A lecture highlighting the role of Echocardiography as a major hemodynamic monitoring tool in the Intensive Care settings and the assessment of loading conditions.

1. Non-invasive Hemodynamic Monitoring by
Echocardiography and Assessment of Loading
Conditions
Senior Clinical Fellow
Adult Intensive Care
Royal Brompton Hospital, London, UK
hatem.soliman@gmail.com
@hatemsoliman
ECHO Network Workshop, Royal Papworth Hospital,
Cambridge. October 12th, 2018
Dr. Hatem Soliman Aboumarie
MBBS, MRCP, MSc (ICM), PGDip (Cardio), EDICM, ASCeXAM

3. Outline
Volume status and Central venous pressure
Pulmonary artery hemodynamics
Left sided filling pressures
Cardiac output and shock states

4. Volume Status

5. Volume Status
Static parameters: IVC & LVEDA
Dynamic parameters for the assessment of fluid responsiveness
Systemic venous flow: Vena cavae, jugular and hepatic veins
Tricuspid valve inflow and tissue Doppler imaging

6. LVEDA
Left parasternal short-axis view, mid-papillary level
Normal: 9.5–22 cm2; very low (<5.5 cm2/m2 BSA)  Hypovolemia
Suboptimal image quality (especially endocardial definition
and off-axis position)
Pitfall
Leung JM, Levine EH. Anesthesiology 1994 Nov;81(5)1102-1109.
Static parameters

7. Measuring the IVC
0.5– 3 cm from the caval–atrial junction in the subcostal view

8. IVC vs. RAP GuidelinesStatic parameters
ASE Guidelines

9.  cardiac index
 RV afterload
Courtesy of Prof. Xavier Monnet
Mechanical breath  Biphasic response
Early  LV SV (due to squeezing pulmonary
blood volume)
Few beats later  LV SV (due reduced RV
SV)

10. Respiratory Variations

11. Heart-lung interactions
IVC/SVC Collapsibility (Spontaneous Breathing)
IVC/SVC Dispensability (Mechanical Ventilation)
CO/SV/aortic velocity variability (Mechanical Ventilation)
C. Charron, V. Caille et al, Current Opinion in Critical Care, vol. 12, no. 3, pp. 249–254, 2006.
Volume responsiveness  SV by 15% or more after a fluid challenge

12. Collapsibility Index
CI = (Dmax − Dmin )/Dmax x 100%
DI = (Dmax − Dmin )/Dmin x 100%
In Mechanically Ventilated patients
Distensibility Index
In the spontaneously breathing patient

13. Barbier C, et al Intensive Care Med. 2004 Sep;30(9):1740-1746.
IVC Distensibility Index
Fluid responsive

14. SVC Collapsibility Index
= (Dmax - Dmin)/Dmax x 100
SVC collapsibility index of >36%  Fluid responsive.
Vieillard-Baron A. et al 2004. Intensive Care Medicine 30 1734–1739.
The most reliable index of fluid responsiveness

15. Movement in and out of plane  will exaggerate IVC collapsibility
Beware of hepatic vein confluence
Do not mistakenly interrogate the aorta
Falsely  : RV failure, tamponade, pulmonary embolism, TR, pulmonary
hypertension, ECMO cannulae
Falsely  : Increased intra-abdominal pressure, status asthmaticus
IVC Pitfalls

16. A pre-bolus threshold of 12% discriminates
between responders and non-responders.
Aortic Blood Velocity Respiratory Variation
Teboul JL et al. Chest 2001, 119:867–873

17. Pitfalls
Beware of RV failure
Cor pulmonale
Severe ARDS
Severe pulmonary hypertension
Cardiac translation  ↗ AoV variability
High PEEP  ↗ AoV variability
Invalid if open chest

18. Passive Leg Raise (PLR)
Gives 300-500 mL auto-transfusion
Only dynamic test validated in spontaneously
breathing patients.
Be careful
Abdominal compartment syndrome
Unstable pelvic/low lumbar fracture
12%PLR-induced changes in VTIAo
Lamia B, et al. Intensive Care Med. 2007;33:1125-1132.
Maizel J, et al. Intensive Care Med. 2007;33:1133-1138.

