[ Education and Clinical Practice How I Do It ]

Stroke Volume Determination by

Echocardiography
Michael Sattin, MD; Zain Burhani, MD; Atul Jaidka, MD; Scott J. Millington, MD;
and Robert T. Arntfield, MD

Basic critical care echocardiography emphasizes two-dimensional (2D) findings, such as ven-
tricular function, inferior vena cava size, and pericardial assessment, while generally excluding
quantitative findings and Doppler-based techniques. Although this approach offers advantages,
including efficiency and expedited training, it complicates attempts to understand the hemo-
dynamic importance of any 2D abnormalities detected. Stroke volume (SV), as the summative
event of the cardiac cycle, is the most pragmatic available indicator through which a clinician
can rapidly determine, no matter the 2D findings, whether aberrant cardiac physiology is
contributing to the state of shock. An estimate of SV allows 2D findings to be placed into better
context in terms of both hemodynamic significance and acuity. This article describes the
technique of SV determination, reviews common confounding factors and pitfalls, and suggests
a systematic approach for using SV measurements to help integrate important 2D findings into
the clinical context. CHEST 2022; 161(6):1598-1605

KEY WORDS: critical care echocardiography; left ventricular outflow tract; pulsed-wave
Doppler; stroke volume; ultrasound; velocity-time integral

Point-of-care ultrasound has become a core volume (SV) and have made this a core skill
competency for trainees in emergency within our local training programs.
medicine and critical care,1-5 as well as a
There are tools other than echocardiography
growing list of other acute care specialties.6-8
for estimating SV, including pulmonary artery
Its importance has been further highlighted
catheterization, arterial pulse contour analysis,
with the development of a distinct
and bioreactance devices, among others.13
certification pathway for critical care
Each of these devices has its own advantages
echocardiography (CCE) in North
and limitations, but many are invasive, and all
America9-11 and its emphasis in
require proprietary devices or monitoring
echocardiography society guidelines.12 As
systems that are often impractical or not
uptake of CCE grows, however, so too does
readily available. As such, we propose using
the importance of ensuring that clinicians
ultrasound for this purpose, as a noninvasive
correctly match pathologic cardiac findings
and near universally available tool.
to their clinical significance. For this task, we
routinely use and advocate for the Although there are several available
echocardiographic determination of stroke ultrasound techniques to measure SV, the

ABBREVIATIONS: 2D = two-dimensional; CCE = critical care echo-
cardiography; CSA = cross-sectional area; LV = left ventricular;
LVOT = left ventricular outflow tract; LVOTd = left ventricular
outflow tract diameter; PW = pulsed-wave; SV = stroke volume; VTI =
velocity-time integral
AFFILIATIONS: From the University of Western Ontario (M. Sattin, Z.
Burhani, A. Jaidka, and R. T. Arntfield), London, ON, Canada; and
University of Ottawa / The Ottawa Hospital (S. J. Millington), Ottawa,
ON, Canada.
CORRESPONDENCE TO: Michael Sattin, MD; email: msattin@uwo.ca
Copyright ! 2022 American College of Chest Physicians. Published by
Elsevier Inc. All rights reserved.
DOI: https://doi.org/10.1016/j.chest.2022.01.022

