Med Intensiva.

2012;36(3):220---232

www.elsevier.es/medintensiva

UPDATE IN INTENSIVE CARE MEDICINE: HEMODYNAMIC MONITORIZATION IN THE CRITICAL

PATIENT

Role of echocardiography in the hemodynamic monitorization of

critical patients夽
J.M. Ayuela Azcarate a,∗ , F. Clau Terré b , A. Ochagavia c , R. Vicho Pereira d

a
Servicio de Medicina Intensiva, Hospital General Yagüe, Burgos, Spain
b
Servicio de Medicina Intensiva, Hospital de Vall d’Hebrón, Barcelona, Spain
c
Servicio de Medicina Intensiva, Corporación Sanitaria y Universitaria Parc Taulí, Sabadell, Barcelona, Spain
d
Servicio de Medicina Intensiva Clínica USP-Palmaplanas, Palma de Mallorca, Spain

KEYWORDS Abstract The use of echocardiography in intensive care units in shock patients allows us to
Echocardiography; measure various hemodynamic variables in an accurate and non-invasive manner.
Hemodynamic; By using echocardiography not only as a diagnostic technique but also as a tool for continuous
Left ventricular hemodynamic monitorization, the intensivist can evaluate various aspects of shock states, such
function; as cardiac output and fluid responsiveness, myocardial contractility, intracavitary pressures,
Monitoring; heart---lung interaction and biventricular interdependence.
Critical care patients However, to date there has been little guidance orienting echocardiographic hemodynamic
parameters in the intensive care unit, and intensivists are usually not familiar with this tool.
In this review, we describe some of the most important hemodynamic parameters that can be
obtained at the patient bedside with transthoracic echocardiography in critically ill patients.
© 2011 Elsevier España, S.L. and SEMICYUC. All rights reserved.

PALABRAS CLAVE Papel de la ecocardiografía en la monitorización hemodinámica de los pacientes

Ecocardiografía; críticos
Hemodinámica;
Función del Resumen El uso de la ecocardiografía en las unidades de cuidados intensivos para los pacientes
ventrículo izquierdo; en estado de shock permite la medición precisa de varias variables hemodinámicas de una forma
Monitorización; no invasiva.
Pacientes críticos Mediante el uso de la ecocardiografía, no como un instrumento diagnostico sino como
herramienta de monitorización hemodinámica continua, el intensivista puede evaluar varios
aspectos de los estados de shock, como el gasto cardíaco y la respuesta de fluidos, contractilidad
miocárdica, las presiones intracavitarias, la interacción corazón-pulmón y las interdependencia
biventricular.

夽 Please cite this article as: Ayuela Azcarate JM, et al. Papel de la ecocardiografía en la monitorización hemodinámica de los pacientes

críticos. Med Intensiva. 2012;36:220---32.

∗ Corresponding author.

E-mail address: [email protected] (J.M. Ayuela Azcarate).

2173-5727/$ – see front matter © 2011 Elsevier España, S.L. and SEMICYUC. All rights reserved.
Role of echocardiography in the hemodynamic monitorization of critical patients 221

Sin embargo, hasta la fecha, ha habido pocas guías que orienten respecto a los parámetros
hemodinámicos ecocardiográficos en la unidad de cuidados intensivos, y la mayoría de los
intensivistas por lo general no están familiarizados con esta herramienta.
En esta revisión, se describen algunos de los parámetros hemodinámicos más importantes
que pueden obtenerse con la ecocardiografía transtorácica en los pacientes críticos.
© 2011 Elsevier España, S.L. y SEMICYUC. Todos los derechos reservados.

