Hemodynamic Monitoring Utilizing

Transesophageal Echocardiography: The

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

Chest 2005;127;379-390
DOI 10.1378/chest.127.1.379
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 opinions/hypotheses
Hemodynamic Monitoring Utilizing
Transesophageal Echocardiography*
The Relationships Among Pressure, Flow, and
Function
Jan I. Poelaert, MD, PhD, FCCP; and Guido Schüpfer, MD
(CHEST 2005; 127:379 –390)
Key words: echocardiography; hemodynamic; left ventricular
function; monitoring
Abbreviations: A wave ⫽ late-filling wave; CW ⫽ continuous-
wave; ⫹dP/dtmax ⫽ positive maximum first derivative of pres-
sure, corrected for time; Ea ⫽ arterial elastance; E/A ⫽ ratio of
the early and rapid-filling wave to the late-filling wave; E
wave ⫽ early and rapid-filling wave; LA ⫽ left atrium atrial;
LAP ⫽ left atrial pressure; LV ⫽ left ventricle/ventricular;
LVEDA ⫽ left ventricular end-diastolic area; LVEDP ⫽ left
ventricular end-diastolic pressure; LVEDV ⫽ left ventricular
end-diastolic volume; PCWP ⫽ pulmonary capillary wedge pres-
sure; PW ⫽ pulsed-wave; PWR ⫽ cardiac power; RV ⫽ right
ventricle/ventricular; RVOT ⫽ right ventricular outflow tract;
SV ⫽ stroke volume; TDI ⫽ tissue Doppler imaging; TEE ⫽
transesophageal echocardiography; VTI ⫽ velocity-time integral
C ardiac imaging is an important cornerstone in
decision making and management in cardiovas-
cular medicine. Echocardiography and Doppler ul-
trasonography developed as the main and most
commonly used bedside imaging techniques. Trans-
thoracic echocardiography is an invaluable imaging
technique with respect to the diagnosis of cardio-
vascular disease. The impact of echocardiography
on the change in the therapy and management of
*From the Department of ICU (Dr. Poelaert), University Hos-
pital, Gent, Belgium; and Klinik für Anästhesie und Operative
Intensivmedizin (Dr. Schüpfer), Kantonsspital, Luzern, Switzer-
land.
This research was supported in part with a grant from the
International Research Centre, Gent, Belgium. Jan Poelaert was
supported by a grant from the Research Fund “Bijzonder
Onderzoeksfonds” (No. B/03719) of Ghent University, Gent,
Belgium (2002–2003).
Manuscript received January 9, 2004; revision accepted August
24, 2004.
Reproduction of this article is prohibited without written permis-
sion from the American College of Chest Physicians (e-mail:
permissions@chestnet.org).
Correspondence to: Jan Poelaert, MD, PhD, FCCP, Cardiac
Anaesthesia and Postoperative Cardiac Surgical ICU, Depart-
ment of ICU, University Hospital, De Pintelaan 185, B9000 Gent,
Belgium; e-mail: jan.poelaert@ugent.be
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Copyright © 2005 by American College of Chest Physicians
hospitalized patients was found to be as high as 57%,
although changes occurred more frequently in ICU
patients compared to those admitted to the hospital
(54% vs 37%, respectively).1,2 Nevertheless, the
transthoracic approach for echocardiography has
certain specific limitations regarding the visualiza-
tion of different cardiac structures and great vessels.
Table 1 demonstrates in detail the potential advan-
tages and shortcomings of both techniques. Trans-
esophageal echocardiography (TEE) with Doppler
imaging has opened a completely different window,
and has become a fascinating and appealing tool, not
only for diagnosis in routine cardiology practice3 but
also for perioperative hemodynamic monitoring,
having a decisive impact on surgical management.
Moreover, owing to its bedside availability, TEE
facilitates the routine diagnosis and management of
cardiovascular failure both intraoperatively and in
ICU patients.4
Circulatory failure of cardiac origin in adults often
is due to ventricular failure. More than 50% of all
patients who are scheduled for surgery or are admit-
ted to the ICU have experienced cardiac problems.
Impaired cardiac function, which is often seen in
critically ill patients, is mostly evidenced as pump
failure. Several etiologic factors of pump dysfunction
(eg, ischemia, septic cardiomyopathy, inflammatory
responses, right ventricular (RV) failure in conjunc-
tion with pulmonary hypertension, or a combination
of several factors) have been well-studied during the
last decades. Left ventricular (LV) function is a
determinative parameter in various diseases, al-
though the role of the RV in critically ill patients
should not be underestimated.5 Therefore, the clin-
ical evaluation of cardiac function must pertain to the
assessment of the LV and the RV with respect to
increased morbidity and mortality. Crucial in the
discussion is the early detection of LV systolic and
diastolic dysfunction by sensitive monitors, in partic-
