Log in | Register

Systematic review of cardiac output measurements by echocardiography vs. thermodilution: the techniques are not interchangeable

Mik Wetterslev| Hasse Møller-Sørensen| Rasmus Rothmann Johansen| Anders Perner
Systematic Review
Volume 42, Issue 8 / August , 2016

Pages 1223 - 1233

Abstract

Purpose

Echocardiography is frequently used in the hemodynamic evaluation of critically ill patients, but inaccurate measurements may lead to wrong clinical decisions. The aim of our systematic review was to investigate the interchangeability of echocardiography with thermodilution technique in measuring cardiac output and its changes.

Methods

In August 2015 we systematically searched electronic databases and included studies investigating the echocardiographic measurement of cardiac output compared with thermodilution technique using the Bland–Altman method. Two authors independently reviewed the studies and extracted data on type of measurements, clinical setting and characteristics, and those of the Bland–Altman and trending ability analyses.

Results

We identified 13,834 citations and included 24 studies in the final analysis. The median number of participants was 32 (range 8–65). Most of the studies assessed left-sided heart structures and the majority had small bias, wide limits of agreement, and high percentage error between echocardiography and thermodilution. In only two of the 24 studies the precision of each technique (echocardiography and thermodilution) was assessed before comparing them. In the single study evaluating trending ability using valid methodology, agreement was observed between echocardiography and thermodilution in detecting the directional changes in cardiac output, but the magnitude of changes varied considerably.

Conclusions

The majority of studies comparing echocardiography with thermodilution were difficult to interpret, but current evidence does not support interchangeability between these techniques in measuring cardiac output. The techniques may be interchangeable in tracking directional changes in cardiac output, but this has to be confirmed in large high-quality studies.

