Continuous and less invasive central hemodynamic monitoring by blood pressure waveform analysis

Cuffless Blood Pressure Measurement

Cuffless blood pressure (BP) measurement has become a popular field due to clinical need and technological opportunity. However, no method has been broadly accepted hitherto. The objective of this review is to accelerate progress in the development and application of cuffless BP measurement methods. We begin by describing the principles of conventional BP measurement, outstanding hypertension/hypotension problems that could be addressed with cuffless methods, and recent technological advances, including smartphone proliferation and wearable sensing, that are driving the field. We then present all major cuffless methods under investigation, including their current evidence. Our presentation includes calibrated methods (i.e., pulse transit time, pulse wave analysis, and facial video processing) and uncalibrated methods (i.e., cuffless oscillometry, ultrasound, and volume control). The calibrated methods can offer convenience advantages, whereas the uncalibrated methods do not require periodic cuff device usage or demographic inputs. We conclude by summarizing the field and highlighting potentially useful future research directions. Expected final online publication date for the Annual Review of Biomedical Engineering, Volume 24 is June 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

Hemodynamic variations in arterial wave reflection associated with the application of increasing levels of PEEP in healthy subjects

Positive end-expiratory pressure (PEEP) may affect arterial wave propagation and reflection, thus influencing ventricular loading conditions. The aim of the study was to investigate the hemodynamic variations in arterial wave reflection (i.e., wave reflection time, augmentation index, left ventricular ejection time, diastolic time, SEVR) associated with the application of increasing levels of PEEP in healthy subjects. We conducted a prospective observational study. Study population was selected from students and staff. Pulse contour wave analysis was performed from the right carotid artery during stepwise increase in PEEP levels (from 0 cmH₂O, 5 cmH₂0, 10 cmH₂O) with applanation tonometry. Sixty-two healthy volunteers were recruited. There were no significant changes in heart rate, augmentation index (AIx), left ventricular ejection time, Diastolic time (DT) among all of the different steps. A significant increase of time to the inflection point (Ti) was observed during all steps of the study. Diastolic area under the curve (AUC) divided by systolic-AUC (SEVR) increased from baseline to PEEP = 5 cmH₂O, and from baseline to PEEP = 10 cmH₂O. AIx and Ti were significantly correlated (directly) at the baseline and during PEEP = 10 cmH₂O. Ti and DT were significantly correlated at the baseline and during PEEP = 5 cmH₂O. In our preliminary results, low levels of PEEP played a role in the interaction between the heart and the vascular system, apparently mediated by a prolongation of the diastolic phase and a reduction in the systolic work of the heart.

Clinical trials registration number: NCT03294928, 19/09/2017.

Comparison of accuracy of two uncalibrated pulse contour cardiac output monitors in off-pump coronary artery bypass surgery patients using pulmonary artery catheter-thermodilution as a reference

Background

Cardiac output (CO) is a key measure of adequacy of organ and tissue perfusion, especially in critically ill or complex surgical patients. CO monitoring technology continues to evolve. Recently developed CO monitors rely on unique algorithms based on pulse contour analysis of an arterial blood pressure (ABP) waveform. The objective of this investigation was to compare the accuracy of two monitors using different methods of pulse contour analysis – the Retia Argos device and the Edwards Vigileo-FloTrac device – with pulmonary artery catheter (PAC)-thermodilution as a reference.

Methods

Fifty-eight patients undergoing off-pump coronary artery bypass surgery formed the study cohort. A total of 572 triplets of CO measurements from each device – Argos, Vigileo-FloTrac (third generation), and thermodilution – were available before and after interventions (e.g., vasopressors, fluids, and inotropes). Bland–Altman analysis accounting for repeated measurements per subject and concordance analysis were applied to assess the accuracy of the CO values and intervention-induced CO changes of each pulse contour device against thermodilution. Cluster bootstrapping was employed to statistically compare the root-mean-squared-errors (RMSE = √(μ² + σ²), where μ and σ are the Bland–Altman bias and precision errors) and concordance rates of the two devices.