Introduction direction and velocity of blood flow in the different cham-

bers and major vessels. Knowing the flow velocity, and
Hemodynamic instability is common in critical patients, simplifying the Bernoulli equation, we can calculate the
and the usefulness of monitorization systems in situations pressure gradient between the cavities, establish the valve
of shock is based on the capacity to obtain quantifiable areas and determine the intracavitary pressures of the dif-
and reliable hemodynamic variables able to assess preload ferent heart chambers.
(central venous pressure or pulmonary capillary pressure), TEE is reserved for situations where the existing win-
afterload (vascular resistances), and contractility (ventri- dow is inadequate or suboptimal for TTE; when we need
cle function and cardiac output, CO).1 Once these variables to evaluate structures that are difficult to examine with
have been obtained, they can be grouped to establish hemo- TTE (e.g., the appendages, thoracic aorta or valve pros-
dynamic profiles in specific clinical situations producing theses); or where a diagnosis must be established in which
shock, such as hypovolemia, left or right ventricle dys- high imaging quality is crucial----as in acute aortic syndrome,
function or diminished peripheral resistances, and to assess endocarditis and its complications, and the detection of
different anatomical structures (pericardium, major vessels thrombi or masses, or prosthesis dysfunction.9,10
and heart valves). As with all imaging techniques, its main limitation is
The need to obtain continuous hemodynamic informa- dependency on operator experience and on the apparatus
tion in these patients, and the ongoing controversy over use being used. Adequate training and capacitation are there-
of the Swan-Ganz catheter, have focused attention on the fore needed. Recent articles11---14 show the usefulness of
usefulness of ultrasound in determining systolic and dias- different echocardiographic methods in obtaining hemody-
tolic function indexes that can be used for monitoring the namic measurements that can be used for both diagnostic
cardiovascular system.2 purposes and for analyzing the variability and changes
The role of echocardiography as a useful tool for the induced by applied treatments.
evaluation and monitorization of cardiovascular function in Likewise, focused ultrasound and echocardiography
these patients has been clearly established, with class A (FUSE)15,16 has been shown to be useful in critical, emer-
indication as recently defined by the recommendations for gency and out-hospital patient care.17,18 In this context,
the appropriate use of echocardiography.3 This is because in a basic two-dimensional echocardiographic study allows us
addition to its applicability at the patient bedside, its non- to establish or discard clinical situations based on binary
invasiveness in the case of transthoracic echocardiography (yes/no) responses to ensure the provision of urgent treat-
(TTE) or semi-invasive nature in the case of transesophageal ment.
echocardiography (TEE), the technique offers further advan- A series of basic questions must be considered on per-
tages of great importance in evaluating patients with forming echocardiography in the critical patient under
hemodynamic instability, such as immediate (real-time) conditions of shock.
image analysis and the obtainment of reliable etiological
as well as functional parameters.4---6 How is patient left ventricle function (LVF)?
Usefulness of echocardiography in situations The analysis of LVF is one of the basic elements and the
of hemodynamic instability in the critical first to be considered before carrying out volume replace-
patient ment and/or providing inotropic support. There are multiple
causes of reversible left ventricle myocardial dysfunction in
The current technological advances applied to echocardio- non-cardiac critical disease in the Intensive Care Unit (ICU):
graphy make it possible to study most patients via the pancreatitis, sepsis, neurogenic causes, intoxications, brain
transthoracic route, using the standard windows and planes death and anaphylaxis. A left ventricle dysfunction rate of
(Fig. 1) from which clinically applicable conclusions can be up to 40% has also been described in septic shock.
drawn. The quantitative methods used for estimating left ven-
Two-dimensional (2D) echocardiography7 allows us to tricle systolic function with echocardiography include linear
visualize most of the heart structures, with an assessment determinations in M-mode, two-dimensional measurements
of the morphology and size of the right and left cavities, in 2D-mode, and calculations derived from intracardiac
cardiac walls and of the presence of masses within the flows using Doppler echocardiography (Table 1).
heart chambers. This information is basically qualitative, At basic level, and following the criteria of the Focused
and Doppler ultrasound8 in its different modes (pulsed, con- Echocardiography Entry Level (FEEL) protocol,19,20 the eval-
tinuous and color) is required to obtain information on the uation of LVF should be made visually with the purpose
222 J.M. Ayuela Azcarate et al.

of establishing whether the left ventricle (LV) is dilated,

Table 1 Echocardiographic parameters in evaluating left
and whether function is normal or moderately/severely
ventricle function.
depressed, in order to integrate the response in the clini-
Evaluation of left ventricle function cal context, with a view to defining a correct management
strategy.
Echocardiography, two-dimensional and M-mode: Subjective visual estimation of the ejection fraction (EF)
Size and configuration of cavities. is widely used in daily clinical practice, though experience is
Global systolic function and ejective phase indexes: required on the part of the explorer in order to establish the
Ejection fraction (EF) different degrees of dysfunction (<30% severely depressed,
Shortening fraction (SF) >30% to <40% moderately depressed, >40% to <55% slightly
Global and regional systolic function of LV and RV. depressed and >55% normal) with acceptable correlation to
Detection and assessment of pericardial effusion. the quantitative determinations.21
Assessment of valve anatomy. The extreme values are easily identified. In this context,
Echo-Doppler: a group of intensivists with 2 h of theoretical training and
Calculation of cardiac output. only 4 h of practice, using a portable echocardiograph, were
Evaluation of regurgitations and valve stenoses. able to correctly identify normal LVF in 92% of the cases and
Evaluation of diastolic function. depressed LVF in 80% of the cases----the most common error
Estimation of pulmonary capillary pressure (PCP). being the overestimation of ventricle function.22
Other forms of quantitative evaluation require greater
experience. With the transducer in the parasternal lon-
gitudinal plane and combining two-dimensional imaging

Figure 1 Schematic representation of windows and images obtained by transthoracic echocardiography. Parasternal longitudinal
plane of the LV (1A) showing the left atrium (LA), left ventricle (LV), aorta (Ao) and right ventricle (RV). Parasternal transverse plane
at major vessel level (1B), with the right ventricle outlet tract (RVOT), pulmonary artery (PA) and right atrium. Apical four-chambers
plane (1C), and subcostal plane (1D) showing the right and left cavities.
Role of echocardiography in the hemodynamic monitorization of critical patients 223

