Hemodynamic Monitoring Utilizing

Transesophageal Echocardiography: The

Relationships Among Pressure, Flow, and
Function
Jan I. Poelaert and Guido Schüpfer

Chest 2005;127;379-390
DOI 10.1378/chest.127.1.379
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 opinions/hypotheses
Hemodynamic Monitoring Utilizing
Transesophageal Echocardiography*
The Relationships Among Pressure, Flow, and
Function
Jan I. Poelaert, MD, PhD, FCCP; and Guido Schüpfer, MD

(CHEST 2005; 127:379 –390) hospitalized patients was found to be as high as 57%,
although changes occurred more frequently in ICU
Key words: echocardiography; hemodynamic; left ventricular
function; monitoring
patients compared to those admitted to the hospital
(54% vs 37%, respectively).1,2 Nevertheless, the
Abbreviations: A wave ⫽ late-filling wave; CW ⫽ continuous-
transthoracic approach for echocardiography has
wave; ⫹dP/dtmax ⫽ positive maximum first derivative of pres- certain specific limitations regarding the visualiza-
sure, corrected for time; Ea ⫽ arterial elastance; E/A ⫽ ratio of tion of different cardiac structures and great vessels.
the early and rapid-filling wave to the late-filling wave; E
wave ⫽ early and rapid-filling wave; LA ⫽ left atrium atrial; Table 1 demonstrates in detail the potential advan-
LAP ⫽ left atrial pressure; LV ⫽ left ventricle/ventricular; tages and shortcomings of both techniques. Trans-
LVEDA ⫽ left ventricular end-diastolic area; LVEDP ⫽ left esophageal echocardiography (TEE) with Doppler
ventricular end-diastolic pressure; LVEDV ⫽ left ventricular
end-diastolic volume; PCWP ⫽ pulmonary capillary wedge pres- imaging has opened a completely different window,
sure; PW ⫽ pulsed-wave; PWR ⫽ cardiac power; RV ⫽ right and has become a fascinating and appealing tool, not
ventricle/ventricular; RVOT ⫽ right ventricular outflow tract;
SV ⫽ stroke volume; TDI ⫽ tissue Doppler imaging; TEE ⫽ only for diagnosis in routine cardiology practice3 but
transesophageal echocardiography; VTI ⫽ velocity-time integral also for perioperative hemodynamic monitoring,
having a decisive impact on surgical management.
Moreover, owing to its bedside availability, TEE
C ardiac imaging is an important cornerstone in
decision making and management in cardiovas-
facilitates the routine diagnosis and management of
cardiovascular failure both intraoperatively and in
cular medicine. Echocardiography and Doppler ul-
trasonography developed as the main and most ICU patients.4
commonly used bedside imaging techniques. Trans- Circulatory failure of cardiac origin in adults often
thoracic echocardiography is an invaluable imaging is due to ventricular failure. More than 50% of all
technique with respect to the diagnosis of cardio- patients who are scheduled for surgery or are admit-
vascular disease. The impact of echocardiography ted to the ICU have experienced cardiac problems.
on the change in the therapy and management of Impaired cardiac function, which is often seen in
critically ill patients, is mostly evidenced as pump
*From the Department of ICU (Dr. Poelaert), University Hos- failure. Several etiologic factors of pump dysfunction
pital, Gent, Belgium; and Klinik für Anästhesie und Operative (eg, ischemia, septic cardiomyopathy, inflammatory
Intensivmedizin (Dr. Schüpfer), Kantonsspital, Luzern, Switzer- responses, right ventricular (RV) failure in conjunc-
land.
This research was supported in part with a grant from the tion with pulmonary hypertension, or a combination
International Research Centre, Gent, Belgium. Jan Poelaert was of several factors) have been well-studied during the
supported by a grant from the Research Fund “Bijzonder last decades. Left ventricular (LV) function is a
Onderzoeksfonds” (No. B/03719) of Ghent University, Gent,
Belgium (2002–2003). determinative parameter in various diseases, al-
Manuscript received January 9, 2004; revision accepted August though the role of the RV in critically ill patients
24, 2004. should not be underestimated.5 Therefore, the clin-
Reproduction of this article is prohibited without written permis-
sion from the American College of Chest Physicians (e-mail: ical evaluation of cardiac function must pertain to the
permissions@chestnet.org). assessment of the LV and the RV with respect to
Correspondence to: Jan Poelaert, MD, PhD, FCCP, Cardiac increased morbidity and mortality. Crucial in the
Anaesthesia and Postoperative Cardiac Surgical ICU, Depart-
ment of ICU, University Hospital, De Pintelaan 185, B9000 Gent, discussion is the early detection of LV systolic and
Belgium; e-mail: jan.poelaert@ugent.be diastolic dysfunction by sensitive monitors, in partic-

