Clinician Update

Echo-Doppler Hemodynamics
An Important Management Tool for Today’s Heart Failure Care
Roy Beigel, MD; Bojan Cercek, MD, PhD; Robert J. Siegel, MD; Michele A. Hamilton, MD
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Case Presentation have been hospitalized, with consid- readmissions, length of stay, and
A 52-year-old man with dilated car- eration of right heart catheterization costs,3 we must revisit our approach.
diomyopathy (left ventricular ejection if hemodynamic assessment were The use of pulmonary artery flotation
fraction 25%), recently discharged needed to guide further treatment. catheter monitoring requires intensive
from a heart failure (HF) admission, However, in our efforts to improve the care unit or specialty unit hospitaliza-
presented to the office with weakness quality and safety of care, with poten- tion, has significant procedure-related
and shortness of breath. On examina- tially competing imperatives to reduce risks, may not be accurate in all
tion, his weight was stable, his blood
pressure was 88/60 mm Hg, his jugular
veins were difficult to assess owing to
obesity, with a few bibasilar crackles,
distant heart sounds with a 2/6 holo-
systolic murmur and a soft S3, a pro-
truding abdomen, and 1 to 2+ pitting
lower-extremity edema. Laboratory
results showed a rise in creatinine from
1.5 to 2.6 mg/dL, a rise in serum urea
nitrogen from 38 to 52 mg/dL, and a
rise in brain natriuretic peptide from
106 to 280 pg/mL.
This patient presented a clinical
challenge, because it was not clear
whether his symptoms were related to
progressive HF with worsening car-
diorenal syndrome, or conversely, to
relative hypovolemia. Unfortunately,
physical examination and laboratory
studies can be misleading in the set-
ting of HF exacerbation,1 and changes
in weight are known to lag behind Figure 1. Evaluating the central venous pressure (CVP). A and B, The inferior vena cava
is 2.6 cm in diameter, without respiratory collapse during inspiration (Ins), consistent with
important hemodynamic shifts.2 an elevated CVP. This is opposed to a patient with a small IVC (C and D) with inspiratory
Traditionally, this patient would likely collapse, consistent with a normal CVP. IVC indicates inferior vena cava.

From The Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA (R.B., B.C., R.J.S., M.A.H.); and The Heart Institute, Sheba Medical Center,
Tel Hashomer, and the Sackler School of Medicine, Tel Aviv University, Israel (R.B.).
Correspondence to Michele A. Hamilton, MD, 8536 Wilshire Blvd, Suite #302, Beverly Hills, CA 90211. E-mail Michele.hamilton@cshs.org
(Circulation. 2015;131:1031-1034. DOI: 10.1161/CIRCULATIONAHA.114.011424.)
© 2015 American Heart Association, Inc.
Circulation is available at http://circ.ahajournals.org DOI: 10.1161/CIRCULATIONAHA.114.011424