with the M-mode, the ultrasound beam should be made

Table 2 Echocardiographic parameters in evaluating right
to section the LV as perpendicular as possible (never
ventricle function and central venous pressure.
tangentially), in order to register the smallest diame-
ters, the end-diastolic diameter (DEd coincides with the Evaluation of right ventricle function
peak of the R-wave of the ECG tracing) and the end-
systolic diameter (DEs with the maximum excursion point Basic level. Discard acute cor pulmonale:
of the endocardial margin). From these values we calcu- RV dilatation and LV relationship.
late the shortening fraction (SF = (DEd − DEs)/DEd × 100), Paradoxical septal motion
which expresses the percentage relationship between the TAPSE
diastolic and systolic diameters standardized with respect Dilatation of inferior vena cava, non-collapsible
to the diastolic diameter (normal value > 30%), and the Advanced level. Evaluate RV function:
ejection fraction, which relates the end-diastolic ventric- Dimensions of RV and RA
ular volume (VEd) and the end-systolic ventricular volume Systolic function and BSA
(VEs), standardized with respect to the end-diastolic volume Pulmonary artery flow: type and acceleration time
(EF = (VEd − VEs)/VEd × 100). Systolic pulmonary artery pressure due to TI
The technique has important limitations in the case of Doppler tissue imaging (DTI)
non-global structural and functional alterations (ischemic Inferior vena cava and right atrial pressure
heart disease) or when the section plane does not meet the
required perpendicularity between the cardiac walls. It is
therefore very dependent upon the operator. The method-
ology is also dependent upon preload and contractility, and How is patient right ventricle function? Is there
only assesses the function of the segments sectioned by the acute cor pulmonale?
ultrasound beam. Accordingly, function of the left ventricle
is estimated assuming contraction to be symmetrical. Nev- Until recently, right ventricle function (RVF) has been
ertheless, the parameters are easy to obtain, reproducible ignored, partly due to a lack of awareness of its importance,
and reliable for evaluating function, since no mathematical and partly because of technical difficulties in assessing func-
model needs to be assumed. tion in a reliable and reproducible manner. Under normal
In relation to the different methods available for conditions, the right ventricle (RV) functions as a low-
measuring the ejection fraction with two-dimensional pressure chamber, with great capacity to adapt to volume
echocardiography,23---25 the so-called modified Simpson overload, but with a poor response to pressure increments
method has been established by consensus as the option in the pulmonary territory. However, knowledge of RVF is
of choice. This method assumes the volume of the left of great diagnostic interest in pulmonary embolism, acute
ventricle to conform a series of ellipses stacked over the respiratory distress syndrome or cardiac tamponade, and
length of the cavity, using measurements in orthogonal for assessing the interactions with function in patients sub-
planes to determine the systolic and diastolic volumes. The jected to mechanical ventilation.
standard planes are the apical four-chamber (4C) and two- With the use of different planes and despite the anatomi-
chambers (2C) planes, taking special care not to include cal and technical difficulties involved (complex geometry of
the papillary muscles in the planimetric tracing of the the RV, with an irregular, half-moon shape and thin walls, an
cavities, using a complex formula included in the mea- irregular endocardial surface with the presence of a moder-
suring software of the system. In this way, calculation ator band and trabeculae that make it difficult to recognize
is made of the end-systolic volume (ESV) and the end- the endocardial margins), echocardiography27,28 allows us
diastolic volume (EDV), with the ejection fraction being to study the global right-side cavities, particularly with the
derived from the formula: EF = (EDV − ESV)/EDV. The main two-dimensional mode, which serves as a guide for measure-
limitations of the method are the difficulty in many cases ments in M-mode and orientation of the ultrasound beam in
of delimiting the endocardial margin, and the establish- the Doppler technique (Table 2).
ment of an apical sagittal plane at true apical level (of According to the echocardiographic protocol, the
lesser thickness than the surrounding level), where it is parasternal longitudinal plane (LP) is generally the first
very common to obtain a two-chambers apical acquisition plane obtained, and reveals the size of the RV and its rela-
tangential and not orthogonal to the four-chamber apical tionship with the LV. It therefore offers a first impression
acquisition. of the presence or absence of dilatation: an end-diastolic
These methods analyze LVF globally, but can also be used diameter of the RV in LP is >30 mm is considered pathological
to assess segmental systolic function. In this context, in the (normal = 9---26 mm in left lateral decubitus).
presence of myocardial ischemia we observe a decrease in The apical four-chambers plane is the projection offering
contractility of the affected ventricular segments that can the best information and with which it is easier to obtain
be evidenced by echocardiography as a decrease in seg- measurements of both the right atrium and right ventri-
ment motility and systolic thickening (hypokinesia). In turn, cle. In general, different studies have demonstrated the
if ischemia is prolonged, motility and systolic thickening are possibility of measuring29 the diameters, establishing the
abolished (akinesis). areas via planimetry, and of calculating the ejection frac-
The left ventricle model currently accepted for the tion, though the procedure is difficult due to the geometry of
analysis of segmental contractility26 includes 17 segments the RV. In this context, different methods have been devel-
obtained from apical four-, two- and five-chamber planes, oped, involving the measurements of different diameters,
and parasternal transverse planes in the three sections. that are scantly reproducible in routine emergency practice.
224 J.M. Ayuela Azcarate et al.

Figure 2 Tricuspid annular plane systolic excursion (TAPSE) represented between the two asterisks (1) and registry of systolic wave
velocity using Doppler tissue imaging (DTI) (2), showing a systolic wave (S) and two retrograde E- and A-waves. Normal registries.

