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350 oracic ultrasound
Figure 47 – Algorithm showing the role of echocardiography in the diagnosis of infective endocarditis.
➣ Fluid responsiveness
Volume expansion has a definite role in the treatment of critically ill patients with hemorrhage,
hypovolemia, severe sepsis and shock. Euvolemia relative to an ongoing pathophysiology is
therefore essential to avoid fluid overload, with edema and respiratory distress syndrome
(ARDS) or, on the contrary, fluid depletion with hypoperfusory ischaemia.
e goal in subjects with circulatory dysfunction is the adequate perfusion for maintaining
a physiologic tissue oxygen delivery.
Cardiac output (CO) is a variable closely related to the cardiac venous return and it depends
on it for each level of cardiac function and peripheral vascular resistance. Consequently, CO
is proportional to the flow that reaches the heart and it depends on the cardiac performance.
e relationships between preload and cardiac output are expressed by the Frank Starling
curves. In hypovolemia, an increased preload, in the absence of heart or lung disease, optimizes
the stroke volume. is state is referred to as preload-dependent.
Fluid responsiveness is a significant increase in cardiac output in relation to a volume expansion,
consistent with the ascending portion of the Frank Starling curve for every cardiac performance.
e measurement of CO is an essential parameter for monitoring the critically ill patient,
but it is not easy on a clinical base. e Swan Ganz catheter has been the gold standard for
this measurement, but its use has been drastically reduced in light of the results of studies of
the past five years. e interest in ultrasound lies therefore in its ability to determine, quantitatively, the hemodynamic data.
e use of ultrasound for the determination of the fluid responsiveness depends on the production of static and dynamic images (and on estimates of velocity and flow) of the inferior
vena cava, the superior vena cava and the heart, in baseline situations, during mechanical
ventilation or in response to fluid challenges.
Table 10 summarizes some non-invasive methods to determine CO. Table 11 briefly describes
the static and dynamic variables that can be acquired in echocardiography.
Echocardiography 351
Table 10 – Non-invasive methods to determine cardiac output
Method Benefits Disadvantages
EsophagealDoppler
(CardioQ)
Transthoracic
echocardiography(TTE)
Transesophageal
echocardiography(TEE)
NICO(NonInvasiveCO):
measurementofcardiac
outputwiththeFick
technique,withpartial
rebreathingofCO2
Thoracicelectrical
bioimpedance
PCE(Pulsecontour
evaluation):PiCCO,Lidco,
FloTrac
Canbeusedintheawake
patient
Continuousmonitoring
Relativelyeasytouse
Non-invasiveandbedside
Possibilitytoassessuid
responsiveness
GoodestimateofCO
correlatedwithCOestimated
bythermodilution
Possibilitytoassessuid
responsiveness
GoodestimateofCO
Minimallyinvasive
Non-invasive
Continuousmonitoring
Minimallyinvasive
Possibilitytoassessuid
responsiveness
Estimateofextravascular
lungwater
Operator-dependent
Movementsandmalpositionof
theprobe
Possibilityoferrorinthe
assessmentoftheoutowtractof
theleftventricle
Conditionedbyasuitableacoustic
window
Poorlytoleratedbytheawake
patient
Operator-dependent
Possibilityofesophagealinjury
Requiresendotrachealintubation,
mechanicalventilationand
hemodynamicstabilityofthe
patient
Dependentonmechanical
ventilation
Requiresaccuratepositioningof
theelectrodes
Limitedapplications
Problematicanalysisincaseof
arrhythmias
Artifactsofthearterialcurveswith
interpretationproblems
Needtocalibratethemethodwith
astandardone(thermodilution)
From Table 11, in particular, we derive the data acquired through the ultrasound examination. It is clear that the skills needed in some cases, require special expertise. It is equally clear
that some assessment methods (such as those which interpret the diameters of the superior
vena cava) require transesophageal echocardiography, which is not discussed here. So, it is
necessary to make a simple selection between the various approaches to blood volume, that
emphasizes non-specialist techniques. What has already been described in the chapter on
echocardiography or in specific works can complete this analysis.
In this context static and dynamic echographic parameters are distinguished.