Results

The RMSE (mean (95% confidence intervals)) for CO values was 1.16 (1.00–1.32) L/min for the Argos device and 1.54 (1.33–1.77) L/min for the Vigileo-FloTrac device; the concordance rate for intervention-induced CO changes was 87 (82–92)% for the Argos device and 72 (65–78)% for the Vigileo-FloTrac device; and the RMSE for the CO changes was 17 (15–19)% for the Argos device and 21 (19–23)% for the Vigileo-FloTrac device (p < 0.0167 for all comparisons).

Conclusions

In comparison with CO measured by the PAC, the Argos device proved to be more accurate than the Vigileo-FloTrac device in CO trending and absolute CO measurement in patients undergoing off-pump coronary artery bypass surgery.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12871-021-01415-5.

Passive leg movement in chronic obstructive pulmonary disease: evidence of locomotor muscle vascular dysfunction

Chronic obstructive pulmonary disease (COPD), characterized by pulmonary dysfunction, is now also recognized to be associated with free radical-mediated vascular dysfunction. However, as previous investigations have utilized the brachial artery flow-mediated dilation technique, whether such vascular dysfunction exists in the locomotor muscle of patients with COPD remains unclear. Therefore, in patients with COPD (n = 13, 66 ± 6 yr) and healthy age- and sex-matched control subjects (n = 12, 68 ± 6 yr), second-by-second measurements of leg blood flow (LBF) (ultrasound Doppler), mean arterial pressure (MAP) (Finapres), and leg vascular conductance (LVC) were recorded before and during both 2 min of continuous upright seated continuous-movement passive leg movement (PLM) and a single-movement PLM (sPLM). In response to PLM, both peak change in LBF (COPD 321 ± 54, Control 470 ± 55 ∆mL/min) and LVC (COPD 3.0 ± 0.5, Control 5.4 ± 0.5 ∆mL·min^-1·mmHg^-1) were significantly attenuated in patients with COPD compared with control subjects (P < 0.05). This attenuation in the patients with COPD was also evident in response to sPLM, with peak change in LBF tending to be lower (COPD 142 ± 26, Control 169 ± 14 ∆mL/min) and LVC being significantly lower (P < 0.05) in the patients than the control subjects (COPD 1.6 ± 0.4, Control 2.5 ± 0.3 ∆mL·min^-1·mmHg^-1). Therefore, utilizing both PLM and sPLM, this study provides evidence of locomotor muscle vascular dysfunction in patients with COPD, perhaps due to redox imbalance and reduced nitric oxide bioavailability, which is in agreement with an increased cardiovascular disease risk in this population. This locomotor muscle vascular dysfunction, in combination with the clearly dysfunctional lungs, may contribute to the exercise intolerance associated with COPD.NEW & NOTEWORTHY Utilizing both the single and continuous passive leg movement (PLM) models, which induce nitric oxide (NO)-dependent hyperemia, this study provides evidence of vascular dysfunction in the locomotor muscle of patients with chronic obstructive pulmonary disease (COPD), independent of central hemodynamics. This impaired hyperemia may be the result of an oxidant-mediated attenuation in NO bioavailability. In addition to clearly dysfunctional lungs, vascular dysfunction in locomotor muscle may contribute to the exercise intolerance associated with COPD and increased cardiovascular disease risk.

