Comparison of transesophageal echocardiographic, fick, and thermodilution cardiac output in critically ill patients

doi:10.1016/S0883-9441(96)90006-4

Journal of Critical Care

Volume 11, Issue 3, September 1996, Pages 109-116

https://doi.org/10.1016/S0883-9441(96)90006-4 Get rights and content

Abstract

$Purpose:$ Recent observations have highlighted errors in the thermodilution technique of measuring cardiac output. Thus, cardiac output measurements using transesophageal echocardiography and the Fick method were compared with simultaneous thermodilution measurements.

$Methods:$ In 13 mechanically ventilated critically ill patients, cardiac output was determined simultaneously using (1) transesophageal echocardiography (CO_TEE), (2) the Fick method (CO_FICK), and (3) thermodilution (CO_TD) immediately before and after a rapid infusion of 500 mL of saline. Left ventricular end-diastolic and end-systolic areas were measured using the transesophageal echocardiographic transgastric short axis view, and CO_TEE was calculated from the corresponding volumes. Absolute cardiac output values and the changes from before to after saline infusion (ΔCO) were compared using analysis of variance, linear regression, and the Bland and Altman method.

$Results:$ There were no significant differences between CO_TEE (8.0 ± 3.4), CO_FICK (8.4 ± 3.3), and CO_TD (8.3 ± 3.0) or between ΔCO_TEE, ΔCO_FCK, and ΔCO_TD using analysis of variance. However, correlations between CO_TEE and CO_TD (r² = 0.46; P < .00001), CO_FICK and CO_TD (r² = 0.46; P < .00001), and CO_TEE and CO_FICK (r² = 0.42; P < .00001) were only moderately good. Using the method of Bland and Altman, the mean difference (±2 standard deviations) between CO_TEE and CO_TD was 0.3 ± 4.3 L/min, between CO_FICK and CO_TD was −1.0 ± 3.8 L/min, and between CO_TEE and CO_FICK was 0.6 ± 5.6 L/min, whereas the difference between ΔCO_TEE and ΔCO_TD was 0% ± 26%, between ΔCO_FICK and ΔCO_TD was 9% ± 46%, and between ΔCO_TEE and ΔCO_FICK was 8% ± 39%.

$Conclusions:$ There are substantial differences in cardiac output as measured by these three methods, best demonstrated using the method of Bland and Altman. The variability of cardiac output and its derivatives (eg, oxygen delivery) should be borne in mind when making clinical decisions on individual patients.

References (29)

P.A. Chandraratna et al.
Determination of cardiac output by transcutaneous continuous-wave ultrasonic Doppler computer
Am J Cardiol
(1984)
T. Konishi et al.
Comparison of thermodilution and Fick methods for measurement of cardiac output in tricuspid regurgitation
Am J Cardiol
(1992)
C. Putterman
Swan-Ganz catheter: A decade of hemodynamic monitoring
J Crit Care
(1989)
J.J. Ronco et al.
Validation of an indirect calorimeter to measure oxygen consumption in critically ill patients
J Crit Care
(1991)
S.A. Rubin et al.
Accuracy of cardiac output, oxygen uptake, and arteriovenous oxygen difference at rest, during exercise, and after vasodilator therapy in patients with severe, chronic heart failure
Am J Cardiol
(1982)
A.H. Schuster et al.
Doppler echocardiographic measurement of cardiac output: Comparison with a non-golden-standard
Am J Cardiol
(1984)
F.G. Spinale et al.
The effects of valvular regurgitation on thermodilution ejection fraction measurements
Chest
(1992)
J.M. Bland et al.
Statistical methods for assessing agreement between two methods of clinical measurement
Lancet
(1986)
T.R. Chappell et al.
Independence of oxygen consumption and systemic oxygen transport in patients with either stable pulmonary hypertension or refractory left ventricular failure
Am Rev Respir Dis
(1983)
G. Fegler
Measurement of cardiac output in anaesthetized animals by a thermodilution method
Q J Exp Physiol
(1954)

H.A. Feldman

Families of lines: Random effects in linear regression analysis

J Appl Physiol

(1988)

T.L. Force et al.

