Pulsed wave Doppler measurement of cardiac output from the right ventricular outflow tract

Cardiac output measurements via echocardiography versus thermodilution: A systematic review and meta-analysis

Echocardiography, as a noninvasive hemodynamic evaluation technique, is frequently used in critically ill patients. Different opinions exist regarding whether it can be interchanged with traditional invasive means, such as the pulmonary artery catheter thermodilution (TD) technique. This systematic review aimed to analyze the consistency and interchangeability of cardiac output measurements by ultrasound (US) and TD. Five electronic databases were searched for studies including clinical trials conducted up to June 2019 in which patients’ cardiac output was measured by ultrasound techniques (echocardiography) and TD. The methodological quality of the included studies was evaluated by two independent reviewers who used the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2), which was tailored according to our systematic review in Review Manager 5.3. A total of 68 studies with 1996 patients were identified as eligible. Meta-analysis and subgroup analysis were used to compare the cardiac output (CO) measured using the different types of echocardiography and different sites of Doppler use with TD. No significant differences were found between US and TD (random effects model: mean difference [MD], -0.14; 95% confidence interval, -0.30 to 0.02; P = 0.08). No significant differences were observed in the subgroup analyses using different types of echocardiography and different sites except for ascending aorta (AA) (random effects model: mean difference [MD], -0.37; 95% confidence interval, -0.74 to -0.01; P = 0.05) of Doppler use. The median of bias and limits of agreement were -0.12 and ±0.94 L/min, respectively; the median of correlation coefficient was 0.827 (range, 0.140–0.998). Although the difference in CO between echocardiography by different types or sites and TD was not entirely consistent, the overall effect of meta-analysis showed that no significant differences were observed between US and TD. The techniques may be interchangeable under certain conditions.

Minimally invasive beat-by-beat monitoring of cardiac power in normal hearts and during acute ventricular dysfunction

Cardiac power, the product of aortic flow and blood pressure, appears to be a fundamental cardiovascular parameter. The simplified version named cardiac power output (CPO), calculated as the product of cardiac output (CO) in L/min and mean arterial pressure (MAP) in mmHg divided by 451, has shown great ability to predict outcome in a broad spectrum of cardiac disease. Beat‐by‐beat evaluation of cardiac power (PWR) therefore appears to be a possibly valuable addition when monitoring circulatory unstable patients, providing parameters of overall cardiovascular function. We have developed a minimally invasive system for cardiac power measurement, and aimed in this study to compare this system to an invasive method (ttPWR). Seven male anesthetized farm pigs were included. A laptop with in‐house software gathered audio from Doppler signals of aortic flow and blood pressure from the patient monitor to continuously calculate and display a minimally invasive cardiac power trace (uPWR). The time integral per cardiac cycle (uPWR‐integral) represents cardiac work, and was compared to the invasive counterpart (ttPWR‐integral). Signals were obtained at baseline, during mechanically manipulated preload and afterload, before and after induced global ischemic left ventricular dysfunction. We found that the uPWR‐integral overestimated compared to the ttPWR‐integral by about 10% (P < 0.001) in both normal hearts and during ventricular dysfunction. Bland–Altman limits of agreement were at +0.060 and −0.054 J, without increasing spread over the range. In conclusion we find that the minimally invasive system follows its invasive counterpart, and is ready for clinical research of cardiac power parameters.

Delta-opioid augments cardiac contraction through β-adrenergic and CGRP-receptor co-signaling