CHEST / 127 / 1 / JANUARY, 2005 379
 Table 1—Indications of Transthoracic Pressure and Flow
Echocardiography and TEE
Several pressures are used in daily clinical practice
Transthoracic
Echocardiography TEE
to outline ventricular preload. In this section, the
relationship between various currently used pres-
General screening—overall Hemodynamic instability sures and intracardiac flows will be discussed. In
evaluation
Hemodynamic evaluation Echocardiography when
order to obtain relevant measurements of flow,
ventilated patient (also Doppler echocardiography has to be used. When an
when prone ventilation) ultrasound beam strikes a moving object (eg, a
Exclusion of tamponade Tamponade (local) moving RBC), the frequency of the reflected sound
Pulmonary edema Cardiac surgery: intraoperative is altered. This phenomenon is known as the Dopp-
and postoperative
hemodynamic monitoring
ler shift (Christian Doppler, 1842). Doppler echo-
Noncardiac surgery: cardiography shows the velocity data, which are
intraoperative monitoring derived from the measured frequency shift, and
Acute RV overload (pulmonary Acute RV overload with illustrates them as a spectral display. Movements of
embolism, pulmonary hypoxemia RBCs, which are moving toward the transducer, are
hypertension)
Thoracic trauma (patient not Thoracic trauma (in a
displayed above the zero line, and negative signals
ventilated) ventilated patient) display the movements of the RBCs away from the
Contraindications for TEE Diagnosis/exclusion of thoracic transducer. The following general principles have to
aortic dissection; diagnosis/ be kept in mind when obtaining and interpreting
exclusion of endocarditis; Doppler signals and waveforms9:
exclusion of left atrial
appendage thrombi 1. The Doppler beam must be aligned with the
estimated direction of blood flow. The inter-
cept angle should be ⬍ 20°. Larger angles
induce an unacceptable error. To correct this
ular when rapid fluid shifts occur, as in patients with error, the cosine of the intercept angle must be
hypovolemic or distributive shock. taken into account in calculating the true
LV systolic performance is governed by the fol- Doppler velocity. At an angle of 60°, the trans-
lowing three major determinants: (1) the Frank- mitted velocity will be half that the true veloc-
ity, which is important data in clinical practice.
Starling mechanism, necessitating the measurement
2. Continuous-wave (CW) Doppler ultrasound
of pressures and volumes; (2) contractility, indepen-
must be used whenever high velocities are
dent of loading conditions; and (3) heart rate. An
present. Pulsed-wave (PW) Doppler ultrasound
assessment of ventricular contractility must include can induce an underestimation of flow veloci-
the independence of loading conditions. To describe ties. This is due of the physical characteristics
the hemodynamic status of a patient, most clinicians of both techniques. CW Doppler (with one
routinely employ an analysis of pressures rather than transmitter and one receiver crystal) records
a determination of volumes. Nevertheless, pressures all velocities in the beam axis without a limita-
only provide a rudimentary approximation of the tion in analyzing high flow velocities. Neverthe-
physiologically relevant determinants of ventricular less, CW Doppler lacks the spatial resolution
function, namely, contractility, preload, and after- needed to estimate the correct depth at which
load. Several reviews6 – 8 already have stressed the the measurement is obtained. PW Doppler
elegance of how TEE provides data in this respect. ultrasound is characterized by a crystal, which
Clinically, pressure and flow appear to be the most sends and receives consecutively, considerably
important features. From these parameters, numer- retarding the process of the measurement of
ous variables have been derived describing more Doppler velocities. This allows a precise deter-
precisely hemodynamics of the (left) heart and the mination of the location of the source of the
peripheral circulation. The interplay between pres- frequency shift but immediately limits also the
sure and flow is an important characteristic of car- range of velocity, which can be measured. The
diac function and the dynamics of the circulation that latter can be explained as follows:
is more precise than one parameter alone. The • The depth of the sampling gate. The further
relationship between flow estimated with echocardi- away the sampling place (interrogated tar-
ography and related pressure measurements and the get), the longer the waiting time because of
energy generated by the LV pumping blood into the the consecutiveness of action of both the
circulation is the subject of this review. transmitter crystals and receiver crystals.

