Noninvasive Monitoring of Cardiac Output in Critically

Ill Patients Using Transesophageal Doppler

BRUNO VALTIER, BERNARD P. CHOLLEY, JEAN-PIERRE BELOT, JEAN-EMMANUEL de la COUSSAYE,
JOAQUIM MATEO, and DIDIER M. PAYEN
Department of Anesthesiology, Lariboisire Hospital, Paris; Medical Intensive Care, Louis Mourier Hospital, Colombes;
and Department of Anesthesiology, Nmes, France

Measurement of cardiac output using thermodilution technique in mechanically ventilated patients is

associated with significant morbidity. The goal of the present study was to assess the validity of cardiac output measurement using transesophageal Doppler in critically ill patients. Forty-six patients
from three different intensive care units underwent 136 paired cardiac output measurements using
thermodilution (COTH) and transesophageal Doppler (COTED). In addition, simultaneous suprasternal
Doppler and indirect calorimetry (Fick principle) were used to measure cardiac output in 26 patients
from one center. A good correlation was found between COTH and COTED (r 5 0.95), with a small systematic underestimation (bias 5 0.24 L/min) using transesophageal Doppler. The limits of agreement between COTH and COTED were 12 L/min and 21.5 L/min. Variations in cardiac output between
two consecutive measures using either transesophageal Doppler or thermodilution techniques were
similar in direction and magnitude (bias 5 0 L/min; limits of agreement 5 61.7 L/min). Suprasternal
Doppler and indirect calorimetry yielded similar correlations and agreements in the subset of patients in whom they were used. These results confirm that transesophageal Doppler can provide a
noninvasive, clinically useful estimate of cardiac output and detect hemodynamic changes in mechanically ventilated, critically ill patients. Valtier B, Cholley BP, Belot J-P, de la Coussaye J-E, Mateo J, Payen DM. Noninvasive monitoring of cardiac output in critically ill patients using
transesophageal Doppler.
AM J RESPIR CRIT CARE MED 1998;158:7783.

The management of severe cardiovascular disorders is greatly

facilitated when the patients hemodynamic status can be
quantitatively assessed. The cardiac output is one of the key
parameters used by physicians to determine a therapeutic
strategy and evaluate the effects of treatment. The thermodilution technique is extensively used for measurement of cardiac output in intensive care units (ICUs), regardless of the
many pitfalls that may affect its precision. Despite concerns
about its accuracy, thermodilution is widely accepted for clinical purposes and often regarded as the gold standard by many
intensivists (1). Recently, the use of pulmonary artery catheters for invasive hemodynamic monitoring has been increasingly criticized on account of its unclear risk/benefit ratio (2,
3). Hence, a new technique that could provide a fair estimation of cardiac output in a less invasive and less expensive way
is clearly desirable.
Among the proposed alternatives, ultrasound-based technologies are the most promising. By combining Doppler and
echocardiographic measurements, instantaneous cardiac output can be obtained noninvasively by a transthoracic or trans(Received in original form July 8, 1997 and in revised form February 23, 1998)
This work has been sponsored in part by Direction de la Recherche et de lEnseignement Doctral (DRED), Universit Paris.
Correspondence and requests for reprints should be addressed to Dr. Didier
Payen, Department of Anesthesiology and Intensive Care, Hpital Lariboisire, 2
Rue Ambroise Par, 75475 Paris cedex 10, France. E-mail: dpayen.lariboisiere
@invivo.edu
Am J Respir Crit Care Med Vol 158. pp 7783, 1998
Internet address: www.atsjournals.org

