Hemodynamic Monitoring Utilizing Transesophageal Echocardiography: The Relationships Among Pressure, Flow, and Function

Jan I. Poelaert and Guido Schüpfer Chest 2005;127;379-390 DOI 10.1378/chest.127.1.379

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University Hospital. MD. Left ventricular (LV) function is a determinative parameter in various diseases. Gent. TEE facilitates the routine diagnosis and management of cardiovascular failure both intraoperatively and in ICU patients. Belgium. Ea arterial elastance. 2008 Copyright © 2005 by American College of Chest Physicians . the transthoracic approach for echocardiography has certain specific limitations regarding the visualization of different cardiac structures and great vessels. inflammatory responses. Correspondence to: Jan Poelaert. Kantonsspital. 2004. MD ¨ (CHEST 2005. e-mail: jan. although changes occurred more frequently in ICU patients compared to those admitted to the hospital (54% vs 37%.chestjournal. and Guido Schupfer. LA left atrium atrial. ischemia. Belgium. De Pintelaan 185. PCWP pulmonary capillary wedge pressure. PW pulsed-wave. Schupfer). not only for diagnosis in routine cardiology practice3 but also for perioperative hemodynamic monitoring. left ventricular function. PWR cardiac power. This research was supported in part with a grant from the International Research Centre. PhD. Department of ICU. and Klinik fur Anasthesie und Operative ¨ ¨ Intensivmedizin (Dr. TEE transesophageal echocardiography. although the role of the RV in critically ill patients should not be underestimated. Belgium (2002–2003).poelaert@ugent. Manuscript received January 9. Poelaert. or a combination of several factors) have been well-studied during the last decades. Gent. B9000 Gent. Poelaert). owing to its bedside availability. University Hospital. and has become a fascinating and appealing tool.1.be www. FCCP. septic cardiomyopathy. revision accepted August 24.org). 127:379 –390) Key words: echocardiography.opinions/hypotheses Hemodynamic Monitoring Utilizing Transesophageal Echocardiography* The Relationships Among Pressure. Impaired cardiac function. the clinical evaluation of cardiac function must pertain to the assessment of the LV and the RV with respect to increased morbidity and mortality.org on May 18. is mostly evidenced as pump failure. Belgium. LVEDP left ventricular end-diastolic pressure. FCCP. More than 50% of all patients who are scheduled for surgery or are admitted to the ICU have experienced cardiac problems. The impact of echocardiography on the change in the therapy and management of *From the Department of ICU (Dr. SV stroke volume. LAP left atrial pressure. Transthoracic echocardiography is an invaluable imaging technique with respect to the diagnosis of cardiovascular disease.5 Therefore. hemodynamic. Echocardiography and Doppler ultrasonography developed as the main and most commonly used bedside imaging techniques. which is often seen in critically ill patients. B/03719) of Ghent University. Gent. LVEDA left ventricular end-diastolic area. Switzer¨ land. VTI velocity-time integral an important cornerstone in C ardiac imaging isand management in cardiovasdecision making cular medicine.2 Nevertheless. LV left ventricle/ventricular. Jan Poelaert was supported by a grant from the Research Fund “Bijzonder Onderzoeksfonds” (No.4 Circulatory failure of cardiac origin in adults often is due to ventricular failure. in particCHEST / 127 / 1 / JANUARY. Crucial in the discussion is the early detection of LV systolic and diastolic dysfunction by sensitive monitors. E wave early and rapid-filling wave. PhD. and Function Jan I. right ventricular (RV) failure in conjunction with pulmonary hypertension.org hospitalized patients was found to be as high as 57%. Several etiologic factors of pump dysfunction (eg. 2005 379 Downloaded from chestjournal. Cardiac Anaesthesia and Postoperative Cardiac Surgical ICU. LVEDV left ventricular end-diastolic volume. E/A ratio of the early and rapid-filling wave to the late-filling wave. TDI tissue Doppler imaging. CW continuouswave. monitoring Abbreviations: A wave late-filling wave. 2004. Table 1 demonstrates in detail the potential advantages and shortcomings of both techniques. respectively). having a decisive impact on surgical management. dP/dtmax positive maximum first derivative of pressure. RV right ventricle/ventricular. corrected for time. RVOT right ventricular outflow tract. Flow. Luzern. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (e-mail: permissions@chestnet. Moreover. Transesophageal echocardiography (TEE) with Doppler imaging has opened a completely different window. MD.