A static parameter is measured during a single condition of ventricular load, assuming that
this produces an estimate of the preload of one or both ventricles. An example of this type is
the estimation of the central venous pressure (CVP) with the measurement of the diameter
of the inferior vena cava (for example in end-tidal). A useful and complete correlation does
not exist. We can conclude that a caval diameter less than 10 mm likely indicates a fluid
352 oracic ultrasound
Table 11 – Static and dynamic variables that can be acquired in echocardiography
Echographic variable Formula Parameter
%Δinferiorevenacava Diameteroftheinferiorvenacava
(D):
Dmax–Dmin/Dmaxx100
%Δsuperiorvenacava Diameterofthesuperiorvenacava
(D):
Dmax–Dmin/Dmaxx100
Systolicvolume(assessedwith
TEE)
Δ systolicvolume(inTTEor
TEE)associatedwithpassive
legraising
End-diastolicareaoftheleft
ventricle(LV)
Rightventricularsystolic
pressure
Cardiacoutput (LVOTxvelocityintegral/aortic
Leftatrialpressure 1,24x(E/E’)+1,9** Static
Leftventricularllingpressure
(wedgepressure)
*ThisformulaiscalledmodiedBernoulliequationandhasageneralizedmeaning.InDoppler
ultrasound,thepressuregradientbetweentwoadjoiningchambersmay,withincertainlimits,be
quantiedbytheequationΔP=4xV2,whereVisthevelocityofow,sampledwithpulsedDoppler,
betweenthetwochambers.
**Inthisequation,theratioE/E’istheratioofthespeedexpressedbythewavesEandE’,respectively
sampledwithpulsedDopplerandtissueDoppler.TheEwaverepresentstherstphaseoftheinow
oftheleftventriclethroughthemitralvalve,theE’waverepresentsthemitralannulusvelocityduring
thisphase.Foranextendedandcomprehensivediscussionoftheseissuesreferenceismadetothetext:
Hemodynamicmonitoringusingechocardiographyinthecriticallyill(DeBackeretal.eds.).SpringerVerlag,Berlin-Heidelberg,2011.
Areaoftheleftventricularoutow
tract(LVOT)xvelocityintegral/
aorticejectiontime
LVOTxvelocityintegral/aortic
ejectiontime,beforeandafter
passivelegraising
PlanimetricareaofVSmeasuredin
transversesection
4x(maximumvelocityofthe
tricuspidregurgitantow)2+right
atrialpressure*
ejectiontime)xheartrate
E/E’<8=estimatedwedge<
12mm/Hg
E/E’>15=estimatedwedge>
18mm/Hg
Dynamic
Dynamic(requiresTEE)
Dynamic(requiresTEE),
associablewithpassiveleg
raisingtest
Dynamic
Static
Static
Static(dynamicifassociated
withpassivelegraisingtest)
Static
responsiveness, while a diameter greater than 20 mm likely excludes this condition. Similarly,
only if a left ventricular end-diastolic area is very small and the heart is hyperkinetic, a likely
fluid responsiveness can be deduced. In essence, the static indices appear, from the data available, much less reliable than the dynamic ones.
Dynamic parameters are used to figure out if the patient’s physiology is in the ascending portion
or on the flat portion of the Frank-Starling curve. In more technical terms, they determine
at what level the ventricle of a patient operates in the preload/stroke volume function curves.
Echocardiography 353
Considering the existing relationships between volume of the cava veins, stroke volume of
the left and right ventricles and intrathoracic pressures, it is necessary to differentiate between
mechanically ventilated patients and patients with spontaneous breathing.
e cardiopulmonary crosstalking is highly influenced by mechanical ventilation. In mechanically ventilated patients the left ventricular stroke volume (SV) increases during inspiration
and decreases during the expiratory phase of the tidal volume. is phenomenon is known
as “reverse pulsus paradoxus”.
During the inspiratory phase of mechanical ventilation, the increase in intrathoracic pressure
results in a fall in the stroke volume of the right ventricle due to the decreased venous return
and the increased right ventricular afterload. is causes, a few seconds (or a few heartbeats)
later, a fall in left ventricular ejection and left stroke volume, which is then to be placed in
the expiratory phase of the respiratory cycle. is respiratory variability of the left stroke
volume therefore indicates that the patient is fluid responsive, that is, his central circulatory
physiology is placed in the ascending part of the Frank-Starling curve.
is evaluation can be done at the bedside, by measuring the respiratory variation in stroke
volume (velocity integral/aortic ejection time (VTI), or stroke distance, multiplied by the
area of the left ventricular outflow tract (LVOT), or simply by using the VTI, considering
the fact that LVOT is constant in the different phases of the cardiac cycle. Although this
method has been validated only with transesophageal ultrasound, it is realistic to consider
that whenever the transthoracic ultrasound is adequate, the results are superimposable. It is
recognized that a respiratory change in VTI greater than 20%, predicts with accuracy the
fluid responsiveness of the patient.
In the ventilated patient (and in the absence of respiratory effort), a useful answer to the
volemic expansion is possible also through the study of the inferior vena cava. Contrary to the
subject with spontaneous breathing, the inferior vena cava in these cases shows an inspiratory
enlargement and expiratory collapse.
e distensibility index of the inferior vena cava (D max - D min/D max x 100) can therefore
predict fluid responsiveness, if it is greater than 18%. ese evaluations may lack accuracy if
the subject shows a pathology of the right ventricle or pericardium.