esophageal approach (4, 5). However, the procedure requires

a trained operator, is often technically difficult in mechanically
ventilated patients, and does not provide continuous monitoring. To overcome these limitations, transesophageal continuous-wave Doppler of the descending aorta has been proposed
to monitor instantaneous cardiac output in anesthetized or
critically ill patients (610). The technique, initially introduced
by Daigle and colleagues (11), measures blood flow velocity in
the descending thoracic aorta, using a transducer that can be
inserted easily in sedated patients and left in place for several
days. Stroke volume may then be derived using an algorithm
based on: (1) the beat-to-beat maximum velocitytime integral (or stroke distance); (2) the cross-sectional area of the descending aorta; and (3) a correcting factor which transforms
descending aortic blood flow into global cardiac output. The
validity of this approach in mechanically ventilated patients is
not fully established, and clinical use of transesophageal Doppler for continuous monitoring of cardiac output is not yet
widely accepted.
The goal of the present study was to assess the validity of
transesophageal Dopplerderived cardiac output measurement in mechanically ventilated, critically ill patients. A multicenter protocol, associating three different intensive care units,
was designed to compare simultaneous cardiac output values
obtained using transesophageal Doppler and thermodilution
techniques. In one center, cardiac output was also obtained
simultaneously using two other techniques: (1) suprasternal
Doppler associated with two-dimensional echocardiography;
and (2) indirect calorimetry using the Fick principle.

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METHODS
A total of forty-six consecutive critically ill patients were enrolled
from one medical and two surgical intensive care units over a period
of 6 mo. The protocol was approved by the local Ethics Committees
and written informed consent was obtained from a patients relative in
each case. Patients were eligible if already mechanically ventilated, sedated, and monitored with a pulmonary artery catheter. Those with
suspected or documented esophageal lesions (history of dysphagia or
previous esophageal surgery) or aortic dissection were excluded. Measurements did not interfere with medical or nursing procedures, and
the pattern of mechanical ventilation was not modified for the study.

Cardiac Output Measurements

Simultaneous measurements of cardiac output were obtained by thermodilution using the pulmonary artery catheter and transesophageal
Doppler. Additional measurements of cardiac output were also attempted using suprasternal Doppler and indirect calorimetry in 24 patients from one center. In each case investigators were blinded to the
values obtained using other techniques.
Transesophageal Doppler. The device consists of a continuouswave Doppler transducer (4 MHz) mounted at 458 at the tip of a
transesophageal probe (diameter 5 8 mm). The probe is connected to
a monitor (DOPTEK-ODM1; Deltex, Chichester, UK) displaying the
blood flow velocity profile after spectral analysis of the reflected Doppler-shift signal (Fast Fourier Transformation). Following oral introduction, the probe was advanced gently until its tip was located in the
mid-esophagus, approximately 35 cm from the incisors, and then rotated so that the transducer faced posteriorly and a characteristic aortic blood flow signal was obtained. Probe position was optimized to
record peak velocity by slow rotation in the long axis and alteration of
the depth of insertion to generate a clear signal. Gain setting was adjusted to obtain the best outline of the aortic velocity waveform and a
300-Hz high-pass filter eliminated the noise related to low-frequency
vessel wall motion. Prior to each measurement, probe position was
verified to ensure optimal acquisition of the maximal velocity signal.
Stroke volume (SV, ml) was calculated as:
SV = CSA Ao K

V Ao ( t )dt

(1)

where VAo(t) represents instantaneous maximum aortic velocity, T is

the cardiac ejection time (the integral of instantaneous maximum velocity during cardiac ejection representing the stroke distance), CSAAo
is the cross-sectional area of the descending thoracic aorta (cm2), and
K is a correcting factor (5 1.43) whose purpose is to transform the
blood flow measured in the descending thoracic aorta into global cardiac output, assuming that a constant fraction (70%) of the total blood
flow passes through the descending aorta. CSAAo is estimated from a
nomogram based on the patients age, weight, and height. The monitor was preset to calculate cardiac output (COTED, L/min) by averaging stroke volume over 10 beats and multiplying the value obtained by
the heart rate.
Thermodilution. Measurements of cardiac output using thermodilution (COTH) were performed using a 7-Fr balloon-tipped pulmonary
artery catheter connected to a cardiac output monitor (Abbott, Mountain View, CA). Injections of iced 5% glucose (10 ml) were made
throughout the respiratory cycle and COTH was obtained by averaging
the results of at least five measurements (1214). Variability of measurements was assumed to be mainly secondary to positive pressure
ventilation (12, 13) and was not a criteria for rejection as long as the
thermodilution curve was satisfactory (14, 15).
Suprasternal Doppler combined with 2D-echocardiography. Noninvasive estimates of instantaneous aortic flow were generated from
pulsed-wave Doppler velocity recordings and echocardiographic measurements of aortic annular area (16). Ascending aortic blood velocity
was recorded with a 2 MHz pulsed-wave Pedof Doppler transducer
(Vingmed SD-50; Horten, Norway) positioned at the suprasternal notch.
The aortic annular diameter (Dao, cm) was measured from parasternal
long-axis 2D echocardiographic recordings obtained with a 2.5-MHz
transducer. Aortic annular area (AAA, cm2) was calculated, assuming
a circular orifice, as:
2
D ao
AAA = -------------------(2)
-.
4