1031
 1032  Circulation  March 17, 2015

Table.  Evaluation of Hemodynamic Parameters by Echocardiography diameter and its change with respira-
tion (Figure 1). Current guidelines8
Parameter Noninvasive Method of Estimation
review optimal imaging techniques,
IVC diameter and CI
including issues in ventilated patients,
Normal Intermediate Elevated and define normal and abnormal infe-
(0–5 mm Hg) (6–9 mm Hg) (10–20 mm Hg) rior vena cava values for estimation of
Size ≤ 2.1 cm Size > 2.1 cm CVP (Table).
CVP/right atrial pressure CI ≥50% Intermediate values No collapse
PAP SPAP=CVP+∆P=CVP+4×Vmax2 from TR jet Pulmonary Artery Pressure
MPAP=CVP+averaging the tracing of the TR jet In patients with HF, the accurate assess-
MPAP=CVP+∆P=CVP+4×Vmax2 from PR jet ment of pulmonary artery pressure
DPAP=CVP+∆P=CVP+4×Vd2 from PR jet (PAP) can be necessary to optimize
patient care. Originally validated with
PCWP/LAP PCWP/LAP likely elevated if the following are present:
invasive hemodynamics,8 echo-Dop-
Mitral inflow parameters: E/A >2, DT <160ms
pler evaluation of all PAP parameters,
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Tissue Doppler: E/E′ >15 (septal E′) systolic (SPAP), mean PAP, and dia-
>12 (lateral E′) stolic PAP, can be performed in most
>13 (averaged E′) HF patients because the majority of
Pulmonary vein Doppler flow: systolic blunting or reversal HF patients have significant valvular
Cardiac output (SV×HR) SV=LVOT VTI×LVOT area=LVOT VTI×π(LVOT diameter/2)2 regurgitation,9 a requisite for complete
CI indicates collapsibility index; CVP, central venous pressure; DPAP diastolic pulmonary artery pressure;
Doppler analysis. Methods for obtain-
DT, deceleration time; E/A, early diastolic to atrial filling velocity; HR, heart rate; IVC, inferior vena cava; LAP, ing PAP measurements are shown and
left atrial pressure; LVOT, left ventricular outflow tract; MPAP, mean PAP; PR, pulmonic valve regurgitation; detailed in Figure 2 and Table. In the
PCWP, pulmonary capillary wedge pressure; SPAP, systolic PAP; SV, stroke volume; TR, tricuspid regurgitation; absence of obstruction of the right ven-
and VTI, velocity time integral. tricular outflow tract or the pulmonary
valve, the noninvasive SPAP is derived
conditions,4 and has not been proven values,6 not only to allow care to be from the sum of the CVP and the peak
to be superior to standard care for initiated promptly, but also to follow pressure gradient across the tricuspid
patients with decompensated HF.5 response to therapy.7 valve between the right atrium and right
Fortunately, echo-Doppler, in addition ventricle during systole, obtained by
to providing clinically useful informa- Assessment of Right spectral Doppler and calculated with the
tion on the structure and function of Atrial Pressure/Central use of the simplified Bernoulli equation
cardiac chambers and valves, has now Venous Pressure (∆P=4 × Vmax2). Although the Bernoulli
been shown to provide estimates of Estimation of central venous pressure method is generally accepted and used
left- and right-sided filling pressures (CVP) and overall volume status can in daily practice, there is still debate
and cardiac output that correlate well be facilitated by echocardiography via regarding its validity, with some studies
with catheter-based hemodynamic measurement of the inferior vena cava not being able to reproduce the high cor-
relation with invasive measurements.10
The inaccuracies in estimation (mostly
underestimation) of SPAP are mostly
attributable to certain patient popula-
tions such as those with emphysema,
or when either the tricuspid regurgita-
tion jet tracing is not complete or in the
presence of wide-open tricuspid regur-
gitation. Also, in the setting of very high
right atrial pressure, in which echocar-
diography may not accurately estimate
Figure 2. Evaluation of the pulmonary artery pressure (PAP) gradients. For evaluation right atrial pressure, the SPAP estimate
of the systolic PAP (SPAP) gradient, the tricuspid regurgitation (TR) Doppler signal is
used (A) – see text. From the velocity time integral from the same TR tracing, the mean
will be affected.11 Keeping in mind
PAP (MPAP) gradient can be obtained. An additional method for calculating the MPAP these same limitations, the mean PAP
gradient (B, a different patient) is from the pulmonic valve regurgitation (PR) jet by using can be estimated either from the veloc-
the maximal velocity (X) and the simplified Bernoulli equation. The diastolic PAP (DPAP) ity time integral obtained by tracing the
gradient can also be similarly calculated from the PR jet end-diastolic velocity (*).
Adding the estimated CVP to these gradients gives the correlating PAPs. PG indicates Doppler waveform used for obtaining
pressure gradient. the SPAP or using the peak pulmonic
 Beigel et al   Echo Doppler for Assessment of Hemodynamics   1033

valve regurgitation jet velocity within

the Bernoulli equation added to the
CVP. With the use of this same calcula-
tion, the peak pulmonic valve regurgi-
tation end-diastolic jet can be used for
estimation of the diastolic PAP.

