (CO) is measured with the thermodilution (TD) or the indirect Fick method (iFM) in right heart catheterization (RHC). The iFM estimates CO using approximation formulas for oxygen consumption ([Formula: see text]O2), but there are significant discrepancies (> 20%) between both methods. Although regularly applied, the formula proposed by Krakau has not been validated. We compared the CO discrepancies between the Krakau formula with the reference (TD) and three established formulas and investigated whether alterations assessed in cardiac magnetic resonance imaging (CMR) determined the extent of the deviations. METHODS This retrospective study included 188 patients aged 63 ± 14 years (30% women) receiving both CMR and RHC. The CO was measured with TD or with the iFM using the formulas by Krakau, LaFarge, Dehmer, and Bergstra for [Formula: see text]O2 estimation (iFM-K/-L/-D/-B). Percentage errors were calculated as twice the standard deviation of the difference between two CO methods divided by their means; a cut-off of < 30% was regarded as acceptable. The iFM and TD-derived CO ratio was built, and deviations > 20% were counted. Logistic regression analyses were performed to identify determinants of a deviation of > 20%. RESULTS The TD-derived CO (5.5 ± 1.7 L/min) was significantly different from all iFM (K: 4.8 ± 1.6, L: 4.3 ± 1.6; D: 4.8 ± 1.5 L/min; B: 5.4 ± 1.8 L/min all p < 0.05). The iFM-K-CO differed from all methods (p < 0.001) except iFM‑D (p = 0.19). Percentage errors between TD-CO and iFM-K/-L/-D/-B were all beyond the acceptance limit (44/45/44/43%), while percentage errors between iFM‑K and other iFM were all < 16%. None of the parameters measured in CMR was predictive of a discrepancy of > 20% between both methods. CONCLUSION The Krakau formula was comparable to other iFM in estimating CO levels, but none showed satisfactory agreement with the TD method. Improved derivation cohorts for [Formula: see text]O2 estimation are needed that better reflect today's patients undergoing RHC.
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Affiliation(s)
- Theresa Reiter
- Department of Internal Medicine I, Cardiology Division, University Hospital Würzburg, Oberdürrbacherstr. 6, 97080, Würzburg, Germany
| | - Julia Kerzner
- Department of Internal Medicine I, Cardiology Division, University Hospital Würzburg, Oberdürrbacherstr. 6, 97080, Würzburg, Germany
| | - Georg Fette
- Department of Clinical Research & Epidemiology, Comprehensive Heart Failure Center, University Hospital Würzburg, Am Schwarzen Berg 26, 97078, Würzburg, Germany
- Chair of Computer Science VI, University of Würzburg, 97074, Würzburg, Germany
| | - Stefan Frantz
- Department of Internal Medicine I, Cardiology Division, University Hospital Würzburg, Oberdürrbacherstr. 6, 97080, Würzburg, Germany
- Department of Clinical Research & Epidemiology, Comprehensive Heart Failure Center, University Hospital Würzburg, Am Schwarzen Berg 26, 97078, Würzburg, Germany
| | - Wolfram Voelker
- Department of Internal Medicine I, Cardiology Division, University Hospital Würzburg, Oberdürrbacherstr. 6, 97080, Würzburg, Germany
| | - Georg Ertl
- Department of Clinical Research & Epidemiology, Comprehensive Heart Failure Center, University Hospital Würzburg, Am Schwarzen Berg 26, 97078, Würzburg, Germany
| | - Wolfgang Bauer
- Department of Internal Medicine I, Cardiology Division, University Hospital Würzburg, Oberdürrbacherstr. 6, 97080, Würzburg, Germany
| | - Caroline Morbach
- Department of Internal Medicine I, Cardiology Division, University Hospital Würzburg, Oberdürrbacherstr. 6, 97080, Würzburg, Germany
- Department of Clinical Research & Epidemiology, Comprehensive Heart Failure Center, University Hospital Würzburg, Am Schwarzen Berg 26, 97078, Würzburg, Germany
| | - Stefan Störk
- Department of Internal Medicine I, Cardiology Division, University Hospital Würzburg, Oberdürrbacherstr. 6, 97080, Würzburg, Germany
- Department of Clinical Research & Epidemiology, Comprehensive Heart Failure Center, University Hospital Würzburg, Am Schwarzen Berg 26, 97078, Würzburg, Germany
| | - Gülmisal Güder
- Department of Internal Medicine I, Cardiology Division, University Hospital Würzburg, Oberdürrbacherstr. 6, 97080, Würzburg, Germany.
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Bombace S, Meucci MC, Fortuni F, Ilardi F, Manzo R, Canciello G, Esposito G, Grayburn PA, Losi MA, Sannino A. Beyond Aortic Stenosis: Addressing the Challenges of Multivalvular Disease Assessment. Diagnostics (Basel) 2023; 13:2102. [PMID: 37370999 PMCID: PMC10297357 DOI: 10.3390/diagnostics13122102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 06/12/2023] [Accepted: 06/14/2023] [Indexed: 06/29/2023] Open
Abstract
Aortic stenosis (AS) can often coexist with other valvular diseases or be combined with aortic regurgitation (AR), leading to unique pathophysiological conditions. The combination of affected valves can vary widely, resulting in a lack of standardized diagnostic or therapeutic approaches. Echocardiography is crucial in assessing patients with valvular heart disease (VHD), but careful consideration of the hemodynamic interactions between combined valvular defects is necessary. This is important as it may affect the reliability of commonly used echocardiographic parameters, making the diagnosis challenging. Therefore, a multimodality imaging approach, including computed tomography or cardiac magnetic resonance, is often not just beneficial but crucial. It represents the future of diagnostics in this intricate field due to its unprecedented capacity to quantify and comprehend valvular pathology. The absence of definitive data and guidelines for the therapeutic management of AS in the context of multiple valve lesions makes this condition particularly challenging. As a result, an individualized, case-by-case approach is necessary, guided primarily by the recommendations for the predominant valve lesion. This review aims to summarize the pathophysiology of AS in the context of multiple and mixed valve disease, with a focus on the hemodynamic implications, diagnostic challenges, and therapeutic options.
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Affiliation(s)
| | - Maria Chiara Meucci
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Rome, Italy
| | - Federico Fortuni
- Department of Cardiology, Leiden University Medical Centre, 2333 ZA Leiden, The Netherlands
- Department of Cardiology, San Giovanni Battista Hospital, 06034 Foligno, Italy
| | - Federica Ilardi
- Department of Advanced Biomedical Sciences, Division of Cardiology, Federico II University, 80131 Naples, Italy
| | - Rachele Manzo
- Department of Advanced Biomedical Sciences, Division of Cardiology, Federico II University, 80131 Naples, Italy
| | - Grazia Canciello
- Department of Advanced Biomedical Sciences, Division of Cardiology, Federico II University, 80131 Naples, Italy
| | - Giovanni Esposito
- Department of Advanced Biomedical Sciences, Division of Cardiology, Federico II University, 80131 Naples, Italy
| | | | - Maria Angela Losi
- Department of Advanced Biomedical Sciences, Division of Cardiology, Federico II University, 80131 Naples, Italy
| | - Anna Sannino
- Department of Advanced Biomedical Sciences, Division of Cardiology, Federico II University, 80131 Naples, Italy
- Baylor Scott & White Research Institute, Plano, TX 75093, USA
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3
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Volodarsky I, Kerzhner K, Haberman D, Cuciuc V, Poles L, Blatt A, Kirzhner E, George J, Gandelman G. Comparison between Cardiac Output and Pulmonary Vascular Pressure Measured by Indirect Fick and Thermodilution Methods. J Pers Med 2023; 13:jpm13030559. [PMID: 36983740 PMCID: PMC10054496 DOI: 10.3390/jpm13030559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 03/04/2023] [Accepted: 03/13/2023] [Indexed: 03/30/2023] Open
Abstract
INTRODUCTION Right heart catheterization (RHC) is a diagnostic procedure, the main purpose of which is to diagnose pulmonary hypertension and investigate its etiology and treatability. In addition to measuring blood pressure in heart chambers, it includes estimating cardiac output (CO) and calculation of pulmonary vascular resistance (PVR) derived from the CO. There are two common methods to evaluate the CO-the indirect Fick method and the thermodilution method. Depending on the clinical conditions, either of the two may be considered better. Several studies have showed that, in most cases, there is no difference between measurements rendered by the two methods. Other studies have raised suspicion of a discrepancy between the two methods in a substantial number of patients. A clear opinion on this matter is missing. AIM To evaluate the agreement between the values of the CO and PVR found by the thermodilution and indirect Fick methods. METHODS We retrospectively included patients that underwent RHC in Kaplan Medical Center during the last two years with a measurement of the CO using both the thermodilution and the indirect Fick methods. The measurements obtained upon RHC and the clinical data of the patients were collected. The values of the CO and PVR measured or calculated using the two methods were compared for each patient. RESULTS We included 55 patients that met the inclusion criteria in this study. The mean CO measured by the thermodilution method was 4.94 ± 1.17 L/min and the mean CO measured by the indirect Fick method was 5.82 ± 1.97 L/min. The mean PVR calculated using the thermodilution method was 3.33 ± 3.04 Woods' units (WU) and the mean PVR calculated using the indirect Fick method was 2.71 ± 2.76 WU. Among the patients with normal mPAP, there was a strong and statistically significant correlation between the PVR values calculated by the two methods (Peasron's R2 = 0.78, p-value = 0.004), while among the patients with elevated mPAP, the correlation between the PVR values calculated by the two methods was not statistically significant. CONCLUSION The findings of this small study demonstrate that, in a proportion of patients, the indirect Fick method and thermodilution method classify the PVR value differently. In our experience, it seems that, in these patients, the indirect Fick method misclassified patients with a pathological finding as normal. We, therefore, recommend that upon performing RHC, at least in patients with mPAP > 25 mmHg, both the thermodilution and indirect Fick methods be performed and, whenever they disagree, the values obtained from the thermodilution method should be preferred.
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Affiliation(s)
- Igor Volodarsky
- Heart Center, Kaplan Medical Center, The Hebrew University of Jerusalem, Pasternak St., 1, Rehovot 76100, Israel
| | - Katerina Kerzhner
- Internal Medicine Department A, Kaplan Medical Center, Pasternak St., 1, Rehovot 76100, Israel
| | - Dan Haberman
- Heart Center, Kaplan Medical Center, The Hebrew University of Jerusalem, Pasternak St., 1, Rehovot 76100, Israel
| | - Valeri Cuciuc
- Heart Center, Kaplan Medical Center, The Hebrew University of Jerusalem, Pasternak St., 1, Rehovot 76100, Israel
| | - Lion Poles
- Heart Center, Kaplan Medical Center, The Hebrew University of Jerusalem, Pasternak St., 1, Rehovot 76100, Israel
| | - Alex Blatt
- Heart Center, Kaplan Medical Center, The Hebrew University of Jerusalem, Pasternak St., 1, Rehovot 76100, Israel
| | - Elena Kirzhner
- Internal Medicine Department A, Kaplan Medical Center, Pasternak St., 1, Rehovot 76100, Israel
| | - Jacob George
- Heart Center, Kaplan Medical Center, The Hebrew University of Jerusalem, Pasternak St., 1, Rehovot 76100, Israel
| | - Gera Gandelman
- Heart Center, Kaplan Medical Center, The Hebrew University of Jerusalem, Pasternak St., 1, Rehovot 76100, Israel
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Scott A, Chen Z, Hernandez DH, Kligerman S, Kim P, Tran H, Adler E, Contijoch F. Pressure Volume Loop Analysis of the Right Ventricle in Heart Failure With Computed Tomography. ASAIO J 2023; 69:e66-e72. [PMID: 36521051 PMCID: PMC9892274 DOI: 10.1097/mat.0000000000001869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Right ventricular (RV) function is an important marker of mortality in chronic left-sided heart failure. Right ventricular function is particularly important for patients receiving left ventricular assist devices as it is a predictor of postoperative RV failure. RV stroke work index (RVSWI), the area enclosed by a pressure-volume (PV) loop, is prognostic of RV failure. However, clinical RVSWI approximates RVSWI as the product of thermodilution-derived stroke volume and the pulmonary pressure gradient. This ignores the energetic contribution of regurgitant flow and does not allow for advanced energetic measures, such as pressure-volume area and efficiency. Estimating RVSWI from forward flow may underestimate the underlying RV function. We created single-beat PV loops by combining data from cine computed tomography (CT) and right heart catheterization in 44 heart failure patients, tested the approximations made by clinical RVSWI and found it to underestimate PV loop RVSWI, primarily due to regurgitant flow in tricuspid regurgitation. The ability of RVSWI to predict post-operative RV failure improved when the single-beat approach was used. Further, RV pressure-volume area and efficiency measures were obtained and show broad agreement with other functional measures. Future work is needed to investigate the utility of these PV metrics in a clinical setting.