For these reasons, analysis is made of the relative size rela- 15 mm are considered pathological and of prognostic value
tionship between RV and LV at the end of diastole (normal (Fig. 2).
ratio < 0.6 with RV < LV; moderate dilatation RV = LV; severe Registry of the maximum velocity of the systolic wave
dilatation RV > LV, with ratio > 1). using Doppler tissue imaging (DTI)32 is carried out at RV lat-
The interventricular septum (IVS) is a muscle wall sepa- eral wall level in four-chambers apical acquisition. A positive
rating the right ventricle (RV) from the left ventricle (LV), wave is recorded after QRS, and is preceded by another
though it is anatomically and functionally part of the latter. wave of shorter duration, corresponding to isovolumetric
The diameter in diastole is 7---11 mm, which is three-fold contraction. Normality is taken to be 15 ± 2 cm/s, while
greater than the RV free wall, with a systolic thickening of RV dysfunction is considered to be present when <10 cm/s
35%. (Fig. 2).
Ultrasound is the only technique allowing us to study By using ultrasound in its M and 2D modes, we can obtain
interventricular dynamics and inter-dependency. Mobility of direct and indirect data relating to pulmonary hypertension,
the IVS can be analyzed using two-dimensional ultrasound, suspect its presence even though its evaluation is not quan-
particularly in the parasternal transverse plane, at mitral titative, and study its repercussions upon the heart valves
valve level. The LV appears as a circle and the septum as an and chambers. However, Doppler echocardiography33 is the
arc encompassing 2/5 of the circumference. Under normal technique that informs of and quantifies pulmonary hyper-
conditions the IVS is convex towards the RV and concave tension.
towards the LV, and maintains this morphology over the Analysis of the morphology of pulmonary flow is car-
entire cardiac cycle. Movement alterations in the form of ried out in the parasternal transverse plane at major vessel
systolic fluttering, or the configuration of the RV in both level, positioning the pulsed Doppler sample volume at pul-
systole and diastole, can be used to identify the existence monary valve level. Under normal conditions a triangular
of diastolic or systolic overload. In situations of RV diastolic pattern is observed, gradually accelerating with a peak in
overload, the IVS undergoes flattening during diastole, since the mid-portion of systole, followed by a slow decrease end-
the RV diastolic pressure equals or exceeds that of the LV. ing just before valve closure (Type I). The presence of a
Systolic overload, in the presence of greater pressure in the mid-systolic notch is indicative of severe pulmonary hyper-
RV than in the LF, is recognized by the presence of a flat- tension (Type III), with a sensitivity of 56% and a specificity of
tened septum (septum in D) in both systole and diastole, 100% for PAPs > 50 mmHg.34,35 Another very useful and acces-
with diminished dynamics. sible option from the same plane is the measurement of
The analysis of segmental contractility alterations the acceleration time (AT) of pulmonary flow, which is mea-
acquires greater importance in right ventricle infarction, sured from the start of the wave to the maximum velocity
which is typically characterized by akinesis or dyskinesia (if >90 ms, pulmonary hypertension is discarded).36---38
of some of the explored surfaces in the different projec- The presence of tricuspid valve insufficiency (TI) is
tions. In pulmonary embolism, in the presence of pressure detected as systolic flow in the right atrium, with a max-
overload, the McConnell sign has been described as contrac- imum velocity that can be quantified by continuous Doppler
tility alteration in the form of akinesis of the free wall but with the help of color Doppler for correct assessment and
without affecting the apical zone----though its usefulness is positioning of the sample, allowing us to calculate the
questionable.30 transvalvular pressure gradient between the right atrium
Tricuspid annular plane systolic excursion (TAPSE) is mea- (RA) and right ventricle (RV) from the modified Bernoulli
sured in M-mode and represents the excursion or distance equation: PRV − PRA = 4Vmax TI2 .
displaced by the tricuspid ring from the end of diastole to Right ventricle systolic pressure equals the sum of the
the end of systole.31 To this effect, and in the apical four- systolic gradient between RA and RV plus the right atrial
chambers plane, the M-mode cursor is positioned at the free pressure (RAP), and in the absence of obstruction of the
margin of the tricuspid ring, with measurement of its sys- right atrium outlet tract, it equals the systolic pressure of
tolic displacement. It is not influenced by heart rate (HR) the pulmonary artery, whereby: PAPs = 4Vmax IT2 + RAP.
but is affected by pre- and afterload. This is an easy method Different alternatives are available for determining the
for assessing right ventricular contractility. Values of under mean right atrial pressure to be summed to the gradient:
Role of echocardiography in the hemodynamic monitorization of critical patients 225

Figure 3 Obtainment of the diameter of the left ventricle outlet tract (LVOT) in the parasternal longitudinal plane (1) and
estimation of the area (0.785 × 2.22 = 3.79 cm2 . We then (2) register the LVOT flow with pulsed Doppler, in the apical 5-chambers
plane, and obtain VTI (velocity time integral) (the figure registers three measurements with a mean of 24 cm). The stroke volume
(SV) = 3.79 × 24 = 91 ml.