When the patient is breathing spontaneously the ventilatory variation of the SV is not valid. In
this case the clinician can evaluate the distensibility index of the inferior vena cava (in this case the
caval collapse is located in the inspiratory phase of the tidal volume). Otherwise he or she should
consider a fluid challenge or, with probably overlapping results, a passive leg raising test (LRT).
eoretically LRT causes an expansion of central blood volume of 300-500 ml, and it consists of lifting the legs of the patient to 45% from the plane of the bed. e end point of this
maneuver can be the stroke volume, VTI or the diameter of the inferior vena cava.
Maizel recently showed that an increase in stroke volume of 12% or greater after LRT is
predictive of central hypovolemia, with values of sensitivity and specificity of 69% and 89%.
A significant correlation has been established between changes of stroke volume or VTI after
LRT and subsequent response to infusion of fluids.
During these maneuvers, however, it is necessary to correctly interpret the measurements. For
example, in subjects with severe hypovolemia, blood compartmentalized in the lower limbs
may in fact be so reduced as not to produce physiological responses. Before making a LRT,
it is also preferable that the patient has remained for a certain time in a supine position with
his trunk raised, in order to obtain a declivous venous filling. Finally, the intra-abdominal
pressure of the patient should be taken into account.
354 oracic ultrasound
➣ Echocardiographic evaluation of stroke volume and derived
parameters
Stroke volume (SV) is an important hemodynamic parameter and it allows the derivation
of other useful data. SV is measured calculating the velocity curve of the blood inside the
outflow tract of the left ventricle during the systolic ejection. By means of a dedicated sampling box, Pulsed Doppler accurately determines the speed of the blood flow in a specific
point, producing a speed/time curve which shows, when the flow is pulsating, a set of values
(maximum, minimum and average velocity, and other numeric estimates). One of these is
called VTI and is the integral of the function speed/time, i.e. the area under the curve during
the systole. VTI is, in short, the distance traveled by the stroke volume, and is also called the
stroke distance. Assuming a pulsating laminar flow in a circular duct, the VTI multiplied
by the area of the duct section expresses the volume of the flow that has passed through the
duct. is method, applied to the left ventricular outflow tract, produces an estimate of the
stroke volume (SV). e factor of SV by heart rate produces the cardiac output in ml/min.
SV can be measured with transesophageal (TEE) or transthoracic echocardiography (TTE).
e measurement through TTE requires optimal visualization of the left ventricular outflow
tract and a correct positioning of the Doppler sampling box, aligned as much as possible with
the blood flow (not less than 70-80°) (Fig. 48). If feasible, the procedure is simple:
1. A parasternal long axis image of the heart is produced. It allows to measure the diameter
of the left ventricular outflow tract (LVOT) in mid systole, placing the calipers at the base
of the valvular aortic cusps when they are open. is image also allows to exclude the
presence of aortic stenosis. LVOT is measured from the white-black interface of the septal
endocardium to the anterior mitral leaflet, parallel to the aortic valve plane and within
0.5-1 cm of the valve orifice.
2. An apical 5 chambers image of the heart is obtained. is allows to place the pulsed
Doppler box (2-4 mm) inside the left ventricular outflow tract just below the aortic valve.
e velocity flow curve is recorded and the operator manually tracks the envelope of the
systolic speeds. e machine returns the VTI (or stroke distance), which is automatically
multiplied by the area of the outflow tract of the left ventricle (derived from the previously measured diameter) obtaining SV. is measurement is calculated by five beats, then
obtaining the average of the values .
If it is executed with accuracy, the Doppler estimate of the SV is quite reproducible. e critical measurement for SV evaluation is the radius of the left ventricular outflow tract (LVOT),
from the power of which the area of LVOT is derived. On the other hand, a relative stability
of the diameter of the LVOT can be correctly assumed in the single patient. is consideration
greatly facilitates the use of ultrasound for monitoring purposes. In this setting, VTI can be
considered a valid surrogate of SV. Normally, in adults at rest, VTI has a value of 20 ± 3 cm,
while the maximum speed of the flow varies between 0.7 and 1.1 m/sec.
Echocardiography 355
Figure 48 – Above: Parasternal long axis view of the left ventricular outflow tract (LVOT). Measurement
of LVOT diameter at the insertion of aortic valve. Calculated area of LVOT is displayed. Below: Pulsed
Doppler trace obtained at the level of LVOT. The maximal velocities (velocity envelope) have been
delineated manually to compute the velocity time interval (VTI). Stroke volume is calculated as the product
between VTI and LVOT area.