19. Volume Status
Static parameters: IVC & LVEDA
Dynamic parameters for the assessment of fluid responsiveness
Systemic venous flow: Vena cavae, jugular and hepatic veins
Tricuspid valve inflow and tissue Doppler imaging

20. Systemic venous flow
Pitfalls
Severe TR  alters systolic venous flow pattern
AF, Post-cardiac surgery  reduces hepatic vein systolic flow regardless of RAP
Vs > Vd  Normal CVP/RAP
Vs < Vd  Elevated CVP/RAP (>8 mm Hg)
Ghio S, Recusani F et al. Echocardiography 2001;18:469–77.
Vena cavae, jugular, hepatic veins

21. Tricuspid valve inflow
E/e’ > 6  CVP/RAP > 10 mm Hg
Pitfalls
Adequate in mech. ventilated patients  IVC might not be applicable
May not be accurate in patients who have undergone cardiac surgery
Nageh MF, et al . Am. J. Cardiol. 1999;84:1448–1451, A8.

22. Pulmonary Artery Hemodynamics

23. Pulmonary Artery Hemodynamics
Systolic PA Pressure
Diastolic PA Pressure
Mean PA Pressure
Pulmonary Vascular Resistance

24. Systolic PA Pressure
Well validated
TR peak systolic gradient + RAP = SPAP
In absence of pulmonic stenosis

25. Pearls
Use multiple imaging planes
Color Doppler signals should be used for optimal alignment with the
regurgitant jet.
Injection of agitated saline  enhance the Doppler flow velocity
tracing and give a better signal  reducing the false-negative
results.

26. Pitfalls
Variations in angle of
interrogation
Underestimation of
RAP
Severe TR
Poor TR signal
Underestimation Overestimation
overestimation of the RAP
overestimation of the TR peak
velocity
Mistakenly using the TV closing spike
for the tricuspid peak velocity.

27. Diastolic PA Pressure
PR end-diastolic gradient + RAP = DPAP

28. Mean PA Pressure
Mean TR gradient + RAP (easiest)
Peak PR gradient + RAP
DPAP + 1/3 (SPAP-DPAP)

29. Pulmonary Vascular Resistance
Abbas AE, et al. J Am Coll Cardiol 2003;41:1021–7.
PVR (WU) = (TR velocity/RVOT VTI) x 10 + 0.16 (Abbas Formula)
(3.9/10.2) x 10 + 0.16 = 3.98 WU
Significant pulmonary HTN = PVR > 3 WU

30. Left sided filling pressures

31. Left-sided filling pressures
Mitral inflow parameters
Pulmonary venous flow
Left atrial dimensions

32. 50% of patients with acute heart failure have preserved
ejection fraction
TDI analysis of the mitral annulus allows for
rapid estimation of left atrial pressure
Left-sided filling pressures

33. E/A ratio >2 and E wave deceleration time <120 ms predict a
LAP >20 mmHg
Lateral e′ <10 and medial e’<7 cm/s are highly suggestive of
diastolic dysfunction and elevated left atrial pressures
Average E/e′ of >14 elevated left atrial pressure
Pearl
Cut-off of E/e′ In Mechanically Ventilated patients 12
Left-sided filling pressures

34. Nagueh Formula
PCWP = 1.24 x (E/e') + 1.9
e' = (e'lateral + e'septal) / 2
www.csecho.ca/cardiomath
Nagueh SF et al. J Am Coll Cardiol 1997;30:1527-1533
www.csecho.ca/cardiomath
Left-sided filling pressures

35. Pitfall
E/e′ ratio is not accurate in normal subjects, patients with
heavy annular calcification, mitral valve and pericardial
disease.
Nagueh S. et al EHJ-CVI (2016) 17, 1321–1360

