ASE GUIDELINES AND STANDARDS

Guidelines for the Use of Echocardiography as a

Monitor for Therapeutic Intervention in Adults: A
Report from the American Society of
Echocardiography
Thomas R. Porter, MD, FASE (Chair), Sasha K. Shillcutt, MD, FASE, Mark S. Adams, RDCS, FASE,
Georges Desjardins, MD, FASE, Kathryn E. Glas, MD, MBA, FASE, Joan J. Olson, BS, RDCS, RVT, FASE,
and Richard W. Troughton, MD, PhD, Omaha, Nebraska; Boston, Massachusetts; Salt Lake City, Utah; Atlanta,
Georgia; Christchurch, New Zealand

(J Am Soc Echocardiogr 2015;28:40-56.)

Keywords: Echocardiography, Monitoring, Therapy, Doppler

TABLE OF CONTENTS

General Considerations 40 Major Vascular Surgery 50

Scope of Work 41 Orthopedic and Spinal Surgery 52
I. Echocardiographic Hemodynamic Monitoring Tools 41 Neurosurgery 52
Two-Dimensional Echocardiographic Monitoring Parameters 42 V. When Has a Meaningful Change in a Monitoring Parameter
LV Chamber Dimensions 42 Occurred? 52
Inferior Vena Cava (IVC) Size and Collapsibility 43 VI. Conclusions Regarding Training and Use of Echocardiography as a
Doppler Monitoring Parameters 43 Monitoring Tool 52
Mitral Inflow 43 Notice and Disclaimer 53
TDI 43 Acknowledgments 53
Calculated Monitoring Parameters 44 Supplementary data 54
SV, Cardiac Output (CO), and SVR Calculations 44 References 54
RV Systolic Function 44
PA Systolic Pressure 45
II. Advantages, Disadvantages, and Recommendations of Echocardiogra-
phy as a Monitoring Tool 45 GENERAL CONSIDERATIONS
III. Clinical Scenarios 45
Acute CHF Monitoring 45
Critical Care Monitoring 47
Recent guidelines have been published providing detailed guidance
Pericardial Tamponade Monitoring 48 on specific echocardiographic diagnostic criteria for measurements
Pulmonary Embolism Therapy Monitoring 48 of diastolic function, chamber dimensions, right ventricular (RV)
Prosthetic Valve Thrombosis Monitoring 48 function, and Doppler measurements. Also, guidelines have been
Echocardiographic Monitoring in Trauma 48 published with respect to requirements for competence in basic
IV. Perioperative Medicine 49 and advanced perioperative transesophageal echocardiography
Echocardiographic Monitoring During Liver, Kidney, and Lung (TEE), as well as focused cardiac ultrasound examinations.
Transplantation 49 Increasingly, however, transthoracic echocardiography (TTE) and

From the University of Nebraska Medical Center, Omaha Nebraska (T.R.P., J.J.O.,
Attention ASE Members:
S.K.S.); Massachusetts General Hospital, Boston, Massachusetts (M.S.A.); the
The ASE has gone green! Visit www.aseuniversity.org to earn free continuing
University of Utah, Salt Lake City, Utah (G.D.); Emory University, Atlanta,
medical education credit through an online activity related to this article.
Georgia (K.E.G.); and the University of Otago, Christchurch, New Zealand (R.W.T.).
Certificates are available for immediate access upon successful completion
The following authors reported no actual or potential conflicts of interest in relation of the activity. Nonmembers will need to join the ASE to access this great
to this document: Mark S. Adams, RDCS, FASE, Georges Desjardins, MD, FASE, member benefit!
Kathryn E. Glas, MD, MBA, FASE, Joan J. Olson, BS, RDCS, RVT, FASE, and
Sasha K. Shillcutt, MD, FASE. The following authors reported relationships with
Reprint requests: American Society of Echocardiography, 2100 Gateway Centre
one or more commercial interests: Thomas R. Porter, MD, FASE, has received
Boulevard, Suite 310, Morrisville, NC 27560 (Email: [email protected]).
research support from Philips Research North America, GE Healthcare, Astellas
Pharma, and Lantheus Medical Imaging; Richard W. Troughton, MD, PhD, has 0894-7317/$36.00
served as a consultant for St. Jude Medical and received research support from Ó 2015 Published by Elsevier Inc.
St. Jude Medical, Roche Diagnostics, Alere, and Roche Pharmaceuticals. http://dx.doi.org/10.1016/j.echo.2014.09.009
40
Journal of the American Society of Echocardiography Porter et al 41
Volume 28 Number 1