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 Table 1—Indications of Transthoracic Pressure and Flow
Echocardiography and TEE
Several pressures are used in daily clinical practice
Transthoracic
Echocardiography TEE
to outline ventricular preload. In this section, the
relationship between various currently used pres-
General screening—overall Hemodynamic instability sures and intracardiac flows will be discussed. In
evaluation
Hemodynamic evaluation Echocardiography when
order to obtain relevant measurements of flow,
ventilated patient (also Doppler echocardiography has to be used. When an
when prone ventilation) ultrasound beam strikes a moving object (eg, a
Exclusion of tamponade Tamponade (local) moving RBC), the frequency of the reflected sound
Pulmonary edema Cardiac surgery: intraoperative is altered. This phenomenon is known as the Dopp-
and postoperative
hemodynamic monitoring
ler shift (Christian Doppler, 1842). Doppler echo-
Noncardiac surgery: cardiography shows the velocity data, which are
intraoperative monitoring derived from the measured frequency shift, and
Acute RV overload (pulmonary Acute RV overload with illustrates them as a spectral display. Movements of
embolism, pulmonary hypoxemia RBCs, which are moving toward the transducer, are
hypertension)
Thoracic trauma (patient not Thoracic trauma (in a
displayed above the zero line, and negative signals
ventilated) ventilated patient) display the movements of the RBCs away from the
Contraindications for TEE Diagnosis/exclusion of thoracic transducer. The following general principles have to
aortic dissection; diagnosis/ be kept in mind when obtaining and interpreting
exclusion of endocarditis; Doppler signals and waveforms9:
exclusion of left atrial
appendage thrombi 1. The Doppler beam must be aligned with the
estimated direction of blood flow. The inter-
cept angle should be ⬍ 20°. Larger angles
induce an unacceptable error. To correct this
ular when rapid fluid shifts occur, as in patients with error, the cosine of the intercept angle must be
hypovolemic or distributive shock. taken into account in calculating the true
LV systolic performance is governed by the fol- Doppler velocity. At an angle of 60°, the trans-
lowing three major determinants: (1) the Frank- mitted velocity will be half that the true veloc-
ity, which is important data in clinical practice.
Starling mechanism, necessitating the measurement
2. Continuous-wave (CW) Doppler ultrasound
of pressures and volumes; (2) contractility, indepen-
must be used whenever high velocities are
dent of loading conditions; and (3) heart rate. An
present. Pulsed-wave (PW) Doppler ultrasound
assessment of ventricular contractility must include can induce an underestimation of flow veloci-
the independence of loading conditions. To describe ties. This is due of the physical characteristics
the hemodynamic status of a patient, most clinicians of both techniques. CW Doppler (with one
routinely employ an analysis of pressures rather than transmitter and one receiver crystal) records
a determination of volumes. Nevertheless, pressures all velocities in the beam axis without a limita-
only provide a rudimentary approximation of the tion in analyzing high flow velocities. Neverthe-
physiologically relevant determinants of ventricular less, CW Doppler lacks the spatial resolution
function, namely, contractility, preload, and after- needed to estimate the correct depth at which
load. Several reviews6 – 8 already have stressed the the measurement is obtained. PW Doppler
elegance of how TEE provides data in this respect. ultrasound is characterized by a crystal, which
Clinically, pressure and flow appear to be the most sends and receives consecutively, considerably
important features. From these parameters, numer- retarding the process of the measurement of
ous variables have been derived describing more Doppler velocities. This allows a precise deter-
precisely hemodynamics of the (left) heart and the mination of the location of the source of the
peripheral circulation. The interplay between pres- frequency shift but immediately limits also the
sure and flow is an important characteristic of car- range of velocity, which can be measured. The
diac function and the dynamics of the circulation that latter can be explained as follows:
is more precise than one parameter alone. The • The depth of the sampling gate. The further
relationship between flow estimated with echocardi- away the sampling place (interrogated tar-
ography and related pressure measurements and the get), the longer the waiting time because of
energy generated by the LV pumping blood into the the consecutiveness of action of both the
circulation is the subject of this review. transmitter crystals and receiver crystals.

380 Opinions/Hypotheses
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 • The PW Doppler ultrasound signal is ob- and volume is difficult to determine, in particular when
tained at the rate of the pulse repetition myocardial ischemia or tamponade occur,21 although,
frequency, which is approaching the fre- in theory, pressure-volume loops will allow the deter-
quency shift of the Doppler effect. mination of LV compliance. The direct assessment of
• With respect to Doppler physics, the trans- ventricular volumes to estimate preload is superior to
ducer must sample twice as fast with a measurements of pressures because of the important
5-MHz probe as with a 2.5-MHz probe to interference by ventricular compliance. Numerous fac-
measure the same Doppler shift. Hence, at tors interfere with this relationship, such as altering
the same pulse repetition frequency the max- compliance during myocardial ischemia, inotropic stim-
imum recordable Doppler velocity with a ulation, and altered intrathoracic pressures.
2.5-MHz probe is twice the recordable ve- Utilizing two-dimensional echocardiography, the
locity with a 5-MHz probe. This phenome- position of the interatrial septum and the curvature
non implies that a 5-MHz probe will scan reflects the relationship between right and left atrial
more superficial layers of tissue than a 2.5- pressures (LAPs).22 Hence, relative pressure differ-
MHz probe. ences between the right and left atrium can be
detected. In addition, the filling status can be
3. The sample volume has to be placed in the roughly estimated. In particular, the movement of
middle of the vessel in order to diminish po- the interatrial septum during the cardiac cycle sug-
tential turbulence. gests pressure differences between the right and left
4. PW Doppler echocardiography is not useful atrium.22 In patients with hypovolemia, this move-
whenever a pressure gradient across a valve is ment is increased. The estimation of RV and LV
present or a subvalvular stenosis has to be preload by means of the position of the interatrial
assessed. In both circumstances, CW Doppler septum cannot be used in the following situations:
echocardiography must be utilized.
• The presence of tricuspid regurgitation with a
Echocardiography is not only an established tool
consequent shift of the septum toward the left
for the assessment of global ventricular function, but
atrium;
appears a well-recognized technique in the evalua-
• Acute mitral regurgitation, in which an increased
tion of regional ventricular function in patients with
septal movement is present; and
potential cardiac disease. For many years, routine
• Mitral stenosis or chronic mitral regurgitation, as
echocardiography allowed only the visual analysis of
in severe LV failure, in which the septal amplitude
a regional dysfunction. The interpretation of myo-
is decreased. This is important information as it
cardial thickening and endocardial motion requires
provides insight into the duration of a diagnosed
an experienced observer, and the method is subjec-
cardiac disease.
tive and not useful in research. Color-coded tissue
Doppler imaging (TDI) was introduced a few years Doppler echocardiography provides a good esti-
ago, permitting the assessment of low-velocity Dopp- mate of left-sided filling pressures using the trans-
ler high-amplitude shifts and the real-time display of mitral flow pattern, the peak flow regurgitation flow
color-coded tissue velocities.10,11 This technique en- velocity, the pulmonary venous flow pattern, and
ables the noninvasive delineation of myocardial ve- myocardial Doppler imaging. The transmitral flow,
locities in a noninvasive manner in the human obtained in a four-chamber view, is directly related
heart11,12 at the level of a segment of the myocardial to the filling of the LV and is governed by the
wall13 or the mitral annulus. In addition, both dia- transmitral pressure gradient. The normal filling
stolic function14,15 and regional systolic function pattern is displayed as a biphasic tracing with an
parameters can be derived from the myocardial wall early and rapid-filling wave (E wave), followed by a
motion Doppler pattern. diastasis period with minimal or no flow (Fig 1).
Finally, a late-filling wave (A wave) follows, caused
by the atrial contraction. Both velocities of the
Left-Sided Filling Pressures
respective flow waves and corresponding time veloc-
Echocardiography permits the indirect estimation of ity integrals are as important characteristics of LV
LV filling pressures in various ways, utilizing both filling.9 Another easily calculated parameter is the
Doppler echocardiography16 –18 and two-dimensional ratio of the peak flow velocities (ie, the ratio of E
echocardiography.18 –20 In patients with normal cardiac wave to A wave [E/A]). A normal flow velocity ratio
function, LV end-diastolic pressure (LVEDP) is di- is in the range of 0.75 to 1.40. The E/A ratio is
rectly related to LV end-diastolic volume (LVEDV). strongly age-dependent. With increasing age, the
Clinically, in patients with decreased ventricular com- E-wave velocity diminishes in favor of the late-filling
pliance, however, the relationship between pressure A wave. It is important to remark that the various

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 Figure 2. A normal pulmonary venous Doppler pattern. Pre-
Figure 1. A normal transmitral flow Doppler pattern. Following ceding a large systolic flow wave, a reverse contraction is seen.
the E wave, the atrial contraction wave is observed. The sometimes biphasic systolic flow wave is followed by the
diastolic flow wave.

