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Comparison of Different Methods to Estimate Cardiac Index in Pulmonary Arterial Hypertension

2019; Lippincott Williams & Wilkins; Volume: 140; Issue: 8 Linguagem: Inglês

10.1161/circulationaha.119.041614

1524-4539

Ghaleb Khirfan, Mostafa Ahmed, Saja Almaaitah, Alla Almoushref, Gamal M. Agmy, Raed A. Dweik, Adriano R. Tonelli,

Cardiovascular Function and Risk Factors

HomeCirculationVol. 140, No. 8Comparison of Different Methods to Estimate Cardiac Index in Pulmonary Arterial Hypertension Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBComparison of Different Methods to Estimate Cardiac Index in Pulmonary Arterial Hypertension Ghaleb Khirfan, MD, Mostafa K. Ahmed, MD, Saja Almaaitah, MD, Alla Almoushref, MD, Gamal M. Agmy, MD, Raed A. Dweik, MD and Adriano R. Tonelli, MD, MSc Ghaleb KhirfanGhaleb Khirfan Department of Pulmonary, Allergy, and Critical Care Medicine (G.K., R.A.D., A.R.T.), Respiratory Institute , Mostafa K. AhmedMostafa K. Ahmed Department of Pulmonary and Critical Care Medicine (M.K.A.), Respiratory Institute Department of Chest Diseases, Faculty of Medicine, Assiut University, Egypt (M.K.A., G.M.A.). , Saja AlmaaitahSaja Almaaitah Department of Internal Medicine (S.A.), Medicine Institute , Alla AlmoushrefAlla Almoushref Pathobiology Department (A.A.), Cleveland Clinic, OH. , Gamal M. AgmyGamal M. Agmy Department of Chest Diseases, Faculty of Medicine, Assiut University, Egypt (M.K.A., G.M.A.). , Raed A. DweikRaed A. Dweik Department of Pulmonary, Allergy, and Critical Care Medicine (G.K., R.A.D., A.R.T.), Respiratory Institute and Adriano R. TonelliAdriano R. Tonelli Adriano Tonelli, MD, Respiratory Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195. Email E-mail Address: [email protected] Department of Pulmonary, Allergy, and Critical Care Medicine (G.K., R.A.D., A.R.T.), Respiratory Institute Originally published19 Aug 2019https://doi.org/10.1161/CIRCULATIONAHA.119.041614Circulation. 2019;140:705–707The cardiac index (CI) is an essential hemodynamic measurement that tracks with disease severity, is associated with outcomes, and influences therapeutic decisions in patients with pulmonary arterial hypertension (PAH).1 Risk assessment in PAH is routinely done with a multidimensional stratification that includes CI either directly or as part of the calculation of pulmonary vascular resistance.1,2 Traditional methods to estimate CI include thermodilution (TDCI), indirect Fick (IFCI) using estimated oxygen consumption, and direct Fick (DFCI). The DFCI remains the gold standard; however, it is rarely performed given the need for special equipment and technical skills. An accurate CI estimate is of high clinical relevance in PAH; therefore, we conducted the present study to compare TDCI and IFCI with the gold standard DFCI in patients with PAH and to assess the impact of CI estimation by different methodologies on the European Society of Cardiology and European Respiratory Society PAH risk group allocation.1This study was approved by the Cleveland Clinic Institutional Review Board. DFCI was estimated either as part of a research protocol (n=50) or at the physicians' discretion (n=25). Written informed consent was obtained in the first group but waived in the second. We included patients diagnosed with PAH with a mean pulmonary artery pressure ≥25 mm Hg from August 2012 to February 2018. Patients had fasted for ≥4 hours and underwent right-sided heart catheterization in the outpatient setting by a single operator (A.R.T.) using only local anesthesia. At the time of right-sided heart catheterization, breath-by breath oxygen uptake (Vo2) was measured with the CCM express indirect calorimeter (MGC Diagnostic Corporation, St. Paul, MN) and averaged over the course of 12 to 15 minutes. DFCI was calculated using the following formula: Vo2 in milliliters per minute/(arteriovenous oxygen content difference×10)/body surface area in meters squared. For IFCI, the Vo2 was estimated by 3 different formulas: Dehmer et al,3 Bergstra et al,4 and LaFarge and Miettinen.5 TDCI was obtained by averaging at least 3 estimates with <15% variation.We included a total of 75 patients with a mean±SD age of 57±17 years, of whom 57 (76%) were women. Patients predominantly had idiopathic or heritable PAH (n=54, 72%) or moderate to severe right ventricular dysfunction (n=45, 60%) and were in World Health Organization functional class II/III (n=63, 84%). The tricuspid regurgitation severity was at least moderate in 48 patients (64%). The mean±SD mean pulmonary artery pressure and pulmonary vascular resistance were 48.4±13.6 mm Hg and 8.8±4.2 Wood units, respectively. The DFCI and TDCI were 2.59±0.85 and 2.57±0.88 L·min−1·m−2, respectively. IFCI with Vo2 estimated by the formulas of Dehmer et al, Bergstra et al, and LaFarge and Miettinen was 2.56±0.76, 2.83±0.86, and 2.17±0.69 L·min−1·m−2, respectively.Differences between DFCI and TDCI and between DFCI and IFCI are shown in the Bland-Altman analysis in the Figure. The absolute difference between DFCI and TDCI was not explained by the severity of tricuspid regurgitation (linear regression with DFCI-TDCI as the dependent and tricuspid regurgitation severity as the independent variable; P=0.41).We compared each method with the DFCI using Wilcoxon signed-rank test. P values for pairwise comparisons were as follows: DFCI versus TDCI, P=0.70; and DFCI versus IFCI using Dehmer et al, Bergstra et al, and LaFarge and Miettinen, P=0.85, P<0.001, and P<0.001, respectively. The intraclass correlation coefficient between DFCI and TDCI or IFCI (Dehmer et al, Bergstra et al, and LaFarge and Miettinen) was 0.88 (95% CI, 0.81–0.92; typical error of the measurement, 0.41), 0.92 (95% CI, 0.88–0.95; typical error of the measurement, 0.31), 0.91 (95% CI, 0.78–0.95; typical error of the measurement, 0.32), and 0.84 (95% CI, 0.37–0.94; typical error of the measurement 0.32), respectively. A difference of ≥ 20% with DFCI was observed in 22 patients (29%) with TDCI and 15 (20%), 26 (35%), and 29 (38.7%) patients with IFCI (Dehmer et al, Bergstra et al, and LaFarge and Miettinen), respectively.Download figureDownload PowerPointFigure. Bland-Altman analyses comparing cardiac index (CI) estimated by thermodilution (TDCI) or indirect Fick (IFCI) with the gold standard direct Fick (DFCI). Horizontal lines are shown at the mean difference and limits of agreement (±1.96 SD of the differences). The gold standard DFCI is shown on the x axis in all panels, contrasted with TDCI (A) and IFCI using the Dehmer et al3 (B), Bergstra et al4 (C) and LaFarge and Miettinen5 (D) formulas for oxygen consumption estimation. Patients with no, mild (1+), or moderate (2+) tricuspid regurgitation (TR) are shown as blue inverted triangles. Patients with moderate/severe (3+) and severe (4+) TR are depicted as green circles. When percentage differences are used instead of absolute values, the bias and 95% limits of agreement (LOA) between DFCI and TDCI were −1 % (LOA, −43% to 41%) and between DFCI and IFCI (Dehmer et al, Bergstra et al, and LaFarge and Miettinen) were −2% (LOA, −34% to 30%), −12 (LOA, −47% to 22%), and 14% (LOA, −14% to 43%), respectively. The LOA of all these methodologies crossed the threshold of 20%, highlighting the significant limitations when measuring CI by TDCI or IFCI. Vo2 (milliliters per minute) was estimated by the equations described by Dehmer et al (125×body surface area [BSA, meters2]), Bergstra et al (157.3×BSA+sex [men=10, women=0]–[10.5×loge age]+4.8), and LaFarge and Miettinen ([138.1–(sex; men=11.49, women=17.04)×loge age]+[0.378×heart rate]×BSA). For simplicity and following contemporary applications, in the Dehmer et al equation, we used an average oxygen uptake of 125 mL·min−1·m−2 instead of the 126 mL·min−1·m−2 described in the original article.On the basis of DFCI, European Society of Cardiology/European Respiratory Society PAH risk groups1 were low, intermediate, and high for 34 (45%), 22 (29%), and 19 (25%) patients, respectively. Concordance between DFCI and TDCI risk group categories was noted in 54 patients (72%). Meanwhile, concordance between DFCI and IFCI (Dehmer et al, Bergstra et al, and LaFarge and Miettinen) European Society of Cardiology/European Respiratory Society PAH risk groups1 was noted in 51 (68%), 46 (61%), and 42 (56%) patients, respectively.In a well-characterized cohort of patients with PAH, we noted a high accuracy between DFCI and TDCI or IFCI using the Dehmer et al equation3; however, the limits of agreement, a reflection of precision, were wide, an important result given the narrow European Society of Cardiology/European Respiratory Society CI band (2–2.5 L·min−1·m−2) to allocate risk groups. Meanwhile, IFCI by the Bergstra et al and LaFarge and Miettinen formulas had poor accuracy and precision given the overestimation and underestimation of Vo2, respectively. The