Doppler echocardiography has to be used. At an angle of 60°. are displayed above the zero line. Clinically. Pulsed-wave (PW) Doppler ultrasound can induce an underestimation of flow velocities. Doppler echocardiography shows the velocity data. the frequency of the reflected sound is altered. LV systolic performance is governed by the following three major determinants: (1) the FrankStarling mechanism. which are moving toward the transducer. exclusion of left atrial appendage thrombi Pressure and Flow Several pressures are used in daily clinical practice to outline ventricular preload. independent of loading conditions.org on May 18. a moving RBC). and negative signals display the movements of the RBCs away from the transducer.Table 1—Indications of Transthoracic Echocardiography and TEE Transthoracic Echocardiography General screening—overall evaluation Hemodynamic evaluation TEE Hemodynamic instability Echocardiography when ventilated patient (also when prone ventilation) Tamponade (local) Cardiac surgery: intraoperative and postoperative hemodynamic monitoring Noncardiac surgery: intraoperative monitoring Acute RV overload with hypoxemia Thoracic trauma (in a ventilated patient) Diagnosis/exclusion of thoracic aortic dissection. pressures only provide a rudimentary approximation of the physiologically relevant determinants of ventricular function. (2) contractility. The following general principles have to be kept in mind when obtaining and interpreting Doppler signals and waveforms9: 1. In order to obtain relevant measurements of flow. which are derived from the measured frequency shift. This phenomenon is known as the Doppler shift (Christian Doppler. Movements of RBCs. pulmonary hypertension) Thoracic trauma (patient not ventilated) Contraindications for TEE ular when rapid fluid shifts occur. which can be measured. Opinions/Hypotheses Exclusion of tamponade Pulmonary edema Acute RV overload (pulmonary embolism. namely. The latter can be explained as follows: • The depth of the sampling gate. The Doppler beam must be aligned with the estimated direction of blood flow. Several reviews6 – 8 already have stressed the elegance of how TEE provides data in this respect. necessitating the measurement of pressures and volumes. To describe the hemodynamic status of a patient. and illustrates them as a spectral display. PW Doppler ultrasound is characterized by a crystal. The interplay between pressure and flow is an important characteristic of cardiac function and the dynamics of the circulation that is more precise than one parameter alone. The intercept angle should be 20°. In this section. and afterload. 1842). The relationship between flow estimated with echocardiography and related pressure measurements and the energy generated by the LV pumping blood into the circulation is the subject of this review. and (3) heart rate. numerous variables have been derived describing more precisely hemodynamics of the (left) heart and the peripheral circulation. the cosine of the intercept angle must be taken into account in calculating the true Doppler velocity. Nevertheless. 380 Downloaded from chestjournal. CW Doppler (with one transmitter and one receiver crystal) records all velocities in the beam axis without a limitation in analyzing high flow velocities. pressure and flow appear to be the most important features. most clinicians routinely employ an analysis of pressures rather than a determination of volumes. When an ultrasound beam strikes a moving object (eg. the longer the waiting time because of the consecutiveness of action of both the transmitter crystals and receiver crystals. which sends and receives consecutively. Continuous-wave (CW) Doppler ultrasound must be used whenever high velocities are present. Larger angles induce an unacceptable error. The further away the sampling place (interrogated target). diagnosis/ exclusion of endocarditis. CW Doppler lacks the spatial resolution needed to estimate the correct depth at which the measurement is obtained. the transmitted velocity will be half that the true velocity. considerably retarding the process of the measurement of Doppler velocities. 2. An assessment of ventricular contractility must include the independence of loading conditions. To correct this error. From these parameters. This is due of the physical characteristics of both techniques. contractility. as in patients with hypovolemic or distributive shock. preload. Nevertheless. the relationship between various currently used pressures and intracardiac flows will be discussed. which is important data in clinical practice. This allows a precise determination of the location of the source of the frequency shift but immediately limits also the range of velocity. 2008 Copyright © 2005 by American College of Chest Physicians .