Doppler velocities are the resulting effect of several whenever a low filling status is present. The change
physiologic characteristics, such as LV compliance in systolic flow velocity from the pulmonary vein is
and relaxation, left atrial (LA) compliance, mitral directly related to changes in cardiac output. The
valve area, and LA pressure (LAP). In addition, ratio of the systolic time-velocity integral and the
mechanical ventilation23 as well as external con- sum of both systolic and diastolic time-velocity inte-
straints (thrombi in the pericardial sac, stiffness of grals correlates most strongly (r ⫽ ⫺0.88)16 when-
the pericardium, or high positive end-expiratory ever pulmonary venous flow wave duration (the a
pressure ventilation with potential cardiac compres- wave) exceeds the transmitral flow wave. This is
sion by the lungs) affects LV filling. Owing to these usually thought to be a sign of adequate filling
various interfering factors, it is conceivable that there pressures.25 A systolic/diastolic flow velocity ratio of
is no correlation between the early filling velocity ⬍ 0.4 reflects the markedly increased ventricular
and the left-sided filling pressure (ie, LAP). As long filling pressures. This is mainly due to reduced LA
as LAP is low in patients with dilated cardiomyopa- compliance.26 This study also shows that LVEDP is
thy, the E-wave velocity, as well as the E/A ratio, will the main determinant of the systolic velocity of the
be low. With the progression of heart failure in these pulmonary vein Doppler pattern (regression analy-
patients, the E-wave velocity will increase, and the sis). A minor interfering factor is the systolic ventric-
E/A ratio will be ⬎ 1. The higher E-wave velocity ular function. To estimate the LVEDP, a pulmonary
will have a shorter deceleration time, reflecting venous Doppler pattern obtained at one of the inlet
decreased ventricular compliance, making an evolu- orifices of the pulmonary veins should help. A ratio
tion toward a restrictive pattern (E ⬎ A),24 a very of the systolic and diastolic flow wave velocities of
stiff LV with a rapid and important rise of ventricular ⬍ 0.4 is suggestive of an increased LVEDP.27 An-
pressures with small amounts of fluid. other important feature is the ratio of the duration of
When present, mitral regurgitation can also be the atrial reverse flow wave at the level of the
used to estimate LV filling. Doppler echocardiogra- pulmonary veins and the atrial contraction wave at
phy permits the estimation of the LAP using the the level of the mitral valve. The difference between
modified Bernoulli equation, as described in the the duration of the atrial reversal flow and the
following formula17: duration of the atrial inflow wave is independent of
age and thus may be used as a reliable index of
LAP ⫽ RRao ⫺ (4 V2tmf)
LVEDP, even in elderly patients. A reverse a wave
in which RRao is the systolic aortic pressure, and duration that exceeds the duration of the atrial inflow
V2tmf is the transmitral peak regurgitant flow ve- wave predicts an LVEDP of ⬎ 15 mm Hg. No
locity. This method is based on the assumption there correlation was found between this index and the
is no pressure gradient between the LV and the LAP, suggesting that this index is a measure of late
ascending aorta. diastolic LV compliance.28 A significant relationship
The pulmonary venous flow pattern (Fig 2) is a was seen between the systolic pulmonary vein Dopp-
third possibility for estimating left-sided filling pres- ler velocity-time integral (VTI, ie, the area under the
sures.25 The systolic flow wave is frequently biphasic curve of a Doppler signal) and the atrial wave VTI,

382 Opinions/Hypotheses
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suggesting a relation between atrial filling and emp- Estimation of Preload
tying. LVEDP is the main determinant of the systolic
velocity of the pulmonary vein Doppler pattern.18,26 TEE permits good qualitative and quantitative
In clinical practice, all three Doppler methods will parameters to estimate preloading conditions in pa-
be used consecutively. tients with either normal ventricular function or
The systolic forward flow wave in the pulmonary vein dysfunction. The short-axis view is in this respect of
Doppler pattern is preceded by a small reverse atrial the utmost importance. In an adequately sedated
contraction wave. The systolic forward flow wave some- ICU patient, the presence of a hyperdynamic ven-
times shows two peaks, which are related to the atrial tricle in the absence of inotropic drugs could be a
relaxation and the mitral annular descent, respective- sign of hypovolemia.33 In addition, the presence of
ly.25 The systolic flow wave is followed by a diastolic kissing walls, with a potential, nearly complete oblit-
flow wave. The pulmonary capillary wedge pressure eration of the outflow tract, is very suggestive of a
(PCWP) correlates best with the atrial reverse flow low filling status.33
wave velocity (r ⫽ 0.81).25 In a study29 of patients who LV volume assessment is done by tracing the
had experienced acute myocardial infarction, it was end-diastolic endocardial border in a mid-esophageal
shown that PCWP had a strong negative relationship long-axis view in a longitudinal plane.34 The software
with the deceleration time of the pulmonary venous used to calculate the volume in the echocardiograph
Doppler pattern in diastole (r ⫽ ⫺0.89), with a sensi- uses the methods of discs (the Simpson rule), which
tivity and specificity of this measure of ⬍ 160 ms in is an extremely well-validated technique, providing
predicting a PCWP of ⬎ 18 mm Hg of 97% and 96%, very accurate data both in adults and children.35
respectively.29 A quantitative estimation can be performed in dif-
In 1998, Nagueh et al30 demonstrated that left- ferent ways using two-dimensional echocardiogra-
sided filling pressures can also be estimated fairly phy. The LV end-diastolic area (LVEDA), measured
accurately by utilizing Doppler myocardial imaging per definition at the midpapillary level of the LV,
(ie, TDI). TDI assesses velocities of the moving correlates well with volumetric analogues.36 In par-
myocardium and, hence, detects the phase shift of ticular, the changes in LVEDA closely resemble
the ultrasound signals reflected by myocardial tis- the changes in LVEDV. Very suggestive for low
sues. Velocities are much lower (ie, ⬍ 10 to 15 cm/s) filling status of the LV is the LVEDA index, referring
than the blood flow velocities. The amplitude of the to a body surface area of ⬍ 5.5 cm2/m2.37 Other
reflected ultrasound wave is higher (40 decibels). authors described in patients with normal LV func-
These two major changes make important adjust- tion during graded hypovolemia a linear decline of
ments necessary in interpreting the results. LVEDA of 0.3 cm2 per percentage blood loss.38,39 A
Therefore, TDI works with a high-pass filter, good correlation (r ⫽ 0.87) was found between
allowing the low velocities to be measured. The changes in the LVEDA index and intrathoracic blood
Doppler settings are adjusted for a Nyquist limit of volume, which was measured with the dye dilution
20 cm/s with the lowest wall filter and a minimum technique in postoperative cardiac surgical patients,
gain setting. Furthermore, TDI has some beneficial although neither parameter (evidently) correlated
attributes, improving its power to be used in criti- with PCWP.40
cally ill patients as follows: TDI is based on fre- Several shortcomings and limitations of LVEDA
quency shift rather than signal amplitude; TDI uses have to be recognized. When regional wall motion
lower transmitting frequencies, permitting better abnormalities are present, the correct use of LVEDA
tissue penetration; and TDI has favorable temporal as a preload parameter is limited. Furthermore, the
resolution. apical region of the LV is more susceptible to
The early diastolic velocity measured with TDI (ie, regional wall motion abnormalities than the base of
arterial elastance [Ea]) behaves as a relative load- the heart.41 In this respect, the above-mentioned
independent index of LV relaxation. The ratio of the Doppler echocardiographic methods and the respi-
E wave to Ea showed the strongest relation to PCWP ration-induced variation in maximal Doppler veloci-
(r ⫽ 0.86), irrespective of the pattern and the ejec- ties must be appreciated.42 Echocardiographic data
tion fraction.31 Whereas the E wave of the transmi- from a single plane seldom provide information
tral flow pattern is load-sensitive, the Ea, obtained by about filling status.
TDI, behaves as a relatively load-independent index Besides using the short-axis view to obtain the
of ventricular relaxation. In 100 patients, a relation LVEDA, a midesophageal view allows the scanning
was described between the E wave/Ea ratio and the of the long axis of the LV. Volume determination of
PCWP (r ⫽ 0.86), irrespective of the pattern and the LV can be performed utilizing the Simpson rule.
ejection fraction,30 although this has not been con- The LV is divided into 20 ellipsoid disks of equal
firmed.32 heights but different diameters. The sum of the