Abbreviations
TEE are being used to monitor SCOPE OF WORK
hemodynamics and direct
ASE = American Society of therapy in critically ill patients. Multidisciplinary guidelines published by the American Society
Echocardiography Case reports, observational of Anesthesiologists and the Society of Cardiovascular
CO = Cardiac output studies, and state-of-the-art litera- Anesthesiologists in 2010 recommend the use of TEE in patients
ture reviews have demonstrated who are undergoing noncardiac surgery and exhibit persistent
DT = Deceleration time the potential role of echocardiog- hypotension or hypoxia despite intervention (category B2 and B3
FAC = Fractional area change raphy in care and decision mak- evidence).1 Clinical data exist on the usefulness of TEE and TTE
ing for medical and surgical in adult patients in critical care units or emergency departments
4C = Four-chamber
patients. Intensivists, trauma phy- who are hemodynamically unstable or who need noninvasive he-
IVC = Inferior vena cava sicians, cardiologists, and anes- modynamic monitoring.9,10 However, prospective, randomized
thesiologists are now using TTE clinical trials are lacking on the morbidity, mortality, and cost-
LA = Left atrial
and TEE to provide hemody- effectiveness of echocardiography in this population. Because of
LAP = Left atrial pressure namic assessments in patients the ethical and logistic challenges in conducting randomized clinical
LAX = Long-axis with life-threatening illnesses trials on patients who are hemodynamically compromised, expert
such as sepsis, respiratory failure, opinion is heavily relied on for criteria and guidelines. Although
LV = Left ventricular congestive heart failure (CHF), expert opinion and a significant body of literature support the use
LVAD = Left ventricular assist shock, and traumatic injuries, as of echocardiography as a tool to guide therapy in patients who
device well as patients with significant are critically ill, standard guidelines that define when and how echo-
respiratory and cardiac diseases cardiography can be used to guide medical and surgical therapy
LVIDD = Left ventricular undergoing noncardiac surgery have not been published.3 This document summarizes the literature
internal diameter at end-
and high-risk noncardiac proce- that supports the use of echocardiography as a monitoring tool in
diastole
dures.1-10 Ramp tests and specific clinical settings. The specific parameters that are used are
LVIDS = Left ventricular weaning protocols using discussed first, followed by guidelines for their use in specific clinical
internal diameter at end- echocardiographic monitoring scenarios.
systole are used in left ventricular
LVOT = Left ventricular (LV) assist device (LVAD)
outflow tract optimization and to guide the
removal of assist devices.11,12 I. ECHOCARDIOGRAPHIC MONITORING TOOLS
ME = Midesophageal
The clinical impact on diagnosis,
MV = Mitral valve decision making, and manage- Echocardiography has the ability to noninvasively evaluate and track
ment has led governing bodies both RV and LV hemodynamic status.14,15 In the following section, we
PA = Pulmonary artery
to address the potential value of discuss echocardiography-based hemodynamic measurements that
PW = Pulsed-wave echocardiography in unstable can be used to serially measure the response to medical interventions
RAP = Right atrial pressure medical and noncardiac surgical such as fluid and drug therapy.
patients. The recent consensus Echocardiography can be used to manage the response to fluid
RV = Right ventricular statement by the American resuscitation in critically ill patients who are at risk for heart failure or
RVIDD = Right ventricular Society of Echocardiography tissue hypoperfusion.16-18 Traditional monitors, such as central
internal diameter in diastole (ASE) on focused echo- venous catheters or pulmonary artery (PA) catheters, have not been
cardiography13 and the standard- found to improve survival or decrease length of stay in hospitalized
RVOT = Right ventricular ization of the basic perioperative patients.19 PA catheters, when used to estimate left atrial (LA) pressure
outflow tract
transesophageal echocardio- (LAP), can cause PA rupture. They are typically calibrated with saline-
SAX = Short-axis graphic examination8 have led filled transducers at the bedside and therefore can be inaccurate in the
to the need for guidelines assessment of LV filling pressures because of waveform artifacts, damp-
SVR = Systemic vascular
resistance
regarding when, and how, to ing, and airway pressure, especially in ventilated patients.19,20
use echocardiography as a quan- Furthermore, PA catheters and central venous catheters do not
TAPSE = Tricuspid annular titative monitoring tool. By accurately measure LV diastolic dysfunction, which is more predictive
plane systolic excursion definition, we propose that of mortality in hospitalized patients.21-25 Echocardiography has the
TDI = Tissue Doppler imaging echocardiography is being used potential to noninvasively measure left-sided filling pressures and guide
as a monitoring tool if, after volume assessments in hospitalized patients who may be at risk for
TEE = Transesophageal a diagnostic assessment, repeti- both systolic and diastolic heart failure.17 Serial examination of two-
echocardiography
tive hemodynamic or anatomic dimensional (2D) and Doppler indices can be used to monitor stroke
TTE = Transthoracic assessments are being made volume (SV) and overall volume status. Several studies have recently
echocardiography over a period of minutes, hours, shown the benefits of goal-directed fluid therapy in surgical
2D = Two-dimensional or days in the same patient patients.26-30 In this setting, 2D echocardiography with Doppler can
to guide management. In this measure changes in SV in response to either a fluid bolus or the
VTI = Velocity-time integral context, this covers all areas administration of a diuretic, while monitoring LAP with transmitral
in which echocardiography is and tissue Doppler imaging (TDI) as well as right atrial pressure
monitoring a therapeutic cardiac or noncardiac intervention, whether (RAP) using vena cava respiratory dynamics. The limitation of
it is fluid resuscitation, pericardial effusion monitoring, ramp or wean- echocardiography in this setting is that it cannot perform continuous
ing protocols in LVAD cases, or during perioperative care. monitoring, and it requires meticulous attention to sample volume
42 Porter et al Journal of the American Society of Echocardiography
January 2015