380 Opinions/Hypotheses
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Copyright © 2005 by American College of Chest Physicians
 • The PW Doppler ultrasound signal is ob-
tained at the rate of the pulse repetition
frequency, which is approaching the fre-
quency shift of the Doppler effect.
• With respect to Doppler physics, the trans-
ducer must sample twice as fast with a
5-MHz probe as with a 2.5-MHz probe to
measure the same Doppler shift. Hence, at
the same pulse repetition frequency the max-
imum recordable Doppler velocity with a
2.5-MHz probe is twice the recordable ve-
locity with a 5-MHz probe. This phenome-
non implies that a 5-MHz probe will scan
more superficial layers of tissue than a 2.5-
MHz probe.
3. The sample volume has to be placed in the
middle of the vessel in order to diminish po-
tential turbulence.
4. PW Doppler echocardiography is not useful
whenever a pressure gradient across a valve is
present or a subvalvular stenosis has to be
assessed. In both circumstances, CW Doppler
echocardiography must be utilized.
Echocardiography is not only an established tool
for the assessment of global ventricular function, but
appears a well-recognized technique in the evalua-
tion of regional ventricular function in patients with
potential cardiac disease. For many years, routine
echocardiography allowed only the visual analysis of
a regional dysfunction. The interpretation of myo-
cardial thickening and endocardial motion requires
an experienced observer, and the method is subjec-
tive and not useful in research. Color-coded tissue
Doppler imaging (TDI) was introduced a few years
ago, permitting the assessment of low-velocity Dopp-
ler high-amplitude shifts and the real-time display of
color-coded tissue velocities.10,11 This technique en-
ables the noninvasive delineation of myocardial ve-
locities in a noninvasive manner in the human
heart11,12 at the level of a segment of the myocardial
wall13 or the mitral annulus. In addition, both dia-
stolic function14,15 and regional systolic function
parameters can be derived from the myocardial wall
motion Doppler pattern.
Left-Sided Filling Pressures
Echocardiography permits the indirect estimation of
LV filling pressures in various ways, utilizing both
Doppler echocardiography16 –18 and two-dimensional
echocardiography.18 –20 In patients with normal cardiac
function, LV end-diastolic pressure (LVEDP) is di-
rectly related to LV end-diastolic volume (LVEDV).
Clinically, in patients with decreased ventricular com-
pliance, however, the relationship between pressure
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and volume is difficult to determine, in particular when
myocardial ischemia or tamponade occur,21 although,
in theory, pressure-volume loops will allow the deter-
mination of LV compliance. The direct assessment of
ventricular volumes to estimate preload is superior to
measurements of pressures because of the important
interference by ventricular compliance. Numerous fac-
tors interfere with this relationship, such as altering
compliance during myocardial ischemia, inotropic stim-
ulation, and altered intrathoracic pressures.
Utilizing two-dimensional echocardiography, the
position of the interatrial septum and the curvature
reflects the relationship between right and left atrial
pressures (LAPs).22 Hence, relative pressure differ-
ences between the right and left atrium can be
detected. In addition, the filling status can be
roughly estimated. In particular, the movement of
the interatrial septum during the cardiac cycle sug-
gests pressure differences between the right and left
atrium.22 In patients with hypovolemia, this move-
ment is increased. The estimation of RV and LV
preload by means of the position of the interatrial
septum cannot be used in the following situations:
• The presence of tricuspid regurgitation with a
consequent shift of the septum toward the left
atrium;
• Acute mitral regurgitation, in which an increased
septal movement is present; and
• Mitral stenosis or chronic mitral regurgitation, as
in severe LV failure, in which the septal amplitude
is decreased. This is important information as it
provides insight into the duration of a diagnosed
cardiac disease.
Doppler echocardiography provides a good esti-
mate of left-sided filling pressures using the trans-
mitral flow pattern, the peak flow regurgitation flow
velocity, the pulmonary venous flow pattern, and
myocardial Doppler imaging. The transmitral flow,
obtained in a four-chamber view, is directly related
to the filling of the LV and is governed by the
transmitral pressure gradient. The normal filling
pattern is displayed as a biphasic tracing with an
early and rapid-filling wave (E wave), followed by a
diastasis period with minimal or no flow (Fig 1).
Finally, a late-filling wave (A wave) follows, caused
by the atrial contraction. Both velocities of the
respective flow waves and corresponding time veloc-
ity integrals are as important characteristics of LV
filling.9 Another easily calculated parameter is the
ratio of the peak flow velocities (ie, the ratio of E
wave to A wave [E/A]). A normal flow velocity ratio
is in the range of 0.75 to 1.40. The E/A ratio is
strongly age-dependent. With increasing age, the
E-wave velocity diminishes in favor of the late-filling
A wave. It is important to remark that the various
CHEST / 127 / 1 / JANUARY, 2005 381