a late-filling wave (A wave) follows.15 and regional systolic function parameters can be derived from the myocardial wall motion Doppler pattern. this movement is increased. CW Doppler echocardiography must be utilized. but appears a well-recognized technique in the evaluation of regional ventricular function in patients with potential cardiac disease.18 –20 In patients with normal cardiac function. the position of the interatrial septum and the curvature reflects the relationship between right and left atrial pressures (LAPs). caused by the atrial contraction. • Acute mitral regurgitation. and altered intrathoracic pressures. LV end-diastolic pressure (LVEDP) is directly related to LV end-diastolic volume (LVEDV).22 Hence. such as altering compliance during myocardial ischemia. The normal filling pattern is displayed as a biphasic tracing with an early and rapid-filling wave (E wave). Doppler echocardiography provides a good estimate of left-sided filling pressures using the transmitral flow pattern.• The PW Doppler ultrasound signal is obtained at the rate of the pulse repetition frequency. the ratio of E wave to A wave [E/A]).5MHz probe. The direct assessment of ventricular volumes to estimate preload is superior to measurements of pressures because of the important interference by ventricular compliance. followed by a diastasis period with minimal or no flow (Fig 1). permitting the assessment of low-velocity Doppler high-amplitude shifts and the real-time display of color-coded tissue velocities. in which the septal amplitude is decreased. the pulmonary venous flow pattern. The interpretation of myocardial thickening and endocardial motion requires an experienced observer. the transducer must sample twice as fast with a 5-MHz probe as with a 2. as in severe LV failure. It is important to remark that the various CHEST / 127 / 1 / JANUARY. pressure-volume loops will allow the determination of LV compliance. Finally. 3.org on May 18.9 Another easily calculated parameter is the ratio of the peak flow velocities (ie.12 at the level of a segment of the myocardial wall13 or the mitral annulus. the movement of the interatrial septum during the cardiac cycle suggests pressure differences between the right and left atrium. Left-Sided Filling Pressures Echocardiography permits the indirect estimation of LV filling pressures in various ways. In both circumstances. obtained in a four-chamber view. at the same pulse repetition frequency the maximum recordable Doppler velocity with a 2. both diastolic function14.40.org and volume is difficult to determine.21 although. For many years. utilizing both Doppler echocardiography16 –18 and two-dimensional echocardiography. • With respect to Doppler physics. and the method is subjective and not useful in research. A normal flow velocity ratio is in the range of 0. This is important information as it provides insight into the duration of a diagnosed cardiac disease. the relationship between pressure www. Both velocities of the respective flow waves and corresponding time velocity integrals are as important characteristics of LV filling. This phenomenon implies that a 5-MHz probe will scan more superficial layers of tissue than a 2.75 to 1. In particular.11 This technique enables the noninvasive delineation of myocardial velocities in a noninvasive manner in the human heart11. the peak flow regurgitation flow velocity. Hence. the filling status can be roughly estimated. The estimation of RV and LV preload by means of the position of the interatrial septum cannot be used in the following situations: • The presence of tricuspid regurgitation with a consequent shift of the septum toward the left atrium.chestjournal. in particular when myocardial ischemia or tamponade occur. Echocardiography is not only an established tool for the assessment of global ventricular function. The transmitral flow. The sample volume has to be placed in the middle of the vessel in order to diminish potential turbulence. and • Mitral stenosis or chronic mitral regurgitation.5-MHz probe to measure the same Doppler shift. 4. and myocardial Doppler imaging. 2005 381 Downloaded from chestjournal. Numerous factors interfere with this relationship. Clinically. With increasing age. the E-wave velocity diminishes in favor of the late-filling A wave.5-MHz probe is twice the recordable velocity with a 5-MHz probe. Color-coded tissue Doppler imaging (TDI) was introduced a few years ago. Utilizing two-dimensional echocardiography. which is approaching the frequency shift of the Doppler effect. 2008 Copyright © 2005 by American College of Chest Physicians . routine echocardiography allowed only the visual analysis of a regional dysfunction. is directly related to the filling of the LV and is governed by the transmitral pressure gradient. in which an increased septal movement is present. relative pressure differences between the right and left atrium can be detected. inotropic stimulation. in patients with decreased ventricular compliance.22 In patients with hypovolemia.10. in theory. In addition. however. The E/A ratio is strongly age-dependent. In addition. PW Doppler echocardiography is not useful whenever a pressure gradient across a valve is present or a subvalvular stenosis has to be assessed.