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respective volumes of the slices allows the calcula- Ejection fraction is a classic example of a load-depen-
tion of the total ventricular volume. This technique dent description of global ventricular function.46 Nev-
has been validated against angiography. ertheless, in view of the discussion on flow and func-
Over the last years, the term fluid responsiveness tion, ejection fraction or, in echocardiographic terms,
has been proposed as an important estimate of the fractional area contraction will not be disputed
optimization of preload (Fig 3). Using methods that With TEE and Doppler echocardiography, it is
are analogous to systolic respiratory pressure varia- relatively easy to estimate swiftly the load-dependent
tion43 and stroke volume variation,44 which have characteristics as SV, cardiac output, and positive
been shown to correlate well with a positive fluid maximum first derivative of pressure, corrected for
responsiveness, Slama et al42 demonstrated the value time (⫹dP/dtmax). The assessment of SV includes
of flow measurements across the aortic valve in the both the measurement of the flow and the determi-
assessment of flow velocity variation with cyclic
nation of the area through which this flow moves
altering of intrathoracic pressures. The VTI at that
forward. The area through which this flow is propa-
level decreased progressively, in close relationship
gated is one aspect of the determination of the stroke
with a graded and controlled blood loss performed in
an animal experimental setting. Respiratory varia- volume. Either the diameter of a certain location or,
tions of VTI are a sensitive index of fluid responsive- preferably, the effective time-averaged surface area
ness, concurring completely with the findings of must be measured. Several localizations have been
systolic pressure variation, stroke volume (SV) vari- used, as follows: RV outflow tract (RVOT) and
ation, and pulse pressure variation. pulmonary artery47– 49; mitral valve; and LV outflow
tract50 –52 at the level of the aortic valve. It is clear
from earlier studies53 that the diameter of the pul-
Flow and Function monary artery is sometimes difficult to measure,
explaining the lower correlation coefficient. Never-
Multiple indexes have been proposed to describe theless, placing the sample volume in the position at
global ventricular function. Both load-dependent and the level of the midpulmonary artery is an easy and
load-independent parameters have been discerned.45 elegant method for assessing SV.53 Some training

Figure 3. Clinical approach of hemodynamic monitoring. Art.syst. ⫽ arterial systolic; CO ⫽ cardiac

output; PHT ⫽ pulmonary hypertension; LCO ⫽ low cardiac output; SVO2 ⫽ mixed venous oxygen
saturation. Pulm. ⫽ pulmonary.

384 Opinions/Hypotheses
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permits even the assessment of SV in the RVOT
from a deep transgastric view.54 The diameter of the
mitral valve is difficult to measure as the annulus is
not circular and changes throughout the cardiac
cycle, not permitting the use of the mitral valve for
measuring SV.55 The measurement of the flow across
the aortic valve is a third possibility.56 To permit the
measurement of the diameter of the aortic valve, a
longitudinal midesophageal image must be obtained
(Fig 4). It has been demonstrated that the direct
measurement of the effective time-averaged aortic
area allows for superb accuracy.50,51 This method can
be performed with the transducer at the midesopha-
geal position, rotating the multiplane probe toward
25° to 40° (Fig 5). In routine clinical practice,
however, the method including the measurement of
the diameter is more easily performed with a lower,
albeit acceptable, precision.52,57–59
The flow is obtained by the measurement of the
area under the curve of a Doppler wave. This gives
information on the VTI (in centimeters) [Fig 6]. VTI Figure 5. The aortic valve (AV) with the three cusps is visualized
at the level of the upper mediastinal level in an intermediate
provides the distance that an RBC is projected plane. This view allows the measurement of a time-averaged
forward during one cardiac cycle and is therefore effective aortic valve area. RA ⫽ right atrium.
directly related to the systolic function of the LV or
RV, depending on the place of the sample volume.
Hence, the SV can be calculated from the follow- when the method of the effective time-averaged
ing different formulas: aortic valve area (AVA) is chosen. This method
SV ⫽ VTI ⴱ AVA provides higher accuracy.
SV ⫽ VTI ⴱ 0.78 ⴱ D2
when the method of measurement of the diameter
(D) is preferred. In clinical practice, however, the
method of measurement of the diameter at the level
of the pulmonary artery or the aortic valve provides
an adequate estimation of the SV.
When aortic stenosis is present, the CW Doppler
signal shows a characteristic image with two densities
of flow.60 The VTI of the most intense part repre-
sents the SV, whereas the external contour shows the
peak velocity, which permits the calculation of the
aortic valve gradient utilizing the modified Bernoulli

Figure 4. A deep transgastric view in the transverse plane is

obtained by introduction of the probe deep in the stomach with
maximal anteflexion and lateral flexion to the left. This view
allows the functional evaluation of the aortic valve, as the
intercept angle between the Doppler beam and blood flow is very Figure 6. A continuous Doppler flow pattern is shown, permit-
low or nonexistent. MV ⫽ mitral valve; AA ⫽ ascending aorta. ting the assessment of the flow across the aortic valve.