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Affiliation(s)
- Anderson Scott
- Department of Bioengineering, Division of Cardiology, UC San Diego 9500 Gilman Drive, La Jolla, CA
| | - Zhennong Chen
- Department of Bioengineering, Division of Cardiology, UC San Diego 9500 Gilman Drive, La Jolla, CA
| | | | - Seth Kligerman
- Department of Radiology, Division of Cardiology, UC San Diego 9500 Gilman Drive, La Jolla, CA
| | - Paul Kim
- Department of Medicine, Division of Cardiology, UC San Diego 9500 Gilman Drive, La Jolla, CA
| | - Hao Tran
- Department of Medicine, Division of Cardiology, UC San Diego 9500 Gilman Drive, La Jolla, CA
| | - Eric Adler
- Department of Medicine, Division of Cardiology, UC San Diego 9500 Gilman Drive, La Jolla, CA
| | - Francisco Contijoch
- Department of Bioengineering, Division of Cardiology, UC San Diego 9500 Gilman Drive, La Jolla, CA
- Department of Radiology, Division of Cardiology, UC San Diego 9500 Gilman Drive, La Jolla, CA
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5
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Hotta N, Tsukinaga A, Yoshitani K, Fukushima S, Ohnishi Y. Prevalence and Severity of Aortic Regurgitation Due to a Percutaneous Left Ventricular Assist Device (Impella 5.0): A Retrospective Observational Study. J Cardiothorac Vasc Anesth 2023; 37:23-30. [PMID: 36372720 DOI: 10.1053/j.jvca.2022.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 10/05/2022] [Accepted: 10/07/2022] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Placement of the Impella 5.0 percutaneous left ventricular assist device may cause aortic regurgitation (AR) due to malcoaptation of the aortic leaflets. The authors investigated the prevalence and severity of AR during Impella 5.0 support. DESIGN Retrospective observational study. SETTING An academic hospital. PARTICIPANTS A total of forty-two consecutive patients who underwent Impella 5.0 implantation from April 2018 to March 2022. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS To investigate AR prevalence, the authors calculated the AR volume by subtracting left ventricular inflow from left-sided systemic flow, the latter of which consisted of flow through the Impella 5.0 cannula and across the aortic valve. Because it is challenging to estimate flow across the aortic valve as distinct from that through Impella 5.0, the authors analyzed 19 of 42 patients whose aortic valves were closed (ie, those with no spontaneous cardiac output). AR due to Impella 5.0 was considered present if the AR fraction was ≥7%. The median AR volume was 0.6 L/min (interquartile range: 0.4-1.5 L/min), which was 13.5% (interquartile range: 11.0 to 30.6%) of the median Impella 5.0 flow. Seventeen of the 19 patients (89.5%) were diagnosed with AR during Impella 5.0 support, and the severity of AR was mild in 11 patients (57.9%) and moderate in 6 (31.6%). CONCLUSIONS The authors revealed a high prevalence of AR during Impella 5.0 support in patients with no spontaneous cardiac output. Moreover, 31.6% of patients had moderate AR.
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Affiliation(s)
- Naoshi Hotta
- Department of Anesthesiology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Akito Tsukinaga
- Department of Anesthesiology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan.
| | - Kenji Yoshitani
- Department of Anesthesiology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Satsuki Fukushima
- Department of Cardiac Surgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Yoshihiko Ohnishi
- Department of Anesthesiology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
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Clinical Decision-Making in Practice with New Critical Care Ultrasound Methods for Assessing Respiratory Function and Haemodynamics in Critically Ill Patients. Clin Pract 2022; 12:986-1000. [PMID: 36547110 PMCID: PMC9776659 DOI: 10.3390/clinpract12060102] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Revised: 11/16/2022] [Accepted: 11/17/2022] [Indexed: 11/26/2022] Open
Abstract
Situations often arise in intensive care units (ICUs) for which only sparse primary evidence or guidelines are applicable or to which existing evidence cannot be applied owing to interactions of multiple disease states. To improve and guide intensive care management in complex scenarios, ultrasonography and echocardiography are invaluable. In five clinical scenarios involving acute deterioration, serial ultrasound examinations of the respiratory system, general critical care ultrasound (GCCUS), and non-invasive haemodynamic critical care echocardiography (CCE) were used routinely. Ultrasonographic results were used to guide further management and initiate experimental therapy or transition from curative to supportive care. The process of initiation of ultrasound examinations to clinical decision-making in these complex scenarios is outlined. These case vignettes highlight the utility of ultrasound and echocardiography. When clinical management is not clear, or evidence is not available, the use of ultrasound for the evaluation of the respiratory system, GCCUS, and non-invasive haemodynamic CCE can help to guide management, reveal newly developed pathologies, lead to clinical management changes, and support the decision for employing experimental therapy approaches in a dynamic way of which few other imaging modalities or monitoring tools are currently capable.
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7
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Garcia AD, Liu W, Agarwal H, Hanna WJ. Dead space ratio as a tool in nitric oxide weaning: a study in pulmonary hypertensive disease. Cardiol Young 2022; 32:1603-1607. [PMID: 34881691 DOI: 10.1017/s1047951121004662] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVES To describe the association between successful weaning of inhaled nitric oxide and trends in dead space ratio during such weans in patients empirically initiated on nitric oxide therapy out of concern of pulmonary hypertensive crisis. PATIENTS Children in a cardiac intensive care unit initiated on inhaled nitric oxide out of clinical concern for pulmonary hypertensive crisis retrospectively over 2 years. MEASUREMENTS AND MAIN RESULTS Twenty-seven patients were included, and nitric oxide was successfully discontinued in 23/27. These patients exhibited decreases in dead space ratio (0.18 versus 0.11, p = 0.047) during nitric oxide weaning, and with no changes in dead space ratio between pre- and post-nitric oxide initiation (p = 0.88) and discontinuation (p = 0.63) phases. These successful patients had a median age of 10 months [4.0, 57.0] and had a pre-existent diagnosis of CHD in 6/23 and pulmonary hypertension in 2/23. Those who failed nitric oxide discontinuation trended with a higher dead space ratio at presentation (0.24 versus 0.10), were more likely to carry a prior diagnosis of pulmonary hypertension (50% versus 8.7%), and had longer mechanical ventilation days (5 versus 12). CONCLUSIONS Patients empirically placed on nitric oxide out of concern of pulmonary hypertensive crisis and successfully weaned off showed unchanged or decreased dead space ratio throughout the initiation to discontinuation phases of nitric oxide therapy. Trends in dead space ratio may aid in determining true need for nitric oxide and facilitate effective weaning. Further studies are needed to directly compare trends between success and failure groups.
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Affiliation(s)
- Alvaro D Garcia
- Pediatric Critical Care Department, Pediatric Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Wei Liu
- Department of Quantitative Health Sciences, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Hemant Agarwal
- Pediatric Critical Care Department, Pediatric Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - William J Hanna
- Pediatric Critical Care Department, Pediatric Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
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8
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Narang N, Thibodeau JT, Parker WF, Grodin JL, Garg S, Tedford RJ, Levine BD, McGuire DK, Drazner MH. Comparison of Accuracy of Estimation of Cardiac Output by Thermodilution Versus the Fick Method Using Measured Oxygen Uptake. Am J Cardiol 2022; 176:58-65. [PMID: 35613956 PMCID: PMC9648100 DOI: 10.1016/j.amjcard.2022.04.026] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 03/24/2022] [Accepted: 04/08/2022] [Indexed: 11/18/2022]
Abstract
The thermodilution (TD) method is routinely used for the estimation of cardiac output (Q̇C). However, its accuracy, compared with the gold-standard Fick method, where systemic oxygen uptake (V̇O2) is directly measured, and Q̇C calculated from V̇O2 and the arterio-venous oxygen difference ("direct" Fick), has not been well validated. The present study determined the agreement between TD and Fick methods in consecutive patients who underwent pulmonary artery catheterization for a broad range of clinical conditions. This is a subanalysis of a previous study comparing the indirect versus Fick method based on a prospective, consecutive patient registry of 253 patients who underwent pulmonary artery catheterization for clinical indications at a single center between 1999 and 2005. We included patients that had an estimation of Q̇C both by the Fick method using measured V̇O2 by exhaled gas analyses from timed Douglas bag collections and by TD. Cardiac index was classified as low when ≤2.2 L/min/m2 or normal when >2.2 L/min/m2. The median (25th, 75th percentile) age of the cohort was 59 (50,67) years, and 50% were female. A total of 43.5% had normal left ventricular function by ventriculography, and 25.7% had ischemic heart disease. Median overall Fick and TD Q̇C were 4.4 (3.5, 5.5) and 4.3 (3.7, 5.2) L/min, respectively (p = 0.04). The median absolute percent error between Fick and TD Q̇C was 17.5 (7.7, 28.4)%, with a typical error of 0.88 L/min (95% confidence interval [CI] 0.82 to 0.95). Median absolute percent error was comparable in the low (n = 118) and normal Q̇CI (n = 135) groups (16.9% vs 18.9%, respectively, p = 0.88). typical error was 0.3 (95% CI 0.27 to 0.33) and 0.49 (95% CI 0.45 to 0.55) L/min/m2 in that comparison. Percent error >25% between Fick and TD Q̇C was observed in over 30% of patients. Overall, Fick and TD Q̇C modestly correlated (Rs = 0.64, p <0.001), with a nondirectional error introduced by TD Q̇C [mean bias of 0.21 (-2.2, 2.7) L/min]. There was poor agreement between TD and the gold-standard Fick method, highlighting the limitations of making clinical decisions based on TD.
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Affiliation(s)
- Nikhil Narang
- Advocate Heart Institute, Advocate Christ Medical Center, Oak Lawn, Illinois; Division of Cardiology, Department of Medicine, University of Illinois-Chicago, Chicago, Illinois.
| | - Jennifer T Thibodeau
- Division of Cardiology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - William F Parker
- Section of Pulmonary and Critical Care, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Justin L Grodin
- Division of Cardiology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Sonia Garg
- Division of Cardiology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Ryan J Tedford
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Benjamin D Levine
- Division of Cardiology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas; Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital, Dallas, Texas
| | - Darren K McGuire
- Division of Cardiology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas; Parkland Health and Hospital System, Dallas, Texas
| | - Mark H Drazner
- Division of Cardiology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
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Schmidt S, Dieks JK, Quintel M, Moerer O. Hemodynamic profiling by critical care echocardiography could be more accurate than invasive techniques and help identify targets for treatment. Sci Rep 2022; 12:7187. [PMID: 35504927 PMCID: PMC9065036 DOI: 10.1038/s41598-022-11252-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 04/19/2022] [Indexed: 11/08/2022] Open
Abstract
In this prospective observational study, non-invasive critical care echocardiography (CCE) was used to obtain quantitative hemodynamic parameters in 107 intensive care unit (ICU) patients; the parameters were then visualized in a novel web graph approach to increase the understanding and impact of CCE abnormalities, as an alternative to thermodilution techniques. Visualizing the CCE hemodynamic data in six-dimensional web graph plots was feasible in almost all ICU patients. In 23.1% of patients, significant tricuspid regurgitation prevented correlation between thermodilution techniques and echocardiographic hemodynamics. Two parameters of longitudinal right ventricular function (TAPSE and S') did not correlate in ICU patients. Clinical surrogate parameters of hemodynamic compromise did not correlate with measured hemodynamics. 26.2% of the patients with mean arterial pressures above 60 mmHg had cardiac indices (CI) below 2.5 L min-1·m-2. A CI below 2.2 L·min-1·m-2 was associated with a significant ICU survival disadvantage. CCE was feasible in addition or as an alternative to thermodilution techniques for the hemodynamic evaluation of ICU patients. Six-dimensional web graph plots visualized the hemodynamic states and were especially useful in conditions in which thermodilution methods were not reliable. Hemodynamic CCE identified patients with previously unknown low CI, which correlated with a higher ICU mortality.