The sometimes biphasic systolic flow wave is followed by the diastolic flow wave. such as LV compliance and relaxation. A minor interfering factor is the systolic ventricular function. As long as LAP is low in patients with dilated cardiomyopathy.27 Another important feature is the ratio of the duration of the atrial reverse flow wave at the level of the pulmonary veins and the atrial contraction wave at the level of the mitral valve. The change in systolic flow velocity from the pulmonary vein is directly related to changes in cardiac output. suggesting that this index is a measure of late diastolic LV compliance. as described in the following formula17: LAP RRao (4 V2tmf) in which RRao is the systolic aortic pressure. A reverse a wave duration that exceeds the duration of the atrial inflow wave predicts an LVEDP of 15 mm Hg. the E-wave velocity. stiffness of the pericardium.25 A systolic/diastolic flow velocity ratio of 0. The higher E-wave velocity will have a shorter deceleration time. A normal pulmonary venous Doppler pattern. will be low. left atrial (LA) compliance.4 is suggestive of an increased LVEDP. making an evolution toward a restrictive pattern (E A).28 A significant relationship was seen between the systolic pulmonary vein Doppler velocity-time integral (VTI. mechanical ventilation23 as well as external constraints (thrombi in the pericardial sac. and V2tmf is the transmitral peak regurgitant flow velocity. Figure 2. even in elderly patients. a pulmonary venous Doppler pattern obtained at one of the inlet orifices of the pulmonary veins should help. With the progression of heart failure in these patients. The difference between the duration of the atrial reversal flow and the duration of the atrial inflow wave is independent of age and thus may be used as a reliable index of LVEDP. The pulmonary venous flow pattern (Fig 2) is a third possibility for estimating left-sided filling pressures. No correlation was found between this index and the LAP. Following the E wave. it is conceivable that there is no correlation between the early filling velocity and the left-sided filling pressure (ie. This method is based on the assumption there is no pressure gradient between the LV and the ascending aorta.24 a very stiff LV with a rapid and important rise of ventricular pressures with small amounts of fluid. the E-wave velocity will increase. In addition. as well as the E/A ratio. and LA pressure (LAP). Doppler echocardiography permits the estimation of the LAP using the modified Bernoulli equation. or high positive end-expiratory pressure ventilation with potential cardiac compression by the lungs) affects LV filling.Figure 1. mitral regurgitation can also be used to estimate LV filling. Preceding a large systolic flow wave. LAP). This is usually thought to be a sign of adequate filling pressures. the area under the curve of a Doppler signal) and the atrial wave VTI. To estimate the LVEDP. Owing to these various interfering factors. Opinions/Hypotheses Downloaded from chestjournal. reflecting decreased ventricular compliance. ie. a reverse contraction is seen.88)16 whenever pulmonary venous flow wave duration (the a wave) exceeds the transmitral flow wave. and the E/A ratio will be 1. the atrial contraction wave is observed.26 This study also shows that LVEDP is the main determinant of the systolic velocity of the pulmonary vein Doppler pattern (regression analysis). mitral valve area. A normal transmitral flow Doppler pattern. This is mainly due to reduced LA compliance. 2008 Copyright © 2005 by American College of Chest Physicians .4 reflects the markedly increased ventricular filling pressures. Doppler velocities are the resulting effect of several physiologic characteristics. A ratio of the systolic and diastolic flow wave velocities of 0. When present. The ratio of the systolic time-velocity integral and the sum of both systolic and diastolic time-velocity integrals correlates most strongly (r 0.25 The systolic flow wave is frequently biphasic 382 whenever a low filling status is present.org on May 18.

