swan song: echocardiography as a pulmonary artery catheter? · interdepartmental division of...
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Interdepartmental
Division of Critical
Care Medicine
Swan Song: Echocardiography as a Pulmonary Artery Catheter?
Interdepartmental
Division of Critical
Care Medicine
The swan is without spot, and it sings sweetly as it dies, that song ending its life…
Leonardo Da Vinci
Interdepartmental
Division of Critical
Care Medicine
Curr Opin Anesthesiol 2016, 29:36–45
Circulation. 2015;131:1031-1034.
Journal of Critical Care 29 (2014) 184.e1–184.e8
Interdepartmental
Division of Critical
Care Medicine
Temporelli, Circ Heart Fail. 2010;3:387-394
Interdepartmental
Division of Critical
Care Medicine
Temporelli, Circ Heart Fail. 2010;3:387-394
Interdepartmental
Division of Critical
Care Medicine
Kelly CR, Rabbani LE. N Engl J Med 2013;369:e35.
Pressure Waveforms in the Right Heart and Pulmonary Artery.
Interdepartmental
Division of Critical
Care Medicine
Ruddski, J Am Soc Echocardiogr 2010;23:685-713
LIVER
IVC
LIVER
IVCRARA
Interdepartmental
Division of Critical
Care Medicine
J Am Soc Echocardiogr 2013;26:1033-42
RA
RV
LA
LV
Interdepartmental
Division of Critical
Care Medicine
J Am Soc Echocardiogr 2013;26:1033-42
Interdepartmental
Division of Critical
Care Medicine
E/Ea > 6 = RAP >10 mmHgSe 79% and Sp 73%
Nageh The american Journal of Cardiology, Vol 84; 1999
Interdepartmental
Division of Critical
Care Medicine
Acceleration rate of E wave
Rate > 560 cm/s2 predicted a RAP > 5mmHg
(Se 100% and Sp 99%)
Independent predictor of RAP
Am Jour of Cardiology 1998
Interdepartmental
Division of Critical
Care Medicine
J Am Soc Echocardiogr 2007;20:982-988RAP = 1.62 E/E’ + 2.13
Interdepartmental
Division of Critical
Care Medicine
Kelly CR, Rabbani LE. N Engl J Med 2013;369:e35.
Pressure Waveforms in the Right Heart and Pulmonary Artery.
Interdepartmental
Division of Critical
Care Medicine
Circulation 70, No 4, 657-662, 1984
Interdepartmental
Division of Critical
Care Medicine
Yock, Circulation 70, No 4, 657-662, 1984
Interdepartmental
Division of Critical
Care Medicine
Apical 4 Chamber
or RV modified
RV inflow
RV inflow/outflow
Alignment with TR jet
Estimation of RVSP. Continuous wave doppler
TR jet velocity in m/s
RVSP = 4 (TR)2 + RAP
Agitated saline
RV
RA
LA
LV
Interdepartmental
Division of Critical
Care Medicine
Soliman, Anaesthesia 2015; 70 : 241-4
RA
RA
RV
RV
LA
LA
AV
Interdepartmental
Division of Critical
Care Medicine
Anesthesiology, V 108, No 1, Jan 2008
Interdepartmental
Division of Critical
Care Medicine
Interdepartmental
Division of Critical
Care Medicine
Schiller, JASE 2013
Interdepartmental
Division of Critical
Care Medicine
Rich, Chest 2013: 143 (6): 1536-9
Interdepartmental
Division of Critical
Care Medicine
Heart 2011;97:612e622.
R= 0.7 (95% CI: 0.65-0.77)
Interdepartmental
Division of Critical
Care Medicine
Kelly CR, Rabbani LE. N Engl J Med 2013;369:e35.
Pressure Waveforms in the Right Heart and Pulmonary Artery.
Interdepartmental
Division of Critical
Care Medicine
In absence of
RVOT obstruction
PV stenosis
VSD
RVSP = PA systolic pressure
RA
RV
LA
AV
PAAo
Interdepartmental
Division of Critical
Care Medicine
Jardin, Viellard Baron, Current Opinion in Critical Care 2005, 11:271—279
Interdepartmental
Division of Critical
Care Medicine
Acceleration time
Mean PA pressure = 79 – (0,45xAT)
if At <120 ms 90 (0.62 x AT)
Dabestani, Am J Cardiol 1987: 59 662-668
Interdepartmental
Division of Critical
Care Medicine
Mean PAP = 4 (early PI vel)2 + RAP
Diastolic PAP = 4 (end PI vel)2 + RAP
Mean PA = 1/3 systolic PA pressure + 2/3 diastolic PA pressure
Rudski, JASE 2010: 23: 685-713
PA
RVOT
Interdepartmental
Division of Critical
Care Medicine
Kelly CR, Rabbani LE. N Engl J Med 2013;369:e35.
Pressure Waveforms in the Right Heart and Pulmonary Artery.
Interdepartmental
Division of Critical
Care Medicine
MV E/e’ 2.82
Circulation, 2000; 102:1788-1794
Interdepartmental
Division of Critical
Care Medicine
Ommen, Circulation, 2000; 102:1788-1794
Interdepartmental
Division of Critical
Care Medicine
J Am Coll Cardiol 1997;30:1527–33
Interdepartmental
Division of Critical
Care Medicine
J Am Soc Echocardiogr 2016;29:277-314
1. Not accurate in 1. Normal subjects (load dependency)2. Heavy annular calcification3. Mitral valve disease4. Pericardial disease
2. ‘‘Gray zone’’ of values
3. Reduced accuracy in patients with CAD and regional dysfunction
4. Different cutoff values depending on the site used
Interdepartmental
Division of Critical
Care Medicine
Kelly CR, Rabbani LE. N Engl J Med 2013;369:e35.
Pressure Waveforms in the Right Heart and Pulmonary Artery.
Interdepartmental
Division of Critical
Care Medicine
Circulation. 1981;63:388 –392
Circulation 1984; 70: 425-431
Interdepartmental
Division of Critical
Care Medicine
Circulation 70, No. 3, 425-431, 1984
CO = LVOT CSA x LVOT VTI x HR
Stroke Volume
LV
Ao
LA
Interdepartmental
Division of Critical
Care Medicine
CO = LVOT CSA x LVOT VTI x HR
Stroke Volume
(Error)2
Appropriate VTIAlignementDistance from the valve
Interdepartmental
Division of Critical
Care Medicine
Other Parameters…
Pulmonary vascular resistance
Systemic vascular resistance
LA pressure from Mitral Regurgitation
LVEDP from Aortic Regurgitation
Interdepartmental
Division of Critical
Care Medicine
R = 0.42
Come, Am J Cardiol 1988; 61:1300-1306
Interdepartmental
Division of Critical
Care Medicine
Final words
Solomon,NEJM 2014, 370; 1083-1085
Laënnec 1816, France
Interdepartmental
Division of Critical
Care Medicine
Public domain