Table 1 Specific echocardiographic monitoring parameters and monitoring values

Specific values to use while guiding

Monitoring parameter Role Reference System requirements Important technical features interventions

Transmitral E/e0 for LAP Pulsed Doppler Doppler alignment E/e0 < 8; normal LVEF = normal LAP
Nagueh et al.15 Tissue Doppler End-expiratory acquisition E/e0 $ 13; normal LVEF = increased
LAP
E/A > 2; DT < 150 msec; depressed
LVEF = increased LAP
E/A < 1 and E < 50 cm/sec; depressed
LVEF = normal LAP
IVC size 2D harmonic Visualization throughout the Size # 2.1 cm; collapses >50%
/collapsibility, for RAP respiratory cycle during sniff = RAP 0–5 mm Hg
Rudski et al.31, Brennan et al.32 Size > 2.1 cm; collapses >50% during
sniff = 5–10 mm Hg
Size > 2.1; collapses <50% during
sniff = 10–20 mm Hg
LV and RV chamber size, areas, 2D harmonic Optimal alignment; endocardial Normal ranges:
and volumes for intravascular border visualization*; avoiding LVIDD men 4.2–5.9 cm*
volume status and function foreshortening LVIDD women 3.9–5.3 cm*
Lang et al.33 LVEDV 46–106 mL women
LVEDV 62–150 mL men
LVESV 14–42 mL women
LVESV 21–61 mL men
RV FAC $ 35%
LVOT stroke distance for 2D harmonic; pulsed Optimal Doppler alignment; Normal values
intravascular volume status Doppler visualization of aortic valve leaflet VTI > 18 cm
Ristow et al.34 opening
PASP for right-sided Pulsed Doppler Optimal Doppler alignment Normal value: PASP < 35 mm Hg
hemodynamics Continuous-wave
Lahm et al.5 Doppler
TAPSE M-mode (TAPSE) Optimal standard 4C view and Normal value: TAPSE $ 16 mm
RV s for RV function during Tissue Doppler (RV s0 ) alignment with TV annulus and RV s0 $ 10 cm/sec
fluid administration right ventricle
Rudski et al.31

LVEDV, LV end-diastolic volume; LVEF, LV ejection fraction LVESV, LV end-systolic volume; PASP, PA systolic pressure; TV, tricuspid valve.
*LV and transmitral Doppler measurements are at the plane of the MV leaflet tips. Please refer to Figure 7 in Lang et al.33 for example images of
biplane LVEDV and LVESV measurements and Figure 9 in Rudski et al.31 for RV FAC image measurements.