Echocardiographic assessment of ventricular function

W. Grossman

Blood Flow Measurement: The Cardiac Output

W.F. Hamilton

Measurement of cardiac output

Cited by (44)

Cardiac Output Measurement With Echocardiography and Pressure Recording Analytical Method in Pediatric Patients Admitted to the Cardiac Intensive Care Unit: A Retrospective Assessment of Bias Between the Two Methods
2021, Journal of Cardiothoracic and Vascular Anesthesia
This study aimed to compare, in a cohort of critically ill children with biventricular anatomy and no cardiovascular shunt, cardiac output (CO) and cardiac index (CI) assessed by echocardiography and a continuous pulse-contour method, MostCare^UP, to measure the differences between these techniques (biasCO and biasCI), and their association with clinical variables.
Retrospective study.
Tertiary pediatric cardiac intensive care unit.
Children admitted to the pediatric cardiac intensive care unit who underwent echocardiography with CO measurement.
None.
Thirty-five patients were included. BiasCO was –0.02 (0.26) L/min (percentage error 36%). BiasCI was 0.07 (0.34) L/min/m² (percentage error 18%). Biases and percentage errors were higher in 24 nonsupervised echocardiographies. A negative biasCO (overestimation by MostCare^UP) was associated with post-surgical status (v cardiomyopathy), higher systolic arterial pressure, and spontaneous breathing (v intubation). When only absolute values were considered, biasCO_NONEG correlated with age, weight, arterial pressure, and heart rate, whereas biasCI_NONEG was associated with a femoral arterial cannula, no use of inotropes, and the absence of mechanical ventilation. After adjustment, biasCO_NONEG remained independently associated with patients’ body weight(p = 0.0001). BiasCI_NONEG showed a nonlinear relationship with weight below 20 kg and above 40 kg.
Children with extreme low or high weights, those who are extubated, and those with a femoral cannula carry the highest bias. When younger patients are considered, CI should be evaluated instead of CO, because biases are better highlighted by indexing data on body surface area. In children, both echocardiography and MostCare^UP may be responsible of inaccurate CO/CI assessment.
Comparison of Cardiac Output of Both 2-Dimensional and 3-Dimensional Transesophageal Echocardiography With Transpulmonary Thermodilution During Cardiac Surgery
2020, Journal of Cardiothoracic and Vascular Anesthesia
Citation Excerpt :
Estimation of cardiac output with TEE was first reported9,13 using the left ventricular outflow tract diameter to estimate the left ventricular outflow tract area and then multiplying by the velocity time integral at that point in the left ventricular outflow tract. Some examples of other cardiac structures used include the right ventricular outflow tract,27 left ventricle,28 pulmonary artery,29 ascending aorta,30,31 and mitral valve.32,33 Current recommendations for measuring the left ventricular outflow tract velocity time integral from the American Society of Echocardiography34 describe tracing the spectral Doppler envelope at the instantaneous dense modal velocities throughout systole.
To compare agreement and variability of cardiac output measurement of 2-dimensional (2D) and 3D transesophageal echocardiography (TEE) with thermodilution before and after bypass.
Prospective observational study.
Two tertiary hospitals.
Cardiac output (CO) was measured simultaneously with thermodilution and TEE by multiplying either the left ventricular outflow tract area (LVOTA) or aortic valve area (AVA), the velocity-time integral (VTI) of flow at the same site, and heart rate. The LVOTA was calculated using diameter for 2D TEE. Planimetry was used for 3D TEE. The AVA was measured using planimetry.
The study comprised 82 adult patients undergoing coronary or valve surgery.
One hundred fifty-four complete sets of measurements were obtained (82 prebypass and 72 postbypass). All TEE methods had acceptable correlation and absence of proportional or fixed bias except for the left ventricular outflow tract (LVOT) VTI modal trace method, which had poor correlation and proportional but not fixed bias (regression coefficient [95% confidence interval], bias [percentage of mean CO]): 2D LVOT VTI modal trace 0.67 (0.54-0.80), –36.4%; 2D LVOT VTI outer edge trace 0.96 (0.80-1.12), –15.3%; 2D AVA planimetry 0.96 (0.75-1.18), +4.9%; 3D LVOT area planimetry 1.18 (0.96-1.41), +0.8%; 3D AVA planimetry 1.20 (0.93-1.46), +0.4%. All TEE methods had wide levels of agreement compared with thermodilution (–3.94 to +0.23 L/min, –2.83 to +1.28 L/min, –2.23 to +2.73 L/min, –2.35 to +2.42 L/min, and –2.57 to +2.61 L/min, respectively). Measurement variability was superior for all TEE methods compared with thermodilution before but not after bypass.
Although limits of agreement of CO measurement with 3D TEE and thermodilution are wide, 2D planimetry of the AVA and continuous wave Doppler may be substituted for thermodilution before and after bypass.