Figure 1. A normal transmitral flow Doppler pattern. Following
the E wave, the atrial contraction wave is observed.
Doppler velocities are the resulting effect of several
physiologic characteristics, such as LV compliance
and relaxation, left atrial (LA) compliance, mitral
valve area, and LA pressure (LAP). In addition,
mechanical ventilation23 as well as external con-
straints (thrombi in the pericardial sac, stiffness of
the pericardium, or high positive end-expiratory
pressure ventilation with potential cardiac compres-
sion by the lungs) affects LV filling. Owing to these
various interfering factors, it is conceivable that there
is no correlation between the early filling velocity
and the left-sided filling pressure (ie, LAP). As long
as LAP is low in patients with dilated cardiomyopa-
thy, the E-wave velocity, as well as the E/A ratio, will
be low. With the progression of heart failure in these
patients, the E-wave velocity will increase, and the
E/A ratio will be ⬎ 1. The higher E-wave velocity
will have a shorter deceleration time, reflecting
decreased ventricular compliance, making an evolu-
tion toward a restrictive pattern (E ⬎ A),24 a very
stiff LV with a rapid and important rise of ventricular
pressures with small amounts of fluid.
When present, mitral regurgitation can also be
used to estimate LV filling. Doppler echocardiogra-
phy permits the estimation of the LAP using the
modified Bernoulli equation, as described in the
following formula17:
LAP ⫽ RRao ⫺ (4 V2tmf)
in which RRao is the systolic aortic pressure, and
V2tmf is the transmitral peak regurgitant flow ve-
locity. This method is based on the assumption there
is no pressure gradient between the LV and the
ascending aorta.
The pulmonary venous flow pattern (Fig 2) is a
third possibility for estimating left-sided filling pres-
sures.25 The systolic flow wave is frequently biphasic
382
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Figure 2. A normal pulmonary venous Doppler pattern. Pre-
ceding a large systolic flow wave, a reverse contraction is seen.
The sometimes biphasic systolic flow wave is followed by the
diastolic flow wave.
whenever a low filling status is present. The change
in systolic flow velocity from the pulmonary vein is
directly related to changes in cardiac output. The
ratio of the systolic time-velocity integral and the
sum of both systolic and diastolic time-velocity inte-
grals correlates most strongly (r ⫽ ⫺0.88)16 when-
ever pulmonary venous flow wave duration (the a
wave) exceeds the transmitral flow wave. This is
usually thought to be a sign of adequate filling
pressures.25 A systolic/diastolic flow velocity ratio of
⬍ 0.4 reflects the markedly increased ventricular
filling pressures. This is mainly due to reduced LA
compliance.26 This study also shows that LVEDP is
the main determinant of the systolic velocity of the
pulmonary vein Doppler pattern (regression analy-
sis). A minor interfering factor is the systolic ventric-
ular function. To estimate the LVEDP, a pulmonary
venous Doppler pattern obtained at one of the inlet
orifices of the pulmonary veins should help. A ratio
of the systolic and diastolic flow wave velocities of
⬍ 0.4 is suggestive of an increased LVEDP.27 An-
other important feature is the ratio of the duration of
the atrial reverse flow wave at the level of the
pulmonary veins and the atrial contraction wave at
the level of the mitral valve. The difference between
the duration of the atrial reversal flow and the
duration of the atrial inflow wave is independent of
age and thus may be used as a reliable index of
LVEDP, even in elderly patients. A reverse a wave
duration that exceeds the duration of the atrial inflow
wave predicts an LVEDP of ⬎ 15 mm Hg. No
correlation was found between this index and the
LAP, suggesting that this index is a measure of late
diastolic LV compliance.28 A significant relationship
was seen between the systolic pulmonary vein Dopp-
ler velocity-time integral (VTI, ie, the area under the
curve of a Doppler signal) and the atrial wave VTI,