placement. Current guidelines suggest that specific parameters be used LVIDS are decreased, while in the setting of decreased SVR,
to detect pressures that are elevated or normal, and not for exact LVIDD is normal and LVIDS is decreased. Both RV and LV internal
values.15 In the setting of advanced decompensated systolic heart fail- diameters can be measured serially to monitor response to fluids.
ure, using serial TDI measurements may be inaccurate in monitoring Measurements should be made in the same echocardiographic
filling pressures.16 Therefore, different recommendations exist for view and serially compared. LV dimensions (LVIDD and LVIDS)
monitoring LAPs in patients with systolic or diastolic heart failure can be measured in the transthoracic echocardiographic parasternal
(Table 131,32). short-axis (SAX) or long-axis (LAX) view using either 2D linear mea-
surements or M-mode imaging at the LV minor axis, 1 cm distal to the
Two-Dimensional Echocardiographic Monitoring mitral valve (MV) annulus at the MV valve leaflet tips.33 The same
Parameters measurements can also be obtained with 2D TEE in the midesopha-
geal (ME) two-chamber view at the MV leaflet tips or using M-mode
LV Chamber Dimensions. Cardiac chambers can be measured imaging in the transgastric LV SAX view at the midpapillary level. The
serially to look for ventricular filling during focused examination of SAX or LAX view can be used for LVIDD and LVIDS, and the trans-
volume status. A small LV internal diameter at end-diastole gastric midpapillary SAX view provides a critical view in monitoring
(LVIDD) can be indicative of hypovolemia; care should be taken to for the development of regional wall motion abnormalities with any
not mistake a low LV internal diameter at end-systole (LVIDS) with of the three major epicardial vessels.8 However, the LAX is preferred
hypovolemia. Hypovolemia is best monitored using end-diastolic because it may be less prone to improper alignment and thus likely to
measurements, because a low LVIDS could also depict decreased sys- detect interval changes in dimension size and fractional shortening.
temic vascular resistance (SVR), increased inotropic state, or Reference ranges for LVIDD are 3.9 to 5.3 cm in women and 4.2
decreased ventricular filling. In hypovolemia, both LVIDD and to 5.9 cm in men.33
 Journal of the American Society of Echocardiography Porter et al 43
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Figure 1 Change in IVC collapsibility index within 24 hours of pericardiocentesis in a patient who had increased central venous pres-
sure (left) before pericardiocentesis and then improved after pericardiocentesis (right). A >10% change in the collapsibility index
should be considered meaningful.