Monitoring of the central blood pressure waveform via a conformal ultrasonic device

Continuous monitoring of the central-blood-pressure waveform from deeply embedded vessels, such as the carotid artery and jugular vein, has clinical value for the prediction of all-cause cardiovascular mortality. However, existing non-invasive approaches, including photoplethysmography and tonometry, only enable access to the superficial peripheral vasculature. Although current ultrasonic technologies allow non-invasive deep-tissue observation, unstable coupling with the tissue surface resulting from the bulkiness and rigidity of conventional ultrasound probes introduces usability constraints. Here, we describe the design and operation of an ultrasonic device that is conformal to the skin and capable of capturing blood-pressure waveforms at deeply embedded arterial and venous sites. The wearable device is ultrathin (240 μm) and stretchable (with strains up to 60%), and enables the non-invasive, continuous and accurate monitoring of cardiovascular events from multiple body locations, which should facilitate its use in a variety of clinical environments.

The Mechanoreflex and Hemodynamic Response to Passive Leg Movement in Heart Failure

BACKGROUND

Sensitization of mechanosensitive afferents, which contribute to the exercise pressor reflex, has been recognized as a characteristic of patients with heart failure (HF); however, the hemodynamic implications of this hypersensitivity are unclear.

OBJECTIVES

The present study used passive leg movement (PLM) and intrathecal injection of fentanyl to blunt the afferent portion of this reflex arc to better understand the role of the mechanoreflex on central and peripheral hemodynamics in HF.

METHODS

Femoral blood flow (FBF), mean arterial pressure, femoral vascular conductance, HR, stroke volume, cardiac output, ventilation, and muscle oxygenation of the vastus lateralis were assessed in 10 patients with New York Heart Association class II HF at baseline and during 3 min of PLM both with fentanyl and without (control).

RESULTS

Fentanyl had no effect on baseline measures but increased (control vs fentanyl, P < 0.05) the peak PLM-induced change in FBF (493 ± 155 vs 804 ± 198 ΔmL·min(-1)) and femoral vascular conductance (4.7 ± 2 vs 8.5 ± 3 ΔmL·min(-1)·mm Hg)(-1) while norepinephrine spillover (103% ± 19% vs 58% ± 17%Δ) and retrograde FBF (371 ± 115 vs 260 ± 68 ΔmL·min(-1)) tended to be reduced (P < 0.10). In addition, fentanyl administration resulted in greater PLM-induced increases in muscle oxygenation, suggestive of increased microvascular perfusion. Fentanyl had no effect on the ventilation, mean arterial pressure, HR, stroke volume, or cardiac output response to PLM.

CONCLUSIONS

Although movement-induced central hemodynamics were unchanged by afferent blockade, peripheral hemodynamic responses were significantly enhanced. Thus, in patients with HF, a heightened mechanoreflex seems to augment peripheral sympathetic vasoconstriction in response to movement, a phenomenon that may contribute to exercise intolerance in this population.

Evaluation of cardiac output by bioreactance technique in patients undergoing liver transplantation

BACKGROUND

This study compared the cardiac output (CO) obtained from PiCCO with that obtained from the noninvasive NICOM method.

METHODS

Twenty-one cirrhotic patients receiving liver transplantation were enrolled. During the operation, their CO was measured by the PiCCO system via the thermodilution method as the standard and by the NICOM method. Two parameters including cardiac index (CI) and stroke volume index (SVI) were collected simultaneously at three phases during the surgery including the dissection phase (T1), the anhepatic phase (T2), and the reperfusion phase (T3). Correlation, Bland and Altman methods, and linear mixed model were used to evaluate the monitoring ability of both systems.

RESULTS

Poor correlation was noted between the data measured by NICOM and PiCCO; the correlation coefficients for CI and SVI measured between the two systems were 0.32 and 0.39, respectively. Bland and Altman analysis showed the percentage error of CI as 63.7%, and that of SVI as 66.6% for NICOM compared to PiCCO. Using the linear mixed model, the CI and SVI measured using NICOM were significantly higher than those using PiCCO (estimated regression coefficient 0.92 and 10.77, both p < 0.001). Mixed model analysis showed no differences between the trends of CI and SVI measured by the two methods.