1598 How I Do It [ 161#6 CHEST JUNE 2022 ]

most accepted method uses spectral Doppler to obtain a left
ventricular outflow tract (LVOT) velocity-time integral
(VTI) measurement. This technique is feasible with
appropriate training,14 recommended by the American
Society of Echocardiography,15 and correlates well with
invasively derived SV and cardiac output
measurements.16-18 The feasibility and accuracy of LVOT
VTI measurements help clinicians to determine whether
abnormal two-dimensional (2D) findings are contributing
to the current clinical presentation, and they can be applied
to patients in a variety of acute care settings such as EDs,
inpatient wards, ICUs, and operating rooms. The ability to
pragmatically and efficiently determine the impact (or lack
thereof) of 2D findings on a patient’s SV allows physicians
to refine their diagnosis and avoid cognitive errors. For this
purpose, we recommend that LVOT VTI is incorporated
into all CCE examinations.
Case
A 71-year-old man presents to the hospital with
hypoxia, fever, and hypotension. He is admitted to the
ICU with pneumonia and septic shock and requires
intubation and vasopressor support. A CCE examination
identifies severe left ventricular (LV) dysfunction and a
moderate pericardial effusion; the physician team is
unsure whether these cardiac findings are contributing
to his current state of shock and hemodynamic
instability. Specifically, they wonder if the addition of an
inotropic agent would be helpful or harmful.
Conceptual Basis
The volume of blood ejected from the left ventricle
during systole passes through the LVOT, which is
chestjournal.org
shaped like a cylinder. Solving for the volume of that
cylinder, therefore, yields the SV (Fig 1):
Cylinder volume ¼ height " CSA
where CSA indicates the cross-sectional area. The height
of the cylinder is the LVOT VTI, obtained by pulsed-
wave (PW) Doppler placed just proximal to the aortic
valve in an apical five- or three-chamber view. The CSA
is derived from the LVOT diameter (LVOTd), using:
LVOTd 2
CSA ¼ p ð Þ
2
The SV formula therefore becomes:
" ! "#
LVOTd 2
SV ¼ VTI " CSA ¼ LVOT VTI " p
2
Because the CSA is a fixed value, the formula can be
simplified even further in many cases:
SVfVTI
Should an estimate of cardiac output be needed, it can be
obtained by using:
Cardiac output ¼ SV " heart rate
LVOT VTI can therefore be used as a surrogate for SV
in most patients based on the fact that LVOTd is a static
measurement, with most adults having an LVOTd of
approximately 2 cm.19 Therefore, in critically ill patients,
changes in LVOT VTI can be assumed to be directly
related to changes in SV in most cases, simplifying the
acquisition of information. It is important to ensure that
Figure 1 – Visualization of the left ventricular
outflow tract as a cylinder in an apical five-
chamber (A) and apical three-chamber (B)
view.
1599
if LVOTd measurements are being made for SV
assessments, that they are done accurately, because as
seen earlier, the error is squared in the equation (see the
Limitations and Pitfalls section).
Acquisition
The following sequence, as seen in Video 1, will allow
most modern ultrasound machines to perform
calculations to determine SV and cardiac output,
without any added steps:
1. A phased-array (“cardiac”) probe is used to obtain
images.
2. An apical five-chamber or apical three-chamber view
is obtained.
3. Color Doppler is used to verify flow within the LVOT,
which also helps rule out outflow tract obstructions or
significant aortic regurgitation (see the Limitations
and Pitfalls section).
4. PW Doppler is used to obtain a VTI proximal to the
aortic valve by using a small sample volume, opti-
mizing the VTI envelope for tracing (Fig 2A).
5. Heart rate is manually input or VTI-to-VTI measure-
ments used on the ultrasound to calculate this factor.
6. A parasternal long-axis view is obtained.
7. The operator should zoom in and measure LVOTd,
from inner-edge to inner-edge in early to mid-systole,
just proximal to the aortic valve (Fig 2B). Alternatives
to measuring LVOTd are reviewed in the Limitations
and Pitfalls section.
Practical Approach
To increase the efficiency in measuring and interpreting
SV and cardiac output, we propose a simple workflow
Figure 2 – Stroke volume assessment using VTI tracing from pulsed-wave Doppler sample of LVOT proximal to the aortic valve in apical five-chamber
view (A) and parasternal long-axis with measurement of LVOT diameter (B). LVOT ¼ left ventricular outflow tract; PG ¼ pressure gradient; Vmax ¼
peak velocity; Vmean ¼ mean velocity; VTI ¼ velocity-time integral.
1600 How I Do It
(Fig 3) that is easy to apply at the bedside. Although this
approach does not replace the need to perform an
accurate initial 2D assessment, it can be used to rapidly
determine the significance of 2D findings in a critically
ill patient.
1. Perform a basic screening CCE examination, taking
note of any abnormal findings.
2. Obtain an apical five-chamber view (or failing that,
an apical three-chamber view) to visualize the
LVOT.
3. Apply color Doppler at the level of the LVOT to rule
out dynamic LVOT obstruction or significant aortic
regurgitation; SV derived from LVOT VTI cannot be
used in these situations (see the Limitations and Pit-
falls section).
4. Measure the LVOT VTI by using PW Doppler.
5. If the LVOT VTI is > 22 cm, there is a high likelihood
that the patient has a normal or elevated SV, and
therefore:
% If the basic 2D examination was abnormal, any
abnormalities (eg, LV dysfunction, right ven-
tricular dysfunction, pericardial effusion) are
unlikely to be the main contributing factor to
the patient’s hemodynamic compromise; they
are more likely to be chronic and well-
compensating phenomena.
% If the basic 2D examination was normal, a VTI of
> 22 cm (and therefore a normal or elevated SV)
suggests that the hemodynamic abnormalities are
likely due to vasodilation and a high cardiac output
state.
6. If the LVOT VTI is < 14 cm, there is a high likelihood
that the patient has a decreased SV and therefore:
[ 161#6 CHEST JUNE 2022 ]
 1 2
Obtain LVOT VTI

