Comparison of subclavian vein to inferior vena cava collapsibility by ultrasound in acute heart failure: A pilot study
Yvonne E Kaptein, Elaine M Kaptein, Yvonne E Kaptein, Elaine M Kaptein
Abstract
Background: Management of acute decompensated heart failure (ADHF) requires accurate assessment of relative intravascular volume, which may be technically challenging. Inferior vena cava (IVC) collapsibility with respiration reflects intravascular volume and right atrial pressure (RAP). Subclavian vein (SCV) collapsibility may provide an alternative.
Hypothesis: The purpose of this study was to examine the relationship between SCV collapsibility index (CI) and IVC CI in ADHF.
Methods: This was a prospective study of non-ventilated patients with ADHF who had paired IVC and SCV ultrasound assessments. As SCV CI is highly position-dependent, measurements were performed supine at 30-45°.
Results: Thirty-three patients were included with 36 encounters. The sample size was adequately powered for receiver-operator characteristic (ROC) analysis. SCV CI correlated with IVC CI during relaxed breathing (R = .65, n = 36, p < .001) and forced inhalation (R = .47, n = 36, p = .0036). SCV CI < 22% and >33% corresponded to IVC CI < 20% and >50% suggesting hypervolemia (sensitivity/specificity: 72%) and hypovolemia (sensitivity/specificity: 78%), respectively. Moderate to severe tricuspid regurgitation (TR) compared to less than moderate TR was associated with lower SCV CI (medians: 12.4% vs. 25.3%, p = .022) and IVC CI (medians: 9.6% vs. 35.6%, p = .0012). SCV CI and IVC CI were not significantly different among chronic kidney disease stages.
Conclusion: In non-ventilated ADHF, SCV CI at 30-45° correlates with paired IVC CI, and may provide an alternative to IVC CI for assessment of relative intravascular volume, which may facilitate clinical management. Moderate to severe TR decreases SCV CI and IVC CI and may result in overestimation of relative intravascular volume.
Keywords: acute decompensated heart failure; inferior vena cava ultrasound; subclavian/proximal axillary vein ultrasound; tricuspid regurgitation.
Conflict of interest statement
The authors declare that there is no conflict of interest.
© 2021 The Authors. Clinical Cardiology published by Wiley Periodicals LLC.
Figures
References
- Tuy T, Peacock WF. Fluid overload assessment and management in heart failure patients. Sem Nephrol. 2012;32(1):112‐120.
- Kaptein MJ, Kaptein EM. Focused real‐time ultrasonography for nephrologists. Int J Nephrol. 2017;2017:3756857.
- Rudski LG, Lai WW, Afilalo J, et al. Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography. J Am Soc Echocardiogr. 2010;23(7):685‐713.
- Beigel R, Cercek B, Luo H, Siegel RJ. Noninvasive evaluation of right atrial pressure. J Am Soc Echocardiogr. 2013;26(9):1033‐1042.
- Toma M, Giovinazzo S, Crimi G, et al. Multiparametric vs. inferior vena cava‐based estimation of right atrial pressure. Front Cardiovasc Med. 2021;8:632302.
- Gaskamp M, Blubaugh M, McCarthy LH, Scheid DC. Can bedside ultrasound inferior vena cava measurements accurately diagnose congestive heart failure in the emergency department? a clin‐IQ. J Patient Cent Res Rev. 2016;3(4):230‐234.
- Goonewardena SN, Gemignani A, Ronan A, et al. Comparison of hand‐carried ultrasound assessment of the inferior vena cava and N‐terminal pro‐brain natriuretic peptide for predicting readmission after hospitalization for acute decompensated heart failure. JACC Cardiovasc Imaging. 2008;1(5):595‐601.
- Monnet X, Teboul JL. Prediction of fluid responsiveness in spontaneously breathing patients. Ann Transl Med. 2020;8(12):790.
- Bentzer P, Griesdale DE, Boyd J, MacLean K, Sirounis D, Ayas NT. Will this hemodynamically unstable patient respond to a bolus of intravenous fluids? JAMA. 2016;316(12):1298‐1309.
- Kaptein MJ, Kaptein EM. Inferior vena cava collapsibility index: clinical validation and application for assessment of relative intravascular volume. Adv Chronic Kidney Dis. 2021;28(3):218‐226.
- Si X, Cao D, Xu H, Guan X. Meta‐analysis of ventilated versus spontaneously breathing patients in predicting fluid responsiveness by inferior vena cava variation. Int J Clin Med. 2018;9:760‐777.
- Giraud R, Abraham PS, Brindel P, Siegenthaler N, Bendjelid K. Respiratory changes in subclavian vein diameters predicts fluid responsiveness in intensive care patients: a pilot study. J Clin Monit Comput. 2018;32:1049‐1055.
- Blehar DJ, Dickman E, Gaspari R. Identification of congestive heart failure via respiratory variation of inferior vena cava diameter. Am J Emerg Med. 2009;27(1):71‐75.