severity of tricuspid regurgitation had no influence on the accuracy of the TDCI estimates. Given the wide limits of agreement, no methodology other than DFCI appears adequate to precisely determine CI, particularly when the CI is <2.5 L·min−1·m−2 by TDCI or IFCI (Dehmer et al), the CI determination does not fit the clinical scenario, or there is discordance with other risk variables.AcknowledgmentsG.K. participated in the design of the study, data collection, statistical analysis, interpretation of the results, writing and critical revision of the manuscript for important intellectual content, and final approval of the manuscript submitted. M.A. participated in the design of the study, data collection, interpretation of the results, writing and critical revision of the manuscript for important intellectual content, and final approval of the manuscript submitted. S.A., A.A., and G.M.A. R.A.D. participated in the interpretation of the results, writing and critical revision of the manuscript for important intellectual content, and final approval of the manuscript submitted. A.R.T. participated in the design of the study, data collection, statistical analysis, interpretation of the results, writing and critical revision of the manuscript for important intellectual content, and final approval of the manuscript submitted. A.R.T. is the guarantor of the article, taking responsibility for the integrity of the work as a whole, from inception to published article.Sources of FundingDr Tonelli is supported by National Institutes of Health grant R01HL130307. Dr Ahmed was supported by the Egyptian Ministry of Higher Education and Scientific Research Scholarship program grant.DisclosuresNone.Footnoteshttps://www.ahajournals.org/journal/circData sharing: The data that support the findings of this study are available from the corresponding author on request.Adriano Tonelli, MD, Respiratory Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195. Email [email protected]orgReferences1. 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The estimation of oxygen consumption.Cardiovasc Res. 1970; 4:23–30. doi: 10.1093/cvr/4.1.23CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Crowe L, Genecand L, Hachulla A, Noble S, Beghetti M, Vallée J and Lador F (2022) Non-Invasive Cardiac Output Determination Using Magnetic Resonance Imaging and Thermodilution in Pulmonary Hypertension, Journal of Clinical Medicine, 10.3390/jcm11102717, 11:10, (2717) Duknic M, Lichtblau M, Saxer S, Berlier C, Schneider S, Schwarz E, Carta A, Furian M, Bloch K and Ulrich S (2021) Comparison of Repetitive Cardiac Output Measurements at Rest and End-Exercise by Direct Fick Using Pulse Oximetry vs. Blood Gases in Patients With Pulmonary Hypertension, Frontiers in Medicine, 10.3389/fmed.2021.776956, 8 Ryan T, Moore R, Lang S, Khoury P, Dandoy C, Davies S and Taylor M (2021) Rapid cardiac MRI protocol for cardiac assessment in paediatric and young adult patients undergoing haematopoietic stem cell transplant: a feasibility study, Cardiology in the Young, 10.1017/S1047951120004990, 31:6, (973-978), Online publication date: 1-Jun-2021. Genecand L, Adler D, Beghetti M and Lador F (2021) Cardiac Output Determination in Precapillary Pulmonary Hypertension: A Systematic Review, Respiration, 10.1159/000517084, 100:12, (1243-1250), . Khirfan G, Almoushref A, Naal T, Abuhalimeh B, Dweik R, Heresi G and Tonelli A (2020) Mixed Venous Oxygen Saturation Is a Better Prognosticator Than Cardiac Index in Pulmonary Arterial Hypertension, Chest, 10.1016/j.chest.2020.06.053, 158:6, (2546-2555), Online publication date: 1-Dec-2020. Arunachalam A, Chaisson N and Tonelli A (2020) Methods to improve the yield of right heart catheterization in pulmonary hypertension, Respiratory Medicine: X, 10.1016/j.yrmex.2020.100015, 2, (100015), Online publication date: 1-Nov-2020. 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Bonno E, Viray M, Jackson G, Houston B and Tedford R (2020) Modern Right Heart Catheterization: Beyond Simple Hemodynamics, Advances in Pulmonary Hypertension, 10.21693/1933-088X-19.1.6, 19:1, (6-15), Online publication date: 1-Jan-2020. August 20, 2019Vol 140, Issue 8 Advertisement Article InformationMetrics © 2019 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.119.041614PMID: 31424987 Originally publishedAugust 19, 2019 Keywordscardiac outputpulmonary hypertensionthermodilutionPDF download Advertisement SubjectsPulmonary Hypertension