4 3
< 14 cm 14–22 cm > 22 cm

High probability for 5 High probability for

Obtain LVOTd
low SV normal/elevated SV

Normal or
Decreased elevated
(eg, < 60cc) (eg, > 60cc)
Is there a 2D Is there a 2D
Calculate SV
abnormality? abnormality?

Yes No No Yes

2D abnormality likely Consider relative High cardiac output / 2D abnormality unlikely

contributory to hypovolemia vasodilatory state contributory to
hemodynamic status hemodynamic status

Figure 3 – Flow diagram showing the process of using LVOT VTI for hemodynamic assessments. The steps are labeled and correspond to the text: (1)
obtain LVOT view (apical five-chamber/apical three-chamber); and (2) obtain LVOT VTI. (3) If elevated LVOT VTI (> 22 cm), consider discordant if 2D
abnormalities and unlikely hypovolemic. (4) If low LVOT VTI (< 14 cm), consider concordant with 2D abnormalities or possibly hypovolemic. (5) If LVOT
VTI indeterminate on its own (14-22 cm), obtain LVOTd to calculate SV and move through the appropriate side of the flow diagram. 2D ¼ two-
dimensional; LVOT ¼ left ventricular outflow tract; LVOTd ¼ left ventricular outflow tract diameter; SV ¼ stroke volume; VTI ¼ velocity-time integral.

% If the basic 2D examination was abnormal, any
abnormalities are likely to be contributing to or
causing the patient’s hemodynamic compromise.
% If the basic 2D examination was normal, a VTI
of < 14 cm (and therefore a low SV) suggests that
the patient is likely to be intravascularly hypo-
volemic and would warrant further fluid respon-
siveness testing (which is beyond the scope of the
current article).
7. If the LVOT VTI is between 14 and 22 cm, a position
of uncertainty exists, and the LVOTd should be
measured to determine a more accurate assessment of
SV, as the LVOT VTI alone may be misleading.
% In clinical practice, this is a frequently encountered
situation because vasodilatory shock is common,
and in our experience many hemodynamically
unstable patients do have LVOT VTI values in this
range.
% Once an LVOTd has been measured once, it does
not need to be repeated on follow-up assessments;
this value does not change.
The cutoff values for the aforementioned “normal” and
“abnormal” LVOT VTI are derived by understanding
that only two variables influence SV in these
calculations: LVOT VTI and LVOTd. Using an upper
limit of 2.3 cm for the average LVOTd (1 SD above the
mean19), any LVOT VTI of # 14 cm yields an SV
of < 60 cc. Similarly, if we apply the same principle to
the lower limit of LVOTd (1.9 cm), any LVOT VTI
of $ 22 cm leads to an SV of > 60 cc. This approach
allows for rapid and generalizable assessments, but as
described previously, if the findings are not in keeping
with the patient’s clinical context, a more rigorous and
comprehensive assessment should always be undertaken.
Common Clinical Applications
Three commonly encountered clinical scenarios in
which SV estimates can be particularly helpful warrant
specific consideration. Patients in shock with a severely
reduced left ventricular ejection fraction (LVEF) can
easily be misdiagnosed and mismanaged if the
assessment is solely based on 2D images (Video 2). A
normal SV in this scenario suggests a chronic, well-
compensated cardiac pathology and a different cause of
shock (likely sepsis in most cases). In contrast, a low SV
confirms that the cardiac pathology is at least
contributing to the state of shock, if not the main source.
With the discovery of a dilated and dysfunctional right
ventricle in a critically ill patient, it is extremely
important to understand whether right ventricular