CONCLUSIONS

NICOM provided a comparable CI and SVI trend when compared to the gold standard PiCCO, but it raises concerns as an effective CO monitor because of its tendency to overestimate CI and SVI especially during the state of high cardiac output.

In-vitro investigation of cerebral-perfusion effects of a rotary blood pump installed in the descending aorta

This study describes use of a cardiovascular simulator to replicate the hemodynamic responses of the cerebrovascular system with a mechanical circulatory support device operating in the descending aorta. To do so, a cerebral autoregulation unit was developed which replicates the dilation and constriction of the native cerebrovascular resistance system and thereby regulates the cerebral flow rate within defined limits. The efficacy of the replicated autoregulation mechanism was investigated by introducing a number of step alterations in mean aortic pressure and monitoring the cerebral flow. The steady responses of the cerebral flow to changes in mean aortic pressure were in good agreement with clinical data. Next, a rotary pump, modeling a mechanical circulatory support device, was installed in the descending aorta and the hemodynamic responses of the cerebral system were investigated over a wide range of pump operating conditions. Insertion of a mechanical circulatory support device in the descending aorta presented an improved cardiac output as a result of afterload reduction. It was observed that the primary drop in cerebral flow, caused by the pump in the descending aorta, was compensated over the course of five seconds due to a gradual decrease in cerebrovascular resistance. The experimental results suggest that the implantation of a mechanical circulatory support device in the descending aorta, a less invasive procedure than typical mechanical circulatory support implantation, will not have an adverse effect on the cognitive function, provided that the cerebral autoregulation is largely unimpaired.

Cardiorespiratory interactions: Noncontact assessment using laser Doppler vibrometry

The application of a noncontact physiological recording technique, based on the method of laser Doppler vibrometry (LDV), is described. The effectiveness of the LDV method as a physiological recording modality lies in the ability to detect very small movements of the skin, associated with internal mechanophysiological activities. The method is validated for a range of cardiovascular variables, extracted from the contour of the carotid pulse waveform as a function of phase of the respiration cycle. Data were obtained from 32 young healthy participants, while resting and breathing spontaneously. Individual beats were assigned to four segments, corresponding with inspiration and expiration peaks and transitional periods. Measures relating to cardiac and vascular dynamics are shown to agree with the pattern of effects seen in the substantial body of literature based on human and animal experiments, and with selected signals recorded simultaneously with conventional sensors. These effects include changes in heart rate, systolic time intervals, and stroke volume. There was also some evidence for vascular adjustments over the respiration cycle. The effectiveness of custom algorithmic approaches for extracting the key signal features was confirmed. The advantages of the LDV method are discussed in terms of the metrological properties and utility in psychophysiological research. Although used here within a suite of conventional sensors and electrodes, the LDV method can be used on a stand-alone, noncontact basis, with no requirement for skin preparation, and can be used in harsh environments including the MR scanner.

Limitations of stroke volume estimation by non-invasive blood pressure monitoring in hypergravity

Background

Altitude and gravity changes during aeromedical evacuations induce exacerbated cardiovascular responses in unstable patients. Non-invasive cardiac output monitoring is difficult to perform in this environment with limited access to the patient. We evaluated the feasibility and accuracy of stroke volume estimation by finger photoplethysmography (SVp) in hypergravity.

Methods

Finger arterial blood pressure (ABP) waveforms were recorded continuously in ten healthy subjects before, during and after exposure to +Gz accelerations in a human centrifuge. The protocol consisted of a 2-min and 8-min exposure up to +4 Gz. SVp was computed from ABP using Liljestrand, systolic area, and Windkessel algorithms, and compared with reference values measured by echocardiography (SVe) before and after the centrifuge runs.

Results

The ABP signal could be used in 83.3% of cases. After calibration with echocardiography, SVp changes did not differ from SVe and values were linearly correlated (p<0.001). The three algorithms gave comparable SVp. Reproducibility between SVp and SVe was the best with the systolic area algorithm (limits of agreement −20.5 and +38.3 ml).

