Adult data clearly demonstrate that TDI measurements of the left and right ventricles correlate with left and right atrial mean pressures, respectively.15,25–27 Data in the pediatric population have shown similar correlations of left ventricular TDI measurements and left atrial mean pressures,13,14,16 but scarce information is available for the RV17,21 in a biventricular physiology, and no data are available for patients with single-ventricle physiology. This study is the first to our knowledge that demonstrates that there are significant correlations between TDI measurements of the RV and CVP in pediatric patients with biventricular and univentricular physiology undergoing cardiac surgery.
Although correlations were found with TDI and CVP in patients with both the univentricular and biventricular CHD postoperatively with the strongest correlations being a′ and E/e′, respectively, there was still variability in these measurements, such that a specific TDI value could not predict a specific CVP. It may be that TDI values may be more useful as trend following changes within a patient versus comparing measurements between patients. Tissue Doppler imaging is not a continuous monitoring device, and it does not yet correlate strongly enough with CVP to replace invasive monitoring in the pediatric intensive care unit. However, with further studies, it may be used adjunctively or in patients where invasive monitoring is technically challenging or relatively contraindicated. A noninvasive method to monitor CVP in this complex population would be useful and as such TDI deserves further study.
Limitations of this study include its small sample size and the heterogeneity of the CHD present. Retrospective regression-based power analysis suggested that a sample size of 27 is required to yield a power of 80% in testing our hypothesis and including two covariates. There is enough power to examine the full sample of patients and the biventicular group of patients. Although there is not enough power to examine the univentricular patients on their own, results from the full sample and the biventricular sample may be able to shed light on the applicability of the overall findings to the univentricular group. For example, the correlations and significance of the RV e′, a′, and TV E values are stronger in the univentricular group than the biventricular group and all patients group, suggesting that these results may be more applicable to the univentricular patients. Patients with single left ventricular morphology and those not in a stable sinus or atrial rhythm were excluded, so no comment can be made on these patient populations. Several dynamic factors common in the intensive care unit, such as inotrope usage and ventilator management, were not controlled for in this study; however, to be clinically useful, a noninvasive measurement would need to accurate in the face of these variables. Despite this heterogeneity, there were still significant relationships between TDI measurements and CVP. Finally, all wave forms were measured by a single observer, so the potential for interobserver variability was not assessed.
Tissue Doppler imaging parameters correlated with CVP in pediatric cardiac patients undergoing cardiac surgery. Significant TDI correlations differed between biventricular versus univentricular patients, thus larger studies are still needed to determine whether TDI can be used consistently to estimate CVP and to determine which parameters are appropriate for the different physiologies present.
1. Gelman S: Venous function and central venous pressure: A physiologic story. Anesthesiology
108: 735–748, 2008.
2. Brierley J, Choong K, Cornell T, et al
: Clinical practice parameters for hemodynamic support of pediatric and neonatal septic shock: 2007 update from the American College of Critical Care Medicine. Crit Care Med
37: 666–688, 2009.
3. Amoozgar H, Behniafard N, Borzoee M, Ajami GH: Correlation between peripheral and central venous pressures in children with congenital heart disease. Pediatr Cardiol
29: 281–284, 2008.
4. Burnell RH: Venous pressure in congestive heart failure in infancy. Arch Dis Child
45: 360–362, 1970.
5. Buchhorn R, Bartmus D, Buhre W, Bursch J: Pathogenetic mechanisms of venous congestion after the Fontan procedure. Cardiol Young
11: 161–168, 2001.
6. Hayashi Y, Uchida O, Takaki O, et al
: Internal jugular vein catheterization in infants undergoing cardiovascular surgery: An analysis of the factors influencing successful catheterization. Anesth Analg
74: 688–693, 1992.
7. Heinemann M, Breuer J, Steger V, et al
: Incidence and impact of systemic venous collateral development after Glenn and Fontan procedures. Thorac Cardiovasc Surg
49: 172–178, 2001.
8. Alvarez Kindelan A, Perez Navero JL, Ibarra de la Rosa I, et al
: Relationship between hemodynamic changes and blood hormone concentrations after cardiac surgery in children with congenital heart disease. Crit Care Med
22: 1754–1761, 1994.
9. Morris K, Beghetti M, Petros A, et al
: Comparison of hyperventilation and inhaled nitric oxide for pulmonary hypertension after repair of congenital heart disease. Crit Care Med
28: 2974–2978, 2000.
10. Janousek J, Vojtovic P, Chaloupecky V, et al
: Hemodynamically optimized temporary cardiac pacing after surgery for congenital heart defects. Pacing Clin Electrophysiol
23: 1250–1259, 2000.