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failure is the cause of hemodynamic collapse or merely
an innocent bystander to an unrelated process. A low SV
suggests the former scenario, and a high or normal SV
the latter. Errors in judgment regarding this paradigm
can lead to delays in care or inappropriate treatment
(Video 3).
One of the scenarios in which LVOT VTI-derived
hemodynamic measurements may be of the most value
is in the case of hyperdynamic LV systolic function. A
common logical fallacy in patients with hypotension and
hyperdynamic LV systolic function is that they are
“underfilled” and will benefit from IV fluid boluses. The
reasons for having hyperdynamic LV systolic function in
critically ill patients are myriad,20 and many of these
patients are already volume replete (Video 4). The ability
to accurately identify those patients with hyperdynamic
circulatory states can prevent the iatrogenic
consequences of excessive fluid administration in
patients unlikely to derive benefit.
Finally, LVOT VTI is of most value when used to serially
assess a patient after changes are made to the patient’s
management or their clinical situation changes. This
reassessment could be part of a broader assessment of
volume responsiveness, assessing response to initiation
or titration of vasoactive or inotropic therapy, or simply
to monitor the trajectory of a critically ill patient.
Because the LVOTd does not change, LVOT VTI
assessments alone can be performed on repeat CCE or
hemodynamic assessments to monitor for response to
therapy and help guide management.
Limitations and Pitfalls
To use LVOT VTI-derived hemodynamic parameters
safely, it is important to understand the limitations and
pitfalls of this technique. It is also important to
understand that measurement of an LVOT VTI does not
lead to a diagnosis of shock, which is made clinically. SV
and cardiac output assessments are thus most
appropriately used to determine if 2D abnormalities are
of clinical significance and to monitor response to
treatment.
Acquisition Errors
As highlighted in Video 1, it is important to obtain the
LVOT VTI tracing accurately. This requires that the PW
Doppler line of interrogation be parallel to the blood
flow within the LVOT. If the angle of insonation is
within 20 degrees, error from real Doppler shift is #
6% and the derived SV will be reliable (Fig 4). The PW
gate also needs to be placed just proximal to the aortic
1602 How I Do It
valve and not within the LV cavity itself (Fig 5). A well-
acquired LVOT VTI is represented by a spectral
envelope, which is “dark” on the inside with a bright
“outline.” When tracing the LVOT VTI, it is important
to be as precise as possible and to approximate the outer
edge as closely as possible (Fig 6).
Dynamic LVOT Obstruction
Dynamic LVOT obstructions, most commonly caused
by systolic anterior motion of the mitral valve, interferes
with accurate LVOT VTI measurements. In the setting
of a dynamic LVOT obstruction, the velocity of blood
flow often exceeds the Nyquist limit, leading to a
phenomenon known as aliasing. Aliasing occurs when
the ultrasound machine is unable to determine the true
direction and velocity of blood flow across the area being
sampled,21 and it is represented by a spectral envelope
that is fused from the top to the bottom of the baseline
(Fig 7A) and cannot be reliably traced. In this setting, SV
assessment is not possible from LVOT VTI. Most novice
operators might only notice a dynamic LVOT
obstruction post hoc, when there is aliasing of the LVOT
VTI, but on 2D imaging it is important to assess for
anterior motion of the mitral leaflets and apparatus
during systole (Fig 7B).
Moderate or Severe Aortic Insufficiency
Moderate or severe aortic insufficiency leads to dual
sources of diastolic filling for the left ventricle, from both
the left atrium and the aorta. The increased LV end-
diastolic volume leads to a supranormal, overestimated
LVOT VTI value. Due to this overestimation, SV
assessment cannot be made from LVOT VTI. Aortic
regurgitation can usually be appreciated, even by novice
users of CCE, in the parasternal long-axis and apical
five-chamber views with color Doppler, by evaluating for
retrograde flow from the aorta back into the left
ventricle during diastole (Fig 7C).
Other Physiological States
Other physiological and pathologic states need to be
considered when using LVOT VTI to estimate SV and
cardiac output. It is important to appreciate that in
patients with variable beat-to-beat SVs (often due to
arrhythmias such as atrial fibrillation), multiple VTIs
need to be acquired and averaged to obtain an accurate
hemodynamic assessment. The number of LVOT VTIs
that need to be averaged to acquire an accurate
hemodynamic assessment seems to vary depending on
the source; however, most guidelines suggest five
consecutive beats as a sufficient minimum.22,23 In
[ 161#6 CHEST JUNE 2022 ]
Figure 4 – Comparing the difference in LVOT VTI generated when the Doppler line of interrogation is parallel to blood flow (A) vs off-axis by greater
than 20 degrees (B). LVOT ¼ left ventricular outflow tract; PG ¼ pressure gradient; Vmax ¼ peak velocity; Vmean ¼ mean velocity; VTI ¼ velocity-
time integral.

