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LETTERS TO THE EDITOR

far smaller numbers of deliveries for rural hospitals, it is important to apply appropriate statistical methods (such as hierarchical
data modeling) when comparing rural with urban hospitals.
These methods are unavailable if you do not have the ability to
identify patients by hospital as well as zip code.
Daniel C. Simonson, CRNA, MHPA
The Spokane Eye Surgery Center
Spokane, Washington
dsimonson@mac.com
REFERENCES
1. Cheesman K, Brady JE, Flood P, Li G. Epidemiology of
anesthesia-related complications in labor and delivery, New
York State, 2002–2005. Anesth Analg 2009;109:1174 – 81
2. Simonson DC, Ahern MM, Hendryx MS. Anesthesia staffing
and anesthetic during cesarean delivery: a retrospective analysis. Nurs Res 2007;56:9 –17
3. Needleman J, Minnick AF. Anesthesia provider model, hospital
resources, and maternal outcomes. Health Serv Res 2009;44:464 – 82

REFERENCES
1. Simonson DC, Ahern MM, Hendryx MS. Anesthesia staffing
and anesthetic complications during cesarean delivery: a retrospective analysis. Nurs Res 2007;56:9 –17
2. Needleman J, Minnick AF. Anesthesia provider model, hospital
resources, and maternal outcomes. Health Serv Res 2009;
44:464 – 82
3. Simonson DC. Additional references on the epidemiology of
anesthesia complications in labor and delivery. Anesth Analg
2010;110:1511–2
4. Cheesman K, Brady JE, Flood P, Li G. Epidemiology of
anesthesia-related complications in labor and delivery, New
York State, 2002–2005. Anesth Analg 2009;109:1174 – 81
DOI: 10.1213/ANE.0b013e3181d32595

Transesophageal Echocardiography
Cardiac Output in FlowTrak/
Vigileo Study

DOI: 10.1213/ANE.0b013e3181d3257f

To the Editor:
In Response:
1,2

Although the 2 studies cited by Mr. Simonson in his
letter3 are similar to our recent report4 in terms of data
sources and methods, there are several notable differences.
Whereas our study was designed to examine the incidence
of and risk factors for obstetric anesthesia complications in
a well-defined population, the studies by Simonson et al.1 and
Needleman and Minnick2 were specifically designed to compare the quality of obstetric care between hospitals with
different anesthesia staffing patterns, in particular, hospitals
staffed by nurse anesthetists versus hospitals staffed by anesthesiologists. As a result, Simonson et al. used the hierarchical
modeling technique to account for the multilevel feature of
their data to address their specific aim. We did not have any
hospital-level data. In our article,4, p 1180 we explicitly discussed
this data limitation and its potential influence on the interpretation of our finding regarding the increased risk of obstetric
anesthesia complications for women living in rural areas.
The 2 studies1,2 also differed from ours in case definitions
and study populations. First, spinal headache, accounting for
about one-third of all obstetric anesthesia complications in our
study, was not included in either the Simonson et al.1 study or
the Needleman-Minnick study.2 Second, whereas our study
included all deliveries occurring in New York hospitals during 2002 to 2005, the Simonson et al. study included only a
select sample of hospitals in Washington State. Given these
differences and the correlation between rural location and
increased use of nurse anesthetists,1 it is no surprise that, after
adjusting for staffing patterns and other hospital characteristics, Mr. Simonson and colleagues did not find any
significant difference in the quality of obstetric care between rural and urban hospitals.
Guohua Li, MD, DrPH
Joanne E. Brady, SM
Khadeen Cheesman, BS
Pamela Flood, MD
Department of Anesthesiology
Columbia University
New York, New York
GL2240@columbia.edu

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n the article by Concha et al.1 comparing cardiac output
(CO) measurements of the FlowTrak/Vigileo monitor
with those obtained by transesophageal echocardiography (TEE), the authors state that they used the transesophageal CO method previously validated by Perrino et al.2
However, an important difference between the validated
technique and that used in their study has implications
with regard to the interpretation of their findings.
Stroke volume by the Doppler method can be understood as the product of blood transit (distance traveled,
which is derived from velocity measurements) and the
cross-sectional area of the flow stream during systole.
Concha et al. chose continuous wave (CW) Doppler measures of blood flow velocity in conjunction with a
2-dimensional measurement of left ventricular outflow
tract (LVOT) diameter to calculate the cross-sectional area.
This is not the method described by Perrino et al.2 in the
cited article, nor is it as Perrino and Maslow describe in the
text, “A Practical Approach to Transesophageal Echocardiography.”3 The method validated in the 1998 article does
use CW Doppler, but matched to the triangular-shaped aortic
valve area, not LVOT area, to best estimate the average
cross-sectional area of the flow stream. The concern with
using LVOT area is the overestimation of the cross-sectional
area of the flow stream across the aortic valve that was
assessed by the CW Doppler. The overestimation of crosssectional area leads to a proportional overestimate of CO.
Darmon et al.4 showed that a circular measurement of the
aortic valve area overestimates the average cross-sectional
area of the flow stream by 36% (3.28 vs 2.41 cm2). Because
LVOT area equals or exceeds the area of the aortic valve
annulus, Concha et al. substantially overestimate CO by
TEE when using LVOT area in conjunction with CW
Doppler velocities from the aortic valve. For this reason, a
pulsed wave Doppler measurement with the sample volume located within the LVOT is preferred for CO calculations based on LVOT area.
The overestimation of CO measurements by the TEE
method used by Concha et al. affects their findings because
they observed a consistent positive bias; TEE measurements exceeded those derived by FlowTrak/Vigileo (mean

