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Cardiac Output Measurements Based on the Pulse Wave Transit Time and Thoracic Impedance Exhibit Limited Agreement With Thermodilution Method During Orthotopic Liver Transplantation

Magliocca, Aurora, MD*,†; Rezoagli, Emanuele, MD*,†; Anderson, Thomas, Anthony, PhD, MD*; Burns, Sara, Maria, MS*; Ichinose, Fumito, MD, PhD*; Chitilian, Hovig, Vatche, MD*

doi: 10.1213/ANE.0000000000002171
Technology, Computing, and Simulation: Original Clinical Research Report

BACKGROUND: Orthotopic liver transplantation (OLT) is characterized by significant intraoperative hemodynamic variability. Accurate and real-time cardiac output (CO) monitoring aids clinical decision making during OLT. The purpose of this study is to compare accuracy, precision, and trending ability of CO estimation obtained noninvasively using pulse wave transit time (estimated continuous cardiac output [esCCO; Nihon Kohden, Tokyo, Japan]) or thoracic bioimpedance (ICON; Osypka Medical GmbH, Berlin, Germany) to thermodilution cardiac output (TDCO) measured with a pulmonary artery catheter.

METHODS: Nineteen patients undergoing OLT were enrolled. CO measurements were collected with esCCO, ICON, and thermodilution at 5 time points: (T1) pulmonary artery catheter insertion; (T2) surgical incision; (T3) portal reperfusion; (T4) hepatic arterial reperfusion; and (T5) abdominal closure. The results were analyzed with Bland-Altman plot, percentage error (the percentage of the difference between the CO estimated with the noninvasive monitoring device and CO measured with the thermodilution technique), 4-quadrant plot with concordance rate (the percentage of the total number of points in the I and III quadrant of the 4-quadrant plot), and concordance correlation coefficient (a measure of how well the pairs of observations deviate from the 45-degree line of perfect agreement).

RESULTS: Although TDCO increased at T3-T5, both esCCO and ICON failed to track the changes of CO with sufficient accuracy and precision. The mean bias of esCCO and ICON compared to TDCO were −2.0 L/min (SD, ±2.7 L/min) and −3.3 L/min (SD, ±2.8 L/min), respectively. The percentage error was 69% for esCCO and 77% for ICON. The concordance correlation coefficient was 0.653 (95% confidence interval [CI], 0.283–0.853) for esCCO and 0.310 (95% CI, −0.167 to 0.669) for ICON. Nonetheless, esCCO and ICON exhibited reasonable trending ability of TDCO (concordance rate: 95% [95% CI, 88–100] and 100% [95% CI, 93–100]), respectively. The mean bias was correlated with systemic vascular resistance (SVR) and arterial elastance (Ea) for esCCO (SVR, r = 0.610, 95% CI, 0.216–0.833, P < .0001; Ea, r = 0.692, 95% CI, 0.347–0.872; P < .0001) and ICON (SVR, r = 0.573, 95% CI, 0.161–0.815, P < .0001; Ea, r = 0.612, 95% CI, 0.219–0.834, P < .0001).

CONCLUSIONS: The noninvasive CO estimation with esCCO and ICON exhibited limited accuracy and precision, despite with reasonable trending ability, when compared to TDCO, during OLT. The inaccuracy of esCCO and ICON is especially large when SVR and Ea were decreased during the neohepatic phase. Further refinement of the technology is desirable before noninvasive techniques can replace TDCO during OLT.

Published ahead of print June 8, 2017.

From the *Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts

Department of Health Science, School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy.

Published ahead of print June 8, 2017.

Accepted for publication March 27, 2017.

Funding: This study was supported by a Sponsored Research Agreement from Nihon Kohden.

Conflicts of Interest: See Disclosures at the end of the article.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website.

A. Magliocca and E. Rezoagli contributed equally to this work; F. Ichinose and H. V. Chitilian contributed equally to this work.

Reprints will not be available from the authors.

Address correspondence to Fumito Ichinose, MD, PhD, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, 149 13th St, CNY 149, Room 4315, Charlestown, MA 02129. Address e-mail to

© 2018 International Anesthesia Research Society
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