• Use of a central venous catheter. the endocardium to the same point of the posterior cusp:
• Use of the diameter of the inferior vena cava (IVC) area = Л × (D/2)2 = 0.785 × D2 .
(normal diameter 16 ± 2 mm) and its inspiratory collapse Stroke volume is determined by echocardiography usu-
(IC) index, due to the existence of good correlation ally by calculating the volume of blood crossing the aortic
between these parameters and right atrial pressure. An valve in each beat. Pulsed Doppler yields the flow velocity
IVC ≤ 21 mm with IC > 50% estimates a RA pressure of spectrum at that level, using the apical 5-chambers plane,
between 0 and 5 mmHg, while IVC > 21 mm and a non- which allows more parallel alignment between the direction
collapsible vein indicates a pressure of ≥15 mmHg. of flow and the Doppler interrogation line. Measurement of
the flow (IVT of the left ventricular outlet tract, LVOT) is
made placing the sample volume close to the valve area. The
The reliability of the estimation is well established in
normal values are between 18 and 23 cm----a value of <12 cm
the echocardiography laboratory; however, there are tech-
indicating low output. At present, all echocardiography sys-
nical limitations in patients admitted to the ICU. Mechanical
tems provide IVT (in cm) when the Doppler signal curve is
ventilation in particular complicates the technique due to
delineated with the incorporated measurement software.
the absence of an adequate echocardiographic window. In
non-ventilated patients, the presence of dyspnea and the
impossibility of tolerating left lateral decubitus are the CO(cm3 /min) = 0.785 × D2 (cm2 ) × IVT(cm/beat) ×
main impediments. The presence of arrhythmias, particu-
HR(beats/min)
larly atrial fibrillation, makes it necessary to average the
measurements over 5---10 beats. Despite these limitations,
the measurement of pulmonary artery systolic pressure using This method,39 despite all the assumptions upon which it
Doppler ultrasound is reliable, with good correlation to the rests and the need for careful and good quality exploration,
invasive methods. has revealed acceptable global correlations with the inva-
sive techniques----though with great individual variability and
the need for a normal left ventricular outlet tract (LVOT) and
Is cardiac output normal or reduced? the absence of significant aortic insufficiency. The main lim-
itation is represented by errors in measurement of the aortic
Cardiac output is an estimator of global cardiovascular sys- ring diameter, particularly when considering that such error
tem function, and is calculated as the product of heart rate is moreover magnified by having to square the measure (i.e.,
and stroke volume (SV). According to classical hydrodynam- raise it to the second power) (Fig. 3).
ics, the volume passing through a certain section can be Precisely with the idea of avoiding this error, Evangelista
calculated by multiplying the area of the section or zone et al.40 have shown that we can obviate measurement of
(A, cm2 ) by the integral of velocity versus time of the flow the aortic ring, since there is a closer correlation between
passing through it (IVT, cm)----this representing the systolic the cardiac index (CI) estimated by thermodilution and
distance traveled by the blood during the measured time the mean velocity in the LVOT obtained by pulsed Doppler
period: SV = A × IVT (Fig. 3). (r = 0.97) than between the cardiac index and the esti-
The area most often used for this purpose in clinical prac- mation made with the usual method described in this
tice is the area of the aortic valve ring. The annular or section (r = 0.90). The resulting regression equation is: CI
ring diameter (D) is measured at the level of insertion of (ml/min/m2 ) = 172 × mean velocity − 172.
the valve cusps or leaflets, which in most cases is correctly The standard deviation of the estimation is
visualized in the parasternal longitudinal plane of the left 0.24 l/min/m2 . The mean flow velocity in the LVOT is
ventricle in TTE and/or in the two-chambers mid-esophageal an extraordinarily useful parameter for estimation of the
plane in TEE, assuming a circular geometry. To this effect cardiac index, and especially for monitoring the changes
zoom is applied to the zone at the start of systole, measur- occurring in the face of new hemodynamic situations or as
ing from the insertion or junction of the anterior cusp on a result of treatment.
226 J.M. Ayuela Azcarate et al.