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equation. This technique cannot be used when sig- namic monitoring. Although this tracing offers consid-
nificant aortic regurgitation is present. erable information about SV, contractility, and loading
The technique of flow calculation is also utilized conditions of the left heart, all information is mainly
when intracardiac shunts are present (eg, atrial septal based on eyeballing. Many investigators searched for
defect). The VTI calculated from in the RVOT other more revealing variables, which could be, how-
(including the measurement of the diameter of the ever, be more difficult to obtain. Many years ago, LV
pulmonary annulus) can be compared with VTI maximal elastance, the line connecting all end-systolic
obtained from flow analysis in the LV outflow tract, points in a pressure-volume diagram, was considered
in order to calculate the flow through the shunt.61 for use.65 Although significant improvements have
⫹dP/dtmax is another flow-derived, load depen- been proposed to upgrade this variable to a more
dent parameter to circumscribe global left ventric- clinically useful parameter,66 several drawbacks have to
ular function (Fig 6).62 The estimation of ⫹dP/ be recognized, diminishing considerably the usefulness
dtmax, as the mean rate of pressure rise, with of this technique in clinical practice.
Doppler echocardiography obliges a leakage of the Another, more clinical, parameter is derived from
mitral or aortic valve. At the mitral valve, ⫹dP/ hydraulic energy. Hydraulic power is based on the
dtmax is calculated using the modified Bernouilli fact that the heart is a pump that is used to circulate
equation.63 If the change pressure gradient is the blood into both the pulmonary and systemic
measured from the ascending limb of the mitral circulation. The cardiac muscle provides the energy
regurgitant flow wave between the velocity levels necessary for this circulation, dispersing more energy
of eg 1 m/s and 3 m/s (Fig 7), change in ventriculo- as the blood proceeds deeper into the smaller ves-
atrial pressure gradient is calculated as sels. The effort performed by the ventricle to pump
4(1)2 ⫹ 4(3)2 ⫽ 32. A change corresponding to the the blood against gravity and to overcome the inertia
left ventriculo-atrial pressure gradient of 4 and of the blood is nothing else than ventricular work.
36 mm Hg, is measured with Doppler echocardi- Cardiac hydraulic power output, the work per time
ography. With this method, it is assumed that any unit, is the product of cardiac flow output and its
gradient across the mitral valve is absent. A normal pressure delivered in the arterial system.67–70 It
value of ⫹dP/dtmax is between 800 to 1,200 mm increases proportionally to the exercise workload
Hg/s. Analogous measurements can be performed performed and represents the rate at which the
from the descending limb of the aortic regurgita- ventricle performs external work.71 Cardiac power
tion flow wave in a deep transgastric transverse (PWR) provides the best representation of the per-
view utilizing CW Doppler providing Doppler- formance obtained in a single cardiac cycle to coun-
derived dP/dtmax.64 Although easy applicable, the terbalance the demand imposed by the metabolizing
Doppler technique may underestimate the true tissues on the cardiac pump. In patients with cardiac
maximum dP/dt. failure, the measurement of PWR at rest and after
the administration of positive inotropic stimulation
provides insight into the cardiac energetic reserve.72
Pressure, Flow, and Function In the absence of mitral regurgitation, the ventric-
ular volume change during systole equals aortic
In clinical practice, the arterial pressure and mor- volumetric flow. Hence, PWR can be described as
phology of the tracing are the mainstays of hemody- follows:

PWR ⫽ Plv ⴱ Fao

where Plv is instantaneous LV pressure and Fao is
instantaneous aortic flow. The product reaches its
maximum after the attainment of the peak flow and
before peak aortic pressure is obtained.8 At this time,
the aortic and ventricular pressures are similar.
Hence, the determination of the different factors,
building up PWR, is in this way markedly facilitated.
As the various parameters of volumetric flow are
easily obtained, the previously mentioned formula
can be rewritten:
Figure 7. Measurement of the time difference between a
regurgitant transmitral velocity of 100 cm/s and 300 cm/s is PWRmax ⫽ PAO ⴱ VAOmax ⴱ AVA ⴱ 1.333 ⴱ 10⫺4
shown. This time difference allows the calculation of the ⫹dP/
dtmax. where PAO is instantaneous aortic pressure, VAO-

386 Opinions/Hypotheses
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 Figure 8. Relationship between LVEDV and preload-adjusted maximal power (pamp) in a group of
postoperative coronary artery patients. The poorer contractile performance, the more the ventricle will
exploit its preload reserve by the Frank-Starling mechanism. Regression statistics with curve
extimation. eda ⫽ end-diastolic volume.