Inferior Vena Cava (IVC) Size and Collapsibility. Hypovolemic Doppler Monitoring Parameters
patients can be identified using measurement of both size and collaps-
ibility of the IVC for estimation of RAP. Fluid responsiveness of patients Mitral Inflow. Mitral inflow velocities, both peak early diastolic veloc-
can be measured using 2D or M-mode assessment of IVC parame- ity (E) and late diastolic velocity (A), are commonly used to determine
ters.29-31 Inspiration in normovolemic, spontaneously breathing patterns of diastolic dysfunction and can also be used to serially
patients causes negative intrathoracic pressure and a decrease in IVC monitor LAP. The mitral E wave represents the LA-LV gradient during
size. An exaggerated response in IVC collapse occurs in patients in early diastole and thus is preload dependent. The mitral A wave is the
the hypovolemic state during inspiration.32 Routine measurements in LA-LV gradient during late diastole and is affected by changes in LV dia-
size of the IVC and collapsibility with respiration have been used in pa- stolic function and LA compliance. Mitral inflow velocities (E wave, A
tients with shock to reliably guide fluid management decisions.30 The wave, DT, and E/A ratio) are measured in the apical 4C view with TTE
transthoracic echocardiographic subcostal window can be used to and the ME 4C view with TEE using PW Doppler (Figure 2). The sam-
view the IVC in the sagittal plane by angling and rotating the transducer pling volume should be 1 cm distal to the MV annulus or at the leaflet
to the left from the subcostal four-chamber (4C) view. M-mode imaging tips during diastole, with a sampling gate of 1 to 3 mm.15
allows high–frame rate measurements of size changes throughout the Comprehensive explanations of mitral inflow indices for classification
respiratory cycle (Figure 1). Care must be taken to ensure that the of diastolic function are described in the ASE recommendations for
IVC does not translate out of the imaging plane during portions of the evaluation of LV diastolic function.15 It is the recommendation of
the respiratory cycle, leading to ‘‘pseudocollapse.’’ Because IVC collapse the writing group that the E- and A-wave velocities be used in conjunc-
will not occur in patients on positive pressure ventilation due to tion with the annular velocities when monitoring for changes in filling
inspiration-induced reductions in venous return, it should not be used pressures or diastolic function. Figure 2 displays the recommended
to monitor RAP in this setting.31 Although isolated measurements of sample volume positions for monitoring the tissue Doppler measure-
IVC collapsibility have been used to predict response to fluid manage- ments of e0 and transmitral measurements of the E and A waves.
ment, there are fewer data to support serial measurements of IVC Although pulmonary venous assessments of systolic filling fractions
collapsibility to guide fluid management. Changes in the IVC collaps- have proved feasible for monitoring LAP with TEE in an elective
ibility index of >10% have been observed with 2-kg weight reductions setting,14 specific cutoffs for normal and abnormal filling pressures
after hemodialysis. In this setting, collapsibility index was better than have not been provided, and their feasibility for monitoring LV filling
dry-weight assessments in predicting adverse outcomes associated pressures by TTE has not been demonstrated.4
with hemodialysis.32 Values for estimation of RAP using the IVC
collapsibility index are referenced in Table 1 from the guidelines for TDI. PW TDI is a sensitive indicator of LV diastolic function. TDI mea-
the echocardiographic assessment of the right heart in adults.31 sures mitral annular velocities during both systole and diastole at end-
 44 Porter et al Journal of the American Society of Echocardiography
January 2015
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Figure 2 Transesophageal echocardiographic sampling volume position for monitoring E-, e0 -, and A-wave velocities.

expiration. TDI is used to measure e0 , the peak early velocity of the LAX view. The deep transgastric LAX view is used in TEE, whereby
mitral annulus. Studies have found e0 to be less load dependent than the PW Doppler sample volume is placed in LVOT. Gradients across
other measures of diastolic function, such as mitral inflow and pulmo- the aortic valve (in the setting of prosthetic valve thrombolysis moni-
nary vein flow velocities.15 The measurement of E/e0 , where E is the toring) should be acquired with continuous-wave Doppler monitoring
mitral inflow peak early diastolic velocity, is a reliable estimate of in this location. Measurement of the baseline LVOT diameter is best
LAP when systolic function is normal (Table 1). Therefore, serial E/e0 accomplished in the ME LAX view. The LVOT diameter can be used
measurements are practical and reliable measurements that can be per- to calculate area, which when combined with the LVOT VTI and heart
formed as a serial assessment of LAP to guide fluid therapy in ambula- rate can be used to calculate SVand CO. Using IVC collapsibility indices
tory and hospitalized subjects at risk for heart failure.4 Measurement of to estimate RAP, and arm blood pressure measurements to calculate
e0 is best performed in the ME 4C view on TEE or the apical 4C view mean arterial pressure, SVR (in Wood units) can be calculated as
on TTE, where Doppler angles are well aligned with the lateral and
septal (or medial) MV annulus (Figure 2). Septal e0 measurement by SVR ¼ MAP  RA pressure ðmm HgÞ=CO ðL=minÞ:
TEE may not be equivalent with that by TTE because of potential
misalignment of the Doppler beam with the direction of tissue motion To convert this to conventional SVR units (dynes $ sec/cm5), this
in the ME 4C view. Care should be taken to measure this within 20 of value should be multiplied by 80. The limitations of echocardio-
angulation of mitral annular motion. The velocity scale should be set to graphic measurements of SV, CO, and time-velocity integrals in the
20 cm/sec below and above the baseline. Both septal and lateral TDI LVOT are that all measurements require accurate alignment with
velocities should be taken and the two averaged for the measurement the LVOT, and consistent sampling should occur just beneath the
of E/e0 .14 Although averaging may be used for overall assessments of aortic valve. The use of an LVOT diameter adds a second potentially
LAP, use of medial e0 alone may be better for serial assessments of more significant error measurement, and it was the recommendation
LAP.4 On the other hand, septal mitral annular e0 measurements of the committee that stroke distance (i.e., LVOT and RVOT time-
may not accurately reflect LV diastolic function in the setting of septal velocity integrals) alone be used for serial measurements, with the
wall motion abnormalities or RV dysfunction.15 assumption that LVOT diameter remains constant.