an E/A ratio > 1, an E-wave deceleration time (DT) of

Table 3 Echocardiographic indexes in evaluation of left
about 180 ms (199 ± 32), and an IVRT in the order of 90 ms
ventricle filling pressures.
(69 ± 12 ms).
Indexes suggesting elevated PCP The diastolic ventricular filling patterns are the result of
the interaction between filling flow and the diastolic proper-
E/A ratio ≥ 2 ties of the LV and the loading conditions.47,48 Thus, the mitral
Mitral filling E-wave deceleration time < 150 ms flow pattern affords global and nonspecific information on
DT of the diastolic wave of PVF ≤ 160 ms diastolic function, resulting from interaction among the ven-
Relationship duration reverse PVF wave and mitral A-wave tricular relaxation state, ventricular compliance and the left
(APdur > Adur ) atrial pressure value. Accordingly, the morphology of the
E/VP > 2.5 → PCP: 15 mmHg curve is modified by different factors, such as the existing
100/[(2 × IVRT) + Vp] > 5.5 → PCP: 15 mmHg hemodynamic conditions, heart rate and age. Its character-
E/e′ > 15 → PCP: 15 mmHg istics and the evolution of the filling patterns in relation
to the degree of diastolic dysfunction are summarized in
Figs. 4 and 5.
Can we estimate the filling pressures? The mitral filling flow velocity curve is technically very
simple to obtain, reproducible and easy to perform at the
The filling pressure values classically have been the values patient bedside. The Mayo Clinic49 investigated the rela-
provided by the pulmonary artery catheter for hemodynamic tionship between these parameters and filling pressure in
assessment of a patient. Posteriorly, with the incorporation two groups of patients: 42 subjects with left ventricular
of the hemodilution techniques, it became possible to cal- systolic dysfunction (EF < 40%) and 55 patients with hyper-
culate SV, CO and peripheral vascular resistance (PVR). The trophic myocardiopathy. In this clinical context, left atrial
usefulness of the filling pressures has been greatly ques- pressure (LAP) was inversely correlated to the DT of the
tioned as a result of scientific confirmation that they are E-wave (r = 0.73, p < 0.001) and directly correlated to the
not valid either for assessing heart function or for predicting E/A ratio (r = 0.49, p = 0.004). An E/A ratio of ≥2 had low
response to volume.41,42 sensitivity (52%) but high specificity (100%) in detecting
Nevertheless, in a patient with hemodynamic instability, LAP ≥ 20 mmHg. In the case of DT < 180 ms there was an
the knowledge of pulmonary wedge pressure is basic when associated PCP of ≥20 mmHg, with a sensitivity and speci-
complemented by important data such as the anatomical ficity of 100%. Due to their dependence upon the ventricular
characteristics of the left ventricle (hypertrophic/dilated) relaxation state, these parameters were only useful in the
and its global function. Wedge pressure is an indicator of advanced systolic dysfunction group (EF < 40%) and under
left ventricle preload, and has diagnostic applications by conditions of sinus rhythm.
allowing us to distinguish among the different etiologies of This study coincides with earlier findings50---52 in patients
lung edema. Although theoretical preload is correlated to with normal systolic function, where none of these mea-
left ventricle end-diastolic volume, in practical terms it is sures showed sensitivity and specificity levels acceptable for
assimilated to wedge pressure. At present, pulmonary cap- clinical use, except in patients with depressed EF.
illary pressure (PCP), as a reflection of left atrial pressure,
can be reliably estimated from diastolic function parameters
obtained by Doppler echocardiography43---46 (Table 3). E-wave velocity by color Doppler in M-mode (Vp)
For recording in the apical four-chambers plane, we ana-
Mitral valve filling flow lyze the color Doppler signal corresponding to mitral filling,
During diastole, left ventricle filling is explored by pulsed adjusting the depth to include the entire left ventricle from
Doppler (Pw), placing the sample volume at the free mar- the mitral valve to the apex (approximately 45 mm). After
gin of the mitral valve leaflets in the apical four-chambers zooming in on the zone, we align the cursor of the M-mode
plane. At each timepoint during diastolic filling, the velocity at the center of the color signal. We thus obtain a wave cor-
represented by the wave reflects the instantaneous pressure responding to propagation of the color Doppler in M-mode,
gradient between the left atrium and ventricle, in accor- which almost instantaneously reaches the apex of the LV in
dance with the Bernoulli equation. individuals with normal relaxation. After freezing the image,
A recording composed of two waves is obtained in individ- we measure Vp as the gradient of the line separating first
uals under sinus node rhythm: the E-wave, corresponding to aliasing of the early diastolic flow (blue/red transition) from
rapid protodiastolic filling, and the A-wave, dependent upon the mitral valve ring to the apex (normal > 60 cm/s). Theo-
atrial contraction. Likewise, on placing the sample volume retically, it could also be measured as the gradient of any of
of the pulsed Doppler between the mitral valve and the left the isovelocity lines; to this effect it is useful to modify the
ventricle outlet tract, in the apical 5-chambers plane and color Doppler baseline.
using color Doppler as a guide, we obtain the systolic flow It has been shown that Vp is independent of mean atrial
curve at that level and can thus measure the isovolumetric pressure and is closely correlated to tau; as a result, it can
relaxation time (IVRT). Its duration is measured between the be used as an estimator of ventricular relaxation.
aortic flow closing artifact and the start of the mitral flow Two combined parameters have been found to be of prac-
(E-wave). tical use:
Typically, the normal mitral filling flow curve in a middle-
aged individual presents an E-wave (velocity 80 ± 16 cm/s) • Usefulness of the ratio of the peak E-wave velocity to
that is slightly larger than the A-wave (56 ± 13 cm/s), with propagation velocity (E/Vp) in estimating PCP. An E/Vp
Role of echocardiography in the hemodynamic monitorization of critical patients 227

Figure 4 Pulsed Doppler recording showing the isovolumetric relaxation time (IVRT) and the ventricular filling patterns in normal
filling (1 and 2) and inadequate relaxation (3), the restrictive pattern (4) and its relation to the ECG tracing. An inadequate relaxation
pattern (2) is characterized by a decrease in E-wave velocity, an increase in A-wave velocity, E/A ratio < 1, and a prolongation of
the deceleration time (DT) of the E-wave and of IVRT. Diminished ventricular elasticity in turn produces an increase in left atrial
pressure that implies a filling pattern inverse to the previously described pattern, known as the restrictive pattern (4), with an
increase in E-wave velocity, a decrease in A-wave velocity, and shortening of DT and IVRT. In the progressive transition between the
inadequate or delayed relaxation pattern and the restrictive pattern, mitral flow may present a ‘‘pseudonormal’’ morphology, that
can shift to an inadequate relaxation pattern if the patient performs the Valsalva maneuver.

