What is the lowest change in cardiac output that transthoracic echocardiography can detect?

Mathieu Jozwiak, Pablo Mercado, Jean-Louis Teboul, Anouar Benmalek, Julia Gimenez, François Dépret, Christian Richard, Xavier Monnet, Mathieu Jozwiak, Pablo Mercado, Jean-Louis Teboul, Anouar Benmalek, Julia Gimenez, François Dépret, Christian Richard, Xavier Monnet

Abstract

Background: In critically ill patients, changes in the velocity-time integral (VTI) of the left ventricular outflow tract, measured by transthoracic echocardiography (TTE), are often used to non-invasively assess the response to fluid administration or for performing tests assessing fluid responsiveness. However, the precision of TTE measurements has not yet been investigated in such patients. First, we aimed at assessing how many measurements should be averaged within one TTE examination to reach a sufficient precision for various variables. Second, we aimed at identifying the least significant change (LSC) of these variables between successive TTE examinations.

Methods: We prospectively included 100 haemodynamically stable patients in whom TTE examination was planned. Three TTE examinations were performed, the first and the third by one operator and the second by another one. We calculated the precision and LSC (1) within one examination depending on the number of averaged measurements and (2) between measurements performed in two successive examinations.

Results: In patients in sinus rhythm, averaging three measurements within an examination was enough for obtaining an acceptable precision (interquartile range highest value < 10%) for VTI. In patients with atrial fibrillation, averaging five measurements was necessary. The precision of some other common TTE variables depending on the number of measurements is provided. Between two successive examinations performed by the same operator, the LSC was 11 [5-18]% for VTI. If two operators performed the examinations, the LSC for VTI significantly increased to 14 [8-26]%. The LSC between two examinations for other TTE variables is also provided.

Conclusions: Averaging three measurements within one TTE examination is enough for obtaining precise measurements for VTI in patients in sinus rhythm but not in patients with atrial fibrillation. Between two TTE examinations performed by the same operator, the LSC of VTI is compatible with the assessment of the effects of a 500-mL fluid infusion but is not precise enough for assessing the effects of some tests predicting preload responsiveness.

Keywords: Fluid challenge; Fluid responsiveness; Intensive care unit; Ultrasound; Velocity-time integral.

Conflict of interest statement

Ethics approval and consent to participate

This study was approved by the Institutional Review Board of our institution (Comité pour la protection des personnes Ile de France VII, number IDRCB 2016-A00939-42). All patients or next of kin were informed about the study and consented to participate.

Consent for publication

Not applicable.

Competing interests

JLT and XM are members of the medical advisory board of Pulsion Medical Systems. The other authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Figures

Fig. 1
Fig. 1
Method for assessing intra-examination precision (a) and inter-examination least significant change (b). CV coefficient of variation, SD standard deviation. Asterisk indicates that for the sake of simplicity, the figure is presented as if all end-expiratory cycles were consecutive. If we could not record enough cycles during the end-expiratory period of one cycle, the values recorded during the end-expiration in several cycles were used
Fig. 2
Fig. 2
Intra-examination precision according to the number of measurements averaged within one transthoracic echocardiography examination. Data are expressed as median and interquartile ranges. *p < 0.05 sinus rhythm vs. atrial fibrillation. Solid lines indicate patients in sinus rhythm (n = 84). Dashed lines indicate patients with atrial fibrillation (n = 16). E/e’ ratio, ratio of the early peak velocity of transmitral flow over the early diastolic peak velocity of the lateral mitral annulus; LVEF, left ventricular ejection fraction; RVEDA/LVEDA ratio, ratio of the end-diastolic right over left ventricular areas; TAPSE, tricuspid annular plane systolic excursion; VTI, velocity-time integral
Fig. 3
Fig. 3
Inter-examination least significant change (LSC) between two transthoracic echocardiography examinations performed by the same operator. Data are expressed as median and interquartile ranges. a Solid lines indicate patients in sinus rhythm (n = 84). Dashed lines indicate patients with atrial fibrillation (n = 16). b Solid lines indicate patients without invasive mechanical ventilation (n = 46). Dashed lines indicate patients with invasive mechanical ventilation (n = 54). E/e’ ratio, ratio of the early peak velocity of transmitral flow over the early diastolic peak velocity of the lateral mitral annulus; LVEF, left ventricular ejection fraction; RVEDA/LVEDA ratio, ratio of the end-diastolic right over left ventricular areas; TAPSE, tricuspid annular plane systolic excursion; VTI, velocity-time integral

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