Conclusions

Non-invasive ABP photoplethysmographic monitoring is an interesting technique to estimate relative stroke volume changes in moderate and sustained hypergravity. This method may aid physicians for aeronautic patient monitoring.

In vitro comparison of two different mechanical circulatory support devices installed in series and in parallel

This study investigates the novel approach of placing a ventricular assist pump in the descending aorta in series configuration with the heart and compares it with the two traditional approaches of left-ventricle-to-ascending-aorta (LV-AA) and left-ventricle-to-descending-aorta (LV-DA) placement in parallel with the heart. Experiments were conducted by using the in-house simulator of the cardiovascular blood-flow loop (SCVL). The results indicate that the use of the LV-AA in-parallel configuration leads to a significant improvement in the systemic and pulmonic flow as the level of continuous flow is increased; however, this approach is considered highly invasive. The use of the LV-DA in-parallel configuration leads to an improvement in the systemic and pulmonic flow at lower levels of continuous flow but at higher levels of pump support leads to retrograde flow. In both in-parallel configurations, increasing the level of pump continuous flow leads to a decrease in pulsatility to a certain extent. The results of placing the pump in the descending aorta in series configuration show that the pressure drop upstream of the pump facilitates cardiac output as a result of afterload reduction. In addition, the pressure rise downstream of the pump may assist with renal perfusion. However, at the same time, the pressure drop generated at the proximal part of the descending aorta induces a slight drop in carotid perfusion, which would be autoregulated by the brain in a native cardiovascular system. The pulse wave analysis shows that placing the pump in the descending aorta leads to improved pulsatility in comparison with the traditional in-parallel configurations.

In vitro cardiovascular system emulator (bioreactor) for the simulation of normal and diseased conditions with and without mechanical circulatory support

This article presents a new device designed to simulate in vitro flow rates, pressures, and other parameters representing normal and diseased conditions of the human cardiovascular system. Such devices are sometimes called bioreactors or "mock" simulator of cardiovascular loops (SCVLs) in literature. Most SCVLs simulate the systemic circulation only and have inherent limitations in studying the interaction of left and right sides of circulation. Those SCVLs that include both left and right sides of the circulation utilize header reservoirs simulating cycles with constant atrial pressures. The SCVL described in this article includes models for all four chambers of the heart, and the systemic and pulmonary circulation loops. Each heart chamber is accurately activated by a separate linear motor to simulate the suction and ejection stages, thus capturing important features in the perfusion waveforms. Four mechanical heart valves corresponding to mitral, pulmonary, tricuspid, and aortic are used to control the desired unidirectional flow. This SCVL can emulate different physiological and pathological conditions of the human cardiovascular system by controlling the different parameters of blood circulation through the vascular tree (mainly the resistance, compliance, and elastance of the heart chambers). In this study, four cases were simulated: healthy, congestive heart failure, left ventricular diastolic dysfunction conditions, and left ventricular dysfunction with the addition of a mechanical circulatory support (MCS) device. Hemodynamic parameters including resistance, pressure, and flow have been investigated at aortic sinus, carotid artery, and pulmonary artery, respectively. The addition of an MCS device resulted in a significant reduction in mean blood pressure and re-establishment of cardiac output. In all cases, the experimental results are compared with human physiology and numerical simulations. The results show the capability of the SCVL to replicate various physiological and pathological conditions with and without MCS.

Evaluation of a model-based hemodynamic monitoring method in a porcine study of septic shock

INTRODUCTION

The accuracy and clinical applicability of an improved model-based system for tracking hemodynamic changes is assessed in an animal study on septic shock.

METHODS

This study used cardiovascular measurements recorded during a porcine trial studying the efficacy of large-pore hemofiltration for treating septic shock. Four Pietrain pigs were instrumented and induced with septic shock. A subset of the measured data, representing clinically available measurements, was used to identify subject-specific cardiovascular models. These models were then validated against the remaining measurements.