Validation study of the accuracy of echocardiographic measurements of systemic blood flow volume in newborn infants
2013, Journal of the American Society of Echocardiography
Citation Excerpt :
LVO and SVC flow volume as assessed by PC MRI had scan-rescan RIs (equivalent to the 95% confidence interval) of 11.5% and 12.8%, respectively.11 In the absence of any true gold standard, and acknowledging that all other “gold standards” such as the Fick method and thermodilution, also have intrinsic variability,28,29 we feel that PC MRI is the best comparator currently available for the validation of echocardiographic findings in this population. Our findings broadly support the use of echocardiographic assessments of LVO, which appear to be performed with a relatively high degree of accuracy.
The echocardiographic assessment of circulatory function in sick newborn infants has the potential to improve patient care. However, measurements are prone to error and have not been sufficiently validated. Phase-contrast magnetic resonance imaging (MRI) provides highly validated measures of blood flow and has recently been applied to the newborn population. The aim of this study was to validate measures of left ventricular output and superior vena caval flow volume in newborn infants.
Echocardiographic and MRI assessments were performed within 1 working day of each other in a cohort of newborn infants.
Examinations were performed in 49 infants with a median corrected gestational age at scan of 34.43 weeks (range, 27.43–40 weeks) and a median weight at scan of 1,880 g (range, 660–3,760 g). Echocardiographic assessment of left ventricular output showed a strong correlation with MRI assessment (R² = 0.83; mean bias, −9.6 mL/kg/min; limits of agreement, −79.6 to +60.0 mL/kg/min; repeatability index, 28.2%). Echocardiographic assessment of superior vena caval flow showed a poor correlation with MRI assessment (R² = 0.22; mean bias, −13.7 mL/kg/min; limits of agreement, −89.1 to +61.7 mL/kg/min; repeatability index, 68.0%). Calculating superior vena caval flow volume from an axial area measurement and applying a 50% reduction to stroke distance to compensate for overestimation gave a slightly improved correlation with MRI (R² = 0.29; mean bias, 2.6 mL/kg/min; limits of agreement, −53.4 to +58.6 mL/kg/min; repeatability index, 54.5%).
Echocardiographic assessment of left ventricular output appears relatively robust in newborn infant. Echocardiographic assessment of superior vena caval flow is of limited accuracy in this population, casting doubt on the utility of the measurement for diagnostic decision making.
Planimetry of the aortic valve orifice area: Comparison of multislice spiral computed tomography and magnetic resonance imaging
2011, European Journal of Radiology
We sought to determine the comparability of multislice computed tomography (MSCT) and magnetic resonance imaging (MRI) for measuring the aortic valve orifice area (AVA) and grading aortic valve stenosis.
Twenty-seven individuals, among them 18 patients with valvular stenosis, underwent AVA planimetry by both MSCT and MRI. In the subset of patients with valvular stenosis, AVA was also calculated from transthoracic Doppler echocardiography (TTE) using the continuity equation.
There was excellent correlation between MSCT and MRI (r = 0.99) and limits of agreement were in an acceptable range (±0.42 cm²) although MSCT yielded a slightly smaller mean AVA than MRI (1.57 ± 0.83 cm² vs. 1.67 ± 0.98 cm², p < 0.05). However, in the subset of patients with valvular stenosis, the mean AVA was not different between MSCT and MRI (1.05 ± 0.30 cm² vs. 1.04 ± 0.39 cm²; p > 0.05). The mean AVAs on both MSCT and MRI were systematically larger than on TTE (0.88 ± 0.28 cm², p < 0.001 each). Using an AVA of 1.0 cm² on TTE as reference, the best threshold for detecting severe-to-critical stenosis on MSCT and MRI was an AVA of 1.25 cm² and 1.30 cm², respectively, resulting in an accuracy of 96% each.
Our study specifies recent reports on the suitability of MSCT for quantifying AVA. The data presented here suggest that certain methodical discrepancies of AVA measurements exist between MSCT, MRI and TTE. However, MSCT and MRI have shown excellent correlation in AVA planimetry and similar accuracy in grading aortic valve stenosis.
Planimetry of mitral valve stenosis by magnetic resonance imaging
2005, Journal of the American College of Cardiology
Citation Excerpt :
In routine clinical practice, both CATH and ECHO are used to assess MS. Cardiac catheterization is widely accepted as the gold standard, and MVA is calculated by the Gorlin formula from the mean transvalvular gradient and valvular flow (6). Because of the indirect measurements, however, the accuracy of MVA calculation has often been challenged (9,10). Despite these limitations, the Gorlin formula remains the standard criterion against which new noninvasive methods must be judged.
We sought to determine whether noninvasive planimetry of the mitral valve area (MVA) by magnetic resonance imaging (MRI) is feasible and reliable in patients with mitral stenosis (MS).