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Affiliation(s)
- Stefan Schmidt
- Department of Anesthesiology, Emergency and Intensive Care Medicine, University Medical Center, Georg-August-University Göttingen, Robert-Koch-Str. 40, 37075, Goettingen, Germany
- Department of Pediatric Cardiology and Intensive Care Medicine, University Medical Center, Georg-August-University Göttingen, Robert-Koch-Str. 40, 37075, Goettingen, Germany
| | - Jana-Katharina Dieks
- Department of Pediatric Cardiology and Intensive Care Medicine, University Medical Center, Georg-August-University Göttingen, Robert-Koch-Str. 40, 37075, Goettingen, Germany.
| | - Michael Quintel
- Department of Anesthesiology, Emergency and Intensive Care Medicine, University Medical Center, Georg-August-University Göttingen, Robert-Koch-Str. 40, 37075, Goettingen, Germany
| | - Onnen Moerer
- Department of Anesthesiology, Emergency and Intensive Care Medicine, University Medical Center, Georg-August-University Göttingen, Robert-Koch-Str. 40, 37075, Goettingen, Germany
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10
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Robertson L, Bunclark K, Ross RM, Cannon J, Sheares K, Taboada D, Pepke-Zaba J, Toshner M. The prognostic ability of cardiac output determined by inert gas rebreathing technique in pulmonary hypertension. Chron Respir Dis 2022; 19:14799731221078473. [PMID: 35184583 PMCID: PMC8864257 DOI: 10.1177/14799731221078473] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
This investigation validated the inert gas rebreathing (IGR) technique and
determined IGR prognostic ability compared to invasive cardiac output
measurements in patients with pulmonary hypertension. IGR compared with
thermodilution cardiac output demonstrated a moderate bias. IGR technique
demonstrated long-term prognostic value comparable to invasive cardiac output in
pulmonary hypertension patients
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Affiliation(s)
- Lucy Robertson
- Department of Medicine, University
of Cambridge, Cambridge, UK
- Lucy Robertson, Pulmonary Vascular Disease
Unit, Royal Papworth Hospital, Papworth Road, Cambridge CB2 0AY, UK.
| | | | | | - John Cannon
- Department of Medicine, University
of Cambridge, Cambridge, UK
| | - Karen Sheares
- Department of Medicine, University
of Cambridge, Cambridge, UK
| | - Dolores Taboada
- Department of Medicine, University
of Cambridge, Cambridge, UK
| | | | - Mark Toshner
- Department of Medicine, University
of Cambridge, Cambridge, UK
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11
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Hillerson D, Charnigo R, Moon Kim S, Iyengar A, Lane M, Misumida N, Kolodziej AR, Ogunbayo GO, Abdel-Latif A, Gurley JC, Booth DC. Ratio of Mixed Venous Oxygen Saturation-to-Pulmonary Capillary Wedge Pressure: Insights From the Veterans Affairs Clinical Assessment, Reporting, and Tracking Program. Circ Heart Fail 2022; 15:e008838. [PMID: 35026961 DOI: 10.1161/circheartfailure.121.008838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Hemodynamic values from right heart catheterization aid diagnosis and clinical decision-making but may not predict outcomes. Mixed venous oxygen saturation percentage and pulmonary capillary wedge pressure relate to cardiac output and congestion, respectively. We theorized that a novel, simple ratio of these measurements could estimate cardiovascular prognosis. METHODS We queried Veterans Affairs' databases for clinical, hemodynamic, and outcome data. Using the index right heart catheterization between 2010 and 2016, we calculated the ratio of mixed venous oxygen saturation-to-pulmonary capillary wedge pressure, termed ratio of saturation-to-wedge (RSW). The primary outcome was time to all-cause mortality; secondary outcome was 1-year urgent heart failure presentation. Patients were stratified into quartiles of RSW, Fick cardiac index (CI), thermodilution CI, and pulmonary capillary wedge pressure alone. Kaplan-Meier curves and Cox proportional hazards models related comparators with outcomes. RESULTS Of 12 019 patients meeting inclusion criteria, 9826 had values to calculate RSW (median 4.00, interquartile range, 2.67-6.05). Kaplan-Meier curves showed early, sustained separation by RSW strata. Cox modeling estimated that increasing RSW by 50% decreases mortality hazard by 19% (estimated hazard ratio, 0.81 [95% CI, 0.79-0.83], P<0.001) and secondary outcome hazard by 28% (hazard ratio, 0.72 [95% CI, 0.70-0.74], P<0.001). Among the 3793 patients with data for all comparators, Cox models showed RSW best associated with outcomes (by both C statistics and Bayes factors). Furthermore, pulmonary capillary wedge pressure was superior to thermodilution CI and Fick CI. Multivariable adjustment attenuated without eliminating the association of RSW with outcomes. CONCLUSIONS In a large national database, RSW was superior to conventional right heart catheterization indices at assessing risk of mortality and urgent heart failure presentation. This simple calculation with routine data may contribute to clinical decision-making in this population.
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Affiliation(s)
- Dustin Hillerson
- Lexington Veterans Affairs Health Care System, University of Kentucky, Lexington. (596), KY (D.H., M.L., N.M., A.A.-L., D.C.B.).,Gill Heart and Vascular Institute, University of Kentucky, Lexington. (D.H., R.C., A.I., N.M., A.R.K., G.O.O., A.A.-L., J.C.G., D.C.B.)
| | - Richard Charnigo
- Gill Heart and Vascular Institute, University of Kentucky, Lexington. (D.H., R.C., A.I., N.M., A.R.K., G.O.O., A.A.-L., J.C.G., D.C.B.).,Department of Biostatistics, University of Kentucky, Lexington. (R.C.)
| | - Sun Moon Kim
- Reid Heart Center, FirstHealth of the Carolinas, Pinehurst, NC (S.M.K.).,Department of Medicine, University of North Carolina at Chapel Hill (S.M.K.)
| | - Amrita Iyengar
- Gill Heart and Vascular Institute, University of Kentucky, Lexington. (D.H., R.C., A.I., N.M., A.R.K., G.O.O., A.A.-L., J.C.G., D.C.B.).,College of Medicine, University of Kentucky, Lexington. (A.I.)
| | - Matthew Lane
- Lexington Veterans Affairs Health Care System, University of Kentucky, Lexington. (596), KY (D.H., M.L., N.M., A.A.-L., D.C.B.).,College of Pharmacy, University of Kentucky, Lexington. (M.L.)
| | - Naoki Misumida
- Lexington Veterans Affairs Health Care System, University of Kentucky, Lexington. (596), KY (D.H., M.L., N.M., A.A.-L., D.C.B.).,Gill Heart and Vascular Institute, University of Kentucky, Lexington. (D.H., R.C., A.I., N.M., A.R.K., G.O.O., A.A.-L., J.C.G., D.C.B.)
| | - Andrew R Kolodziej
- Gill Heart and Vascular Institute, University of Kentucky, Lexington. (D.H., R.C., A.I., N.M., A.R.K., G.O.O., A.A.-L., J.C.G., D.C.B.)
| | - Gbolahan O Ogunbayo
- Gill Heart and Vascular Institute, University of Kentucky, Lexington. (D.H., R.C., A.I., N.M., A.R.K., G.O.O., A.A.-L., J.C.G., D.C.B.)
| | - Ahmed Abdel-Latif
- Lexington Veterans Affairs Health Care System, University of Kentucky, Lexington. (596), KY (D.H., M.L., N.M., A.A.-L., D.C.B.).,Gill Heart and Vascular Institute, University of Kentucky, Lexington. (D.H., R.C., A.I., N.M., A.R.K., G.O.O., A.A.-L., J.C.G., D.C.B.)
| | - John C Gurley
- Gill Heart and Vascular Institute, University of Kentucky, Lexington. (D.H., R.C., A.I., N.M., A.R.K., G.O.O., A.A.-L., J.C.G., D.C.B.)
| | - David C Booth
- Lexington Veterans Affairs Health Care System, University of Kentucky, Lexington. (596), KY (D.H., M.L., N.M., A.A.-L., D.C.B.).,Gill Heart and Vascular Institute, University of Kentucky, Lexington. (D.H., R.C., A.I., N.M., A.R.K., G.O.O., A.A.-L., J.C.G., D.C.B.)
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12
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Mantovani F, Fanti D, Tafciu E, Fezzi S, Setti M, Rossi A, Ribichini F, Benfari G. When Aortic Stenosis Is Not Alone: Epidemiology, Pathophysiology, Diagnosis and Management in Mixed and Combined Valvular Disease. Front Cardiovasc Med 2021; 8:744497. [PMID: 34722676 PMCID: PMC8554031 DOI: 10.3389/fcvm.2021.744497] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 09/13/2021] [Indexed: 11/24/2022] Open
Abstract
Aortic stenosis (AS) may present frequently combined with other valvular diseases or mixed with aortic regurgitation, with peculiar physio-pathological and clinical implications. The hemodynamic interactions between AS in mixed or combined valve disease depend on the specific combination of valve lesions and may result in diagnostic pitfalls at echocardiography; other imaging modalities may be helpful. Indeed, diagnosis is challenging because several echocardiographic methods commonly used to assess stenosis or regurgitation have been validated only in patients with the single-valve disease. Moreover, in the developed world, patients with multiple valve diseases tend to be older and more fragile over time; also, when more than one valvular lesion needs to address the surgical risk rises together with the long-term risk of morbidity and mortality associated with multiple valve prostheses, and the likelihood and risk of reoperation. Therefore, when AS presents mixed or combined valve disease, the heart valve team must integrate various parameters into the diagnosis and management strategy, including suitability for single or multiple transcatheter valve procedures. This review aims to summarize the most critical pathophysiological mechanisms underlying AS when associated with mitral regurgitation, mitral stenosis, aortic regurgitation, and tricuspid regurgitation. We will focus on echocardiography, clinical implications, and the most important treatment strategies.
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Affiliation(s)
| | - Diego Fanti
- University of Verona, Section of Cardiology, Verona, Italy
| | - Elvin Tafciu
- University of Verona, Section of Cardiology, Verona, Italy
| | - Simone Fezzi
- University of Verona, Section of Cardiology, Verona, Italy
| | - Martina Setti
- University of Verona, Section of Cardiology, Verona, Italy
| | - Andrea Rossi
- University of Verona, Section of Cardiology, Verona, Italy
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13
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Ylikauma LA, Ohtonen PP, Erkinaro TM, Vakkala MA, Liisanantti JH, Satta JU, Juvonen TS, Kaakinen TI. Bioreactance and fourth-generation pulse contour methods in monitoring cardiac index during off-pump coronary artery bypass surgery. J Clin Monit Comput 2021; 36:879-888. [PMID: 34037919 PMCID: PMC8150147 DOI: 10.1007/s10877-021-00721-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 05/18/2021] [Indexed: 11/30/2022]
Abstract
The pulmonary artery catheter (PAC) is considered the gold standard for cardiac index monitoring. Recently new and less invasive methods to assess cardiac performance have been developed. The aim of our study was to assess the reliability of a non-invasive monitor utilizing bioreactance (Starling SV) and a non-calibrated mini-invasive pulse contour device (FloTrac/EV1000, fourth-generation software) compared to bolus thermodilution technique with PAC (TDCO) during off-pump coronary artery bypass surgery (OPCAB). In this prospective study, 579 simultaneous intra- and postoperative cardiac index measurements obtained with Starling SV, FloTrac/EV1000 and TDCO were compared in 20 patients undergoing OPCAB. The agreement of data was investigated by Bland-Altman plots, while trending ability was assessed by four-quadrant plots with error grids. In comparison with TDCO, Starling SV was associated with a bias of 0.13 L min-1 m-2 (95% confidence interval, 95% CI, 0.07 to 0.18), wide limits of agreement (LOA, - 1.23 to 1.51 L min-1 m-2), a percentage error (PE) of 60.7%, and poor trending ability. In comparison with TDCO, FloTrac was associated with a bias of 0.01 L min-1 m-2 (95% CI - 0.05 to 0.06), wide LOA (- 1.27 to 1.29 L min-1 m-2), a PE of 56.8% and poor trending ability. Both Starling SV and fourth-generation FloTrac showed acceptable mean bias but imprecision due to wide LOA and high PE, and poor trending ability. These findings indicate limited reliability in monitoring cardiac index in patients undergoing OPCAB.