obtained by TDI. correlates well with volumetric analogues.81). respectively. a relation was described between the E wave/Ea ratio and the PCWP (r 0. Velocities are much lower (ie.30 although this has not been confirmed. which is an extremely well-validated technique. The amplitude of the reflected ultrasound wave is higher (40 decibels).40 Several shortcomings and limitations of LVEDA have to be recognized. with a potential. nearly complete obliteration of the outflow tract. although neither parameter (evidently) correlated with PCWP. The systolic forward flow wave sometimes shows two peaks. The pulmonary capillary wedge pressure (PCWP) correlates best with the atrial reverse flow wave velocity (r 0. Furthermore. TDI works with a high-pass filter.36 In particular.25 The systolic flow wave is followed by a diastolic flow wave.35 A quantitative estimation can be performed in different ways using two-dimensional echocardiography. which are related to the atrial relaxation and the mitral annular descent. improving its power to be used in critically ill patients as follows: TDI is based on frequency shift rather than signal amplitude. When regional wall motion abnormalities are present. The short-axis view is in this respect of the utmost importance. which was measured with the dye dilution technique in postoperative cardiac surgical patients. The LV is divided into 20 ellipsoid disks of equal heights but different diameters. In an adequately sedated ICU patient. it was shown that PCWP had a strong negative relationship with the deceleration time of the pulmonary venous Doppler pattern in diastole (r 0. Nagueh et al30 demonstrated that leftsided filling pressures can also be estimated fairly accurately by utilizing Doppler myocardial imaging (ie. the changes in LVEDA closely resemble the changes in LVEDV. TDI has some beneficial attributes. irrespective of the pattern and the ejection fraction.29 In 1998. Besides using the short-axis view to obtain the LVEDA.31 Whereas the E wave of the transmitral flow pattern is load-sensitive.87) was found between changes in the LVEDA index and intrathoracic blood volume.org Estimation of Preload TEE permits good qualitative and quantitative parameters to estimate preloading conditions in patients with either normal ventricular function or dysfunction.38. referring to a body surface area of 5. The LV end-diastolic area (LVEDA).34 The software used to calculate the volume in the echocardiograph uses the methods of discs (the Simpson rule). the apical region of the LV is more susceptible to regional wall motion abnormalities than the base of the heart.39 A good correlation (r 0. Therefore. TDI).org on May 18. hence. TDI assesses velocities of the moving myocardium and.chestjournal. Volume determination of the LV can be performed utilizing the Simpson rule. permitting better tissue penetration. 2005 383 Downloaded from chestjournal.37 Other authors described in patients with normal LV function during graded hypovolemia a linear decline of LVEDA of 0.89). measured per definition at the midpapillary level of the LV. the above-mentioned Doppler echocardiographic methods and the respiration-induced variation in maximal Doppler velocities must be appreciated.25 In a study29 of patients who had experienced acute myocardial infarction. and TDI has favorable temporal resolution.42 Echocardiographic data from a single plane seldom provide information about filling status. the presence of kissing walls. respectively. In 100 patients. the Ea. arterial elastance [Ea]) behaves as a relative loadindependent index of LV relaxation.86). providing very accurate data both in adults and children. The early diastolic velocity measured with TDI (ie.3 cm2 per percentage blood loss.26 In clinical practice. LVEDP is the main determinant of the systolic velocity of the pulmonary vein Doppler pattern. 2008 Copyright © 2005 by American College of Chest Physicians . These two major changes make important adjustments necessary in interpreting the results. the correct use of LVEDA as a preload parameter is limited.86).33 LV volume assessment is done by tracing the end-diastolic endocardial border in a mid-esophageal long-axis view in a longitudinal plane. all three Doppler methods will be used consecutively.5 cm2/m2. with a sensitivity and specificity of this measure of 160 ms in predicting a PCWP of 18 mm Hg of 97% and 96%. 10 to 15 cm/s) than the blood flow velocities. Very suggestive for low filling status of the LV is the LVEDA index. detects the phase shift of the ultrasound signals reflected by myocardial tissues.32 www. is very suggestive of a low filling status. allowing the low velocities to be measured. TDI uses lower transmitting frequencies.41 In this respect.33 In addition. The ratio of the E wave to Ea showed the strongest relation to PCWP (r 0. The Doppler settings are adjusted for a Nyquist limit of 20 cm/s with the lowest wall filter and a minimum gain setting. behaves as a relatively load-independent index of ventricular relaxation.18.suggesting a relation between atrial filling and emptying. The sum of the CHEST / 127 / 1 / JANUARY. Furthermore. irrespective of the pattern and ejection fraction. the presence of a hyperdynamic ventricle in the absence of inotropic drugs could be a sign of hypovolemia. The systolic forward flow wave in the pulmonary vein Doppler pattern is preceded by a small reverse atrial contraction wave. a midesophageal view allows the scanning of the long axis of the LV.