- Capomolla S, Febo O, Caporotondi A, et al. Non‐invasive estimation of right atrial pressure by combinded Doppler echocardiographic measurements of the inferior vena cava in patients with congestive heart failure. Ital Heart J. 2000;1(10):684‐690.
- Vaturi M, Shapira Y, Vaknin‐Assa H, Oron A, Matesko R, Sagie A. Echocardiographic markers of severe tricuspid regurgitation associated with right‐sided congestive heart failure. J Heart Valve Dis. 2003;12(2):197‐201.
- Kaptein MJ, Kaptein JS, Oo Z, Kaptein EM. Relationship of inferior vena cava collapsibility to ultrafiltration volume achieved in critically ill hemodialysis patients. Int J Nephrol Renovasc Dis. 2018;11:195‐209.
- Kaptein MJ, Kaptein JS, Nguyen CD, et al. Changes in cardiac output with hemodialysis relate to net volume balance and to inferior vena cava ultrasound collapsibility in critically ill patients. Ren Fail. 2020;42(1):179‐192.
- Nishimura RA, Otto CM, Bonow RO, et al. AHA/ACC guideline for the management of patients with valvular heart disease: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014;63(22):2438‐88.
- Via G, Tavazzi G, Price S. Ten situations where inferior vena cava ultrasound may fail to accurately predict fluid responsiveness: a physiologically based point of view. Intensive Care Med. 2016;42(7):1164‐1167.
- Shapira Y, Porter A, Wurzel M, Vaturi M, Sagie A. Evaluation of tricuspid regurgitation severity: echocardiographic and clinical correlation. J Am Soc Echocardiogr. 1998;11(6):652‐659.
- Kent A, Bahner DP, Boulger CT, et al. Sonographic evaluation of intravascular volume status in the surgical intensive care unit: a prospective comparison of subclavian vein and inferior vena cava collapsibility index. J Surg Res. 2013;184(1):561‐566.
- Munir A, D'Cruz I, Minderman D, Shelton M. The right subclavian vein can be used as a surrogate of the inferior vena cava, as an echocardiographic indicator of systemic venous congestion. Am J Med Sci. 2007;333(5):280‐284.
- Kaptein EM, Cantillep A, Kaptein JS, et al. Comparison of respiratory variations of subclavian vein and inferior vena cava in hospitalized patients with kidney disease. Int J Nephrol Renovasc Dis. 2020;13:329‐339.
- Molokoane‐Mokgoro K, Goldstein LN, Wells M. Ultrasound evaluation of the respiratory changes of the inferior vena cava and axillary vein diameter at rest and during positive pressure ventilation in spontaneously breathing healthy volunteers. EMJ. 2018;35(5):297‐302.
- Finnerty NM, Panchal AR, Boulger C, et al. Inferior vena cava measurement with ultrasound: what is the best view and best mode? West J Emerg Med. 2017;18(3):496‐501.
- Fields JM, Lee PA, Jenq KY, Mark DG, Panebianco NL, Dean AJ. The interrater reliability of inferior vena cava ultrasound by bedside clinician sonographers in emergency department patients. Acad Emerg Med. 2011;18(1):98‐101.
- Berthelot E, Jourdain P, Bailly MT, et al. Echocardiographic evaluation of left ventricular filling pressure in patients with heart failure with preserved ejection fraction: usefulness of inferior vena cava measurements and 2016 EACVI/ASE recommendations. J Card Failure. 2020;26(6):507‐514.
- Kircher BJ, Himelman RB, Schiller NB. Noninvasive estimation of right atrial pressure from the inspiratory collapse of the inferior vena cava. Am J Cardiol. 1990;66(4):493‐496.
- Nakao S, Come PC, McKay RG, Ransil BJ. Effects of positional changes on inferior vena caval size and dynamics and correlations with right‐sided cardiac pressure. Am J Cardiol. 1987;59(1):125‐132.
- Moreno FL, Hagan AD, Holmen JR, Pryor TA, Strickland RD, Castle CH. Evaluation of size and dynamics of the inferior vena cava as an index of right‐sided cardiac function. Am J Cardiol. 1984;53(4):579‐585.
- Goksuluk D, Korkmaz S, Zararsiz G, et al. easyROC: a web‐tool for ROC curve analysis (ver. 1.3.1). 2016. Accessed November 18, 2021.
- Goksuluk D, Korkmaz S, Zararsiz G, Karaagaoglu AE. easyROC: an interactive web‐tool for ROC curve analysis using R language environment. The R Journal. 2016;8(2):213‐230.
- Panebianco NL, Shofer F, Cheng A, Fischer J, Cody K, Dean AJ. The effect of supine versus upright patient positioning on inferior vena cava metrics. Am J Emerg Med. 2014;32(11):1326‐1329.
Source: PubMed