Accurate assessment of MVA is particularly important for the management of patients with valvular stenosis. Current standard techniques for assessing the severity of MS include echocardiography (ECHO) and cardiac catheterization (CATH).
In 22 patients with suspected or known MS, planimetry of MVA was performed with a 1.5-T magnetic resonance scanner using a breath-hold balanced gradient echo sequence (true FISP). Data were compared with echocardiographically determined MVA (ECHO-MVA, n = 22), as well as with invasively calculated MVA by the Gorlin-formula at (CATH-MVA, n = 17).
The correlation between MRI- and CATH-MVA was 0.89 (p < 0.0001), and the correlation between MRI- and ECHO-MVA was 0.81 (p < 0.0001). The MRI-MVA slightly overestimated CATH-MVA by 5.0% (1.60 ± 0.45 cm²vs. 1.52 ± 0.49 cm², p = NS) and ECHO-MVA by 8.1% (1.61 ± 0.42 cm²vs. 1.48 ± 0.42 cm², p < 0.05). On receiver-operating characteristic curve analysis, a value of MRI-MVA below 1.65 cm²indicated mitral stenosis (CATH-MVA ≤1.5 cm²), with a good sensitivity and specificity (89% and 75%, respectively).
Magnetic resonance planimetry of the mitral valve orifice in mitral stenosis offers a reliable and safe method for noninvasive quantification of mitral stenosis. In the clinical management of patients with mitral stenosis, it has to be considered that planimetry by MRI slightly overestimates MVA, as compared with MVA calculated echocardiographically and at catheterization.
Measurement of cardiac output before and after cardiopulmonary bypass: Comparison among aortic transit-time ultrasound, thermodilution, and noninvasive partial CO<inf>2</inf> rebreathing
2004, Journal of Cardiothoracic and Vascular Anesthesia
$Objectives :$ A noninvasive continuous cardiac output system (NICO) has been developed recently. NICO uses a ratio of the change in the end-tidal carbon dioxide partial pressure and carbon dioxide elimination in response to a brief period of partial rebreathing to measure CO. The aim of this study was to compare the agreement among NICO, bolus (TDCO), and continuous thermodilution (CCO), with transit-time flowmetry of the ascending aorta using an ultrasonic flow probe (UFP) before and after cardiopulmonary bypass (CPB).
$Design :$ Prospective, observational human study.
$Setting :$ Veterans Affairs Medical Center Hospital.
$Participants :$ Sixty-eight patients.
$Methods :$ Matched sets of CO measurements between NICO, TDCO, CCO, and UFP were collected in 68 patients undergoing elective CABG at specific time periods before and after separation from CPB. After anesthetic induction, all patients had an NICO sensor attached between the endotracheal tube and the breathing circuit, a PAC floated into the pulmonary artery for TDCO and CCO monitoring, and a UFP positioned on the ascending aorta and used for the reference CO. Bland-Altman analysis was used to compare the agreement among the different methods.
$Measurements and Main Results :$ Bland-Altman analysis of CO measurements before CPB yielded a bias, precision, and percent error of 0.04 L/min ± 1.07 L/min (44.8%) for NICO, 0.18 L/min ± 1.01 L/min (41.7%) for TDCO, and 0.29 L/min ± 1.40 L/min (57.5%) for CCO compared with simultaneous UFP CO measurements, respectively. After separation from CPB (average 29 mins), bias, precision, and percent error were −0.46 L/min ± 1.06 L/min (37.3%) for NICO, 0.35 L/min ± 1.39 L/min (46.1%) for TDCO, and 0.36 L/min ± 1.96 L/min (64.7%) for CCO compared with UFP CO measurements, respectively.
$Conclusions :$ Before initiation of CPB, the accuracy for all 3 techniques was similar. After separation from CPB, the tendency was for NICO to underestimate CO and for TDCO and CCO to overestimate it. NICO offers an alternative to invasive CO measurement.

View all citing articles on Scopus

^☆: This study was supported by the Heart and Stroke Foundation of British Columbia and Yukon. Keith Walley is a Scholar of the Heart and Stroke Foundation of Canada.

¹: O. Axler was supported in part by a grant from the American Hospital in Paris and General Electric France.

View full text

Original investigationComparison of transesophageal echocardiographic, fick, and thermodilution cardiac output in critically ill patients☆

Abstract

Am J Cardiol

Am J Cardiol

J Crit Care

J Crit Care

Am J Cardiol

Am J Cardiol

Chest

Statistical methods for assessing agreement between two methods of clinical measurement

Lancet

Independence of oxygen consumption and systemic oxygen transport in patients with either stable pulmonary hypertension or refractory left ventricular failure

Am Rev Respir Dis

Measurement of cardiac output in anaesthetized animals by a thermodilution method

Q J Exp Physiol

Families of lines: Random effects in linear regression analysis

J Appl Physiol

Echocardiographic assessment of ventricular function

Blood Flow Measurement: The Cardiac Output

Measurement of cardiac output

Original investigation
Comparison of transesophageal echocardiographic, fick, and thermodilution cardiac output in critically ill patients☆