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Affiliation(s)
- Laura Anneli Ylikauma
- Medical Research Center Oulu, Research Group of Surgery, Anesthesiology and Intensive Care Medicine, Oulu University Hospital and University of Oulu, Oulu, Finland.
| | - Pasi Petteri Ohtonen
- Medical Research Center Oulu, Research Group of Surgery, Anesthesiology and Intensive Care Medicine, Oulu University Hospital and University of Oulu, Oulu, Finland.,Division of Operative Care, Oulu University Hospital, Oulu, Finland
| | - Tiina Maria Erkinaro
- Medical Research Center Oulu, Research Group of Surgery, Anesthesiology and Intensive Care Medicine, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Merja Annika Vakkala
- Medical Research Center Oulu, Research Group of Surgery, Anesthesiology and Intensive Care Medicine, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Janne Henrik Liisanantti
- Medical Research Center Oulu, Research Group of Surgery, Anesthesiology and Intensive Care Medicine, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Jari Uolevi Satta
- Medical Research Center Oulu, Research Group of Surgery, Anesthesiology and Intensive Care Medicine, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Tatu Sakari Juvonen
- Medical Research Center Oulu, Research Group of Surgery, Anesthesiology and Intensive Care Medicine, Oulu University Hospital and University of Oulu, Oulu, Finland.,Department of Cardiac Surgery, Heart and Lung Center, Helsinki University Central Hospital, Helsinki University Hospital, Helsinki, Finland
| | - Timo Ilari Kaakinen
- Medical Research Center Oulu, Research Group of Surgery, Anesthesiology and Intensive Care Medicine, Oulu University Hospital and University of Oulu, Oulu, Finland
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14
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The contemporary pulmonary artery catheter. Part 2: measurements, limitations, and clinical applications. J Clin Monit Comput 2021; 36:17-31. [PMID: 33646499 PMCID: PMC7917533 DOI: 10.1007/s10877-021-00673-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 02/08/2021] [Indexed: 12/25/2022]
Abstract
Nowadays, the classical pulmonary artery catheter (PAC) has an almost 50-year-old history of its clinical use for hemodynamic monitoring. In recent years, the PAC evolved from a device that enabled intermittent cardiac output measurements in combination with static pressures to a monitoring tool that provides continuous data on cardiac output, oxygen supply and-demand balance, as well as right ventricular performance. In this review, which consists of two parts, we will introduce the difference between intermittent pulmonary artery thermodilution using bolus injections, and the contemporary PAC enabling continuous measurements by using a thermal filament which heats up the blood. In this second part, we will discuss in detail the measurements of the contemporary PAC, including continuous cardiac output measurement, right ventricular ejection fraction, end-diastolic volume index, and mixed venous oxygen saturation. Limitations of all of these measurements are highlighted as well. We conclude that thorough understanding of measurements obtained from the PAC is the first step in successful application of the PAC in daily clinical practice.
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15
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Brown JA, Aranda-Michel E, Kilic A, Serna-Gallegos D, Bianco V, Thoma FW, Sultan I. The impact of pulmonary artery catheter use in cardiac surgery. J Thorac Cardiovasc Surg 2021; 164:1965-1973.e6. [PMID: 33642109 DOI: 10.1016/j.jtcvs.2021.01.086] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 01/19/2021] [Accepted: 01/21/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Pulmonary artery catheterization provides continuous monitoring of hemodynamic parameters that may aid in the perioperative management of patients undergoing cardiac surgery. However, prior data suggest that pulmonary artery catheterization has limited benefit in intensive care and surgical settings. Thus, this study sought to determine the impact of pulmonary artery catheter insertion on short-term postoperative outcomes in a large, contemporaneous cohort of patients undergoing open cardiac surgery compared with standard central venous pressure monitoring. METHODS This was an observational study of open cardiac surgeries from 2010 to 2018. Patients with pulmonary artery catheter insertion were identified and matched against patients without pulmonary artery catheter insertion via 1:1 nearest neighbor propensity matching. Multivariable analysis was performed to assess the impact of pulmonary artery catheterization on operative mortality in the overall cohort, as well as recent heart failure, mitral valve disease, and tricuspid insufficiency subgroups. RESULTS Of the 11,820 patients undergoing (Society of Thoracic Surgeons indexed) coronary or valvular surgery, 4605 (39.0%) had pulmonary artery catheter insertion. Propensity score matching yielded 3519 evenly balanced pairs. Compared with central venous pressure monitoring, pulmonary artery catheter use was not associated with improved operative mortality in the overall cohort or in the recent heart failure, mitral valve disease, or tricuspid insufficiency subgroups. Intensive care unit length of stay was longer (P < .001), and there were more packed red blood cell transfusions in the pulmonary artery catheterization group (P < .001); however, postoperative outcomes were otherwise similar, including stroke, sepsis, and new renal failure (P > .05). CONCLUSIONS These findings suggest that pulmonary artery catheterization may have limited benefit in cardiac surgery.
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Affiliation(s)
- James A Brown
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Edgar Aranda-Michel
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Arman Kilic
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Derek Serna-Gallegos
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Valentino Bianco
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Floyd W Thoma
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Ibrahim Sultan
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa.
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16
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Wernhart S, Hedderich J, Weihe E. Vital capacity and valvular dysfunction could serve as non-invasive predictors to screen for exercise pulmonary hypertension in the elderly based on a new diagnostic score. J Cardiovasc Thorac Res 2021; 13:68-78. [PMID: 33815705 PMCID: PMC8007893 DOI: 10.34172/jcvtr.2021.05] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 01/05/2021] [Indexed: 11/09/2022] Open
Abstract
Introduction: Exercise pulmonary hypertension (exPH) has been defined as total pulmonary resistance (TPR) >3 mm Hg/L/min and mean pulmonary artery pressure (mPAP) >30 mm Hg, albeit with a considerable risk of false positives in elderly patients with lower cardiac output during exercise.
Methods: We retrospectively analysed patients with unclear dyspnea receiving right heart catheterisation at rest and exercise (n=244) between January 2015 and January 2020. Lung function testing, blood gas analysis, and echocardiography were performed. We elaborated a combinatorial score to advance the current definition of exPH in an elderly population (mean age 67.0 years±11.9). A stepwise regression model was calculated to non-invasively predict exPH.
Results: Analysis of variables across the achieved peak power allowed the creation of a model for defining exPH, where three out of four criteria needed to be fulfilled: Peak power ≤100 Watt, pulmonary capillary wedge pressure ≥18 mm Hg, pulmonary vascular resistance >3 Wood Units, and mPAP ≥35 mm Hg. The new scoring model resulted in a lower number of exPH diagnoses than the current suggestion (63.1% vs. 78.3%). We present a combinatorial model with vital capacity (VCmax) and valvular dysfunction to predict exPH (sensitivity 93.2%; specificity 44.2%, area under the curve 0.73) based on our suggested criteria. The odds of the presence of exPH were 2.1 for a 1 l loss in VCmax and 3.6 for having valvular dysfunction.
Conclusion: We advance a revised definition of exPH in elderly patients in order to overcome current limitations. We establish a new non-invasive approach to predict exPH by assessing VCmax and valvular dysfunction for early risk stratification in elderly patients.
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Affiliation(s)
- Simon Wernhart
- Department of Cardiology, Fachkrankenhaus Kloster Grafschaft, Schmallenberg, Germany.,University Hospital Essen, University Duisburg-Essen, West German Heart- and Vascular Center, Department of Cardiology and Vascular Medicine, Hufelandstrasse 55, 45147 Essen, Germany
| | - Jürgen Hedderich
- Medistat-Biomedical Statistics, Medistat GmbH, Kronshagen, Germany
| | - Eberhard Weihe
- Institute of Anatomy and Cell Biology of the Philipps-University Marburg, Germany
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17
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Khan F, Okuno T, Malebranche D, Lanz J, Praz F, Stortecky S, Windecker S, Pilgrim T. Transcatheter Aortic Valve Replacement in Patients With Multivalvular Heart Disease. JACC Cardiovasc Interv 2020; 13:1503-1514. [DOI: 10.1016/j.jcin.2020.03.052] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 02/07/2020] [Accepted: 03/13/2020] [Indexed: 12/21/2022]
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18
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Abstract
PURPOSE OF REVIEW Bedside cardiac output (CO) measurement is an important part of routine hemodynamic monitoring in the differential diagnosis of circulatory shock and fluid management. Different choices of CO measurement devices are available. The purpose of this review is to review the importance of CO [or stroke volume (SV)] measurement and to discuss the various methods (devices) used in determination of CO. RECENT FINDINGS CO measurement devices can be classified into two types: those use simple physical principles with minimal assumptions, and those predicting CO via mathematical modelling with a number of assumptions. Both have pros and cons, with the former being more accurate but with limited continuous monitoring capability whereas the latter less accurate but usually equipped with continuous monitoring functionality. With frequent updates in mathematical models, research data constantly become outdated in this area. Recent data suggest devices based on mathematical modelling have limited accuracies and poor precisions. SUMMARY Measurement of CO or SV is important in critically ill patients. Most devices have accuracy and reliability issues. The choice of device should depend on the purpose of measurement. For diagnostic purposes, devices based on simple physical principles, especially thermodilution and transthoracic echocardiography are more reliable due to accuracy.
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19
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20
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Kresoja KP, Faragli A, Abawi D, Paul O, Pieske B, Post H, Alogna A. Thermodilution vs estimated Fick cardiac output measurement in an elderly cohort of patients: A single-centre experience. PLoS One 2019; 14:e0226561. [PMID: 31860679 PMCID: PMC6924680 DOI: 10.1371/journal.pone.0226561] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Accepted: 11/28/2019] [Indexed: 11/19/2022] Open
Abstract
Aims Patients referred to the cath-lab are an increasingly elderly population. Thermodilution (TD, gold standard) and the estimated Fick method (eFM) are interchangeably used in the clinical routine to measure cardiac output (CO). However, their correlation in an elderly cohort of cardiac patients has not been tested so far. Methods A single, clinically-indicated right heart catheterization was performed on each patient with CO estimated by eFM and TD in 155 consecutive patients (75.1±6.8 years, 57.7% male) between April 2015 and August 2017. Whole Body Oxygen Consumption (VO2) was assumed by applying the formulas of LaFarge (LaF), Dehmer (De) and Bergstra (Be). CO was indexed to body surface area (Cardiac Index, CI). Results CI-TD showed an overall moderate correlation to CI-eFM as assessed by LaF, De or Be (r2 = 0.53, r2 = 0.54, r2 = 0.57, all p < .001, respectively) with large limits of agreement (-0.64 to 1.09, -1.07 to 0.77, -1.38 to 0.53 l/m2/min, respectively). The mean difference of CI between methods was 0.22, -0.15 and -0.42 (all p<0.001 for difference to TD), respectively. A rate of error ≥20% occurred with the equations by LaF, De or Be in 40.6%, 26.5% and 36.1% of patients, respectively. A CI <2.2 l/m2min was present in 42.6% of patients according to TD and in 60.0%, 31.0% and in 16.1% of patients according to eFM by the formulas of LaF, De or Be. Conclusion Although CI-eFM shows an overall reasonable correlation with CI-TD, the predictive value in a single patient is low. CI-eFM cannot replace CI-TD in elderly patients.