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1998

Stroke volume was calculated by multiplying AAA by the Doppler

velocitytime integral of the ascending aortic blood flow during systole. Five consecutive beats were averaged to allow for respiratory
variation, and the value obtained was multiplied by heart rate to calculate cardiac output (COSSD) (4, 16, 17).

Indirect calorimetry using the Fick principle. Oxygen uptake (VO2)

and carbon dioxide production were measured using a gas exchange
monitor (Deltatrac, Datex, Helsinki, Finland). Inspiratory and expiratory oxygen concentration were determined using a fast response
paramagnetic oxygen analyzer (OM-101; Datex). Before each study,
the gas sensor was calibrated after a warm-up period of at least 30 min
with air and a gas mixture containing 95% oxygen and 5% CO2. This
method has been validated in critically ill patients ventilated with a
fraction of inspired oxygen (FIO2) of less than 0.60 (18). Arteriovenous
difference (AVD) was calculated as the difference between arterial
and mixed venous oxygen contents and cardiac output (COIC) as (19):
O
V
2
CO IC = ------------.
AVD

(3)

Statistics
Correlation between techniques was determined using simple linear
regression analysis with Bland and Altman representation (20) to explore the possibility of systematic errors. Significance of biases was
tested using paired t test. In order to correct for the distribution of differences, data were logarithmically transformed to obtain new limits
of agreement, as recommended by Bland and Altman (20). In all patients who underwent more than one measurement of cardiac output
during the study, the variations between two time points in COTH and
COTED were compared using two-way analysis of variance (ANOVA)
for repeated measures. Correlation and agreement studies were also
performed on variations. The reproducibility of each technique was
assessed in six patients judged to be in stable hemodynamic condition.
Intra-observer variability was calculated as the standard deviation of
the differences between five measurements obtained over a short period of time divided by the mean cardiac output.

RESULTS
One hundred thirty-six paired cardiac output measurements
were made, using transesophageal Doppler and the thermodilution technique, in 46 mechanically ventilated, critically ill
patients recruited from three different ICUs. Table 1 shows
selected clinical characteristics, including information regarding inotropic support and positive end-expiratory pressure
(PEEP). Esophageal intubation with the Doppler probe was
easily accomplished in all patients, except three who required
a direct laryngoscopy. In all cases an adequate signal was obtained within a few minutes, regardless of the presence of a
gastric suction tube. The probe was left in place for up to 48 h
(median: 36 h, quartile range: 2742 h) without adverse effects.
TABLE 1
SELECTED CLINICAL CHARACTERISTICS OF PATIENTS
Patients, n
Age, yr
Male/female ratio
Main diagnosis, n
Focal pneumonia
Adult respiratory distress syndrome
Septic shock
Cardiac failure
Acute pancreatitis
Polytrauma
PEEP level . 10 cm of water, n
Catecholamine infusion, n
Dobutamine
Norepinephrine
Dopamine
Epinephrine

46
50 6 20
38:8
5
7
16
8
4
6
10
15
2
10
4

Valtier, Cholley, Belot, et al.: Transesophageal Doppler Cardiac Output

Figure 1. (A) Scatterplot of paired cardiac output measurements

obtained using thermodilution (COTH) and transesophageal Doppler (COTED), with the solid line representing linear regression. (B)
Bland and Altman (20) representation of the agreement between
the two techniques. The solid line represents the mean difference
between COTH and COTED (systematic bias), and the dotted lines
define the limits of agreement (95% confidence interval).