addition, there are certain physiological states that lead
to a high cardiac output at baseline such as cirrhosis,
thyrotoxicosis, and pregnancy, among others. In these
instances, interpreting LVOT VTI values without
clinical context can be challenging and may lead to
improper interpretation.
LVOTd Measurement
As discussed previously, the LVOTd measurement is
squared in the formula for SV, and thus any error in
acquiring or measuring this value can lead to significant
overestimation or underestimation of the true SV. In
practice, there are a few ways to try and minimize this
error that we would emphasize. The first is having the
LVOTd measured by an experienced sonographer and
using that value for all future SV calculations. This also
applies to looking back at previous echocardiograms, and
if the patient has not undergone cardiac surgery in the
interim, a previously reported LVOTd is a good option.
In some instances, if the LVOTd cannot be measured
and is not available from previous echocardiogram
reports, a range of possible SV might be inferred, or an
alternative method for SV assessment may be required if
exact values are required (uncommon in practice).

Figure 5 – The difference between an LVOT VTI obtained from an appropriate sample location in LVOT with aortic valve closure captured at the end
of systole (A) and a location too proximal in the left ventricular cavity (B). LVOT ¼ left ventricular outflow tract; PG ¼ pressure gradient; Vmax ¼
peak velocity; Vmean ¼ mean velocity; VTI ¼ velocity-time integral.

chestjournal.org 1603
Figure 6 – Demonstration of the significant difference in values obtained from overtracing (23.9 cm) (A) and undertracing (13.7cm) (B) the same LVOT
VTI. LVOT ¼ left ventricular outflow tract; PG ¼ pressure gradient; Vmax ¼ peak velocity; Vmean ¼ mean velocity; VTI ¼ velocity-time integral.

Required Training incorporating LVOT VTI with structured feedback on

Although there are no agreed upon criteria for gaining
competency in LVOT VTI assessment, the technique
seems feasible and reproducible in the hands of
experienced clinicians, with low intra-observer and
interobserver variability.24 One of the only studies
assessing necessary training requirements showed that
20 h of hands-on training by a cardiac sonographer
(primarily in techniques similar to described in the
current article) led to high rates of optimal LVOTd and
LVOT VTI acquisition (90% and 78.4%, respectively)
that were comparable to those of a cardiac
sonographer.14 In our experience, over many years and
training hundreds of trainees, clinicians can frequently
become competent with this technique following a short
period of hands-on instruction and can integrate it into
their practice following 30 to 40 CCE examinations
technique and acquisition. This has been observed while
training clinicians to perform LVOT VTI over the
duration of 4-week CCE electives at our centers.
Clinicians who plan to use this technique should seek
additional training in CCE, as LVOT VTI requires less
training and expertise than 2D echocardiography.
Case Resolution
SV and cardiac output calculations for the study patient
yielded values of 70 mL and 6.5 L/min, respectively, and
were interpreted as consistent with distributive shock.
The LV dysfunction and pericardial effusion were
determined to be chronic and noncontributory to the
current shock state, which was believed to be related to
ongoing vasoplegia from sepsis. Vasopressors were
continued, inotropic medications withheld, and no

Figure 7 – Depiction of aliased left ventricular outflow tract velocity-time integral in a patient with dynamic left ventricular outflow tract obstruction
(A), as well as two-dimensional visualization of systolic anterior motion of the mitral valve (B). C, Color Doppler findings as expected in moderate to
severe aortic regurgitation.

1604 How I Do It [ 161#6 CHEST JUNE 2022 ]

further fluid was administered based on this
hemodynamic information (Video 2). The patient slowly
improved over the next 48 h and was transferred out of
the ICU on day 3.
Conclusions
When using 2D echocardiography to assess critically ill
patients, the absence of quantitative hemodynamic
information to help determine the importance of
abnormal findings is often a major challenge. By
estimating SV and cardiac output, clinicians may readily
corroborate the magnitude of the effect of any
pathologic ultrasound findings. In turn, this knowledge
facilitates a more confident and tailored approach to the
management of circulatory failure, helping to avoid bias
and to quantify the response to interventions. Despite
being well validated, the routine use of LVOT VTI as
part of CCE has not yet received broad endorsement.
Our experience suggests, however, that SV and cardiac
output measurements enrich the quality and impact of
CCE, and this technique should be considered an
essential skill for any frontline clinician managing
critically ill patients.
Acknowledgments
Financial/nonfinancial disclosures: None declared.
Additional information: The Videos are available online under
“Supplementary Data.”
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