Keywords

References

  1. Rhodes A, Cecconi M, Hamilton M, Poloniecki J, Woods J, Boyd O, Bennett D, Grounds RM (2010) Goal-directed therapy in high-risk surgical patients: a 15-year follow-up study. Intensive Care Med 36:1327–1332
  2. Nilsson LB, Nilsson JC, Skovgaard LT, Berthelsen PG (2004) Thermodilution cardiac output—are three injections enough? Acta Anaesthesiol Scand 48:1322–1327
    • View reference on publisher's website
    • View reference on PubMed
  3. Berthelsen PG, Eldrup N, Nilsson LB, Rasmussen JP (2002) Thermodilution cardiac output. Cold vs. room temperature injectate and the importance of measuring the injectate temperature in the right atrium. Acta Anaesthesiol Scand 46:1103–1110
    • View reference on publisher's website
    • View reference on PubMed
  4. Monnet X, Persichini R, Ktari M, Jozwiak M, Richard C, Teboul JL (2011) Precision of the transpulmonary thermodilution measurements. Crit Care 15:R204
    • View reference on publisher's website
    • View reference on PubMed
  5. Moller-Sorensen H, Graeser K, Hansen KL, Zemtsovski M, Sander EM, Nilsson JC (2014) Measurements of cardiac output obtained with transesophageal echocardiography and pulmonary artery thermodilution are not interchangeable. Acta Anaesthesiol Scand 58:80–88
    • View reference on publisher's website
    • View reference on PubMed
  6. Moller-Sorensen H, Hansen KL, Ostergaard M, Andersen LW, Moller K (2012) Lack of agreement and trending ability of the endotracheal cardiac output monitor compared with thermodilution. Acta Anaesthesiol Scand 56:433–440
    • View reference on publisher's website
    • View reference on PubMed
  7. Polanczyk CA, Rohde LE, Goldman L, Cook EF, Thomas EJ, Marcantonio ER, Mangione CM, Lee TH (2001) Right heart catheterization and cardiac complications in patients undergoing noncardiac surgery: an observational study. JAMA 286:309–314
    • View reference on publisher's website
    • View reference on PubMed
  8. Sandham JD, Hull RD, Brant RF, Knox L, Pineo GF, Doig CJ, Laporta DP, Viner S, Passerini L, Devitt H, Kirby A, Jacka M (2003) A randomized, controlled trial of the use of pulmonary-artery catheters in high-risk surgical patients. N Engl J Med 348:5–14
    • View reference on publisher's website
    • View reference on PubMed
  9. Haji DL, Royse A, Royse CF (2013) Review article: clinical impact of non-cardiologist-performed transthoracic echocardiography in emergency medicine, intensive care medicine and anaesthesia. Emerg Med Australas 25:4–12
    • View reference on publisher's website
    • View reference on PubMed
  10. Romero-Bermejo FJ, Ruiz-Bailen M, Guerrero-De-Mier M, Lopez-Alvaro J (2011) Echocardiographic hemodynamic monitoring in the critically ill patient. Curr Cardiol Rev 7:146–156
    • View reference on publisher's website
    • View reference on PubMed
  11. Guarracino F, Baldassarri R (2009) Transesophageal echocardiography in the OR and ICU. Minerva Anestesiol 75:518–529
    • View reference on PubMed
  12. Figueiredo A, Germano N, Guedes P, Marcelino P (2011) The evolving concepts of haemodynamic support: from pulmonary artery catheter to echocardiography and theragnostics. Curr Cardiol Rev 7:136–145
    • View reference on publisher's website
    • View reference on PubMed
  13. Quinones MA, Otto CM, Stoddard M, Waggoner A, Zoghbi WA (2002) Recommendations for quantification of Doppler echocardiography: a report from the Doppler Quantification Task Force of the Nomenclature and Standards Committee of the American Society of Echocardiography. J Am Soc Echocardiogr 15:167–184
    • View reference on publisher's website
    • View reference on PubMed
  14. Bland JM, Altman DG (1986) Statistical methods for assessing agreement between two methods of clinical measurement. Lancet 1:307–310
    • View reference on publisher's website
    • View reference on PubMed
  15. Berthelsen PG, Nilsson LB (2006) Researcher bias and generalization of results in bias and limits of agreement analyses: a commentary based on the review of 50 Acta Anaesthesiologica Scandinavica papers using the Altman–Bland approach. Acta Anaesthesiol Scand 50:1111–1113
    • View reference on publisher's website
    • View reference on PubMed
  16. Cecconi M, De Backer D, Antonelli M, Beale R, Bakker J, Hofer C, Jaeschke R, Mebazaa A, Pinsky MR, Teboul JL, Vincent JL, Rhodes A (2014) Consensus on circulatory shock and hemodynamic monitoring. Task force of the European Society of Intensive Care Medicine. Intensive Care Med 40:1795–1815