Cardiac output ranged from 1.7 to 14.8 L/min when measured using transesophageal Doppler, and from 1.4 to 15.3 L/
min using the thermodilution technique. Figure 1 demonstrates (1) the close correlation between COTED and COTH
(correlation coefficients 5 0.95; p , 0.0001), and (2) the agreement between the two techniques. The mean difference between
the paired values (COTH 2 COTED), representing the bias of
transesophageal Doppler with respect to thermodilution, was
0.24 L/min (p , 0.003), while the limits of agreement (bias 6
2 SD) were 2.04 and 21.56 L/min. The scatter of differences
tended to increase with the increase in mean cardiac output
(Figure 1B). We therefore performed a logarithmic transformation of these data and obtained a new bias of 0.03, and new
agreement limits of 0.29 and 20.23. The antilogs of these new
limits were 1.33 and 0.79, respectively, indicating that COTED
may differ from COTH within a range of 133% to 221%.
Twenty-three patients underwent more than one measurement of their cardiac output during the study, allowing us to
compare the variations between two consecutive cardiac output values as measured with the two methods in 88 instances.
The median delay between the two cardiac output determinations was 1.5 h (quartile range: 0.56.4 h). The two-way ANOVA
for repeated measures showed no statistical difference between
the variation measured by thermodilution and their paired
counterparts measured using transesophageal Doppler. The

79

Figure 2. (A) Scatterplot of paired variations in cardiac output obtained using thermodilution (DCOTH) and transesophageal Doppler (DCOTED), with the solid line representing linear regression.
Dotted lines at zero intercept delineate four quadrants: upper left
and lower right quadrants contain the points corresponding to opposite variations in COTH and COTED. (B) Bland and Altman (20) representation of the agreement between variations measured using
the two techniques. The solid line represents the mean difference
between DCOTH and DCOTED (systematic bias), and the dotted lines
define the limits of agreement (95% confidence interval).

absence of significant interaction confirmed a similar direction

of change using both techniques. Variations in cardiac output
measured using thermodilution (DCOTH) correlated very well
with those measured using transesophageal Doppler (DCOTED),
as shown in Figure 2A (r 5 0.90, p , 0.0001). The agreement
between these variations was characterized by the absence of
systematic bias (0 L/min) and limits of agreement of 1.7 and
21.7 L/min (Figure 2B). In the subgroup of patients ventilated
with PEEP levels higher than 10 cm of water (n 5 10), the two
methods remained closely correlated (n 5 35; r 5 0.95; p ,
0.0001) with a bias of 0.2 L/min (p , 0.01), and limits of agreement of 2.1 and 21.7 L/min.
Suprasternal Doppler assessment was attempted in 24 patients but yielded a satisfactory signal in only 17 (71%). Fiftythree cardiac output measurements were obtained simultaneously using suprasternal Doppler, transesophageal Doppler,
and the thermodilution technique. The correlation and agreement between COSSD and COTED are shown in Figure 3.
The requirements for reliable oxygen consumption measurement using indirect calorimetry were met in 13 of the
same 24 patients (54%). The 46 cardiac output measurements
obtained using this technique also correlated well with those

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1998

Figure 3. (A) Scatterplot of paired cardiac output measurements

obtained using suprasternal Doppler (COSSD) and transesophageal
Doppler (COTED), with the solid line representing linear regression.
(B) Bland and Altman (20) representation of the agreement between the two techniques. The solid line represents the mean difference between COSSD and COTED (systematic bias), and the dotted
lines define the limits of agreement (95% confidence interval).