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Affiliation(s)
- Karl-Patrik Kresoja
- Department of Internal Medicine and Cardiology, Campus Virchow Klinikum (CVK), Charité–University Medicine, Berlin, Germany
- Berlin Institute of Health, Berlin, Germany
- German Cardiovascular Research Centre (DZHK), partner site Berlin, Germany
| | - Alessandro Faragli
- Department of Internal Medicine and Cardiology, Campus Virchow Klinikum (CVK), Charité–University Medicine, Berlin, Germany
- Berlin Institute of Health, Berlin, Germany
- German Cardiovascular Research Centre (DZHK), partner site Berlin, Germany
| | - Dawud Abawi
- Department of Internal Medicine and Cardiology, Campus Virchow Klinikum (CVK), Charité–University Medicine, Berlin, Germany
| | - Oliver Paul
- Department of Internal Medicine and Cardiology, Campus Virchow Klinikum (CVK), Charité–University Medicine, Berlin, Germany
| | - Burkert Pieske
- Department of Internal Medicine and Cardiology, Campus Virchow Klinikum (CVK), Charité–University Medicine, Berlin, Germany
- Berlin Institute of Health, Berlin, Germany
- German Cardiovascular Research Centre (DZHK), partner site Berlin, Germany
- German Heart Center Berlin, Berlin, Germany
| | - Heiner Post
- Department of Internal Medicine and Cardiology, Campus Virchow Klinikum (CVK), Charité–University Medicine, Berlin, Germany
- German Cardiovascular Research Centre (DZHK), partner site Berlin, Germany
- Department of cardiology and angiology, St. Marien-Hospital Mülheim, Mülheim, Germany
| | - Alessio Alogna
- Department of Internal Medicine and Cardiology, Campus Virchow Klinikum (CVK), Charité–University Medicine, Berlin, Germany
- Berlin Institute of Health, Berlin, Germany
- German Cardiovascular Research Centre (DZHK), partner site Berlin, Germany
- * E-mail:
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21
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Opotowsky AR, Hess E, Maron BA, Brittain EL, Barón AE, Maddox TM, Alshawabkeh LI, Wertheim BM, Xu M, Assad TR, Rich JD, Choudhary G, Tedford RJ. Thermodilution vs Estimated Fick Cardiac Output Measurement in Clinical Practice: An Analysis of Mortality From the Veterans Affairs Clinical Assessment, Reporting, and Tracking (VA CART) Program and Vanderbilt University. JAMA Cardiol 2019; 2:1090-1099. [PMID: 28877293 DOI: 10.1001/jamacardio.2017.2945] [Citation(s) in RCA: 81] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Thermodilution (Td) and estimated oxygen uptake Fick (eFick) methods are widely used to measure cardiac output (CO). They are often used interchangeably to make critical clinical decisions, yet few studies have compared these approaches as applied in medical practice. Objectives To assess agreement between Td and eFick CO and to compare how well these methods predict mortality. Design, Setting, and Participants This investigation was a retrospective cohort study with up to 1 year of follow-up. The study used data from the Veterans Affairs Clinical Assessment, Reporting, and Tracking (VA CART) program. The findings were corroborated in a cohort of patients cared for at Vanderbilt University, an academic referral center. Participants were more than 15 000 adults who underwent right heart catheterization, including 12 232 in the Veterans Affairs cohort between October 1, 2007, and September 30, 2013, and 3391 in the Vanderbilt cohort between January 1, 1998, and December 31, 2014. Exposures A single cardiac catheterization was performed on each patient with CO estimated by both Td and eFick methods. Cardiac output was indexed to body surface area (cardiac index [CI]) for all analyses. Main Outcomes and Measures All-cause mortality over 90 days and 1 year after catheterization. Results Among 12 232 VA patients (mean [SD] age, 66.4 [9.9] years; 3.3% female) who underwent right heart catheterization in this cohort study, Td and eFick CI estimates correlated modestly (r = 0.65). There was minimal mean difference (eFick minus Td = -0.02 L/min/m2, or -0.4%) but wide 95% limits of agreement between methods (-1.3 to 1.3 L/min/m2, or -50.1% to 49.4%). Estimates differed by greater than 20% for 38.1% of patients. Low Td CI (<2.2 L/min/m2 compared with normal CI of 2.2-4.0 L/min/m2) more strongly predicted mortality than low eFick CI at 90 days (Td hazard ratio [HR], 1.71; 95% CI, 1.47-1.99; χ2 = 49.5 vs eFick HR, 1.42; 95% CI, 1.22-1.64; χ2 = 20.7) and 1 year (Td HR, 1.53; 95% CI, 1.39-1.69; χ2 = 71.5 vs eFick HR, 1.35; 1.22-1.49; χ2 = 35.2). Patients with a normal CI by both methods had 12.3% 1-year mortality. There was no significant additional risk for patients with a normal Td CI but a low eFick CI (12.9%, P = .51), whereas a low Td CI but normal eFick CI was associated with higher mortality (15.4%, P = .001). The results from the Vanderbilt cohort were similar in the context of a more balanced sex distribution (46.6% female). Conclusions and Relevance There is only modest agreement between Td and eFick CI estimates. Thermodilution CI better predicts mortality and should be favored over eFick in clinical practice.
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Affiliation(s)
- Alexander R Opotowsky
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts.,Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
| | - Edward Hess
- Veterans Affairs Eastern Colorado Health Care System, Denver
| | - Bradley A Maron
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts.,Veterans Affairs Boston Healthcare System, Boston, Massachusetts
| | - Evan L Brittain
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee.,Vanderbilt Translational and Clinical Cardiovascular Research Center, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Anna E Barón
- Veterans Affairs Eastern Colorado Health Care System, Denver
| | - Thomas M Maddox
- Veterans Affairs Eastern Colorado Health Care System, Denver.,University of Colorado School of Medicine, Denver
| | - Laith I Alshawabkeh
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts.,Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
| | - Bradley M Wertheim
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Meng Xu
- Department of Biostatistics, Vanderbilt University, Nashville, Tennessee
| | - Tufik R Assad
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Jonathan D Rich
- Division of Cardiology, Department of Medicine, Northwestern University, Chicago, Illinois
| | - Gaurav Choudhary
- Providence Veterans Affairs Medical Center, Providence, Rhode Island.,Alpert Medical School of Brown University, Providence, Rhode Island
| | - Ryan J Tedford
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston
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22
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Grafton G, Cascino TM, Perry D, Ashur C, Koelling TM. Resting Oxygen Consumption and Heart Failure: Importance of Measurement for Determination of Cardiac Output With the Use of the Fick Principle. J Card Fail 2019; 26:664-672. [PMID: 30753933 DOI: 10.1016/j.cardfail.2019.02.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 02/01/2019] [Accepted: 02/03/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND Resting oxygen consumption (VO2) is often estimated and frequently used to guide therapeutic decisions in symptomatic heart failure (HF) patients. The relationship between resting VO2 and symptomatic HF and the accuracy of estimations of VO2 in this population are unknown. METHODS AND RESULTS We performed a cross-sectional study of HF patients (n = 691) and healthy control subjects (n = 77). VO2 was measured with the use of a metabolic cart, and estimated VO2 was calculated with the use of the Dehmer, LaFarge, and Bergstra formulas and the thermodilution method. The measured and estimated VO2 were compared and the potential impact of estimations determined. In the multivariable model, resting VO2 decreased with increasing New York Heart Association (NYHA) functional class in a stepwise fashion (β NYHA functional class IV vs control = -36 mL O2/min; P < .001). Estimations of VO2 with the use of derived equations diverged from measured values, particularly for patients with NYHA functional class IV limitations. The percentage difference of measured VO2 versus estimated VO2 was >25% in 39% (n = 271), 25% (n = 170), 82% (n = 566), and 39% (n = 271) of HF patients when using the Dehmer, LaFarge, Bergstra, and thermodilution-derived estimations of VO2 respectively. CONCLUSIONS Resting VO2 decreases with increasing NYHA functional class and is lower than in control subjects. Using estimations of VO2 to calculate CO may introduce clinically important error.
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Affiliation(s)
- Gillian Grafton
- Division of Cardiovascular Medicine, Henry Ford, Detroit, Michigan
| | - Thomas M Cascino
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan.
| | - Daniel Perry
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan
| | - Carmel Ashur
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan
| | - Todd M Koelling
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan
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23
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Deutsch N, Swink J, Matisoff AJ, Olivieri LJ, Cross RR, Waberski AT, Unegbu C, Cronin IF, Kanter JP, Schwartz JM. Anesthetic considerations for magnetic resonance imaging-guided right-heart catheterization in pediatric patients: A single institution experience. Paediatr Anaesth 2019; 29:8-15. [PMID: 30375141 PMCID: PMC8074513 DOI: 10.1111/pan.13512] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Revised: 08/31/2018] [Accepted: 09/17/2018] [Indexed: 12/22/2022]
Abstract
Cardiac catheterization is an integral part of medical management for pediatric patients with congenital heart disease. Owing to age and lack of cooperation in children who need this procedure, general anesthesia is typically required. These patients have increased anesthesia risk secondary to cardiac pathology. Furthermore, multiple catheterization procedures result in exposure to harmful ionizing radiation. Magnetic resonance imaging-guided right-heart catheterization offers decreased radiation exposure and diagnostic imaging benefits over traditional fluoroscopy but potentially increases anesthetic complexity and risk. We describe our early experience with anesthetic techniques and challenges for pediatric magnetic resonance imaging-guided right-heart catheterization.
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Affiliation(s)
- Nina Deutsch
- Division of Anesthesiology, Pain, and Perioperative Medicine, Children’s National Medical Center, Washington, DC
| | - Jonathan Swink
- Division of Anesthesiology, Pain, and Perioperative Medicine, Children’s National Medical Center, Washington, DC
| | - Andrew J Matisoff
- Division of Anesthesiology, Pain, and Perioperative Medicine, Children’s National Medical Center, Washington, DC
| | - Laura J Olivieri
- Division of Cardiology, Children’s National Medical Center, Washington, DC
| | - Russell R Cross
- Division of Cardiology, Children’s National Medical Center, Washington, DC
| | - Andrew T Waberski
- Division of Anesthesiology, Pain, and Perioperative Medicine, Children’s National Medical Center, Washington, DC
| | - Chinwe Unegbu
- Division of Anesthesiology, Pain, and Perioperative Medicine, Children’s National Medical Center, Washington, DC
| | - Ileen F Cronin
- Division of Cardiology, Children’s National Medical Center, Washington, DC
| | - Joshua P Kanter
- Division of Cardiology, Children’s National Medical Center, Washington, DC
| | - Jamie M Schwartz
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD
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24
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Unger P, Pibarot P, Tribouilloy C, Lancellotti P, Maisano F, Iung B, Piérard L. Multiple and Mixed Valvular Heart Diseases. Circ Cardiovasc Imaging 2018; 11:e007862. [DOI: 10.1161/circimaging.118.007862] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Philippe Unger
- Department of Cardiology, Centre Hospitalier Universitaire Saint-Pierre, Université Libre de Bruxelles, Belgium (P.U.)
| | - Philippe Pibarot
- Department of Medicine, Quebec Heart and Lung Institute, Laval University, Chemin Saint-Foy, Canada (P.P.)
| | | | - Patrizio Lancellotti
- Department of Cardiovascular Science, Groupe Interdisciplinaire de Génoprotéomique Appliquée (GIGA) Cardiovascular Science, Heart Valve Clinic, Imaging Cardiology, University of Liège Hospital, Belgium (P.L.)
| | - Francesco Maisano
- University Heart Centre, University Hospital Zurich, Switzerland (F.M.)
| | - Bernard Iung
- DHU Fire, Department of Cardiology, Bichat Hospital, Assistance Publique-Hopitaux de Paris, Paris Diderot University, France (B.L.)
| | - Luc Piérard
- Department of Cardiology, University Hospital of Liege, Sart Tilman University Hospital Center, Belgium (L.P.)
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25
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26
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Altamirano-Diaz L, Welisch E, Dempsey AA, Park TS, Grattan M, Norozi K. Non-invasive measurement of cardiac output in children with repaired coarctation of the aorta using electrical cardiometry compared to transthoracic Doppler echocardiography. Physiol Meas 2018; 39:055003. [PMID: 29695645 DOI: 10.1088/1361-6579/aac02b] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To evaluate the equivalence of the ICON® electrical cardiometry (EC) haemodynamic monitor to measure cardiac output (CO) relative to transthoracic Doppler echocardiography (TTE) in paediatric patients with repaired coarctation of the aorta (CoA). APPROACH A group of n = 28 CoA patients and n = 27 matched controls were enrolled. EC and TTE were performed synchronously on each participant and CO measurements compared using linear regression and Bland-Altman analysis. The CoA group was further subdivided into two groups, with n = 10 and without n = 18 increased left ventricular outflow tract velocity (iLVOTv) for comparison. MAIN RESULTS CO measurements from EC and TTE in controls showed a strong correlation (R = 0.80, p < 0.001) and an acceptable percentage error (PE) of 28.1%. However, combining CoA and control groups revealed a moderate correlation (R = 0.57, p < 0.001) and a poor PE (44.2%). We suspected that the CO in a subset of CoA participants with iLVOTv was overestimated by TTE. Excluding the iLVOTv CoA participants improved the correlation (R = 0.77, p < 0.001) and resulted in an acceptable PE of 31.2%. SIGNIFICANCE CO measurements in paediatric CoA patients in the absence of iLVOTv are clinically equivalent between EC and TTE. The presence of iLVOTv may impact the accuracy of CO measurement by TTE, but not EC.