Opinions/Hypotheses
suggesting a relation between atrial filling and emp-
tying. LVEDP is the main determinant of the systolic
velocity of the pulmonary vein Doppler pattern.18,26
In clinical practice, all three Doppler methods will
be used consecutively.
The systolic forward flow wave in the pulmonary vein
Doppler pattern is preceded by a small reverse atrial
contraction wave. The systolic forward flow wave some-
times shows two peaks, which are related to the atrial
relaxation and the mitral annular descent, respective-
ly.25 The systolic flow wave is followed by a diastolic
flow wave. The pulmonary capillary wedge pressure
(PCWP) correlates best with the atrial reverse flow
wave velocity (r ⫽ 0.81).25 In a study29 of patients who
had experienced acute myocardial infarction, it was
shown that PCWP had a strong negative relationship
with the deceleration time of the pulmonary venous
Doppler pattern in diastole (r ⫽ ⫺0.89), with a sensi-
tivity and specificity of this measure of ⬍ 160 ms in
predicting a PCWP of ⬎ 18 mm Hg of 97% and 96%,
respectively.29
In 1998, Nagueh et al30 demonstrated that left-
sided filling pressures can also be estimated fairly
accurately by utilizing Doppler myocardial imaging
(ie, TDI). TDI assesses velocities of the moving
myocardium and, hence, detects the phase shift of
the ultrasound signals reflected by myocardial tis-
sues. Velocities are much lower (ie, ⬍ 10 to 15 cm/s)
than the blood flow velocities. The amplitude of the
reflected ultrasound wave is higher (40 decibels).
These two major changes make important adjust-
ments necessary in interpreting the results.
Therefore, TDI works with a high-pass filter,
allowing the low velocities to be measured. The
Doppler settings are adjusted for a Nyquist limit of
20 cm/s with the lowest wall filter and a minimum
gain setting. Furthermore, TDI has some beneficial
attributes, improving its power to be used in criti-
cally ill patients as follows: TDI is based on fre-
quency shift rather than signal amplitude; TDI uses
lower transmitting frequencies, permitting better
tissue penetration; and TDI has favorable temporal
resolution.
The early diastolic velocity measured with TDI (ie,
arterial elastance [Ea]) behaves as a relative load-
independent index of LV relaxation. The ratio of the
E wave to Ea showed the strongest relation to PCWP
(r ⫽ 0.86), irrespective of the pattern and the ejec-
tion fraction.31 Whereas the E wave of the transmi-
tral flow pattern is load-sensitive, the Ea, obtained by
TDI, behaves as a relatively load-independent index
of ventricular relaxation. In 100 patients, a relation
was described between the E wave/Ea ratio and the
PCWP (r ⫽ 0.86), irrespective of the pattern and
ejection fraction,30 although this has not been con-
firmed.32
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Estimation of Preload
TEE permits good qualitative and quantitative
parameters to estimate preloading conditions in pa-
tients with either normal ventricular function or
dysfunction. The short-axis view is in this respect of
the utmost importance. In an adequately sedated
ICU patient, the presence of a hyperdynamic ven-
tricle in the absence of inotropic drugs could be a
sign of hypovolemia.33 In addition, the presence of
kissing walls, with a potential, nearly complete oblit-
eration of the outflow tract, is very suggestive of a
low filling status.33
LV volume assessment is done by tracing the
end-diastolic endocardial border in a mid-esophageal
long-axis view in a longitudinal plane.34 The software
used to calculate the volume in the echocardiograph
uses the methods of discs (the Simpson rule), which
is an extremely well-validated technique, providing
very accurate data both in adults and children.35
A quantitative estimation can be performed in dif-
ferent ways using two-dimensional echocardiogra-
phy. The LV end-diastolic area (LVEDA), measured
per definition at the midpapillary level of the LV,
correlates well with volumetric analogues.36 In par-