Figure 4. (A) Scatterplot of paired cardiac output measurements

obtained using indirect calorimetry (Fick principle, CO IC) and
transesophageal Doppler (COTED), with the solid line representing
linear regression. (B) Bland and Altman (20) representation of the
agreement between the two techniques. The solid line represents
the mean difference between COIC and COTED (systematic bias),
and the dotted lines define the limits of agreement (95% confidence interval).

obtained using transesophageal Doppler (Figure 4A), although the agreement between the two techniques was not as
close as with the two previous methods (Figure 4B).
The results of linear regression and agreement analyses between the four techniques are presented in Table 2.
Variability in cardiac output measurement was 8% for
COTED, 12% for COTH, and 9% for COSSD. No reproducibility
study could be performed using indirect calorimetry due to
the prolonged equilibration time required for each cardiac
output determination.

Doppler. We conclude that transesophageal Doppler can provide a clinically useful estimate of cardiac output and reliably
detect its variations in mechanically ventilated, critically ill patients.

DISCUSSION
Transesophageal Doppler is a new minimally invasive method
for the continuous monitoring of cardiac output in critically ill
patients. In this multicenter trial, the cardiac output values obtained using this technique correlated well with those obtained using thermodilution. The systematic underestimation
of COTED with respect to COTH was small (, 0.25 L/min), and
the limits of agreement were 0.25 6 1.8 L/min. More importantly, variations in cardiac output with time were comparable
using both techniques. Other measures of cardiac output using
suprasternal Doppler or the Fick principle also demonstrated
excellent correlation and good agreement with transesophageal

Methodologic Considerations

The estimation of cardiac output using transesophageal Doppler is based on four assumptions: (1) an accurate measurement of the velocity of descending aortic blood flow; (2) a
flat velocity profile throughout the aorta; (3) an estimated
aortic cross-sectional area close to the mean value during systole; and (4) a constant division of blood flow between the descending aorta (70%) and the brachiocephalic and coronary
arteries (30%). The accuracy of velocity measurement requires a good alignment between the Doppler beam and
blood flow and knowledge of the angle at which the blood
flow is insonated. Alignment is best assessed subjectively by
optimizing the quality of the obtained signal with the aid of
the visual display of instantaneous velocity waveform and the
Doppler sound. The angle between the Doppler beam and
blood flow is roughly the same as that between the transducer
and the probe (458), since the esophagus and aorta are parallel
in the thorax. However, even a 10% change in the alignment
of the Doppler beam with respect to blood flow would result

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Valtier, Cholley, Belot, et al.: Transesophageal Doppler Cardiac Output

TABLE 2
CORRELATION AND AGREEMENT BETWEEN CARDIAC OUTPUT VALUES
OBTAINED USING FOUR MEASUREMENT TECHNIQUES
Techniques
X/Y
TH/TED
SSD/TED
IC/TED
TH/SSD
TH/IC
SSD/IC

No. of
Patients
46
17
13
17
13
13

No. of
Measurements r Value
136
53
46
53
46
46

0.95
0.94
0.89
0.98
0.91
0.91

Regression Line
Equation

p Value
(Correlation)

Bias
(L/min)

p Value
(Bias)

y 5 0.53 1 0.903
y 5 20.11 1 0.993
y 5 0 1 1.043
y 5 0.35 1 0.953
y 5 1.09 1 0.783
y 5 0.9 1 0.803

, 1024
, 1024
, 1024
, 1024
, 1024
, 1024

0.24
0.16
20.29
0
0.51
0.56

, 0.003
NS
NS
NS
, 0.003
, 1023

Limits of Agreement
(L/min)
2.04, 21.56
1.90, 21.58
2.16, 22.74
0.88, 20.88
62.70, 21.68
62.67, 21.55

Definition of abbreviations: TH 5 Thermodilution; TED 5 Transesophageal Doppler; SSD 5 Suprasternal Doppler; IC 5 indirect calorimetry (Fick principle).