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Affiliation(s)
- Luis Altamirano-Diaz
- Department of Paediatrics, Western University, London, Ontario, Canada. Children's Health Research Institute, London, Ontario, Canada. Paediatric Cardiopulmonary Research Laboratory, London Health Sciences Centre, London, Ontario, Canada
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27
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Kyranis SJ, Latona J, Platts D, Kelly N, Savage M, Brown M, Hamilton-Craig C, Scalia GM, Burstow D. Improving the echocardiographic assessment of pulmonary pressure using the tricuspid regurgitant signal-The “chin” vs the “beard”. Echocardiography 2018; 35:1085-1096. [DOI: 10.1111/echo.13893] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Affiliation(s)
- Stephen J. Kyranis
- Department of Echocardiography; The Prince Charles Hospital; Brisbane QLD Australia
- School of Medicine; University of Queensland; Brisbane QLD Australia
| | - Jilani Latona
- Department of Echocardiography; The Prince Charles Hospital; Brisbane QLD Australia
- School of Medicine; University of Queensland; Brisbane QLD Australia
| | - David Platts
- Department of Echocardiography; The Prince Charles Hospital; Brisbane QLD Australia
- School of Medicine; University of Queensland; Brisbane QLD Australia
- Queensland Advanced Heart Failure and Cardiac Transplant Unit; The Prince Charles Hospital; Heart and Lung Institute; Brisbane QLD Australia
| | - Natalie Kelly
- Department of Echocardiography; The Prince Charles Hospital; Brisbane QLD Australia
- School of Medicine; University of Queensland; Brisbane QLD Australia
| | - Michael Savage
- Department of Echocardiography; The Prince Charles Hospital; Brisbane QLD Australia
- School of Medicine; University of Queensland; Brisbane QLD Australia
| | - Martin Brown
- School of Medicine; University of Queensland; Brisbane QLD Australia
- Queensland Advanced Heart Failure and Cardiac Transplant Unit; The Prince Charles Hospital; Heart and Lung Institute; Brisbane QLD Australia
| | - Christian Hamilton-Craig
- Department of Echocardiography; The Prince Charles Hospital; Brisbane QLD Australia
- School of Medicine; University of Queensland; Brisbane QLD Australia
- Centre for Advanced Imaging; University of Queensland; Brisbane QLD Australia
- University of Washington; Seattle WA USA
| | - Gregory M. Scalia
- Department of Echocardiography; The Prince Charles Hospital; Brisbane QLD Australia
- School of Medicine; University of Queensland; Brisbane QLD Australia
| | - Darryl Burstow
- Department of Echocardiography; The Prince Charles Hospital; Brisbane QLD Australia
- School of Medicine; University of Queensland; Brisbane QLD Australia
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28
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Tehrani DM, Grinstein J, Kalantari S, Kim G, Sarswat N, Adatya S, Sayer G, Uriel N. Cardiac Output Assessment in Patients Supported with Left Ventricular Assist Device: Discordance Between Thermodilution and Indirect Fick Cardiac Output Measurements. ASAIO J 2018; 63:433-437. [PMID: 28125464 DOI: 10.1097/mat.0000000000000528] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Cardiac output (CO) assessed by thermodilution (TD) and indirect Fick (iFK) methods is commonly employed in left ventricular assist device (LVAD) patients; however, no study has assessed agreement. This study assesses correlation between these methods and association with hemodynamic/echocardiographic data in LVAD patients. Discordance was defined as a 20% difference between TD and iFK CO measurements. Bias and agreement were determined via the Bland-Altman technique in both the overall sample and iFK-stratified tertiles. Correlation with each assessment of CO and right heart catheterization (RHC) hemodynamics was performed. Among 111 RHCs, the mean CO for TD and iFK were 4.65 ± 1.33 (range: 1.44-9.30) and 5.37 ± 1.51 (range: 3.07-11.80) L/min (p < 0.001), respectively, with a calculated discordance of 45.9%. A correlation coefficient of 0.66 with a bias of -0.72 L/min was found. The lower and upper limit of precision were -3.12 and 1.68 L/min, respectively. By tertile analysis, bias (lower and upper limit of precision) for the low, middle, and high tertile groups were -0.24 (-1.88 and 1.40), -0.48 (-2.50 and 1.53), and -1.39 (-4.18 and 1.39) L/min, respectively. No significant correlation was found between either method with right atrial pressure or pulmonary capillary wedge pressure or any valvular condition. Substantial discrepancies exist between TD and iFK CO in LVAD patients. Although fixed bias was small, the limits of agreement extend into the clinically relevant area, with larger bias being present at higher CO. Studies with flow probes are needed to define which method better represents CO in LVAD patients.
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Affiliation(s)
- David M Tehrani
- From the University of Chicago Medical Center, Chicago, Illinois
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29
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Ramu B, Houston BA, Tedford RJ. Pulmonary Vascular Disease: Hemodynamic Assessment and Treatment Selection—Focus on Group II Pulmonary Hypertension. Curr Heart Fail Rep 2018; 15:81-93. [DOI: 10.1007/s11897-018-0377-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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30
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Petzoldt M, Trepte CJ, Ridder J, Maisch S, Klapsing P, Kersten JF, Richter HP, Kubitz JC, Reuter DA, Goepfert MS. Reliability of transcardiopulmonary thermodilution cardiac output measurement in experimental aortic valve insufficiency. PLoS One 2017; 12:e0186481. [PMID: 29049339 PMCID: PMC5648193 DOI: 10.1371/journal.pone.0186481] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Accepted: 10/02/2017] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Monitoring cardiac output (CO) is important to optimize hemodynamic function in critically ill patients. The prevalence of aortic valve insufficiency (AI) is rising in the aging population. However, reliability of CO monitoring techniques in AI is unknown. The aim of this study was to investigate the impact of AI on accuracy, precision, and trending ability of transcardiopulmonary thermodilution-derived COTCPTD in comparison with pulmonary artery catheter thermodilution COPAC. METHODS Sixteen anesthetized domestic pigs were subjected to serial simultaneous measurements of COPAC and COTCPTD. In a novel experimental model, AI was induced by retraction of an expanded Dormia basket in the aortic valve annulus. The Dormia basket was delivered via a Judkins catheter guided by substernal epicardial echocardiography. High (HPC), moderate (MPC) and low cardiac preload conditions (LPC) were induced by fluid unloading (20 ml kg-1 blood withdrawal) and loading (subsequent retransfusion of the shed blood and additional infusion of 20 ml kg-1 hydroxyethyl starch). Within each preload condition CO was measured before and after the onset of AI. For statistical analysis, we used a mixed model analysis of variance, Bland-Altman analysis, the percentage error and concordance analysis. RESULTS Experimental AI had a mean regurgitant volume of 33.6 ± 12.0 ml and regurgitant fraction of 42.9 ± 12.6%. The percentage error between COTCPTD and COPAC during competent valve function and after induction of substantial AI was: HPC 17.7% vs. 20.0%, MPC 20.5% vs. 26.1%, LPC 26.5% vs. 28.1% (pooled data: 22.5% vs. 24.1%). The ability to trend CO-changes induced by fluid loading and unloading did not differ between baseline and AI (concordance rate 95.8% during both conditions). CONCLUSION Despite substantial AI, transcardiopulmonary thermodilution reliably measured CO under various cardiac preload conditions with a good ability to trend CO changes in a porcine model. COTCPTD and COPAC were interchangeable in substantial AI.
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Affiliation(s)
- Martin Petzoldt
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- * E-mail:
| | - Constantin J. Trepte
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jan Ridder
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Stefan Maisch
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Philipp Klapsing
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jan F. Kersten
- Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hans Peter Richter
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens C. Kubitz
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Daniel A. Reuter
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Matthias S. Goepfert
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Conde-Camacho R, Cabrales-Arévalo J. El cateterismo derecho como herramienta en el diagnóstico de la hipertensión pulmonar. REVISTA COLOMBIANA DE CARDIOLOGÍA 2017. [DOI: 10.1016/j.rccar.2017.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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McKenzie SC, Dunster K, Chan W, Brown MR, Platts DG, Javorsky G, Anstey C, Gregory SD. Reliability of thermodilution derived cardiac output with different operator characteristics. J Clin Monit Comput 2017; 32:227-234. [PMID: 28281192 DOI: 10.1007/s10877-017-0010-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Accepted: 02/25/2017] [Indexed: 11/27/2022]
Abstract
Cardiac output (CO) is commonly measured using the thermodilution technique at the time of right heart catheterisation (RHC). However inter-operator variability, and the operator characteristics which may influence that, has not been quantified. Therefore, this study aimed to assess inter-operator variability with the thermodilution technique using a mock circulation loop (MCL) with calibrated flow sensors. Participants were blinded and asked to determine 4 levels of CO using the thermodilution technique, which was compared with the MCL calibrated flow sensors. The MCL was used to randomly generate CO between 3.0 and 7.0 L/min through changes in heart rate, contractility and vascular resistance with a RHC inserted through the MCL pulmonary artery. Participant characteristics including gender, specialty, age, height, weight, body-mass index, grip strength and RHC experience were recorded and compared to determine their relationship with CO measurement accuracy. In total, there were 15 participants, made up of consultant cardiologists (6), advanced trainees in cardiology (5) and intensive care consultants (4). The majority (9) had performed 26-100 previous RHCs, while 4 had performed more than 100 RHCs. Compared to the MCL-measured CO, participants overestimated CO using the thermodilution technique with a mean difference of +0.75 ± 0.71 L/min. The overall r2 value for actual vs measured CO was 0.85. The difference between MCL and thermodilution derived CO declined significantly with increasing RHC experience (P < 0.001), increasing body mass index (P < 0.001) and decreasing grip strength (P = 0.033). This study demonstrated that the thermodilution technique is a reasonable method to determine CO, and that operator experience was the only participant characteristic related to CO measurement accuracy. Our results suggest that adequate exposure to, and training in, the thermodilution technique is required for clinicians who perform RHC.
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Affiliation(s)
- Scott C McKenzie
- Faculty of Health Sciences, School of Medicine, The University of Queensland, Brisbane, QLD, Australia.,The Prince Charles Hospital, Chermside, QLD, Australia
| | - Kimble Dunster
- Innovative Cardiovascular Engineering and Technology Laboratory, Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - Wandy Chan
- Faculty of Health Sciences, School of Medicine, The University of Queensland, Brisbane, QLD, Australia.,The Prince Charles Hospital, Chermside, QLD, Australia
| | - Martin R Brown
- Faculty of Health Sciences, School of Medicine, The University of Queensland, Brisbane, QLD, Australia.,The Prince Charles Hospital, Chermside, QLD, Australia
| | - David G Platts
- Faculty of Health Sciences, School of Medicine, The University of Queensland, Brisbane, QLD, Australia.,The Prince Charles Hospital, Chermside, QLD, Australia.,Innovative Cardiovascular Engineering and Technology Laboratory, Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia
| | | | - Chris Anstey
- Faculty of Health Sciences, School of Medicine, The University of Queensland, Brisbane, QLD, Australia.,Nambour General Hospital, Nambour, QLD, Australia
| | - Shaun D Gregory
- Faculty of Health Sciences, School of Medicine, The University of Queensland, Brisbane, QLD, Australia. .,Innovative Cardiovascular Engineering and Technology Laboratory, Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia. .,School of Engineering, Griffith University, Brisbane, Australia.