ANESTHESIA & ANALGESIA

Letters to the Editor

TEE CO 6.21 L/min; mean FlowTrak CO 4.84 L/min; mean
difference 28%) (Figs. 1 and 2, Table 3). We believe the
mean bias between TEE and FlowTrak/Vigileo CO measurements to be substantially less than reported (and perhaps
a negative value) because of the TEE CO method used in this
study. Interpretation of this study should recognize that the
chosen TEE method affects the reported mean bias between
techniques but does not alter the SD of the differences
between techniques.5
In conclusion, the method used to measure TEE CO
described in the study by Concha et al. is not recommended
as a reference technique because it will overestimate CO.
Interpretation of their results and the performance of the
FlowTrak/Vigileo should take into consideration overestimations of TEE CO.
William J. Perez, MD, MA
Department of Anesthesiology
The Ohio State University Medical Center
Columbus, Ohio
William.Perez@osumc.edu
Albert C. Perrino, Jr., MD
Yale University School of Medicine
VA Connecticut Healthcare System
New Haven, Connecticut
REFERENCES
1. Concha MR, Mertz VF, Cortinez LI, Gonzalez KA, Butte JM.
Pulse contour analysis and transesophageal echocardiography:
a comparison of measurements of cardiac output during laparoscopic colon surgery. Anesth Analg 2009;109:114 – 8
2. Perrino AC, Harris SN, Luther MA. Intraoperative determination of cardiac output using multiplane transesophageal echocardiography: a comparison to thermodilution. Anesthesiology
1998;89:350 –7
3. Maslow A, Perrino AC. Hemodynamics. In: Perrino AC, Reeves
ST, eds. A Practical Approach to Transesophageal Echocardiography. Philadelphia, PA: Lippincott Williams & Wilkins,
2008:127–30
4. Darmon PL, Hillel Z, Mogtader A, Mindich B, Thys D. A study
of the human aortic valve orifice by transesophageal echocardiography. J Am Soc Echocardiogr 1996;9:668 –74
5. Bland JM, Altman DG. Statistical methods for assessing agreement between two methods of clinical measurement. Lancet
1986;1:307–10
DOI: 10.1213/ANE.0b013e3181d3264c

In Response:
Perez and Perrino1 are correct that Perrino et al.2 used the
triangular-shaped aortic valve area to estimate average
cross-sectional area of the flow stream across the aortic
valve, whereas we used the diameter of the left ventricular
outflow tract to calculate a circular valvular area. The latter
may increase the cross-sectional area used to determine the
stroke volume,3 and consequently, may modify the measured cardiac output (CO). To our knowledge, there are no

May 2010 • Volume 110 • Number 5

studies comparing both methods. However, it is reasonable
to think that the bias found in our study is probably
overestimated by the technique used to measure CO.
In our opinion, the main issue regarding the poor
agreement between FlowTrak/Vigileo and transesophageal echocardiographic CO measurements was not the
mean difference between measurement techniques (bias)
but the large standard deviation of this difference (poor
precision). The bias is just an estimate of how closely the 2
methods agree on average but does not describe the
variability of this estimate, i.e., how well the methods agree
for an individual.4 The poor precision, expressed in percent
error found in our study (40% [27%–50%]), is not affected
by the questioned technique, and consequently, poor agreement between methods will persist but with a smaller bias.
Pulsed wave Doppler has proven useful in the measurement of pulmonary artery flow.5 However, its principal
disadvantage is an inability to measure high velocities,
such as those in the left ventricular outflow tract, without
observing aliasing artifacts.6 In addition, it would again
modify to the original technique, adding a new potential
source of error.
Mario R. Concha, MD
Vero´nica F. Mertz, MD
Luis I. Cortínez, MD
Department of Anesthesiology
Escuela de Medicina
Pontificia Universidad Cato´lica de Chile
Hospital Clínico Universidad Cato´lica de Chile
Santiago, Chile
mconcha@med.puc.cl
REFERENCES
1. Perez WJ, Perrino AC. Transesophageal echocardiography cardiac
output in FlowTrak/Vigileo study. Anesth Analg 2010;110:1512–3
2. Perrino AC Jr, Harris SN, Luther MA. Intraoperative determination of cardiac output using multiplane transesophageal
echocardiography: a comparison to thermodilution. Anesthesiology 1998;89:350 –7
3. Darmon PL, Hillel Z, Mogtader A, Thys DM. A study of the
human aortic valve orifice by transesophageal echocardiography. J Am Soc Echocardiogr 1996;9:668 –74
4. Myles P, Gin T. Regression and correlation. In: ButterworthHeinemann, ed. Statistical Methods for Anaesthesia and Intensive Care. Oxford: Butterworth-Heinemann, 2000:91
5. Savino JS, Troianos CA, Aukburg S, Weiss R, Reichek N.
Measurement of pulmonary blood flow with transesophageal
two-dimensional and Doppler echocardiography. Anesthesiology 1991;75:445–51
6. Edelman SK. The Doppler equation. In: Edelman SK, ed. Understanding Ultrasound Physics. 2nd ed. Woodland, TX: ESP,
Inc., 1997:135
DOI: 10.1213/ANE.0b013e3181d326e7

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