  17. Moher D, Liberati A, Tetzlaff J, Altman DG (2009) Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ 339:b2535
    • View reference on publisher's website
    • View reference on PubMed
  18. Hahn RT, Abraham T, Adams MS, Bruce CJ, Glas KE, Lang RM, Reeves ST, Shanewise JS, Siu SC, Stewart W, Picard MH (2014) Guidelines for performing a comprehensive transesophageal echocardiographic examination: recommendations from the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists. Anesth Analg 118:21–68
    • View reference on publisher's website
    • View reference on PubMed
  19. Muhiudeen IA, Kuecherer HF, Lee E, Cahalan MK, Schiller NB (1991) Intraoperative estimation of cardiac output by transesophageal pulsed Doppler echocardiography. Anesthesiology 74:9–14
    • View reference on publisher's website
    • View reference on PubMed
  20. Savino JS, Troianos CA, Aukburg S, Weiss R, Reichek N (1991) Measurement of pulmonary blood flow with transesophageal two-dimensional and Doppler echocardiography. Anesthesiology 75:445–451
    • View reference on publisher's website
    • View reference on PubMed
  21. Shimamoto H, Kito H, Kawazoe K, Fujita T, Shimamoto Y (1992) Transoesophageal Doppler echocardiographic measurement of cardiac output by the mitral annulus method. Br Heart J 68:510–515
    • View reference on publisher's website
    • View reference on PubMed
  22. Ryan T, Page R, Bouchier-Hayes D, Cunningham AJ (1992) Transoesophageal pulsed wave Doppler measurement of cardiac output during major vascular surgery: comparison with the thermodilution technique. Br J Anaesth 69:101–104
    • View reference on publisher's website
    • View reference on PubMed
  23. Darmon PL, Hillel Z, Mogtader A, Mindich B, Thys D (1994) Cardiac output by transesophageal echocardiography using continuous-wave Doppler across the aortic valve. Anesthesiology 80:796–805
    • View reference on publisher's website
    • View reference on PubMed
  24. Pinto FJ, Siegel LC, Chenzbraun A, Schnittger I (1994) On-line estimation of cardiac output with a new automated border detection system using transesophageal echocardiography: a preliminary comparison with thermodilution. J Cardiothorac Vasc Anesth 8:625–630
    • View reference on publisher's website
    • View reference on PubMed
  25. Izzat MB, Regragui IA, Wilde P, Angelini GD, Bryan AJ (1994) Transesophageal echocardiographic measurements of cardiac output in cardiac surgical patients. Ann Thorac Surg 58:1486–1489
    • View reference on publisher's website
    • View reference on PubMed
  26. Feinberg MS, Hopkins WE, Davila-Roman VG, Barzilai B (1995) Multiplane transesophageal echocardiographic doppler imaging accurately determines cardiac output measurements in critically ill patients. Chest 107:769–773
    • View reference on publisher's website
    • View reference on PubMed
  27. Descorps-Declere A, Smail N, Vigue B, Duranteau J, Mimoz O, Edouard A, Samii K (1996) Transgastric, pulsed Doppler echocardiographic determination of cardiac output. Intensive Care Med 22:34–38
  28. Axler O, Tousignant C, Thompson CR, Dall’ava-Santucci J, Phang PT, Russell JA, Walley KR (1996) Comparison of transesophageal echocardiographic, fick, and thermodilution cardiac output in critically ill patients. J Crit Care 11:109–116
    • View reference on publisher's website
    • View reference on PubMed
  29. Maslow A, Comunale ME, Haering JM, Watkins J (1996) Pulsed wave Doppler measurement of cardiac output from the right ventricular outflow tract. Anesth Analg 83:466–471
    • View reference on PubMed
  30. Estagnasie P, Djedaini K, Mier L, Coste F, Dreyfuss D (1997) Measurement of cardiac output by transesophageal echocardiography in mechanically ventilated patients. Comparison with thermodilution. Intensive Care Med 23:753–759
  31. Perrino AC Jr, Harris SN, Luther MA (1998) Intraoperative determination of cardiac output using multiplane transesophageal echocardiography: a comparison to thermodilution. Anesthesiology 89:350–357
    • View reference on publisher's website
    • View reference on PubMed
  32. Poelaert J, Schmidt C, Van Aken H, Hinder F, Mollhoff T, Loick HM (1999) A comparison of transoesophageal echocardiographic Doppler across the aortic valve and the thermodilution technique for estimating cardiac output. Anaesthesia 54:128–136