of >2.5 offers acceptable predictive value in predict- jet, hypertrophic myocardiopathy, mitral valve stenosis
ing PCP > 15 mmHg (r = 0.80, p < 0.001)----its value being or prosthesis, and in the presence of preserved LV systolic
estimated from PCP = 5.27 × [E/Vp] + 4.6.53 However, its function.
usefulness decreases in the presence of atrial fibrilla- • The combined parameter 1.000/([2 × IVRT] + Vp) is closely
tion, dilated myocardiopathy with an eccentric filling correlated to PCP, according to the regression equation

Figure 5 Restrictive mitral filling pattern (1) in a patient presenting Killip class III after anteroseptal infarction, with DT = 130 ms
and an E/A ratio of >2. E-wave velocity = 1.07 m/s. DTI (2) with e′ -wave velocity = 0.80 cm/s, E/e′ ratio > 12, suggesting increased
filling pressures.
228 J.M. Ayuela Azcarate et al.

Depressed LV function (<40%) Normal global LV function (>40%)

Use mitral filling Use DTI

E/A ratio

Septal E/e’ ≥ 15
E/A <1 E/A ≥ 2
E/e’ ≤ 8 Lateral E/e’ ≥ 12
E ≤ 50 cm/s DT < 150 ms
Mean E/e’ ≥ 13

Normal Elevated Normal Elevated

Figure 6 Doppler evaluation of filling pressures. The extreme values have been represented, use being required of the E/Vp ratio,
pulmonary vein flow, IVRT/T E/e′ < 2, 100/([2 × IVRT] + PV) or combined parameters in the intermediate values.
Source: Adapted from: Nagueh SF, Appleton CP, Gillebert TC, Marino PN, Oh JK, Smiseth OA et al. Recommendations for the
evaluation of left ventricular diastolic function by echocardiography. Eur J Echocardiogr 2009;10:165---93.

PCP = 4.5 × 1.000/[(2 × IVRT) + Vp] − 9, independently of • e′ , early diastolic wave, representing the rapid filling
ventricular systolic function.54 A value of >5.5 for this phase.
parameter discriminates between PCP over or under • a′ , late diastolic wave, representing the late filling phase
15 mmHg in 96% of all cases. In practical terms, and atrial contraction.
IVRT < 80 ms in the presence of a low EF is indicative of
decompensation. The peak velocity of the E-wave obtained by DTI (e′ )
is correlated to ventricular relaxation and is relatively
independent of the preload. The ratio between the peak
Doppler tissue imaging (DTI) velocity of the mitral E-wave and the E velocity of the
When the ultrasound beam is directed towards the heart, lateral mitral ring (E/e′ ) shows close correlations to PCP
the waves are reflected from the cardiac structures. In (PCP = 1.24 [E/e′ ] + 1.9)----values above 15 being predictive
the same way as with the red blood cells, mobile tis- of PCP > 15 mmHg.55 Values of <8 in turn are associated with
sues such as the myocardium reflect low-velocity Doppler normal PCP values). However, E/e′ ratios between 8 and 15
signals. The longitudinal muscle fibers in the heart are have low predictive value. At present, septal E/e′ ≥ 15, lat-
located in the basal segments. Positioning of the pulsed eral E/e′ ≥ 12 and mean E/e′ ≥ 13 is considered indicative of
Doppler sample, generally in the lateral portion of the increased filling pressures.56
mitral valve ring or in the basal portion of the septum, in The method has been validated in the presence of
the apical four-chambers plane, allows us to quantify the sinus node tachycardia, atrial fibrillation and hypertrophic
maximum velocities of this myocardial zone in the differ- myocardiopathy. Its limitations are the presence of mitral
ent phases of the cardiac cycle. By means of a series of valve stenosis or prosthesis, moderate to severe mitral
Doppler signal modifications, we can record a velocity/time valve insufficiency, severe mitral ring calcification and
curve, obtaining a type of signal referred to as Doppler the existence of posterolateral wall akinesis. Recently57
tissue imaging (DTI). In clinical practice, DTI measure- the recommendations for evaluating diastolic function via
ments have been standardized in the mitral and tricuspid echocardiography have been published. In this context,
ring to determine variables of systolic and diastolic func- Fig. 6 shows the recommendations for estimating the fill-
tion. A normal registry comprises systolic and diastolic ing pressures in patients with normal and depressed systolic
waves: function.
The clinical usefulness of the described parameters
depends on two factors: (a) the experience and technical
• Sm, systolic wave, showing two components in some knowledge of the explorer and the available technology;
patients, and representing isovolumetric contraction and and (b) the physiological mechanisms that inter-relate the
the ejective systolic phase. A peak systolic velocity Doppler data with the diastolic properties of the LV, the
Sm > 5.4 cm/s predicts EF >50% with a sensitivity of 88% loading conditions and their variations in different etio-
and a specificity of 97%. logical situations, or the response to applied treatment.
Role of echocardiography in the hemodynamic monitorization of critical patients 229

SHOCK
Evaluation and context

Basic monitorization: OBJECTIVE 1

BP, HR, RF, CVP Echocardiography (FUSE)*
Pulsioxymeter, arterial catheter and
venous catheter

Insufficient treatment response or need Good clinical course

to further explore the physiopathology
of the process

OBJECTIVES 2 AND 3
Echocardiography and Doppler

Good clinical course

Need for continuous hemodynamic
monitorization with other systems

Figure 7 Evaluation and monitorization algorithm based on echocardiography among patients in shock. FUSE: focused ultrasound
exam.