Calculated Monitoring Parameters RV Systolic Function. Echocardiographic evaluation of right heart

function at the bedside is critical in the management of right heart fail-
SV, Cardiac Output (CO), and SVR Calculations. Measurement ure, a common and serious diagnosis in intensive care unit patients.5
of SVof both the right and left ventricles can be performed readily using Because of a lower systolic elastance, the right ventricle is more sen-
PW Doppler.34 These measurements can be reliably obtained using sitive to afterload then the left ventricle.5 Simple, noninvasive mea-
TTE and TEE. Assessment of CO is important in determining responses surements of RV function can be completed using several indices
to medical and surgical therapies, such as administration of inotropic (Table 1). Tricuspid annular plane systolic excursion (TAPSE) is less
agents for the treatment of right and left heart failure.5,34 Using PW preload dependent than other markers of RV function and is per-
Doppler, SV through a site (such as the RV outflow tract [RVOT] or formed in patients using both TTE and TEE.36,37 TAPSE and RV s0
LV outflow tract [LVOT]) can be calculated using two variables: (1) can be measured with TTE in the apical 4C view and with TEE
the velocity-time integral (VTI), or stroke distance, and (2) the cross- using the ME 4C view or transgastric view. For TAPSE, the M-mode
sectional area of the site (using the diameter of the RVOT or cursor is directed through the lateral annulus of the tricuspid valve,
LVOT).35 Thus, and the distance of annular motion during systole is measured
longitudinally. The view that provides optimal longitudinal
Stroke volume (or flow) = Cross sectional area (cm2)  VTI (cm). alignment should be used. A TAPSE measurement of <16 mm, or s0
< 10 cm/sec, is highly specific for RV dysfunction, and both can be
Because CO = SV  heart rate, both right- and left-sided CO can be used to serially monitor RV systolic function. RV internal diameter
serially measured noninvasively before and after medical therapies. In in diastole (RVIDD) and fractional area change (FAC)
clinical practice, RV SV is calculated by using the parasternal SAX measurements can be measured routinely in the apical 4C view on
view. PW Doppler can be used to acquire the RVOT VTI (in centime- TTE and in the ME 4C view with TEE. RVIDD and the RVIDD/
ters) in this view. Because of difficulties in measuring the RVOT diam- LVIDD ratio should be measured at the widest point of the right
eter, it is recommended that the RVOT VTI be used as a monitor of ventricle in a standardized 4C plane.31 Although normal and
RV SV. LV SV is calculated on TTE using the apical five-chamber or abnormal values for longitudinal strain are still to be determined,
Journal of the American Society of Echocardiography Porter et al 45
Volume 28 Number 1