36. Left-sided filling pressures
Mitral inflow
Mitral annulus
Pulmonary venous flow
Left atrial size

37. Lung US for B-lines

38. Cardiac Output

39. CO = HR X Stroke Volume
Cardiac output
SV = LVOT CSA x LVOT VTI

40. (LVOT area x LVOT VTI)
VTI = Velocity Time Integral
LVOT Area = 3.14 x (1⁄2 LVOT diameter)2
Stroke Volume

41. Pearls
The LVOT VTI a surrogate for the stroke volume
Normal value >20 cm
Record the measured LVOT area in the pt. records
Average of 5-10 beats in AF

42. SV variations are exaggerated with:
Pitfalls
Hypovolaemia Larger Tidal Volumes
Cardiac tamponade
Presumes LVOT is circular. It isn’t!
Non-alignment of Doppler beam: VTI will be underestimated
Error in LVOT diameter will be squared

43. Cardiogenic
DistributiveHypovolaemic
Obstructive
Shock

44. Dilated right chambers
Decreased cardiac output
RV/LV area ratio >0.6;
gross dilatation is seen
with a ratio >1.0
Acute PE
Changes in right ventricular contraction
Elevated pulmonary artery pressures
Intra‐ cavity emboli
Normal
Hyperdynamic
Hypodynamic

45. Acute PE
PAcT of 70– 90 ms indicates a pulmonary
artery systolic pressure of >70 mmHg
Mid‐systolic notch also indicates severe
pulmonary hypertension
D‐ shaped LV

46. RA systolic collapse for longer than one-third
of the cardiac cycle
Cardiac Tamponade
RV diastolic collapse
Echo Findings
RA then RVOT then whole RV then LA then LV.
Dilated IVC

47. Exaggerated respiratory variations of the mitral and tricuspid inflow
(Pulsus Paradoxus)
Cardiac Tamponade
Echo Findings

48. The opposite of respiratory variations if positive pressure
ventilation
Cardiac Tamponade
Pitfalls
The speed of accumulation rather than the amount
pVA-ECMO  Not an Echo diagnosis unless flows are compromised

49. Typical with basal septal hypertrophy
Dynamic LVOT Obstruction
Close approximation of lateral wall and septum
Echo Findings
Systolic anterior motion of the anterior mitral leaflet.
Dagger-shaped Doppler pattern of LVOT flow

50. Pitfall
Tachycardia, hypovolemia, and inotropes makes critically ill more prone to it
Dynamic LVOT Obstruction

51. Monitoring of the pt on pVA-ECMO
Underlying LV dysfunction
 afterload due to retrograde VA ECMO flow
Insufficient unloading of LV
Pulmonary congestion, edema, hemorrhage.Blood stagnation in LV

52. LV unloading
Before septostomy After septostomy

53. Weaning and Recovery
LVEF > 35-40%
LVED diameter < 55mm
Aortic velocity time integral (VTI) >10 cm
Aortic Valve opening pattern
Absence of LV dilatation
Intensive Care Med (2015) 41:902-905.

54. Echo-guided ventilator weaning algorithm

55. 6-hour Bundle
April, 2015, www.survivingsepsis.org

56. Integrated
Approach

57. Echo is the single most useful non-invasive hemodynamic tool
PCWP evaluation is possible by Echocardiography
LVOT VTI is a useful surrogate for LV Stroke Volume
1
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take-home messages5
Integrated approach is the key to proper management4
Proper training, accreditation and quality control is pramount.5

58. The Anatomy Lesson of Dr. Nicolaes Tulp. 1632. Rembrandt

60. Non-invasive Hemodynamic Monitoring by
Echocardiography and Assessment of Loading
Conditions
Senior Clinical Fellow
Adult Intensive Care
Royal Brompton Hospital, London, UK
hatem.soliman@gmail.com
@hatemsoliman
ECHO Network Workshop, Royal Papworth Hospital,
Cambridge. October 12th, 2018
Dr. Hatem Soliman Aboumarie
MBBS, MRCP, MSc (ICM), PGDip (Cardio), EDICM, ASCeXAM