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Fanari Z, Grove M, Rajamanickam A, Hammami S, Walls C, Kolm P, Saltzberg M, Weintraub WS, Doorey AJ. Cardiac output determination using a widely available direct continuous oxygen consumption measuring device: a practical way to get back to the gold standard. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2016; 17:256-61. [PMID: 26976237 DOI: 10.1016/j.carrev.2016.02.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2016] [Revised: 02/15/2016] [Accepted: 02/24/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND Accurate assessment of cardiac output (CO) is essential for the hemodynamic assessment of valvular heart disease. Estimation of oxygen consumption (VO2) and thermodilution (TD) are employed in many cardiac catheterization laboratories (CCL) given the historically cumbersome nature of direct continuous VO2 measurement, the "gold standard" for this technique. A portable facemask device simplifies the direct continuous measurement of VO2, allowing for relatively rapid and continuous assessment of CO. METHODS AND MATERIALS Thirty consecutive patients undergoing right heart catheterization had simultaneous determination of CO by both direct continuous and assumed VO2 and TD. Assessments were only made when a plateau of VO2 had occurred. All measurements of direct continuous and assumed VO2, as well as, TD CO were obtained in triplicate. RESULTS Direct continuous VO2 CO and assumed VO2 CO correlated poorly (R=0.57; ICC=0.59). Direct continuous VO2 CO and TD CO also correlated poorly (R=0.51; ICC=0.60). Repeated direct continuous VO2 CO measurements were extremely correlated and reproducible [(R=0.93; ICC=0.96) suggesting that this was the most reliable measurement of CO. CONCLUSIONS CO calculated from direct continuous VO2 measurement varies substantially from both assumed VO2 and TD based CO, which are widely used in most CCL. These differences may significantly impact the CO measurements. Furthermore, continuous, rather than average, measurement of VO2 appears to give highly reproducible results.
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Affiliation(s)
- Zaher Fanari
- Division of Cardiology, University of Kansas School of Medicine, Kansas City, KS, USA.
| | - Matthew Grove
- Section of Cardiology, Carolina East Medical Center, New Bern, NC, USA
| | | | - Sumaya Hammami
- Division of Cardiology, University of Kansas School of Medicine, Kansas City, KS, USA; Section of Cardiology, Christiana Care Health System, Newark, DE, USA
| | - Cassie Walls
- Section of Cardiology, Christiana Care Health System, Newark, DE, USA
| | - Paul Kolm
- Value Institute, Christiana Care Health System, Newark, DE, USA
| | | | - William S Weintraub
- Section of Cardiology, Christiana Care Health System, Newark, DE, USA; Value Institute, Christiana Care Health System, Newark, DE, USA
| | - Andrew J Doorey
- Section of Cardiology, Christiana Care Health System, Newark, DE, USA; Value Institute, Christiana Care Health System, Newark, DE, USA
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Maeder MT, Karapanagiotidis S, Dewar EM, Kaye DM. Accuracy of Echocardiographic Cardiac Index Assessment in Subjects with Preserved Left Ventricular Ejection Fraction. Echocardiography 2015; 32:1628-38. [PMID: 25728504 DOI: 10.1111/echo.12928] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION We aimed to determine the accuracy of the echocardiographic assessment of cardiac index (CI) in subjects with preserved left ventricular ejection fraction (LVEF). METHODS Thirty-three subjects with LVEF >50%, normal sinus rhythm, and a broad spectrum of hemodynamic profiles underwent echocardiography immediately followed by right heart catheterization. As gold standards, CI was assessed using thermodilution [CI (TD)] and the Fick method [CI (F)]. Echocardiographic CI was assessed by four methods: from the left ventricular outflow tract (LVOT) velocity time integral and the LVOT diameter as measured [CI (LVOTm)] as well as estimated from body surface area [CI (LVOTe)], and from stroke volume indices assessed using the biplane [CI (BP)] and monoplane [CI (MP)] methods. RESULTS The mean CI (TD), CI (F), CI (LVOTm), CI (LVOTe), CI (BP), and CI (MP) were 3.0 ± 0.9, 3.1 ± 0.7, 2.8 ± 0.6, 3.3 ± 0.6, 2.0 ± 0.6, and 2.2 ± 0.7 L/min/m(2) . There were modest correlations between CI (TD) and CI (F) and all four noninvasive measures of CI with r(2) values ranging from 0.09 to 0.30. CI (LVOTm) underestimated CI (TD) and CI (F) by 0.3 and 0.3 L/min/m(2) , CI (LVOTe) overestimated CI (TD) and CI (F) by 0.3 and 0.2 L/min/m(2) , and CI (BP) and CI (MP) underestimated CI (TD) and CI (F) by 1.1 and 1.1 L/min/m(2) and 0.9 and 0.9 L/min/m(2) , respectively, with large limits of agreement for all comparisons. CONCLUSIONS In subjects with nondilated left ventricles with preserved LVEF, flow- or volume-based measures of CI by 2D echocardiography may not accurately reflect CI (TD) and CI (F). Further larger studies are required to verify our findings and to evaluate the accuracy of contrast and 3D echocardiography in this setting.
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Affiliation(s)
- Micha T Maeder
- Heart Failure Research Group, Baker IDI Heart and Diabetes Institute, Melbourne, Victoria, Australia.,Heart Center, Alfred Hospital, Melbourne, Victoria, Australia.,Cardiology Division, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Sofie Karapanagiotidis
- Heart Failure Research Group, Baker IDI Heart and Diabetes Institute, Melbourne, Victoria, Australia.,Heart Center, Alfred Hospital, Melbourne, Victoria, Australia
| | - Elizabeth M Dewar
- Heart Failure Research Group, Baker IDI Heart and Diabetes Institute, Melbourne, Victoria, Australia.,Heart Center, Alfred Hospital, Melbourne, Victoria, Australia
| | - David M Kaye
- Heart Failure Research Group, Baker IDI Heart and Diabetes Institute, Melbourne, Victoria, Australia.,Heart Center, Alfred Hospital, Melbourne, Victoria, Australia
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Al-Azem MA, Al-Hazmi MS. Saudi Guidelines on the Diagnosis and Treatment of Pulmonary Hypertension: Intensive care management of pulmonary hypertension. Ann Thorac Med 2014; 9:S121-6. [PMID: 25076990 PMCID: PMC4114270 DOI: 10.4103/1817-1737.134056] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2014] [Accepted: 04/05/2014] [Indexed: 12/20/2022] Open
Abstract
Pulmonary hypertension (PH) in the Intensive Care Unit (ICU) may be due to preexisting pulmonary vascular lung disease, liver disease, or cardiac diseases. PH also may be caused by critical illnesses, such as acute respiratory distress syndrome (ARDS), acute left ventricular dysfunction and pulmonary embolism, or may occur after cardiac or thoracic surgery. Regardless of the underlying cause of PH, the final common pathway for hemodynamic deterioration and death is RV failure, which is the most challenging aspect of patient management. Therapy is thus aimed at acutely relieving RV overload by decreasing PVR and reversing RV failure with pulmonary vasodilators and inotropes.
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Affiliation(s)
- M Ali Al-Azem
- Department of Critical Care Medicine, King Fahd Specialist Hospital, Dammam, Saudi Arabia
| | - Manal S Al-Hazmi
- Department of Pulmonary and Critical Care Medicine, King Fahd Medical City, Riyadh, Saudi Arabia
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Guo L, Cui Y, Pharis S, Walsh M, Atallah J, Tan MW, Rutledge J, Coe JY, Adatia I. Measurement of oxygen consumption in children undergoing cardiac catheterization: comparison between mass spectrometry and the breath-by-breath method. Pediatr Cardiol 2014; 35:798-802. [PMID: 24352664 DOI: 10.1007/s00246-013-0855-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2013] [Accepted: 11/28/2013] [Indexed: 11/24/2022]
Abstract
Accurate measurement of oxygen consumption (VO2) is important to precise calculation of blood flow using the Fick equation. This study aimed to validate the breath-by-breath method (BBBM) of measuring oxygen consumption VO2 compared with respiratory mass spectroscopy (MS) for intubated children during cardiac catheterization. The study used MS and BBBM to measure VO2 continuously and simultaneously for 10 min in consecutive anesthetized children undergoing cardiac catheterization who were intubated with a cuffed endotracheal tube, ventilated mechanically, and hemodynamically stable, with normal body temperature. From 26 patients, 520 data points were obtained. The mean VO2 was 94.5 ml/min (95 % confidence interval [CI] 65.7-123.3 ml/min) as measured by MS and 91.4 ml/min (95 % CI 64.9-117.9 ml/min) as measured by BBBM. The mean difference in VO2 measurements between MS and BBBM (3.1 ml/min; 95 % CI -1.7 to +7.9 ml/min) was not significant (p = 0.19). The MS and BBBM VO2 measurements were highly correlated (R (2) = 0.98; P < 0.0001). Bland-Altman analysis showed good correspondence between MS and BBBM, with a mean difference of -3.01 and 95 % limits of agreement ranging from -26.2 to +20.0. The mean VO2 indexed to body surface area did not differ significantly between MS and BBBM (3.4 ml/min m(2); 95 % CI -1.4 to 8.2; p = 0.162). The mean difference and limits of agreement were -3.8 ml/min m(2) (range, -19.9 to 26.7). Both MS and BBBM may be used to measure VO2 in anesthetized intubated children undergoing cardiac catheterization. The two methods demonstrated excellent agreement. However, BBBM may be more suited to clinical use with children.
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Affiliation(s)
- Long Guo
- Pediatric Cardiology, Stollery Children's Hospital, Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, AB, Canada
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Abstract
Diagnosis and prognostication in patients with complex cardiopulmonary disease can be a clinical challenge. A new procedure, MRI catheterization, involves invasive right-sided heart catheterization performed inside the MRI scanner using MRI instead of traditional radiographic fluoroscopic guidance. MRI catheterization combines simultaneous invasive hemodynamic and MRI functional assessment in a single radiation-free procedure. By combining both modalities, the many individual limitations of invasive catheterization and noninvasive imaging can be overcome, and additional clinical questions can be addressed. Today, MRI catheterization is a clinical reality in specialist centers in the United States and Europe. Advances in medical device design for the MRI environment will enable not only diagnostic but also interventional MRI procedures to be performed within the next few years.
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Affiliation(s)
- Toby Rogers
- Cardiovascular and Pulmonary Branch, Division of Intramural Research, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Kanishka Ratnayaka
- Cardiovascular and Pulmonary Branch, Division of Intramural Research, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD; Department of Cardiology, Children's National Medical Center, Washington, DC
| | - Robert J Lederman
- Cardiovascular and Pulmonary Branch, Division of Intramural Research, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD.
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Boehne M, Baustert M, Paetzel V, Köditz H, Schoof S, Happel CM, Bertram H. Determination of cardiac output by ultrasound dilution technique in infants and children: a validation study against direct Fick principle. Br J Anaesth 2013; 112:469-76. [PMID: 24335550 DOI: 10.1093/bja/aet382] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND In critically ill children, monitoring of cardiac output (CO) is essential to guide haemodynamic management and facilitate cardiovascular therapy. The ultrasound dilution technique (UDT), a novel minimally invasive indicator method, was recently introduced to determine CO. We validated UDT against the 'gold standard' reference technique, the direct Fick principle, in infants and children. METHODS Twenty-six children (median age: 6 yr 2 months; median weight: 19.2 kg) underwent diagnostic heart catheterization. In each child, CO was determined by the Fick principle using direct measurement of oxygen consumption and invasive oximetry. Consecutively, haemodynamically stable conditions provided; three independent measurements of CO were conducted with UDT. CO values were compared using bias and limits of agreement calculated using the Bland-Altman approach and linear regression analysis for the complete study group and for a subgroup with body weight <20 kg (n=14). RESULTS The mean (standard deviation) CO values were 3.76 (1.73) litre min(-1) (range 1.38-6.97) for the direct Fick principle and 3.49 (1.72) litre min(-1) (range 1.31-7.00) for UDT. An excellent correlation (r=0.96) was found between both methods (P<0.0001). The Bland-Altman analysis demonstrated good clinical agreement with a mean bias of 0.26 litre min(-1), limits of agreement of -0.66 and 1.19 litre min(-1), and percentage error of 25.9%. Comparable results were obtained for patients <20 kg (mean bias=0.19 litre min(-1), percentage error=25.5%). CONCLUSIONS CO measurements by UDT agree favourably with Fick-derived CO data and both techniques were found to be equivalent and interchangeable. UDT represents a valid and applicable method for repetitive CO determinations in infants and children.