This technique has been validated against angiography. placing the sample volume in the position at the level of the midpulmonary artery is an easy and elegant method for assessing SV. Respiratory variations of VTI are a sensitive index of fluid responsiveness. and LV outflow tract50 –52 at the level of the aortic valve. the term fluid responsiveness has been proposed as an important estimate of the optimization of preload (Fig 3). Both load-dependent and load-independent parameters have been discerned. Flow and Function Multiple indexes have been proposed to describe global ventricular function. The VTI at that level decreased progressively. ejection fraction or.respective volumes of the slices allows the calculation of the total ventricular volume. stroke volume (SV) variation. The assessment of SV includes both the measurement of the flow and the determination of the area through which this flow moves forward. and pulse pressure variation. Clinical approach of hemodynamic monitoring. in close relationship with a graded and controlled blood loss performed in an animal experimental setting. Several localizations have been used. explaining the lower correlation coefficient. in echocardiographic terms. The area through which this flow is propagated is one aspect of the determination of the stroke volume. SVO2 mixed venous oxygen saturation. PHT pulmonary hypertension. Art. fractional area contraction will not be disputed With TEE and Doppler echocardiography. Pulm. Slama et al42 demonstrated the value of flow measurements across the aortic valve in the assessment of flow velocity variation with cyclic altering of intrathoracic pressures.46 Nevertheless. pulmonary. it is relatively easy to estimate swiftly the load-dependent characteristics as SV.45 Ejection fraction is a classic example of a load-dependent description of global ventricular function. arterial systolic. the effective time-averaged surface area must be measured. cardiac output. preferably. and positive maximum first derivative of pressure. in view of the discussion on flow and function. 2008 Copyright © 2005 by American College of Chest Physicians .53 Some training Figure 3. Over the last years. mitral valve. Nevertheless. corrected for time ( dP/dtmax). concurring completely with the findings of systolic pressure variation. It is clear from earlier studies53 that the diameter of the pulmonary artery is sometimes difficult to measure. as follows: RV outflow tract (RVOT) and pulmonary artery47– 49.44 which have been shown to correlate well with a positive fluid responsiveness. LCO low cardiac output. 384 Opinions/Hypotheses Downloaded from chestjournal. Either the diameter of a certain location or.org on May 18. Using methods that are analogous to systolic respiratory pressure variation43 and stroke volume variation. CO cardiac output.syst.

the CW Doppler signal shows a characteristic image with two densities of flow. 2005 385 Downloaded from chestjournal.57–59 The flow is obtained by the measurement of the area under the curve of a Doppler wave. In routine clinical practice. permitting the assessment of the flow across the aortic valve. rotating the multiplane probe toward 25° to 40° (Fig 5). whereas the external contour shows the peak velocity. It has been demonstrated that the direct measurement of the effective time-averaged aortic area allows for superb accuracy. This gives information on the VTI (in centimeters) [Fig 6].56 To permit the measurement of the diameter of the aortic valve.50. CHEST / 127 / 1 / JANUARY. when the method of the effective time-averaged aortic valve area (AVA) is chosen.permits even the assessment of SV in the RVOT from a deep transgastric view.chestjournal. MV mitral valve.52. A deep transgastric view in the transverse plane is obtained by introduction of the probe deep in the stomach with maximal anteflexion and lateral flexion to the left. not permitting the use of the mitral valve for measuring SV.55 The measurement of the flow across the aortic valve is a third possibility. www.54 The diameter of the mitral valve is difficult to measure as the annulus is not circular and changes throughout the cardiac cycle. the method including the measurement of the diameter is more easily performed with a lower. however. This view allows the measurement of a time-averaged effective aortic valve area. SV VTI 0. the method of measurement of the diameter at the level of the pulmonary artery or the aortic valve provides an adequate estimation of the SV. a longitudinal midesophageal image must be obtained (Fig 4).60 The VTI of the most intense part represents the SV. A continuous Doppler flow pattern is shown.org on May 18. as the intercept angle between the Doppler beam and blood flow is very low or nonexistent. This method provides higher accuracy. In clinical practice. which permits the calculation of the aortic valve gradient utilizing the modified Bernoulli Figure 4. however. Hence. RA right atrium. When aortic stenosis is present. This view allows the functional evaluation of the aortic valve. albeit acceptable. precision. AA ascending aorta. depending on the place of the sample volume.org Figure 6. the SV can be calculated from the following different formulas: SV VTI AVA Figure 5. 2008 Copyright © 2005 by American College of Chest Physicians .78 D2 when the method of measurement of the diameter (D) is preferred. The aortic valve (AV) with the three cusps is visualized at the level of the upper mediastinal level in an intermediate plane.51 This method can be performed with the transducer at the midesophageal position. VTI provides the distance that an RBC is projected forward during one cardiac cycle and is therefore directly related to the systolic function of the LV or RV.