11. Pela G, Regolisti G, Coghi P, et al
: Effects of the reduction of preload on left and right ventricular myocardial velocities analyzed by Doppler tissue echocardiography in healthy subjects. Eur J Echocardiogr
5: 262–271, 2004.
12. Sohn DW, Chai IH, Lee DJ, et al
: Assessment of mitral annulus velocity by Doppler tissue imaging in the evaluation of left ventricular diastolic function. J Am Coll Cardiol
30: 474–480, 1997.
13. Nagueh SF, Middleton KJ, Kopelen HA, et al
: Doppler tissue imaging: A noninvasive technique for evaluation of left ventricular relaxation and estimation of filling pressures. J Am Coll Cardiol
30: 1527–1533, 1997.
14. Eidem BW, McMahon CJ, Ayres NA, et al
: Impact of chronic left ventricular preload and afterload on Doppler tissue imaging velocities: A study in congenital heart disease. J Am Soc Echocardiogr
18: 830–838, 2005.
15. Sundereswaran L, Nagueh SF, Vardan S, et al
: Estimation of left and right ventricular filling pressures after heart transplantation by tissue Doppler imaging. Am J Cardiol
82: 352–357, 1998.
16. Larrazet F, Bouabdallah K, Le Bret E, et al
: Tissue Doppler echocardiographic and color M-mode estimation of left atrial pressure in infants. Pediatr Crit Care Med
6: 448–453, 2005.
17. Nageh MF, Kopelen HA, Zoghbi WA, et al
: Estimation of mean right atrial pressure using tissue Doppler imaging. Am J Cardiol
18. Roberson DA, Cui W, Chen Z, et al
: Annular and septal Doppler tissue imaging in children: Normal z-score tables and effects of age, heart rate, and body surface area. J Am Soc Echocardiogr
20: 1276–1284, 2007.
19. Eidem BW, McMahon CJ, Cohen RR, et al
: Impact of cardiac growth on Doppler tissue imaging velocities: A study in healthy children. J Am Soc Echocardiogr
17: 212–221, 2004.
20. Roberson DA, Cui W: Right ventricular Tei index in children: Effect of method, age, body surface area, and heart rate. J Am Soc Echocardiogr
20: 764–770, 2007.
21. Watanabe M, Ono S, Tomomasa T, et al
: Measurement of tricuspid annular diastolic velocities by Doppler tissue imaging to assess right ventricular function in patients with congenital heart disease. Pediatr Cardiol
24: 463–467, 2003.
22. Harada K, Tamura M, Toyono M, Yasuoka K: Comparison of the right ventricular Tei index by tissue Doppler imaging to that obtained by pulsed Doppler in children without heart disease. Am J Cardiol
90: 566–569, 2002.
23. Tei C, Nishimura RA, Seward JB, Tajik AJ: Noninvasive Doppler-derived myocardial performance index: Correlation with simultaneous measurements of cardiac catheterization measurements. J Am Soc Echocardiogr
10: 169–178, 1997.
24. Tei C, Ling LH, Hodge DO, et al
: New index of combined systolic and diastolic myocardial performance: A simple and reproducible measure of cardiac function—A study in normals and dilated cardiomyopathy. J Cardiol
26: 357–366, 1995.
25. Nagueh SF, Lakkis NM, Middleton KJ, et al
: Doppler estimation of left ventricular filling pressures in patients with hypertrophic cardiomyopathy. Circulation
99: 254–261, 1999.
26. Nagueh SF, Mikati I, Kopelen HA, et al
: Doppler estimation of left ventricular filling pressure in sinus tachycardia. A new application of tissue doppler imaging. Circulation
98: 1644–1650, 1998.
27. Ommen SR, Nishimura RA, Appleton CP, et al
: Clinical utility of Doppler echocardiography and tissue Doppler imaging in the estimation of left ventricular filling pressures: A comparative simultaneous Doppler-catheterization study. Circulation
102: 1788–1794, 2000.
28. Dokainish H, Nguyen JS, Sengupta R, et al
: Do additional echocardiographic variables increase the accuracy of E/e' for predicting left ventricular filling pressure in normal ejection fraction? An Echocardiographic and Invasive Hemodynamic Study. J Am Soc Echocardiogr
23: 156–161, 2010.
29. Pettersen E, Helle-Valle T, Edvardsen T, et al
: Contraction pattern of the systemic right ventricle shift from longitudinal to circumferential shortening and absent global ventricular torsion. J Am Coll Cardiol
49: 2450–2456, 2007.