this parameter has been used to monitor RV systolic function during Table 2 Summary of clinical scenarios in which
therapeutic interventions in pulmonary hypertension.38 echocardiographic monitoring is considered helpful and the
PA Systolic Pressure. Besides serial quantification of RV function, level of support on the basis of a number of clinical studies
pulmonary pressures can also be evaluated by calculating the RV-RA examining utility in this setting
gradient using the modified Bernoulli equation (4V2). Using the peak
Predominant
tricuspid regurgitant jet velocity as V, the RV-RA gradient can be Clinical scenario monitoring tool Level of data support*
calculated.35 Because RAP can be determined by assessing IVC size
and collapsibility, PA systolic pressure can be estimated as Acute CHF/LVAD TTE B2
RAP + RV-RA gradient, where RV-RA gradient is 4  (peak tricuspid Critical care TTE B2
regurgitant jet velocity). The peak tricuspid regurgitant jet velocity is Trauma TTE/TEE D1
measured using continuous-wave Doppler parallel to the tricuspid re- Tamponade monitoring TTE B2
gurgitant jet. This can be performed with TTE in the apical 4C view, Pulmonary embolism TTE B2
parasternal SAX view, or RV inflow view. Doppler through the
Prosthetic valve TTE/TEE B2
tricuspid valve in TEE is best performed in either the ME 4C view thrombus
or the RV inflow view obtained from transducer angles that align
Kidney/liver/lung TEE Kidney-B3
the Doppler cursor parallel to the color Doppler jet. An additional transplantation Liver-B2
transesophageal view that is useful for Doppler alignment is obtained Lung-B2
by rotating the viewing angle to 130 to 145 to obtain an apical LAX
Major vascular surgery TEE B2
plane and then rotating clockwise to visualize the tricuspid valve re-
Orthopedic/spinal TEE B2
gurgitant jet using current guidelines.39 Although measurements are
surgery
taken in multiple views with both TTE and TEE, the highest velocity
Neurosurgery/sitting TEE B2
signal should be used for serial measurements (as this represents the
position
most parallel alignment).
B2, observational studies permit inference of benefit of the guiding
tools listed in Table 3 and clinical outcomes on the basis of noncom-
II. ADVANTAGES, DISADVANTAGES, AND parative observational studies with associative (e.g. relative risk, cor-
RECOMMENDATIONS OF ECHOCARDIOGRAPHY AS A relation) or descriptive statistics; B3, observational studies permit
inference of benefit of the monitoring tools in Table 3 on the basis
MONITORING TOOL
of case reports only; D1, lack of scientific evidence in the literature
to address whether the monitoring tools in Table 2 affect outcomes.
Patient monitoring is currently performed in most critical care and in- *Please refer to Thys et al.1 for reference to the entire level-of-support
traoperative settings with serial measurements of vital signs, oxygen classification.
saturation, end-tidal carbon dioxide monitoring, and occasionally
PA catheters. The use of echocardiographic monitoring is a new of fluid management or drug interventions needs to be assessed
concept that has emerged in several different fields that include cardi- rapidly. These are listed in Table 3. Despite this expert opinion, the
ology, emergency medicine, anesthesiology, and critical care. As writing group could find no formal clinical studies in which moni-
echocardiography becomes more portable, monitoring with echocar- toring of echocardiographic Doppler parameters was compared
diographic techniques will be used to greater degrees in patient man- with other monitoring modalities in the setting of sepsis, respiratory
agement decisions. Although echocardiographic monitoring has failure, or trauma. Monitoring in CHF, pulmonary embolism, and
proved useful in several specific areas outlined in this review, the tech- pericardial tamponade are discussed separately.
nique is heavily operator dependent and demands that continuous
quality improvement measures be implemented for all practicing
echocardiographers within an institution, to ensure that Doppler Acute CHF Monitoring
and anatomic measurements are following established technical
In the setting of heart failure, most monitoring applications have dealt
guidelines that have been published . Second, the data presented in
with situations in which Doppler has been used to assess the effects of
this document derive for the most part from single-center experiences
therapeutic interventions that will eventually be used for longer term
and were not rigorously evaluated in prospective studies examining
therapy. Transmitral E- and A-wave velocity ratios, combined with E-
differences in patient outcome as a result of echocardiographic
wave DT, have been used to assess responsiveness to nitroprusside
monitoring. The writing committee has developed a ‘‘level of data
infusion and carvedilol therapy, which may also predict prognosis.40
support’’ that displays the number of studies that have been
Patients with heart failure and depressed ejection fractions who had
performed for each of the proposed clinical scenarios in which echo-
E/A ratios > 1, combined with EDTs < 130 msec, and who did not
cardiographic monitoring may be useful (Table 2). Note that in the
reverse these parameters with nitroprusside infusion, had the worst
setting of trauma, there are no clinical comparative studies published,
prognosis. Changes in mitral filling parameters after leg lifting or nitro-
despite numerous reviews suggesting that echocardiographic moni-
prusside infusion were predictive of tolerance to carvedilol therapy
toring would be useful.
and patient outcome. More recently, studies have evaluated E/e0 to
monitor LAP in response to interventions in patients with symptom-
atic heart failure (New York Heart Association classes II and III) in an
III. CLINICAL SCENARIOS outpatient setting and have demonstrated that the E/medial e0 ratio
most accurately reflects changes in LAP.4
Expert opinion supports the use of primarily TTE to guide the man- Although E/e0 monitoring has been shown to reflect changes in
agement of patients in specific clinical settings in which monitoring pulmonary capillary wedge pressure in small numbers of patients
46 Porter et al Journal of the American Society of Echocardiography
January 2015