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Affiliation(s)
- M Boehne
- Department of Paediatric Cardiology and Intensive Care Medicine, Hannover Medical School, Carl-Neuberg-Straße 1, 30625 Hannover, Germany
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Marik PE. Obituary: pulmonary artery catheter 1970 to 2013. Ann Intensive Care 2013; 3:38. [PMID: 24286266 PMCID: PMC4175482 DOI: 10.1186/2110-5820-3-38] [Citation(s) in RCA: 106] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2013] [Accepted: 11/21/2013] [Indexed: 11/14/2022] Open
Abstract
The birth of the intermittent injectate-based conventional pulmonary artery catheter (fondly nicknamed PAC) was proudly announced in the New England Journal of Medicine in 1970 by his parents HJ Swan and William Ganz. PAC grew rapidly, reaching manhood in 1986 where, in the US, he was shown to influence the management of over 40% of all ICU patients. His reputation, however, was tarnished in 1996 when Connors and colleagues suggested that he harmed patients. This was followed by randomized controlled trials demonstrating he was of little use. Furthermore, reports surfaced suggesting that he was unreliable and inaccurate. It also became clear that he was poorly understood and misinterpreted. Pretty soon after that, a posse of rivals (bedside echocardiography, pulse contour technology) moved into the neighborhood and claimed they could assess cardiac output more easily, less invasively and no less reliably. To make matter worse, dynamic assessment of fluid responsiveness (pulse pressure variation, stroke volume variation and leg raising) made a mockery of his ‘wedge’ pressure. While a handful of die-hard followers continued to promote his mission, the last few years of his existence were spent as a castaway until his death in 2013. His cousin (the continuous cardiac output PAC) continues to eke a living mostly in cardiac surgery patients who need central access anyway. This paper reviews the rise and fall of the conventional PAC.
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Affiliation(s)
- Paul E Marik
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, 825 Fairfax Avenue, Suite 410, Norfolk, VA, USA.
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Noninvasive transcutaneous Doppler ultrasound-derived hemodynamic reference ranges in Chinese adolescents. Pediatr Crit Care Med 2013; 14:e225-32. [PMID: 23439468 DOI: 10.1097/pcc.0b013e3182772f78] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The ultrasonic cardiac output monitor is a noninvasive, quantitative method for measuring and monitoring cardiovascular hemodynamic parameters in patients. The aims of this study were first to establish reference ranges for cardiovascular indices measured by the ultrasonic cardiac output monitor in Chinese children aged 12-18 yr, second to assess the interobserver reliability of the method, and third to compare these ranges with a Caucasian group from Australia. DESIGN, SETTING, AND SUBJECTS This was a population-based cross-sectional cohort study of Chinese adolescents 12-18 years old, performed in secondary schools in Hong Kong. INTERVENTIONS Ultrasonic cardiac output monitor scans were performed on each subject to measure stroke volume, cardiac output, and systemic vascular resistance together with standard oscillometric measurement of blood pressure and heart rate. Ultrasonic cardiac output monitor parameters were also standardized by deriving body surface area referenced indices. Normal ranges were defined as lying within two standard deviations on either side of the mean. To assess interobserver variability, a second, blinded operator repeated 17% of scans. MEASUREMENTS AND MAIN RESULTS A total of 590 Chinese adolescents (49% boys) were scanned. Normal ranges for cardiac output, cardiac index, stroke volume, stroke volume index, stroke volume resistance, and systemic vascular resistance index are presented. Males had a significantly higher mean stroke volume, cardiac output, and systemic vascular resistance index compared with females (p < 0.05), but no significant differences were found for the indexed values. When compared with a group of 31 Australian Caucasian adolescents (71% boys), Chinese adolescents have a significantly lower cardiac output and stroke volume (p <0.05), but these differences disappeared when adjusted for body surface area (i.e., stroke volume index, cardiac index, and systemic vascular resistance index). Interobserver variability of ultrasonic cardiac output monitor-derived stroke volume showed a coefficient of variation of 10.2%, a correlation coefficient of 0.90 (95% confidence interval 0.85-0.93), while Bland-Altman analysis showed a mean bias of 1.5% (95% limits of agreement were -19.9% to 23.0%). CONCLUSIONS This study presents normal values for cardiovascular indices in Chinese adolescents using the ultrasonic cardiac output monitor. When referenced to body surface area, the differences between Caucasians and Chinese were insignificant.
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Thermodilution and Fick cardiac outputs differ: impact on pulmonary hypertension evaluation. Can Respir J 2013; 19:261-6. [PMID: 22891186 DOI: 10.1155/2012/261793] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The relationship between thermodilution and indirect Fick cardiac output determination methods has not been well described. OBJECTIVE To describe the relationship between these two cardiac output determination methods in patients evaluated for pulmonary hypertension and to highlight potential clinical implications. METHODS A retrospective review of charts of all adult patients who underwent a right heart catheterization (RHC) between January 1, 2007 and November 10, 2010, and participated in the pulmonary hypertension program of the pulmonary division at an academic institution was conducted. For validation, the charts of all patients who underwent RHC during the same period within the cardiology division were reviewed. RESULTS A total of 198 patients underwent 213 RHCs, 79 (40%) of whom had pulmonary arterial hypertension, were included. Forty-three per cent of patients had >20% difference between thermodilution and Fick. The average difference (thermodilution - Fick ±SD) was -0.39±2.03 L⁄min (n=213; P=0.006). There was no significant difference in bias or variability between thermodilution and Fick among patients with tricuspid regurgitant jet velocity (TRJ) of <3 m⁄s versus those with TRJ >3 m⁄s (-0.41±2.10 L⁄min versus -0.36±1.93 L⁄min, respectively; P=0.87). In a multivariable analysis, the thermodilution-Fick difference increased with age (P=0.001). DISCUSSION The presence of such discrepancy in 36% of patients evaluated for heart failure and⁄or heart transplant validated the results. In total, 37% of the 1315 procedures (213 performed by pulmonologists and 1102 performed by cardiologists) had a difference of >20% between thermodilution and Fick. CONCLUSION Significant discrepancy exists between thermodilution and indirect Fick methods. This discrepancy potentially impacts pulmonary arterial hypertension prognostication and diagnosis, and is independent of TRJ.
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A practical method of measuring oxygen consumption in children with complex mixing circulations by the use of thermodilution cardiac output studies. J Thorac Cardiovasc Surg 2013; 146:1179-84. [PMID: 23380516 DOI: 10.1016/j.jtcvs.2012.09.103] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2012] [Revised: 09/06/2012] [Accepted: 09/21/2012] [Indexed: 11/23/2022]
Abstract
OBJECTIVE We describe a method to measure oxygen consumption (VO2) and pulmonary vascular resistive index (PVRI) based on thermodilution cardiac output in patients with complex mixing circulations. We apply this method to patients with a bidirectional cavopulmonary anastomosis (BDCPA). We compare our measured VO2 with a predicted VO2 based on a formula using height and weight. METHODS We reviewed data based on cardiac catheterization and thermodilution cardiac output in a series of 25 catheterizations in patients with BDCPA. We used this data to measure VO2 and PVRI, and looked for a correlation between the predicted and measured VO2. We also assessed whether any other hemodynamic parameter correlated with measured VO2. RESULTS There was no significant correlation between the predicted and the measured VO2 (correlation coefficient = -0.258, P = .21). We did find a significant correlation in the difference between the measured and predicted VO2 against the measured VO2 such that at a lower measured VO2 the predictive formula tended to overestimate VO2 and at a higher VO2 the formula underestimated VO2 (correlation coefficient = 0.963, P < .0001). Body surface area did not correlate with measured VO2 (correlation coefficient = 0.28, P < .16). Mixed venous oxygen content showed a weak negative correlation with VO2 (correlation coefficient = -0.54, P = .005). CONCLUSIONS An assessment of PVRI that is based on a predicted VO2 is unreliable in this patient population. No hemodynamic parameter correlated well with VO2. The use of a measured VO2 is necessary in determining PVRI in these patients.
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Tandon A, Grayburn PA. Imaging of Low-Gradient Severe Aortic Stenosis. JACC Cardiovasc Imaging 2013; 6:184-95. [DOI: 10.1016/j.jcmg.2012.11.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2012] [Revised: 11/20/2012] [Accepted: 11/26/2012] [Indexed: 02/06/2023]
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Affiliation(s)
- Paul A Grayburn
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX 75226, USA.
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Pulmonary artery vs. transpulmonary thermodilution for the assessment of cardiac output in mitral regurgitation: a prospective observational study. Eur J Anaesthesiol 2012; 29:431-7. [PMID: 22569023 DOI: 10.1097/eja.0b013e3283542222] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
CONTEXT With increasing prevalence of mitral regurgitation, even noncardiac anaesthesiologists will be confronted by this disorder and will need to be familiar with the extended haemodynamic monitoring required. The assessment of cardiac output (CO) measured by transpulmonary thermodilution (COTP) has become an accepted alternative to the CO measured by thermodilution via pulmonary artery catheter (COPAC). However, the integrity of COTP in severe mitral regurgitation requires systematic evaluation. OBJECTIVE This study was designed to test the hypothesis that transpulmonary thermodilution is compromised by severe mitral regurgitation. DESIGN Prospective method comparison study. SETTING Single university-affiliated hospital. PARTICIPANTS Thirty patients with mitral regurgitation undergoing elective mitral valve repair. MAIN OUTCOME MEASURE COTP and COPAC were determined in triplicate after induction of anaesthesia, and at the end of surgery after closure of the chest. The methods were compared using bias and precision statistics. RESULTS Echocardiography revealed severe mitral regurgitation in most patients (n = 27) after induction of anaesthesia. The least significant change in COTP (the minimum change in COTP required to detect a real change with a probability of 95%) was increased under the condition of mitral regurgitation (15.4 ± 10.2% after anaesthesia induction vs. 9.3 ± 5.9% after valve repair, P = 0.008), whereas it remained constant in COPAC (9.6 ± 5.4 vs. 8.5 ± 7.2%, P = 0.55). There was no significant bias between COTP and COPAC after anaesthesia induction [mean CO, 4.03 ± 0.92 l min; bias 0.12 l min (95% confidence interval, CI, -0.073 to 0.311)], and after valve repair [mean CO 7.47 ± 1.44 l min; bias 0.045 l min (95% CI, -0.147 to 0.237)]. The percentage error was 28.4 and 13.6%, respectively. CONCLUSION The results suggest that even severe mitral regurgitation has no significant impact on the accuracy of COTP. The precision of COTP was reduced under the condition of mitral regurgitation.
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Ahmed M, Hill J. A Rational Approach to Assess Volume Status in Patients with Decompensated Heart Failure. Curr Heart Fail Rep 2012; 9:139-47. [DOI: 10.1007/s11897-012-0084-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Pulmonary Artery Catheter (PAC) Accuracy and Efficacy Compared with Flow Probe and Transcutaneous Doppler (USCOM): An Ovine Cardiac Output Validation. Crit Care Res Pract 2012; 2012:621496. [PMID: 22649718 PMCID: PMC3357512 DOI: 10.1155/2012/621496] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2012] [Accepted: 02/23/2012] [Indexed: 12/13/2022] Open
Abstract
Background. The pulmonary artery catheter (PAC) is an accepted clinical method of measuring cardiac output (CO) despite no prior validation. The ultrasonic cardiac output monitor (USCOM) is a noninvasive alternative to PAC using Doppler ultrasound (CW). We compared PAC and USCOM CO measurements against a gold standard, the aortic flow probe (FP), in sheep at varying outputs. Methods. Ten conscious sheep, with implanted FPs, had measurements of CO by FP, USCOM, and PAC, at rest and during intervention with inotropes and vasopressors. Results. CO measurements by FP, PAC, and USCOM were 4.0 ± 1.2 L/min, 4.8 ± 1.5 L/min, and 4.0 ± 1.4 L/min, respectively, (n = 280, range 1.9 L/min to 11.7 L/min). Percentage bias and precision between FP and PAC, and FP and USCOM was -17 and 47%, and 1 and 36%, respectively. PAC under-measured Dobutamine-induced CO changes by 20% (relative 66%) compared with FP, while USCOM measures varied from FP by 3% (relative 10%). PAC reliably detected -30% but not +40% CO changes, as measured by receiver operating characteristic area under the curve (AUC), while USCOM reliably detected ±5% changes in CO (AUC > 0.70). Conclusions. PAC demonstrated poor accuracy and sensitivity as a measure of CO. USCOM provided equivalent measurements to FP across a sixfold range of outputs, reliably detecting ±5% changes.
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Rao S, Tate D, Stouffer G. Hemodynamic findings in severe tricuspid regurgitation. Catheter Cardiovasc Interv 2012; 81:162-9. [DOI: 10.1002/ccd.24309] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2011] [Accepted: 12/24/2011] [Indexed: 11/10/2022]
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