➣ Clinical application of contrast echocardiography in the
emergency room and ICU
e response of ultrasound contrast media to acoustic waves has led to different strategies to
visualize the vascular and endocavitary contrast enhancement in echo imaging. e low power
imaging technique is the most widely used. is method examines the non linear response
of gaseous microbubble (in our experience, Sonovue®). Low amplitude backscatter can be
isolated from tissue signal for processing, and allows continuous imaging to be performed
without massive bubble destruction. is permits the evaluation of wall motion, endocardial
borders and perfusion in real time (Fig. 49). Combining high power burst of ultrasound followed by low power imaging, allows to follow the replenishment of vessel, cardiac cavities
and myocardium capillaries over time.
Figure 49 – Contrast enhanced echocardiography (Sonovue®). A: Apical four chambers view, non
enhanced scan. B: Contrast enhanced US. Endocardial border is clearly demonstrated. C: Ejection
fraction estimation by contrast enhanced echocardiography.
356 oracic ultrasound
e European Association of Echocardiography has recently published recommendations for
the clinical use of contrast echocardiography38.
Table 12 summarizes the main indications for contrast enhanced echocardiography in
emergency.
Table 12 – Main indications for contrast enhanced echocardiography in emergency
• Better evaluation of global and regional systolic performance
• Good visualization of endocardial border
• Detection and ruling out of post infarction left ventricular pseudoaneurism
• Detection of ventricular thrombi and endocavitary masses
• Detection of correct pericardial puncture during pericardiocentesis
• Detection of correct positioning of central venous catheters
• Distinction between systolic and diastolic heart failure
• Echocardiography in technical challenging situations
• Enhancement of Doppler signal in aortic stenosis diagnosis
• Enhancement of Doppler signal in systolic pulmonary pressure estimation
• Echocardiographic study of mycardial perfusion
• Definition of left apical abnormalities in ischaemic and Takotsubo disease
Contrast echocardiography for enhancing ventricular borders in suboptimal studies actually
represents the main indication of ultrasound contrast agents and is useful in approximately
10-20% of echocardiographic examinations. Moreover, perfusion study with microbubbles
may add information for diagnosis and risk stratification for patients presenting at the emergency room or hospitalized in intensive care unit39.
➤ Recommended readings
Various readings allow to properly investigate many topics discussed in this chapter.
Armstrong WF, Ryan T. Feigenbaum’s Echocardiography. Lippincott William & Wilkins, 2009.
One of the reference books for echocardiography.
De Backer et al. (eds) Hemodynamic monitoring using echocardiography in the critically ill. Springer-Verlag,
Berlin-Heidelberg, 2011.
Updated Review of the principles and applications of hemodynamic monitoring with ultrasound.
Guarracino F. Il monitoraggio emodinamico in area critica. Elsevier, Milano 2009.
Summary of methods for multi-instrumental monitoring of the patient in the ICU.
Otto CM. Practice of clinical echocardiography, 3nd edition. WB Saunders, Philadelphia, PA, 2008.
Clinical text on echocardiography.
Sarti L, Lorini FL (eds.). Echocardiography for intensivists. Springer, Italy, 2012.
Text on echocardiography for intensivists with many applications of ultrasound in the ICU, not only for the
study of the heart, but also for hemodynamic and pleuropulmonary assessment.
Testa A (ed.). Manuale di ecografia clinica in urgenza. Verduci, Roma, 2008.
Practical handbook of ultrasound in urgency, with extensive references to cardiac, pulmonary, pleural ultra-
sound, and to the study of hemodynamics with ultrasound.
Neskovic AN, Hagendorff A, Echocardiography in the Emergency Room. In: Galiuto L, Badano L, Fox
K, Sicari R, Zamorano JL, eds. e EAE Textbook of Echocardiography, Oxford University Press, 2011
Echocardiography 357
Arntfield RT, Millington SJ. Point of care cardiac ultrasound applications in the emergency department and
intensive care unit. A review. Current Cardiology Reviews 2012;8:98-108
Platz E, Solomon SD. Point of care echocardiography In the accountable care organization era. Circ Cardiovasc
Imaging 2012;5:676-682
Neskovic AN, Hagendorff A, Lancelotti P, Guarracino F, Varga A, Cosyns B, Flachkampf FA, Popescu
BA, Gargani L, Zamorano JL, Badano LP. Emergency echocardiography: e European Association of
Cardiovascular Imaging recommendations. Eur Heart J 2013;14:1-11
Via G, Hussain A, Wells M et al. International evidence based recommendations for focused cardiac ultrasound. J Am Soc Echocardiogr 2014;27:683
Lang RM, Biering M, Devereux RB, Flachskampf FA, Foster E, Pellikka PA, Picard MH, Roman MJ,
Seward J, Shanewise JS, Solomon SD, Spencer KT Sutton MSJ, Stewart WJ. Recommenadations for
chamber quantification: a report from the American Siciety of Echocardiography’s Guidelines and Standard
Committee and the Chamber Quantification Writing Group, developed in conjunction with the European
Association of Echocardiography, a branch of the European Society of Cardiology. J Am Soc Echocardiogr
2005;18.1440-1463.
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