RESULTS

The system accurately matched independent measures of left and right ventricle end diastolic volumes and maximum left and right ventricular pressures to percentage errors less than 20% (except for the 95th percentile error in maximum right ventricular pressure) and all R(2) > 0.76. An average decrease of 42% in systemic resistance, a main cardiovascular consequence of septic shock, was observed 120 minutes after the infusion of the endotoxin, consistent with experimentally measured trends. Moreover, modelled temporal trends in right ventricular end systolic elastance and afterload tracked changes in corresponding experimentally derived metrics.

CONCLUSIONS

These results demonstrate that this model-based method can monitor disease-dependent changes in preload, afterload, and contractility in porcine study of septic shock.

Basis of monitoring central blood pressure and hemodynamic parameters by peripheral arterial pulse waveform analyses

In hypertension clinics, central blood pressure (CBP) should be estimated, instead of directly measured, by the "signal processing" of a noninvasive peripheral pressure waveform. This paper deals with the data obtained in our three separate studies focusing on a major estimation method, i.e., radial artery late systolic shoulder pressure (rSBP2)-based CBP estimation. Study 1: Using a wave separation analysis of precise animal data of pressure wave transmission along the upper-limb arteries, we first demonstrate that pulse pressure amplification is largely attributable to local wave reflection alone. Study 2: A frequency component analysis of simultaneously recorded human central and radial artery pressure waveforms showed a predominance of lower (1st+2nd) harmonic components in determining the central augmentation peak amplitude. The features of a central pressure waveform, including its phase property, may contribute to the less-altered transmission of augmentation peak pressure to rSBP2. Study 3: Comparisons of noninvasive rSBP2 with direct or estimated central systolic blood pressure (cSBP) revealed broad agreement but also augmentation-dependent biases. Based on the features of the biases as well as the counterbalanced relationship between pulse pressure amplification and the transmission-induced alterations of augmentation peak amplitude observed in Study 2, we propose an improved cSBP estimate, SBPm, the simple arithmetic mean of rSBP2 and peripheral systolic blood pressure.

Passive limb movement: evidence of mechanoreflex sex specificity

Previous studies have determined that premenopausal women exhibit an attenuated metaboreflex; however, little is known about sex specificity of the mechanoreflex. Thus, we sought to determine if sex differences exist in the central and peripheral hemodynamic responses to passive limb movement. Second-by-second measurements of heart rate, stroke volume, cardiac output (CO), mean arterial pressure, and femoral artery blood flow (FBF) were recorded during 3 min of supine passive knee extension in 24 young healthy subjects (12 women and 12 men). Normalization of CO and stroke volume to body surface area, expressed as cardiac index and stroke index, eliminated differences in baseline central hemodynamics, whereas, peripherally, basal FBF and femoral vascular conductance were similar between the sexes. In response to passive limb movement, women displayed significantly attenuated peak central hemodynamic responses compared with men (heart rate: 9.0 ± 1 vs. 14.8 ± 2% change, stroke index: 4.5 ± 0.6 vs. 7.8 ± 1.2% change, cardiac index: 9.6 ± 1 vs. 17.2 ± 2% change, all P < 0.05), whereas movement induced similar increases in peak FBF (167 ± 32 vs. 193 ± 17% change) and femoral vascular conductance (172 ± 31 vs. 203 ± 16% change) in both sexes (women vs. men, respectively). Additionally, there was a significant positive relationship between individual peak FBF and peak CO response to passive movement in men but not in women. Thus, although both sexes exhibited similar movement-induced hyperemia and peripheral vasodilatory function, the central hemodynamic response was blunted in women, implying an attenuated mechanoreflex. Therefore, this study reveals that, as already recognized with the metaboreflex, there is likely a sex-specific attenuation of the mechanoreflex in women.