Analogous measurements can be performed from the descending limb of the aortic regurgitation flow wave in a deep transgastric transverse view utilizing CW Doppler providing Dopplerderived dP/dtmax. PWR can be described as follows: PWR Plv Fao where Plv is instantaneous LV pressure and Fao is instantaneous aortic flow. the determination of the different factors. Another. In patients with cardiac failure.71 Cardiac power (PWR) provides the best representation of the performance obtained in a single cardiac cycle to counterbalance the demand imposed by the metabolizing tissues on the cardiac pump. Although this tracing offers considerable information about SV. A change corresponding to the left ventriculo-atrial pressure gradient of 4 and 36 mm Hg. all information is mainly based on eyeballing. This technique cannot be used when significant aortic regurgitation is present.333 10 4 where PAO is instantaneous aortic pressure. Flow.61 dP/dtmax is another flow-derived. was considered for use. is in this way markedly facilitated. Pressure. 2008 Copyright © 2005 by American College of Chest Physicians . contractility. 386 PWRmax PAO VAOmax AVA 1. dP/ dtmax is calculated using the modified Bernouilli equation. the line connecting all end-systolic points in a pressure-volume diagram. The VTI calculated from in the RVOT (including the measurement of the diameter of the pulmonary annulus) can be compared with VTI obtained from flow analysis in the LV outflow tract. however. is the product of cardiac flow output and its pressure delivered in the arterial system.65 Although significant improvements have been proposed to upgrade this variable to a more clinically useful parameter. A normal value of dP/dtmax is between 800 to 1. as the mean rate of pressure rise. Cardiac hydraulic power output. Hence. with Doppler echocardiography obliges a leakage of the mitral or aortic valve. With this method.62 The estimation of dP/ dtmax. Many investigators searched for other more revealing variables. atrial septal defect). change in ventriculoatrial pressure gradient is calculated as 4(1)2 4(3)2 32. the aortic and ventricular pressures are similar. Hence. in order to calculate the flow through the shunt. it is assumed that any gradient across the mitral valve is absent. Many years ago. The technique of flow calculation is also utilized when intracardiac shunts are present (eg. be more difficult to obtain. The cardiac muscle provides the energy necessary for this circulation. load dependent parameter to circumscribe global left ventricular function (Fig 6). the Doppler technique may underestimate the true maximum dP/dt. and loading conditions of the left heart. Hydraulic power is based on the fact that the heart is a pump that is used to circulate the blood into both the pulmonary and systemic circulation. the work per time unit. As the various parameters of volumetric flow are easily obtained. the arterial pressure and morphology of the tracing are the mainstays of hemody- namic monitoring. is measured with Doppler echocardiography. Measurement of the time difference between a regurgitant transmitral velocity of 100 cm/s and 300 cm/s is shown. The effort performed by the ventricle to pump the blood against gravity and to overcome the inertia of the blood is nothing else than ventricular work. LV maximal elastance. At the mitral valve. parameter is derived from hydraulic energy.200 mm Hg/s. which could be. The product reaches its maximum after the attainment of the peak flow and before peak aortic pressure is obtained.equation. diminishing considerably the usefulness of this technique in clinical practice. the previously mentioned formula can be rewritten: Figure 7. building up PWR.66 several drawbacks have to be recognized.63 If the change pressure gradient is measured from the ascending limb of the mitral regurgitant flow wave between the velocity levels of eg 1 m/s and 3 m/s (Fig 7).org on May 18.67–70 It increases proportionally to the exercise workload performed and represents the rate at which the ventricle performs external work. This time difference allows the calculation of the dP/ dtmax.8 At this time. more clinical. dispersing more energy as the blood proceeds deeper into the smaller vessels. the measurement of PWR at rest and after the administration of positive inotropic stimulation provides insight into the cardiac energetic reserve.64 Although easy applicable. and Function In clinical practice. the ventricular volume change during systole equals aortic volumetric flow. VAOOpinions/Hypotheses Downloaded from chestjournal.72 In the absence of mitral regurgitation.