ticular, the changes in LVEDA closely resemble
the changes in LVEDV. Very suggestive for low
filling status of the LV is the LVEDA index, referring
to a body surface area of ⬍ 5.5 cm2/m2.37 Other
authors described in patients with normal LV func-
tion during graded hypovolemia a linear decline of
LVEDA of 0.3 cm2 per percentage blood loss.38,39 A
good correlation (r ⫽ 0.87) was found between
changes in the LVEDA index and intrathoracic blood
volume, which was measured with the dye dilution
technique in postoperative cardiac surgical patients,
although neither parameter (evidently) correlated
with PCWP.40
Several shortcomings and limitations of LVEDA
have to be recognized. When regional wall motion
abnormalities are present, the correct use of LVEDA
as a preload parameter is limited. Furthermore, the
apical region of the LV is more susceptible to
regional wall motion abnormalities than the base of
the heart.41 In this respect, the above-mentioned
Doppler echocardiographic methods and the respi-
ration-induced variation in maximal Doppler veloci-
ties must be appreciated.42 Echocardiographic data
from a single plane seldom provide information
about filling status.
Besides using the short-axis view to obtain the
LVEDA, a midesophageal view allows the scanning
of the long axis of the LV. Volume determination of
the LV can be performed utilizing the Simpson rule.
The LV is divided into 20 ellipsoid disks of equal
heights but different diameters. The sum of the
CHEST / 127 / 1 / JANUARY, 2005 383
respective volumes of the slices allows the calcula-
tion of the total ventricular volume. This technique
has been validated against angiography.
Over the last years, the term fluid responsiveness
has been proposed as an important estimate of the
optimization of preload (Fig 3). Using methods that
are analogous to systolic respiratory pressure varia-
tion43 and stroke volume variation,44 which have
been shown to correlate well with a positive fluid
responsiveness, Slama et al42 demonstrated the value
of flow measurements across the aortic valve in the
assessment of flow velocity variation with cyclic
altering of intrathoracic pressures. The VTI at that
level decreased progressively, in close relationship
with a graded and controlled blood loss performed in
an animal experimental setting. Respiratory varia-
tions of VTI are a sensitive index of fluid responsive-
ness, concurring completely with the findings of
systolic pressure variation, stroke volume (SV) vari-
ation, and pulse pressure variation.
Flow and Function
Multiple indexes have been proposed to describe
global ventricular function. Both load-dependent and
load-independent parameters have been discerned.45
Ejection fraction is a classic example of a load-depen-
dent description of global ventricular function.46 Nev-
ertheless, in view of the discussion on flow and func-
tion, ejection fraction or, in echocardiographic terms,
fractional area contraction will not be disputed
With TEE and Doppler echocardiography, it is
relatively easy to estimate swiftly the load-dependent
characteristics as SV, cardiac output, and positive
maximum first derivative of pressure, corrected for
time (⫹dP/dtmax). The assessment of SV includes
both the measurement of the flow and the determi-
nation of the area through which this flow moves
forward. The area through which this flow is propa-
gated is one aspect of the determination of the stroke
volume. Either the diameter of a certain location or,
preferably, the effective time-averaged surface area
must be measured. Several localizations have been
used, as follows: RV outflow tract (RVOT) and
pulmonary artery47– 49; mitral valve; and LV outflow
tract50 –52 at the level of the aortic valve. It is clear
from earlier studies53 that the diameter of the pul-
monary artery is sometimes difficult to measure,
explaining the lower correlation coefficient. Never-
theless, placing the sample volume in the position at
the level of the midpulmonary artery is an easy and
elegant method for assessing SV.53 Some training