in less than 5% error in the final velocity measurement since

the principal determinant is the cosine of the angle (6). A
flat velocity profile implies that all red blood cells move at
the same speed through the vessel. In fact, the flow velocity
profile in the descending thoracic aorta is rather parabolic
than flat (21), i.e., the red blood cells at the center of the vessel
move faster than those at the periphery. Hence, use of the
maximum velocity envelope to compute stroke distance may
result in overestimation of stroke volume. Bedside measurement of the cross-sectional area of the descending aorta can
only be performed by using transesophageal echocardiography.
This technique is not available everywhere, and the manufacturers of the transesophageal Doppler probe have incorporated
a nomogram to estimate the cross-sectional area of the descending aorta based on the patients age, weight, and height. Systematic errors due to a discrepancy between the actual area and
the nomogram value would not affect the trend of cardiac output variation with time (7). Finally, the division of blood flow
between cephalic and caudal territories may also vary according to hemodynamic conditions, reflex activation, or metabolic
activity within different organs. Therefore, the assigned constant ratio of 70:30% may become inaccurate under a variety
of pathophysiologic conditions (7, 22). To overcome the uncertainty surrounding this arbitrary ratio, previous studies have
incorporated calibration of the descending aortic velocity with
respect to simultaneous suprasternal Doppler measurements
of cardiac output (7, 8, 10, 23). In fact, this calibration process
was time-consuming, required a trained operator for suprasternal Doppler assessment, was a source of error, and could not
account for possible secondary variations in the flow division
between supra-aortic vessels and the descending aorta.
All techniques for cardiac output measurement currently
available in clinical practice have well-documented limitations. The thermodilution technique has been extensively
scrutinized and shown to be affected by a variety of external
factors (15, 19, 2426) as well as patient-related conditions
(i.e., tricuspid regurgitation, intracardiac shunts, and low cardiac output states) (27, 28). Indirect calorimetry is unreliable
in patients with an (FIO2) greater than 0.6 (18), and cardiac
output estimation using the Fick principle may be adversely
affected by the lack of hemodynamic stability frequently encountered in mechanically ventilated, critically ill patients (19,
24). A significant proportion of patients was unsuitable for
cardiac output measurement using suprasternal Doppler, due
to a poor ultrasound window. In addition, although its accuracy is excellent, this approach is time-consuming and can only
be performed by a trained operator.
Present Findings

Despite the abovementioned methodologic limitations, the

correlation between cardiac output obtained using the ther-

modilution technique and transesophageal Doppler was good.

Single-center studies comparing thermodilution and transesophageal Doppler in anesthetized patients have reported a
wide range of correlation coefficients (r) between the two
techniques. Poor correlation (r 5 0.52) was observed in a
study where repeated measurements were performed without
readjusting the probe position after initial placement (23).
However, the majority of authors reposition their probes, usually by a small rotation, to recover the optimal signal and obtain a better correlation (r 5 0.900.98) (6, 7, 10). Our bias
analysis demonstrated that the mean difference between the
two techniques was small (0.24 L/min), indicating a minimal
systematic underestimation of cardiac output by transesophageal Doppler with respect to thermodilution. The limits of
agreement between the two techniques, 1.8 L/min above and
below the bias, were in the range of previous observations (10,
22). The relatively large scatter of differences between the two
techniques reflects the lack of precision of both methods of
measurement. Indeed, the 95% confidence interval is highly
dependent on the repeatability and accuracy of the techniques
compared. According to Bland and Altman, a new method
that is perfect will not agree with a reference method, which
is the most variable (20). We noted a greater variability of
COTH than COTED (12% versus 8%), consistent with previous
reports (7, 9). A meta-analysis evaluating the reproducibility
of the thermodilution technique suggested that differences between measurements greater than 15% were necessary to consider a change significant (1). Therefore, although isolated
COTED values should be interpreted with caution, our findings
indicate that transesophageal Doppler is adequate for differentiating clinically important ranges of cardiac output. More
importantly, we found that variations in cardiac output with
time were similar regardless of the measurement technique
employed. Variations were in the same direction and the
agreement demonstrated the absence of systematic bias (0 L/
min) and a spread of 61.7 L/min in DCOTH 2 DCOTED, similar to that observed in COTH 2 COTED. This confirms that the
trend in cardiac output variation evaluated using transesophageal Doppler is comparable to that measured with thermodilution, as already suggested by other investigators (79).
To further establish the validity of transesophageal Doppler, we obtained simultaneous cardiac output measurements
using suprasternal Doppler and indirect calorimetry using the
Fick principle. These techniques were only available at one
center and could not be applied successfully in every patient
due to the technical limitations mentioned earlier. Cardiac
output derived using both techniques correlated well with the
COTED values. Interestingly, the best correlation and agreement involving transesophageal Doppler was observed with
suprasternal Doppler (Figure 3), indicating that the variability
related to factors other than Doppler velocimetry itself was

