Posted on by INTENSIVE
Author: Tom Rozen
Peer reviewer: Lloyd Roberts
Measuring the cardiac output is straightforward, and relies on a few simple concepts which we review here:
- The Left Ventricular Outflow Tract (LVOT) is assumed to be roughlycircular. Measure a diameter and you can calculate the area of thecircle.
- Pulsed Wave Doppler (PW) through the same point, in the centre of the LVOT tells us how fast that blood is travelling at any time.
- The area under the curve then tells us how far the column of blood has been pushed. (Y axis is in m/sec, X axis in seconds, so the area under the curve will tell us how far the blood has moved travelling at these velocities for this amount of time.)
- Work out the volume of the cylinder – Multiply the area ofthe LVOT (acircle) by the length the blood travelsand you get the stroke volume (ie volume ejectedper beat)
- Thestroke volume multiplied by theheart rategives usthe cardiac output (expressed as L/Min).
- Divide the cardiac output by the body surface area and we get the Cardiac Index.
Summary of the required echo steps
Step 1
Measure theLVOT diameter (Parasternal long axis, 2D). Zoom into be accurate. Measure up to 0.5cm back from the aortic valve leaflet insertion points (on the ventricular side).
Step 2
Using pulse wave Doppler (PW) line up the LVOT in the apical views, using either the apical 5 chamber or the apical 3 chamber. Aim to be as close as possible to the aortic valve, but not into the area of flow acceleration.The flow of blood is laminar through the PW gate, which is why the all the velocities follow a narrow band and the PW waveform is not “filled in”.The PW gate should be 2-4mm.
Step 3
Obtain the PW waveform. To get themost accurate reading, move sample volume toward aortic valveuntil flow accelerates.Then move sample volumes slightly awayfrom the aortic valve, toward apex until laminar flow returns.
In a surface echo, the blood flows through the LVOTaway from the probe so the curve is below the line. It should look hollow if the blood has laminar flow. Trace along theedge of the modal velocity (the outside of the chin, not the beard of the waveform)to measure the area under the curve (theVelocity Time Integral – VTI expressedin cm).
References
Recommendations for Cardiac Chamber Quantification by Echocardiography in AdultsASE 2015
Guidelines for the Use of Echocardiography as a Monitor for Therapeutic Intervention in AdultsASE2105
(First published on Echopraxis by Tom Rozen on 20/02/2014; reviewed by Lloyd Roberts)