Pulmonary Capillary Wedge

Pressure/Left Atrial Pressure
The echo-Doppler estimate of the
pulmonary capillary wedge pressure
(PCWP)/left atrial pressure (LAP)
can provide clinically useful informa-
tion such as the delineation of the eti-
ology of pulmonary hypertension or
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measurement of the transpulmonary

gradient for transplant candidacy.12
For patients with at least moderate
mitral regurgitation, the continuous
wave mitral regurgitation tracing can
be used to estimate the PCWP/LAP13;
however, the assessment of the PCWP/
LAP is most often done using parame-
ters of diastolic function.14 As shown in
Figure 3 and Table, the commonly used
parameters include mitral inflow veloc-
ities, tissue Doppler of the septal and
lateral mitral annulus, spectral Doppler
of the pulmonary venous flow, and left
atrial size. Estimation of the LAP by
echocardiography is best suited for dif-
ferentiating high from low LAPs with
overlap in patients with intermediate
LAPs. A multiparameter approach has
demonstrated a sensitivity and specific-
ity for elevated PCWP/PAP of >85%.15
Figure 3. Echocardiographic parameters for evaluation of pulmonary capillary wedge/left
atrial pressure (PCWP/LAP). Left, Findings associated with an elevated PCWP/LAP. Top,
Cardiac Output Mitral inflow velocities: the ratio of early diastolic to atrial filling velocity (E/A) is >2 along
The cardiac output is a product of the with a short deceleration time (white line). Middle, Tissue Doppler: the E/E′ of 20.5 is
consistent with elevated filling pressures. Bottom, Spectral Doppler of pulmonary venous
stroke volume multiplied by the heart flow shows a blunted systolic component (S) and a prominent diastolic (D) component.
rate. In the absence of significant aortic Right, Findings associated with a normal or low PCWP/LAP. The E/A, deceleration time,
regurgitation, the velocity time integral E/E′, and spectral Doppler pattern are all normal. DT indicates deceleration time; and E/A,
of the Doppler signal obtained from the early diastolic to atrial filling velocity.
left ventricular outflow tract multiplied
by the cross-sectional area of the left integral and area, but may be more sus- CVP of <5 mm Hg), an estimated SPAP
ventricular outflow tract allows a nonin- ceptible to inaccuracies, because the of 45 mm Hg, and diastolic parameters
vasive estimation of the stroke volume, right ventricular outflow tract geometry indicating low/normal PCWP/LAP. The
which has proven to be fairly accurate is even more variable than the left ven- calculated cardiac output was 3.9 L/
despite the generally oval shape of the tricular outflow tract. min. His diuretic dosage was reduced,
left ventricular outflow tract (rather than with improvement in symptoms and
the assumed circular shape in echo- Case Summary/Discussion normalization of laboratory results over
Doppler measurements).16 Obtaining In the patient presented, echocardiog- the following week, thus avoiding hos-
the right-sided cardiac output is done raphy was performed that day in the pitalization and invasive monitoring.
in a similar fashion by using the right office, demonstrating a small, collaps- At subsequent visits, these Doppler
ventricular outflow tract velocity time ing inferior vena cava (suggesting a parameters were repeated when needed
 1034  Circulation  March 17, 2015
to assist in his care. This case illustrates
the potential benefit of the proficiency
of echocardiographic laboratories in
hemodynamic measures and widespread
availability of same-day, point-of-care
studies. Echo-Doppler may also be use-
ful for the serial assessment of acute
hemodynamic interventions in hospital-
ized patients17 and possibly in outpatient
intravenous diuretic programs. Future
advances in hand-held echocardiogra-
phy (specifically its Doppler capability)
and other measures, such as implantable
hemodynamic monitoring devices,18
may also prove helpful as hospital sys-
Downloaded from http://circ.ahajournals.org/ by guest on January 4, 2018
tems assume more responsibility for
outcomes, overall costs, and the integra-
tion of inpatient and outpatient care.
Disclosures
None.
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 Echo-Doppler Hemodynamics: An Important Management Tool for Today's Heart Failure
Care
Roy Beigel, Bojan Cercek, Robert J. Siegel and Michele A. Hamilton

Circulation. 2015;131:1031-1034
doi: 10.1161/CIRCULATIONAHA.114.011424
Downloaded from http://circ.ahajournals.org/ by guest on January 4, 2018

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