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

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

384 Opinions/Hypotheses
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Copyright © 2005 by American College of Chest Physicians
permits even the assessment of SV in the RVOT
from a deep transgastric view.54 The diameter of the
mitral valve is difficult to measure as the annulus is
not circular and changes throughout the cardiac
cycle, not permitting the use of the mitral valve for
measuring SV.55 The measurement of the flow across
the aortic valve is a third possibility.56 To permit the
measurement of the diameter of the aortic valve, a
longitudinal midesophageal image must be obtained
(Fig 4). It has been demonstrated that the direct
measurement of the effective time-averaged aortic
area allows for superb accuracy.50,51 This method can
be performed with the transducer at the midesopha-
geal position, rotating the multiplane probe toward
25° to 40° (Fig 5). In routine clinical practice,
however, the method including the measurement of
the diameter is more easily performed with a lower,
albeit acceptable, precision.52,57–59
The flow is obtained by the measurement of the
area under the curve of a Doppler wave. This gives
information on the VTI (in centimeters) [Fig 6]. VTI Figure 5. The aortic valve (AV) with the three cusps is visualized
at the level of the upper mediastinal level in an intermediate
provides the distance that an RBC is projected plane. This view allows the measurement of a time-averaged
forward during one cardiac cycle and is therefore effective aortic valve area. RA ⫽ right atrium.
directly related to the systolic function of the LV or
RV, depending on the place of the sample volume.
Hence, the SV can be calculated from the follow- when the method of the effective time-averaged
ing different formulas: aortic valve area (AVA) is chosen. This method
SV ⫽ VTI ⴱ AVA provides higher accuracy.
SV ⫽ VTI ⴱ 0.78 ⴱ D2
when the method of measurement of the diameter
(D) is preferred. In clinical practice, however, the
method of measurement of the diameter at the level
of the pulmonary artery or the aortic valve provides
an adequate estimation of the SV.
When aortic stenosis is present, the CW Doppler
signal shows a characteristic image with two densities
of flow.60 The VTI of the most intense part repre-
sents the SV, whereas the external contour shows the
peak velocity, which permits the calculation of the
aortic valve gradient utilizing the modified Bernoulli