max is instantaneous maximum aortic blood flow maximal power diagram with respect to LVEDV.76
velocity, AVA is time-averaged aortic valve area, and This implies certain limitations of the power mea-
PWRmax is the maximum PWR (in watts). In clinical surement in, for instance, severely hypertensive or
conditions, instantaneous aortic pressure is arterial hypotensive patients. This method cannot be used in
BP at the time point at which the product of pressure patients with severe mitral regurgitation or aortic
and flow becomes is at the maximum. valve disease.
The clinical attractiveness of the parameter PWR
is high, taking into consideration various criteria,
such as the integrity of the heart in relation to the Consequences for Daily Practice
circulation, accounting for both the pressure-gener-
ating and flow-generating capacity of the cardiac Echocardiography permits a rational approach to
muscle in healthy and diseased hearts.70 In addition, the problem of hypotension. As stated earlier,7 the
PWR can be measured with a single-beat technique, basic and starting view of each type of investigation
without cumbersome manipulations of loading con- (ie, either transthoracic or transesophageal) must be
ditions,8 which is even useful in patients with atrial a short-axis view of the LV, as this image provides
fibrillation.73 A close relationship was shown to exist information on the following three fundamental is-
between preload-adjusted maximal power and ven- sues: (1) global contractility; (2) the presence of
tricular maximal elastance.73 regional wall motion abnormalities; and (3) the first
PWR shows great stability concerning the changes indication of volemia. If global contractility is nor-
of afterload but is also highly sensitive to preloading mal, any other cause of the hypotension than the
alterations. Therefore, several authors have proposed heart should be investigated (eg, sepsis, vasoplegia,
the correction of PWR with the square of the and technical problems). If hypotension is combined
LVEDV,71,74 the LV end-diastolic diameter, 75 or the with a decreased global LV function, a complete
LVEDA.8,71 A close relationship between LVEDV, echocardiogram should reveal the causes of this
as a marker of preload, and maximum PWR/LVEDA hemodynamic instability. In addition, some relatively
ratio,2 as a measure of myocardial contractility, is easy hemodynamic features can be measured and
shown in Figure 8. This graph demonstrates clearly estimated to obtain a global picture of the hemody-
the higher dependence of ventricles with poor per- namics. Contractility, preload, and afterload can be
formance on preload in maintaining their output readily estimated in a fairly reliable manner. In
possibilities. Figure 3, we have proposed a practical scheme that
The ability of PWR to characterize global LV can be used whenever the problem of hypotension
contractility is less accurate beyond physiologic pres- is present, and that can be worked out rapidly to
sures and volumes. This has mainly to do with the allow quick and adequate management. In another
reliance on the intercept of the preload-adjusted study,77 the importance of the quick and decisive

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management of hemodynamic instability and hypo- measures of myocardial velocity throughout the cardiac cycle
tension has been shown again. After the interpreta- by tissue Doppler imaging to quantify regional left ventricular
function. Am Heart J 1996; 131:1203–1213
tion of these data, therapeutic handling can already
13 Jamal F, Strotmann J, Weidemann F, et al. Noninvasive
start. For the purposes of continuous monitoring of quantification of the contractile reserve of stunned myocar-
cardiac output and mixed venous oxygen saturation, dium by ultrasonic strain rate and strain. Circulation 2001;
there is still time enough to insert a pulmonary artery 104:1059 –1065
catheter afterward. 14 Sohn D-W, Chai I-H, Lee D-J, et al. Assessment of mitral
annulus velocity by Doppler tissue imaging in the evaluation
of left ventricular diastolic function. J Am Coll Cardiol 1997;
30:474 – 480
Conclusions 15 Kim Y-L, Sohn D-W. Mitral annulus velocity in the estima-
tion of left ventricular filling pressures: prospective study in
The end points of hemodynamic management 200 patients. J Am Soc Echocardiogr 2000; 13:980 –985
have traditionally focused on improving cardiac out- 16 Kuecherer HF, Muhiudeen IA, Kusumoto FM, et al. Esti-
put.78 Over the last years, an analysis of the literature mation of mean left atrial pressure from transesophageal
pulsed Doppler echocardiography of pulmonary venous flow.
has shown some fascinating advances when combin- Circulation 1990; 82:1127–1139
ing Doppler flow measurements and arterial pres- 17 Gorcsan III J, Snow F, Paulsen W, et al. Noninvasive
sure waveforms. It might be speculated that modern estimation of left atrial pressure in patients with congestive
hemodynamic management will be directed toward heart failure and mitral regurgitation by Doppler echocardi-
the enhancement of the cardiac pumping reserve, ography. Am Heart J 1991; 121:858 – 863
18 Appleton C, Galloway J, Gonzalez M, et al. Estimation of left
and the optimization of perfusion at the tissue and ventricular filling pressures using two-dimensional and Dopp-
cellular levels. ler echocardiography in adult patients with cardiac disease:
additional value of analyzing left atrial size, left atrial ejection
fraction and the difference in duration of pulmonary venous
and mitral flow velocity at atrial contraction. J Am Coll
References Cardiol 1993; 22:1972–1982
1 Vignon P, Mentec H, Terré S, et al. Diagnostic accuracy and 19 Yoshida K, Yoshikawa J, Yamaura Y, et al. Value of accelera-
therapeutic impact of transthoracic and transesophageal tion flows and regurgitant jet direction by color Doppler flow
echocardiography in mechanically ventilated patients in the mapping in the evaluation of mitral valve prolapse. Circula-
ICU. Chest 1994; 106:1829 –1834 tion 1990; 81:879 – 885
2 Tam J, Nichol J, MacDiarmid A, et al. What is real clinical 20 Stewart WJ, Currie PJ, Salcedo EE, et al. Evaluation of mitral
utility of echocardiography? A prospective observational leaflet motion by echocardiography and jet direction by
study. J Am Soc Echocardiogr 1999; 12:689 – 697 Doppler color flow mapping to determine the mechanisms of
3 Seward JB, Khanderia BK, Oh JK, et al. Critical appraisal of mitral regurgitation. J Am Coll Cardiol 1992; 20:1353–1361
transesophageal echocardiography: limitations, pitfalls and 21 Hansen RM, Viquerat CE, Matthay MA, et al. Poor correla-
complications. J Am Soc Echocardiogr 1992; 5:288 –305 tion between pulmonary arterial wedge pressure and left
4 Poelaert JI, Trouerbach J, De Buyzere M, et al. Evaluation of end-diastolic volume after coronary artery bypass graft sur-
transesophageal echocardiography as a diagnostic and thera- gery. Anesthesiology 1986; 64:764 –770
peutic aid in a critical care setting. Chest 1995; 107:774 –779 22 Kusumoto F, Muhiudeen I, Kuecherer H, et al. Response of
5 Laver M, Strauss W, Pohost G. Right and left ventricular the interatrial septum to transatrial pressure gradients and its
geometry: adjustments during acute respiratory failure. Crit potential for predicting pulmonary capillary wedge pressure:
Care Med 1979; 7:509 –519 an intraoperative study using transesophageal echocaridogra-
6 Chang M, Mondy J III, Meredith J, et al. Redefining phy in patients during mechanical ventilation. J Am Coll
cardiovascular performance during resuscitation: ventricular Cardiol 1993; 21:721–728
stroke work, power and the pressure-volume diagram. 23 Poelaert J, Reichert S, Everaert J, et al. Transesophageal
J Trauma 1998; 45:470 – 478 echo-Doppler evaluation of the hemodynamic effects of
7 Poelaert J, Schmidt C, Colardyn F. Transoesophageal echo- positive pressure ventilation after coronary artery bypass
cardiography in the critically ill. Anaesthesia 1998; 53:55– 68 surgery. J Cardiothorac Vasc Anesth 1992; 6:438 – 443
8 Schmidt C, Roosens C, Struys M, et al. Contractility in 24 Appleton C, Hatle L, Popp R. Relation of transmitral flow
humans after coronary artery surgery: echocardiographic velocity patterns to left ventricular diastolic function: new
assessment with preload-adjusted maximal power. Anesthesi- insights from a combined hemodynamic and Doppler echo-
ology 1999; 91:58 –70 cardiographic study. J Am Coll Cardiol 1988; 12:426 – 440
9 Nishimura RA, Miller FA Jr, Callahan MJ. Doppler echocar- 25 Nishimura R, Abel M, Hatle L, et al. Relation of pulmonary
diography: theory, instrumentation, technique and applica- vein to mitral flow velocities by transesophageal Doppler
tion. Mayo Clin Proc 1985; 60:321–343 echocardiography: effect of different loading conditions. Cir-
10 Sutherland G, Stewart M, Groundstroem K, et al. Color culation 1990; 81:1488 –1497
Doppler myocardial imaging: a new technique for the assess- 26 Rossvoll O, Hatle L. Pulmonary venous flow velocities re-
ment of myocardial function. J Am Soc Echocardiogr 1994; corded by transthoracic Doppler ultrasound: relation to left
7:441– 458 ventricular diastolic pressures. J Am Coll Cardiol 1993;
11 Miyatake K, Yamagishi M, Tanaka N, et al. New method of 21:1687–1696
evaluating left ventricular wall motion by color-coded tissue 27 Klein A, Tajik A. Doppler assessment of pulmonary venous
Doppler imaging: in vitro and in vivo studies. J Am Coll flow in healthy subjects and in patients with heart disease.
Cardiol 1995; 25:717–724 J Am Soc Echocardiogr 1991; 4:379 –392
12 Gorcsan J III, Gulati V, Mandarino W, et al. Color-coded 28 Klein A, Abdalla I, Murray D, et al. Age independence of the