    • View reference on publisher's website
    • View reference on PubMed
  33. Zhao X, Mashikian JS, Panzica P, Lerner A, Park KW, Comunale ME (2003) Comparison of thermodilution bolus cardiac output and Doppler cardiac output in the early post-cardiopulmonary bypass period. J Cardiothorac Vasc Anesth 17:193–198
    • View reference on publisher's website
    • View reference on PubMed
  34. Bettex DA, Hinselmann V, Hellermann JP, Jenni R, Schmid ER (2004) Transoesophageal echocardiography is unreliable for cardiac output assessment after cardiac surgery compared with thermodilution. Anaesthesia 59:1184–1192
    • View reference on publisher's website
    • View reference on PubMed
  35. Parra V, Fita G, Rovira I, Matute P, Gomar C, Pare C (2008) Transoesophageal echocardiography accurately detects cardiac output variation: a prospective comparison with thermodilution in cardiac surgery. Eur J Anaesthesiol 25:135–143
    • View reference on publisher's website
    • View reference on PubMed
  36. Missant C, Rex S, Wouters PF (2008) Accuracy of cardiac output measurements with pulse contour analysis (PulseCO) and Doppler echocardiography during off-pump coronary artery bypass grafting. Eur J Anaesthesiol 25:243–248
    • View reference on publisher's website
    • View reference on PubMed
  37. Mayer SA, Sherman D, Fink ME, Homma S, Solomon RA, Lennihan L, Beckford A, Klebanoff LM (1995) Noninvasive monitoring of cardiac output by Doppler echocardiography in patients treated with volume expansion after subarachnoid hemorrhage. Crit Care Med 23:1470–1474
    • View reference on publisher's website
    • View reference on PubMed
  38. McLean AS, Needham A, Stewart D, Parkin R (1997) Estimation of cardiac output by noninvasive echocardiographic techniques in the critically ill subject. Anaesth Intensive Care 25:250–254
    • View reference on PubMed
  39. Marcelino P, Germano N, Marum S, Fernandes AP, Ribeiro P, Lopes MG (2006) Haemodynamic parameters obtained by transthoracic echocardiography and Swan-Ganz catheter: a comparative study in liver transplant patients. Acta Med Port 19:197–205
    • View reference on PubMed
  40. Temporelli PL, Scapellato F, Eleuteri E, Imparato A, Giannuzzi P (2010) Doppler echocardiography in advanced systolic heart failure: a noninvasive alternative to Swan-Ganz catheter. Circ Heart Fail 3:387–394
    • View reference on publisher's website
    • View reference on PubMed
  41. Tian Z, Liu YT, Fang Q, Ni C, Chen TB, Fang LG, Gao P, Jiang XC, Li MT, Zeng XF (2011) Hemodynamic parameters obtained by transthoracic echocardiography and right heart catheterization: a comparative study in patients with pulmonary hypertension. Chin Med J 124:1796–1801
    • View reference on PubMed
  42. Huang SJ, McLean AS (2012) Appreciating the strengths and weaknesses of transthoracic echocardiography in hemodynamic assessments. Cardiol Res Pract 2012:894308
    • View reference on PubMed
  43. van den Berg PC, Grimbergen CA, Spaan JA, Pinsky MR (1997) Positive pressure inspiration differentially affects right and left ventricular outputs in postoperative cardiac surgery patients. J Crit Care 12:56–65
    • View reference on publisher's website
    • View reference on PubMed
  44. Pinsky MR (2007) Heart–lung interactions. Curr Opin Crit Care 13:528–531
    • View reference on publisher's website
    • View reference on PubMed
  45. Hansen KL, Udesen J, Thomsen C, Jensen JA, Nielsen MB (2009) In vivo validation of a blood vector velocity estimator with MR angiography. IEEE Trans Ultrason Ferroelectr Freq Control 56:91–100
    • View reference on publisher's website
    • View reference on PubMed
  46. Hansen KL, Moller-Sorensen H, Kjaergaard J, Jensen, MB, Lund, JT, Pedersen MM, Olesen JB, Jensen JA, Nielsen MB (2015) Vector flow imaging compared with conventional Doppler ultrasound and thermodilution for estimation of blood flow in the ascending aorta. Ultrason Imaging. doi:10.1177/0161734615620137
  47. Dubrey SW, Falk RH (1997) Optimal number of beats for the Doppler measurement of cardiac output in atrial fibrillation. J Am Soc Echocardiogr 10:67–71
    • View reference on publisher's website
    • View reference on PubMed
  48. Nishikawa T, Dohi S (1993) Errors in the measurement of cardiac output by thermodilution. Can J Anaesth 40:142–153