Cardiac epinephrine and calcitonin gene-related peptide (CGRP) are produced by intrinsic cardiac adrenergic cells (ICA cells) residing in human and animal hearts. ICA cells are neuroparicine cells expressing δ-opioid receptors (DOR). We hypothesized that δ-opioid stimulation of ICA cells enhances epinephrine and CGRP release, which results in the augmentation of heart contraction. Rats were injected with DOR-agonist DPDPE (100 μg/kg) with or without 10-min pretreatment with either β-adrenergic receptor (β-AR) blocker propranolol (2mg/kg) or CGRP-receptor (CGRPR) blocker CGRP(8-37) (300 μg/kg), or their combination. Hemodynamics were monitored with echocardiogram and systolic blood pressure (SBP) was monitored via a tail arterial catheter. Changes in left ventricular fraction-shortening (LVFS) and heart rate (HR) were observed at 5-min after DPDPE infusion. At 5-min DPDPE induced a 36 ± 18% (p<0.001) increase of the LVFS, which continues to increase to 51 ± 24% (p<0.0001) by 10 min, and 68 ± 19% (p<0.001) by 20 min. The increase in LVFS was accompanied by the decrease of HR by 9±5% (p<0.01) by 5 min and 11 ± 6% (p<0.001) by 15 min post DPDPE infusion. This magnitude of HR reduction was observed for the remainder of the 20 min. Despite the HR-reduction, cardiac output was increased by 17 ± 8% (p<0.05) and 28±5% (p<0.001) by 5- and 20-min post DPDPE administration, respectively. There was a modest (9 ± 9%, p=0.03) decrease in SBP that was not apparent until 20 min post DPDPE infusion. The positive inotropism of DPDPE was abrogated in animals pretreated with propranolol, CGRP(8-37), or combined propranolol+CGRP(8-37). Furthermore, in whole animal and cardiomyocyte cell culture preparations, DPDPE induced myocardial protein-kinase A (PKA) activation which was abrogated in the animals pretreated with propranolol+CGRP(8-37). DOR agonists augment myocardial contraction through enhanced β-AR and CGRPR co-signaling.

Can intraoperative TEE correctly measure residual shunt after surgical repair of ventricular septal defects?

PURPOSE

No groups have yet succeeded in identifying the need for re-repair of residual shunt after surgical repair of ventricular septal defect (VSD) based on quantitative evaluation of the ratio of the pulmonary blood flow to the systemic blood flow (Qp/Qs) by transesophageal echocardiography (TEE). Hence, we studied the accuracy of Qp/Qs as estimated by intraoperative TEE.

METHODS

Twenty-six patients undergoing VSD closure were studied. After separation from the cardiopulmonary bypass, the presence and severity of residual leakage was evaluated by color Doppler image, and the Qp/Qs (TEE-derived Qp/Qs) was calculated by measuring the vessel diameter and the velocity-time integral of the flow profiles in the main pulmonary artery and left ventricular outflow tract. Transthoracic echocardiography (TTE) was performed at pre-discharge and at 6-12 months after the correction to confirm the presence and severity of residual leakage.

RESULTS

TEE detected only minor leakage, with no indication for re-repair, in 8 of the 26 patients. Nevertheless, TEE-derived Qp/Qs varied from 0.57 to 2.07 and were incorrect in 17 patients (65.4%). This meant that when TEE-derived Qp/Qs was outside the acceptable range, the patient was judged not to be in need of re-repair. TTE at pre-discharge confirmed trivial leakage in 3 patients in whom TEE had also identified similar leakages. These leakages were not observed at the follow-up TTE.

CONCLUSION

TEE-derived Qp/Qs lacks the accuracy required to play a crucial role in quantitatively measuring the severity of residual shunt, while two-dimensional TEE can reliably detect residual leakage after VSD closure and lead to optimal judgment on the need for re-repair.

Respiratory changes in inferior vena cava diameter are helpful in predicting fluid responsiveness in ventilated septic patients

OBJECTIVE

To evaluate the extent to which respiratory changes in inferior vena cava (IVC) diameter can be used to predict fluid responsiveness.

DESIGN

Prospective clinical study.

SETTING

Hospital intensive care unit.

PATIENTS

Twenty-three patients with acute circulatory failure related to sepsis and mechanically ventilated because of an acute lung injury.

MEASUREMENTS

Inferior vena cava diameter (D) at end-expiration (Dmin) and at end-inspiration (Dmax) was measured by echocardiography using a subcostal approach. The distensibility index of the IVC (dIVC) was calculated as the ratio of Dmax - Dmin / Dmin, and expressed as a percentage. The Doppler technique was applied in the pulmonary artery trunk to determine cardiac index (CI). Measurements were performed at baseline and after a 7 ml/kg volume expansion using a plasma expander. Patients were separated into responders (increase in CI > or =15%) and non-responders (increase in CI <15%).

RESULTS

Using a threshold dIVC of 18%, responders and non-responders were discriminated with 90% sensitivity and 90% specificity. A strong relation (r = 0.9) was observed between dIVC at baseline and the CI increase following blood volume expansion. Baseline central venous pressure did not accurately predict fluid responsiveness.

CONCLUSION

Our study suggests that respiratory change in IVC diameter is an accurate predictor of fluid responsiveness in septic patients.