388 Opinions/Hypotheses
Downloaded from chestjournal.org on May 18, 2008
Copyright © 2005 by American College of Chest Physicians
 difference in duration of pulmonary venous atrial reversal volume on left ventricular stroke volume variation measured
flow and transmitral A-wave flow in normal subjects. J Am by pulse contour analysis in mechanically ventilated patients.
Soc Echocardiogr 1998; 11:458 – 465 Intensive Care Med 2003; 29:476 – 480
29 Yamamuro A, Yoshida K, Hozumi T, et al. Noninvasive 45 Loick H, Schmidt C, Van Aken H, et al. High thoracic
evaluation of pulmonary wedge pressure in patients with epidural anesthesia, but not clonidine, attenuates the postop-
acute myocardial infarction by deceleration time of pulmo- erative stress response via sympatholysis and reduces the
nary venous flow velocity in diastole. J Am Coll Cardiol 1999; release of troponin T in patients undergoing coronary artery
34:90 –94 bypass grafting. Anesth Analg 1999; 88:701–709
30 Nagueh S, Mikati I, Kopelen H, et al. Doppler estimation of 46 Rowbotham J, Takata M, Berman M, et al. Ejection fraction
left ventricular filling pressure in sinus tachycardia: a new revisited. Anesthesiology 1991; 74:172–183
application of tissue Doppler imaging. Circulation 1998; 47 Ihlen H, Amlie J, Dale J, et al. Determination of cardiac
98:1644 –1650 output by Doppler echocardiography. Br Heart J 1984;
31 Sundereswaran L, Nagueh S, Vardan S, et al. Estimation of 51:54 – 60
left and right ventricular filling pressures after heart trans- 48 Muhiudeen IA, Kuecherer HF, Lee E, et al. Intraoperative
plantation by tissue Doppler imaging. Am J Cardiol 1998; estimation of cardiac output by transesophageal pulsed Dopp-
82:352–357 ler echocardiography. Anesthesiology 1991; 74:9 –14
32 Bouhemad B, Nicolas-Robin A, Benois A, et al. Echocardio- 49 Hozumi T, Shakado M, Applegate A, et al. Accuracy of
pgraphic Doppler assessment of pulmonary capillary wedge cardiac output estimation with biplane transesophageal echo-
pressure in surgical patients with postoperative circulatory cardiography. J Am Soc Echocardiogr 1993; 6:62– 68
shock and acute lung injury. Anesthesiology 2003; 98:1091– 50 Darmon PL, Hillel Z, Mogtader A, et al. Cardiac output by
1100 transesophageal echocardiography using continuous-wave
33 Leung JM, Levine EH. Left ventricular end-systolic cavity Doppler across the aortic valve. Anesthesiology 1994; 80:796 –
obliteration as an estimate of intraoperative hypovolemia. 805
Anesthesiology 1994; 81:1102–1109 51 Perrino A Jr, Harris S, Luther M. Intraoperative determina-
34 Shanewise J, Cheung A, Aronson S, et al. ASE/SCA guide- tion of cardiac output using muliplane transesophageal echo-
lines for performing a comprehensive intraoperative multi- cardiography: a comparison to thermodilution. Anesthesiol-
plane transesophageal echocardiographic examination: rec- ogy 1998; 89:350 –357
ommendations of the American Society of Echocardiography 52 Poelaert J, Schmidt C, Van Aken H, et al. A comparison of
Council for intraoperative echocardiography and the Society transoesophageal echocardiographic Doppler across the aor-
of Cardiovascular Anesthesiologists task force for certification tic valve and thermodilution technique for estimating cardiac
in perioperative transesophageal echocardiography. J Am Soc output. Anaesthesia 1999; 54:128 –136
Echocardiogr 1999; 12:884 –900 53 Savino JS, Troinaos CA, Aukburg S, et al. Measurement of
35 Kishkurno S, Takahashi Y, Harada K, et al. Postnatal changes pulmonary blood flow with transesophageal two-dimensional
in left ventricular volume and contractility in healthy term and Doppler echocardiography. Anesthesiology 1991; 75:
infants. Pediatr Cardiol 1997; 18:91–95 445– 451
36 Appleyard R, Glantz S. Two-dimensions describe left ventric- 54 Maslow A, Comunale ME, Haering JM, et al. Pulsed wave
ular volume change during hemodynamic transients. Am J Doppler measurement of cardiac output from the right
Physiol 1990; 258:H277–H284 ventricular outflow tract. Anesth Analg 1996; 83:466 – 471
37 Skarvan K, Lambert A, Filipovic M, et al. Reference values 55 Shimamoto H, Kito H, Kawazoe K, et al. Transoesophageal
for left ventricular function in subjects under general anaes- Doppler echocardiographic measurement of cardiac out-
thesia and controlled ventilation assessed by two-dimensional put by the mitral annulus method. Br Heart J 1992;
transoesophageal echocardiography. Eur J Anaesthesiol 2001; 68:510 –515
18:713–722 56 Katz WE, Gasior TA, Quinlan JJ, et al. Transgastric continu-
38 Reich D, Konstadt S, Nejat M, et al. Intraoperative trans- ous-wave Doppler to determine cardiac output. Am J Cardiol
esophageal echocardiography for the detection of cardiac 1993; 71:853– 857
preload changes induced by transfusion and phlebotomy in 57 Sahn DJ. Determination of cardiac output by echocardio-
pediatric patients. Anesthesiology 1993; 79:10 –15 graphic Doppler methods: relative accuracy of various sites
39 Cheung A, Joseph S, Weiss S, et al. Echocardiographic and for measurement [editorial]. J Am Coll Cardiol 1985; 6:663–
hemodynamic indexes of left ventricular preload in patients 664
with normal and abnormal ventricular function. Anesthesiol- 58 Izzat MB, Regragui IA, Wilde P, et al. Transesophageal
ogy 1994; 81:376 –387 echocardiographic measurements of cardiac output in cardiac
40 Hinder F, Poelaert J, Schmidt C, et al. Assessment of surgical patients. Ann Thorac Surg 1994; 58:1486 –1489
cardiovascular volume status by transoesophageal echocardi- 59 Feinberg MS, Hopkins WE, Davila-Roman VG, et al. Multi-
ography and dye dilution during cardiac surgery. Eur J plane transesophageal echocardiographic Doppler imaging
Anaesthesiol 1998; 15:633– 640 accurately determines cardiac output measurements in criti-
41 Diedericks J, Leone B, Foex P. Regional differences in left cally ill patients. Chest 1995; 107:769 –773
ventricular wall motion in the anesthetized dog. Anesthesiol- 60 Maslow A, Mashikian J, Haering J, et al. Transesophageal
ogy 1989; 70:82–90 echocardiographic evaluation of native aortic valve area:
42 Slama M, Masson H, Teboul JL, et al. Respiratory variations utility of the double-envelope technique. J Cardiothorac Vasc
of aortic VTI: a new index of hypovolemia and fluid respon- Anesth 2001; 15:293–299
siveness. Am J Physiol Heart Circ Physiol 2002; 283:H1729 – 61 Takahashi Y, Harada K, Ishida A, et al. Changes in left
H1733 ventricular volume and systolic function before and after the
43 Coriat P, Vrillon M, Perel A, et al. A comparison of systolic closure of ductus arteriosus in full-term infants. Early Hum
blood pressure variations and echocardiographic estimates of Dev 1996; 44:77– 85
end-diastolic left ventricular size in patients after aortic 62 Mason D. Usefulness and limitations of the rate of rise of
surgery. Anesth Analg 1994; 78:46 –53 intraventricular pressure (dP/dt) in the evaluation of myocar-
44 Reuter D, Bayerlein J, Goepfert M, et al. Influence of tidal dial contractility in man. Am J Cardiol 1969; 23:516 –527