8.73 PWR shows great stability concerning the changes of afterload but is also highly sensitive to preloading alterations. Consequences for Daily Practice Echocardiography permits a rational approach to the problem of hypotension. as this image provides information on the following three fundamental issues: (1) global contractility. and PWRmax is the maximum PWR (in watts). preload. without cumbersome manipulations of loading conditions.74 the LV end-diastolic diameter. AVA is time-averaged aortic valve area. instantaneous aortic pressure is arterial BP at the time point at which the product of pressure and flow becomes is at the maximum. Therefore. severely hypertensive or hypotensive patients. and (3) the first indication of volemia. we have proposed a practical scheme that can be used whenever the problem of hypotension is present. vasoplegia. the more the ventricle will exploit its preload reserve by the Frank-Starling mechanism. accounting for both the pressure-generating and flow-generating capacity of the cardiac muscle in healthy and diseased hearts. and afterload can be readily estimated in a fairly reliable manner. The ability of PWR to characterize global LV contractility is less accurate beyond physiologic pressures and volumes. any other cause of the hypotension than the heart should be investigated (eg. eda end-diastolic volume. If global contractility is normal. and maximum PWR/LVEDA ratio.8 which is even useful in patients with atrial fibrillation.70 In addition. sepsis. and technical problems).Figure 8. such as the integrity of the heart in relation to the circulation. taking into consideration various criteria.chestjournal. Contractility. 75 or the LVEDA. If hypotension is combined with a decreased global LV function. This has mainly to do with the reliance on the intercept of the preload-adjusted www. In Figure 3. 2008 Copyright © 2005 by American College of Chest Physicians . This method cannot be used in patients with severe mitral regurgitation or aortic valve disease. (2) the presence of regional wall motion abnormalities.org maximal power diagram with respect to LVEDV. This graph demonstrates clearly the higher dependence of ventricles with poor performance on preload in maintaining their output possibilities. The clinical attractiveness of the parameter PWR is high. max is instantaneous maximum aortic blood flow velocity. In clinical conditions. In another study. Relationship between LVEDV and preload-adjusted maximal power (pamp) in a group of postoperative coronary artery patients. PWR can be measured with a single-beat technique. 2005 387 Downloaded from chestjournal. either transthoracic or transesophageal) must be a short-axis view of the LV. As stated earlier.2 as a measure of myocardial contractility. and that can be worked out rapidly to allow quick and adequate management. for instance. as a marker of preload. is shown in Figure 8. The poorer contractile performance. a complete echocardiogram should reveal the causes of this hemodynamic instability.77 the importance of the quick and decisive CHEST / 127 / 1 / JANUARY.73 A close relationship was shown to exist between preload-adjusted maximal power and ventricular maximal elastance. several authors have proposed the correction of PWR with the square of the LVEDV. In addition.org on May 18. some relatively easy hemodynamic features can be measured and estimated to obtain a global picture of the hemodynamics.71 A close relationship between LVEDV. Regression statistics with curve extimation.7 the basic and starting view of each type of investigation (ie.76 This implies certain limitations of the power measurement in.71.

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