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relatively small. Among those factors, the algorithm used to

compute stroke volume appears to generate very few inaccuracies. Hence, the assumptions concerning the precision of the
velocity measurement, the flow velocity profile, and the crosssectional area of the descending aorta as well as the division of
flow between supra-aortic vessels and the descending aorta
appear valid.
The best correlation and agreement was observed between
COTH and COSSD (Table 2). All other techniques agreed similarly, indicating that all methods were roughly of equal merit.
Transesophageal Doppler for Cardiac Output Monitoring

Transesophageal Doppler is a simple technique, and most users acknowledge that it is fairly easy to achieve adequate probe
positioning and obtain reproducible results (9, 29). Freund (8)
noted a dramatic improvement in the skills of untrained operators after performing only 10 measurements. However, in the
present study only trained operators performed each type of
measurement. Interobserver variability has previously been
shown to be less than 10% using transesophageal Doppler (6).
We found intra-observer variability to be slightly less with transesophageal Doppler (8%) than with thermodilution (12%),
confirming previous observations (7, 9).
Potential side effects of transesophageal cardiac output
monitoring include esophageal damage. Some authors have
left the probe in place for over 2 wk without adverse effects
(29), but there has been no systematic fibroscopic evaluation
of esophageal mucosal injury at the time of probe removal.
A major advantage of transesophageal Doppler over other
currently available techniques is its ability to provide continuous, real-time monitoring. In contrast to continuous cardiac
output monitoring using a pulmonary artery catheter, which
only provides repeated measurements of mean cardiac output,
transesophageal Doppler displays the instantaneous aortic velocity spectrum. Probe displacement can occur during prolonged monitoring as a result of various causes (e.g., nursing
procedures, deglutition, gravity) and results in a poorly defined velocity envelope. It is mandatory to ensure an adequate
signal prior to interpreting Doppler-derived data. Failure to
reposition the probe prior to each measurement may lead to
grossly erroneous cardiac output values and poor agreement
with other techniques (23). The monitor can be set to calculate
cardiac output either on a beat-to-beat basis or after averaging
stroke volume over a number of consecutive beats (maximum
20), according to the operators choice. In addition, the device
derives parameters from the shape of the velocity envelope,
such as peak velocity, mean acceleration of blood flow, and
the rate-corrected flow time during systole. Some insight into
volemic status, peripheral resistance, and left ventricular function can be obtained from these parameters in the ascending
aorta (30, 31). Although additional studies are needed to establish the validity of these indices when obtained in the descending thoracic aorta using transesophageal Doppler, several reports support their usefulness for optimizing therapeutic
strategies in critically ill patients (3234). In a recent randomized trial, Sinclair and colleagues (35) showed that patients
with femoral neck fracture undergoing intravascular colloid
resuscitation guided by transesophageal Doppler during surgical repair had a significantly reduced hospital stay (39%) compared with control subjects (35).
In conclusion, although transesophageal Doppler cannot
replace the pulmonary artery catheter, it offers an instantaneous, reasonably accurate, and noninvasive estimate of cardiac output. In addition, the variations in cardiac output occurring spontaneously or in response to treatment are tracked
similarly by the two techniques. Transesophageal Doppler

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may prove clinically useful in a large number of critically ill

patients in whom hemodynamic monitoring is desirable without the risks associated with right heart catheterization.
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