The main limitations of these studies are the number of Is the heart dependent upon preload?
patients involved, their very different characteristics, and
the by now classical controversy regarding the relationship Measurement of the size of the heart cavities (left ventri-
between pulmonary wedge pressure and left atrial pressure, cle end-diastolic surface and volume) has been proposed as
and its usefulness as an indicator of left ventricular preload. reliable preload indexes. However, there are no sufficiently
Thus, no single parameter is correlated in a universal and sensitive concrete values allowing us to predict the response
statistically significant manner to PCP, and we must use and to volume expansion.
integrate all the information that can be obtained from the Recently, Doppler ultrasound and 2D imaging have led
different echocardiographic methods, either isolatedly or in to the development of new hypovolemia indicators and
combination. to the prediction of response to volume expansion. These
Nevertheless, data such as the E/A ratio, IVRT, DT of the parameters should serve to identify those patients who will
E-wave in patients with depressed EF, and the E/e′ ratio benefit from volume expansion, increasing their systolic
via DTI (at present all systems are equipped with DTI) in volume (responders) and at the same time avoiding use-
patients with normal EF not only can be easily obtained but less and potentially harmful therapy (non-responders). The
moreover form part of the routine protocol used in basic dynamic parameters, which analyze cardiovascular response
echocardiographic studies such as measurement of the size to the respiratory changes in pleural pressure produced by a
of the different heart chambers or the evaluation of systolic mechanical respiratory cycle, are the variables which have
or valve function. Other data, including pulmonary vein flow been most extensively studied to date.
(PVF), or combined parameters, can be used in those cases
in which the mitral filling pattern presents some of the limi- Analysis of the diameter of the inferior vena cava (IVC)
tations commented above. It should be remembered that all The subcostal plane often allows us to evaluate the infe-
of them are quickly obtainable by transthoracic echocardio- rior vena cava and the suprahepatic veins and to indirectly
graphy at the patient bedside, and can be repeated as often estimate right atrial pressure. Changes in intraabdominal
as necessary. pressure and breathing rapidly modify their volume. During
230 J.M. Ayuela Azcarate et al.

inspiration, venous return increases and the IVC decreases

Table 4 Echocardiographic parameters in hemodynamic
in diameter. The size and decrease in diameter during
monitorization.
inspiration (collapse index: maximum diameter in expira-
tion − minimum diameter in inspiration/maximum diameter Preload Contractility
in expiration) are related to mean right atrial pressure. Diameter of inferior vena Visual estimation visual
The respiratory variability index of the IVC (IVC) has cava and RA pressure of LV and RV function
been defined as Dmax − Dmin /(Dmax + Dmin )/2 × 100, where Diameter, area and Systolic collapse of LV cavity
Dmax and Dmin are respectively the maximum and minimum end-diastolic volume
values of the IVC in a mechanical respiratory cycle. The of LV and RV
observation of VCd ≥ 12% allows us to distinguish between Estimation of filling Ejection fraction
volume expansion responders and non-responders, with high pressures: E/A and E/e′ and shortening
sensitivity and specificity.58 ratios
Variation infusion of fluids Cardiac output and VTI
Analysis of the variability of the diameter of the superior Pulmonary flow and TI
vena cava (SVC) TAPSE
In patients subjected to mechanical ventilation, trans- TDI-s of RV free wall
esophageal echocardiography can be used to explore the
inspiratory increase in pleural pressure during lung insuf-
flation, which produces a total or partial collapse of the
consider that the use of this protocol does not discard
SVC. The observation of collapse suggests that at this point
other monitorization methods; rather, the protocol can be
the external pressure exerted by the chest cavity upon the
used as a complement to other techniques depending on
superior vena cava is greater than the venous pressure. In
the concrete parameters to be examined, the invasive-
this context, variability in the diameter of the SVC of over
ness allowed by the patient condition, and the continuity
36% has been shown to predict a positive response to vol-
considered opportune. In aspects such as the evaluation
ume expansion, with a sensitivity of 90% and a specificity of
of extrapulmonary water in patients with respiratory dis-
100%.59,60
tress syndrome, close monitorization of right-side cardiac
function in patients subjected to mechanical ventilation,
Analysis of the variation in aortic peak flow velocity pulmonary hypertension of any origin, etc., or the defini-
(PFV) tion of tissue perfusion and O2 transport and consumption
This parameter is obtained by recording aortic flow in the (DO2 /VO2 ), use must be made of the existing monitorization
left ventricle outlet tract (see cardiac output). A value PFV systems along with echocardiography.
(PVmax − PVmin /PVmax + PVmin /2 × 100) of 12% can also be used
in the evaluation of volume expansion.61---64
Financial support
Conclusions
This study has not been funded by any institution or aid.
Echocardiography, by generating a large body of infor-
mation on the anatomy of the heart, ventricle function Conflict of interest
and the hemodynamic condition of the critical patient, is
becoming increasingly common in the ICU as a diagnostic The authors declare no conflicts of interest.
tool and for evaluating cardiovascular function. Only ade-
quate training can allow intensivists to perform reliable
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