www.chestjournal.org CHEST / 127 / 1 / JANUARY, 2005 389

Downloaded from chestjournal.org on May 18, 2008
Copyright © 2005 by American College of Chest Physicians
63 Rhodes J, Udelson J, Marx G, et al. A new noninvasive volume. Circulation 1991; 84:1698 –1708
method for the estimation of peak dP/dt. Circulation 1993; 72 Marmor A, Raphael T, Marmor M, et al. Evaluation of
88:2693–2699 contractile reserve by dobutamine echocardiography: nonin-
64 Kang H-J, Kim Y-J, Sohn D-W, et al. Prediction of postop- vasive estimation of the severity of heart failure. Am Heart J
erative left ventricular systolic function with Doppler-derived 1996; 132:1196 –1201
dP/dt in patients with chronic aortic regurgitation. J Am Soc 73 Takagaki M, McCarthy P, Chung M, et al. Preload-adjusted
Echocardiogr 2003; 16:1111–1115 maximal power: a novel index of left ventricular contractility
65 Sagawa K. The end-systolic pressure-volume relation of the in atrial fibrillation. Heart 2002; 88:170 –176
ventricle: definition, modification, and clinical use. Circula- 74 Sharir T, Feldman MD, Haber H, et al. Ventricular systolic
tion 1981; 63:1223–1227
assessment in patients with dilated cardiomyopathy by pre-
66 Takeuchi M, Igarashi Y, Tomimoto S, et al. Single beat
load-adjusted maximal power: validation and noninvasive
estimation of the slope of the end-systolic pressure-volume
application. Circulation 1994; 89:2045–2053
relation in the human left ventricle. Circulation 1991; 83:
202–212 75 Pagel PS, Nijhawan N, Warltier DC. Quantitation of
67 Stein PD, Sabbah HN. Ventricular performance measured volatile anesthetic-induced depression of myocardial con-
during ejection: studies in patients of the rate of change of tractility using a single beat index derived from maximal
ventricular power. Am Heart J 1976; 91:599 – 606 ventricular power. J Cardiothorac Vasc Anesth 1993; 7:
68 Stein P, Sabbah H. Rate of change of ventricular power: an 688 – 695
indicator of ventricular performance during ejection. Am 76 Segers P, Tchana-Sato V, Leather HA, et al. Determinants
Heart J 1976; 91:219 –227 of left ventricular preload-adjusted maximal power. Am J
69 Milnor W. The heart as a pump. In: Milnor W, ed. Cardio- Physiol Heart Circ Physiol 2003; 284:H2295–H2301
vascular physiology. New York, NY: Oxford University Press, 77 Rivers E, Nguyen B, Havstad S, et al. Early goal-directed
1990; 111–139 therapy in the treatment of severe sepsis and septic shock.
70 Tan L. Evaluation of cardiac dysfunction, cardiac reserve and N Engl J Med 2001; 345:1368 –1377
inotropic response. Postgrad Med J 1991; 67:S10 –S20 78 Shoemaker W, Appel P, Kram H, et al. Prospective trial of
71 Kass D, Beyar R. Evaluation of contractile state by maximal supranormal values of survivors as therapeutic goals in high
ventricular power divided by the square of end-diastolic risk surgical patients. Chest 1988; 94:1176 –1186

390 Opinions/Hypotheses
Downloaded from chestjournal.org on May 18, 2008
Copyright © 2005 by American College of Chest Physicians
 Hemodynamic Monitoring Utilizing Transesophageal
Echocardiography: The Relationships Among Pressure, Flow, and
Function
Jan I. Poelaert and Guido Schüpfer
Chest 2005;127;379-390
DOI 10.1378/chest.127.1.379
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