    • View reference on publisher's website
    • View reference on PubMed
  49. Vincent JL, Rhodes A, Perel A, Martin GS, Della Rocca G, Vallet B, Pinsky MR, Hofer CK, Teboul JL, de Boode WP, Scolletta S, Vieillard-Baron A, De Backer D, Walley KR, Maggiorini M, Singer M (2011) Clinical review: update on hemodynamic monitoring—a consensus of 16. Crit Care 15:229
    • View reference on publisher's website
    • View reference on PubMed
  50. Rhodes A, Cusack RJ, Newman PJ, Grounds RM, Bennett ED (2002) A randomised, controlled trial of the pulmonary artery catheter in critically ill patients. Intensive Care Med 28:256–264
  51. Jansen JR (1995) The thermodilution method for the clinical assessment of cardiac output. Intensive Care Med 21:691–697
  52. Jullien T, Valtier B, Hongnat JM, Dubourg O, Bourdarias JP, Jardin F (1995) Incidence of tricuspid regurgitation and vena caval backward flow in mechanically ventilated patients. A color Doppler and contrast echocardiographic study. Chest 107:488–493
    • View reference on publisher's website
    • View reference on PubMed
  53. Artucio H, Hurtado J, Zimet L, de Paula J, Beron M (1997) PEEP-induced tricuspid regurgitation. Intensive Care Med 23:836–840
  54. Balik M, Pachl J, Hendl J (2002) Effect of the degree of tricuspid regurgitation on cardiac output measurements by thermodilution. Intensive Care Med 28:1117–1121
  55. Thiele RH, Bartels K, Gan TJ (2015) Cardiac output monitoring: a contemporary assessment and review. Crit Care Med 43:177–185
    • View reference on publisher's website
    • View reference on PubMed
  56. Ostergaard M, Nilsson LB, Nilsson JC, Rasmussen JP, Berthelsen PG (2005) Precision of bolus thermodilution cardiac output measurements in patients with atrial fibrillation. Acta Anaesthesiol Scand 49:366–372
    • View reference on publisher's website
    • View reference on PubMed
  57. Reuter DA, Huang C, Edrich T, Shernan SK, Eltzschig HK (2010) Cardiac output monitoring using indicator-dilution techniques: basics, limits, and perspectives. Anesth Analg 110:799–811
    • View reference on publisher's website
    • View reference on PubMed
  58. Leibowitz AB, Oropello JM (2007) The pulmonary artery catheter in anesthesia practice in 2007: an historical overview with emphasis on the past 6 years. Semin Cardiothorac Vasc Anesth 11:162–176
    • View reference on publisher's website
    • View reference on PubMed
  59. Lee AJ, Cohn JH, Ranasinghe JS (2011) Cardiac output assessed by invasive and minimally invasive techniques. Anesthesiol Res Pract 2011:475151
    • View reference on PubMed
  60. Cecconi M, Rhodes A, Poloniecki J, Della Rocca G, Grounds RM (2009) Bench-to-bedside review: the importance of the precision of the reference technique in method comparison studies—with specific reference to the measurement of cardiac output. Crit Care 13:201
    • View reference on publisher's website
    • View reference on PubMed
  61. Critchley LA, Critchley JA (1999) A meta-analysis of studies using bias and precision statistics to compare cardiac output measurement techniques. J Clin Monit Comput 15:85–91
    • View reference on publisher's website
    • View reference on PubMed
  62. Critchley LA, Lee A, Ho AM (2010) A critical review of the ability of continuous cardiac output monitors to measure trends in cardiac output. Anesth Analg 111:1180–1192
    • View reference on publisher's website
    • View reference on PubMed
  63. Critchley LA, Yang XX, Lee A (2011) Assessment of trending ability of cardiac output monitors by polar plot methodology. J Cardiothorac Vasc Anesth 25:536–546
    • View reference on publisher's website
    • View reference on PubMed
  64. Squara P, Cecconi M, Rhodes A, Singer M, Chiche JD (2009) Tracking changes in cardiac output: methodological considerations for the validation of monitoring devices. Intensive Care Med 35:1801–1808
  65. Geisen M, Spray D, Nicholas Fletcher S (2014) Echocardiography-based hemodynamic management in the cardiac surgical intensive care unit. J Cardiothorac Vasc Anesth 28:733–744
    • View reference on publisher's website
    • View reference on PubMed
  66. Huttemann E (2006) Transoesophageal echocardiography in critical care. Minerva Anestesiol 72:891–913
    • View reference on PubMed

Sign In

Connect with ICM

Top 5 Articles Editors Picks Supplement