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

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

www.chestjournal.org CHEST / 127 / 1 / JANUARY, 2005 385

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equation. This technique cannot be used when sig-
nificant aortic regurgitation is present.
The technique of flow calculation is also utilized
when intracardiac shunts are present (eg, atrial septal
defect). The VTI calculated from in the RVOT
(including the measurement of the diameter of the
pulmonary annulus) can be compared with VTI
obtained from flow analysis in the LV outflow tract,
in order to calculate the flow through the shunt.61
⫹dP/dtmax is another flow-derived, load depen-
dent parameter to circumscribe global left ventric-
ular function (Fig 6).62 The estimation of ⫹dP/
dtmax, as the mean rate of pressure rise, with
Doppler echocardiography obliges a leakage of the
mitral or aortic valve. At the mitral valve, ⫹dP/
dtmax is calculated using the modified Bernouilli
equation.63 If the change pressure gradient is
measured from the ascending limb of the mitral
regurgitant flow wave between the velocity levels
of eg 1 m/s and 3 m/s (Fig 7), change in ventriculo-
atrial pressure gradient is calculated as
4(1)2 ⫹ 4(3)2 ⫽ 32. A change corresponding to the
left ventriculo-atrial pressure gradient of 4 and
36 mm Hg, is measured with Doppler echocardi-
ography. With this method, it is assumed that any
gradient across the mitral valve is absent. A normal
value of ⫹dP/dtmax is between 800 to 1,200 mm
Hg/s. Analogous measurements can be performed
from the descending limb of the aortic regurgita-
tion flow wave in a deep transgastric transverse
view utilizing CW Doppler providing Doppler-
derived dP/dtmax.64 Although easy applicable, the
Doppler technique may underestimate the true
maximum dP/dt.
Pressure, Flow, and Function
In clinical practice, the arterial pressure and mor-
phology of the tracing are the mainstays of hemody-
Figure 7. Measurement of the time difference between a
regurgitant transmitral velocity of 100 cm/s and 300 cm/s is
shown. This time difference allows the calculation of the ⫹dP/
dtmax.
386
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Copyright © 2005 by American College of Chest Physicians
namic monitoring. Although this tracing offers consid-
erable information about SV, contractility, and loading
conditions of the left heart, all information is mainly
based on eyeballing. Many investigators searched for
other more revealing variables, which could be, how-
ever, be more difficult to obtain. Many years ago, LV
maximal elastance, the line connecting all end-systolic
points in a pressure-volume diagram, was considered
for use.65 Although significant improvements have
been proposed to upgrade this variable to a more
clinically useful parameter,66 several drawbacks have to
be recognized, diminishing considerably the usefulness
of this technique in clinical practice.
Another, more clinical, parameter is derived from
hydraulic energy. Hydraulic power is based on the
fact that the heart is a pump that is used to circulate
the blood into both the pulmonary and systemic
circulation. The cardiac muscle provides the energy
necessary for this circulation, dispersing more energy
as the blood proceeds deeper into the smaller ves-
sels. The effort performed by the ventricle to pump
the blood against gravity and to overcome the inertia
of the blood is nothing else than ventricular work.
Cardiac hydraulic power output, the work per time
unit, is the product of cardiac flow output and its
pressure delivered in the arterial system.67–70 It
increases proportionally to the exercise workload
performed and represents the rate at which the
ventricle performs external work.71 Cardiac power
(PWR) provides the best representation of the per-
formance obtained in a single cardiac cycle to coun-
terbalance the demand imposed by the metabolizing
tissues on the cardiac pump. In patients with cardiac
failure, the measurement of PWR at rest and after
the administration of positive inotropic stimulation
provides insight into the cardiac energetic reserve.72
In the absence of mitral regurgitation, the ventric-
ular volume change during systole equals aortic
volumetric flow. Hence, PWR can be described as
follows:
PWR ⫽ Plv ⴱ Fao
where Plv is instantaneous LV pressure and Fao is
instantaneous aortic flow. The product reaches its
maximum after the attainment of the peak flow and
before peak aortic pressure is obtained.8 At this time,
the aortic and ventricular pressures are similar.
Hence, the determination of the different factors,
building up PWR, is in this way markedly facilitated.
As the various parameters of volumetric flow are
easily obtained, the previously mentioned formula
can be rewritten:
PWRmax ⫽ PAO ⴱ VAOmax ⴱ AVA ⴱ 1.333 ⴱ 10⫺4
where PAO is instantaneous aortic pressure, VAO-
Opinions/Hypotheses
 Figure 8. Relationship between LVEDV and preload-adjusted maximal power (pamp) in a group of
postoperative coronary artery patients. The poorer contractile performance, the more the ventricle will
exploit its preload reserve by the Frank-Starling mechanism. Regression statistics with curve
extimation. eda ⫽ end-diastolic volume.

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

www.chestjournal.org CHEST / 127 / 1 / JANUARY, 2005 387

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Copyright © 2005 by American College of Chest Physicians
management of hemodynamic instability and hypo-
tension has been shown again. After the interpreta-
tion of these data, therapeutic handling can already
start. For the purposes of continuous monitoring of
cardiac output and mixed venous oxygen saturation,
there is still time enough to insert a pulmonary artery
catheter afterward.
Conclusions
The end points of hemodynamic management
have traditionally focused on improving cardiac out-
put.78 Over the last years, an analysis of the literature
has shown some fascinating advances when combin-
ing Doppler flow measurements and arterial pres-
sure waveforms. It might be speculated that modern
hemodynamic management will be directed toward
the enhancement of the cardiac pumping reserve,
and the optimization of perfusion at the tissue and
cellular levels.
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 Hemodynamic Monitoring Utilizing Transesophageal
Echocardiography: The Relationships Among Pressure, Flow, and
Function
Jan I. Poelaert and Guido Schüpfer
Chest 2005;127;379-390
DOI 10.1378/chest.127.1.379
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