Table 3 Specific clinical settings in which echocardiographic monitoring could potentially guide therapeutic interventions

Specific clinical scenario Recommended monitoring parameters

Critical Care Hypotension IVC collapsibility index

Regional wall motion
LVOT VTI response to passive leg raising
CHF IVC collapsibility index
Transmitral E/e0
E/A ratio with EDT
RV s0
TAPSE
Regional wall motion
Sepsis* IVC collapsibility index
LVIDD, LVIDS
Regional wall motion
Respiratory failure* IVC collapsibility index
Possible pulmonary embolus RV s0
TAPSE
Doppler PASP
RVOT VTI
Regional wall motion
RVIDD/LVIDD ratio
Pericardial effusion/tamponade Pericardial effusion size
Right ventricular diastolic collapse
IVC collapsibility index
Prosthetic valve dysfunction Transvalvular gradient
Trauma* Blunt trauma IVC collapsibility
Aortic trauma LVIDD, LVIDS
Myocardial contusion Pericardial effusion size
Regional wall motion
Burns IVC collapsibility
LVIDD, LVIDS
Transmitral E/A ratio, E/e0
Perioperative Thoracoabdominal cross-clamping Regional wall motion
LVIDD, LVIDS
Liver transplantation LV regional wall motion
LVIDD, LVIDS
RV s0
TAPSE
RV cavity monitoring for emboli
Renal transplantation LV regional wall motion
LVIDD, LVIDS
RV s0
TAPSE
Transmitral E/e0 and E/A ratio
RV cavity monitoring for emboli
Orthopedic/spinal/neurologic surgery RV s0
TAPSE
Transmitral E/e0
RV cavity monitoring for emboli
PASP, PA systolic pressure.
*Although potentially useful and used clinically in this setting, no clinical studies have been published examining these echocardiographic param-
eters in monitoring patients in this setting.

with acute decompensated heart failure,41,42 the writing committee only small subsets of the study population had serial E/e0 measure-
currently recommends that E/e0 not be used in monitoring LAP of ments compared with serial changes in LAPs.
patients with decompensated heart failure with depressed systolic One evolving area in which echocardiographic guidance has become
function (‘‘cold and wet patients’’), as others have shown that these helpful in CHF is assessing responsiveness to LVAD therapy.
parameters do not predict LAPs or guide management in this Echocardiographic parameters have been used to serially monitor
clinical setting.16 The primary focus of these studies was to use E/e0 ramped interventions and determine whether patients can be weaned
to predict initial pressures, not on E/e0 as a monitoring tool. As a result, from LVAD therapy. Ramp protocols are defined as dynamic assessments
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Figure 3 Echocardiographic parameters obtained during the ramp protocol to optimize LVAD settings and assist in the detection of
device malfunction. (A) LVIDD changes, (B) changes in aortic valve opening, (C) aortic regurgitation, (D) mitral regurgitation, and (E)
changes in RV systolic pressure with each setting change. Reproduced with permission from Uriel et al.11

of LV size, hemodynamics, and valvular function with echocardiography for monitoring patients with respiratory failure, sepsis, or unex-
during incremental device speeds. They have been shown in single- plained arrest has not been elucidated. In these settings, there are
center studies to improve speed optimization and assist in the detection several parameters that could be followed that would be unique
of device thrombosis. In this setting, the LVAD backup speed is started at to echocardiography over other monitoring tools, such as PA cathe-
the lowest usable setting (8,000 rpm) and then increased serially while ters or oxygen saturation monitors (Table 4), but to date, no clinical
monitoring LVIDD, LVIDS, aortic valve opening, aortic and mitral regur- studies comparing the techniques have been performed. There are
gitation severity, and RV systolic pressure (Figure 3). Normal results advantages and disadvantages with either technique. Although serial
would be gradual reductions in LVIDD as the speed is increased to echocardiography has the advantage of providing anatomic infor-
12,000 rpm, while flat responses would indicate device malfunction.11 mation regarding changes in systolic and diastolic function, PA cath-
In these protocols, LVIDD is plotted as a function of change in revolutions eters are more useful when many serial interventions that may affect
per minute. An LVIDD slope $ 0.16 was diagnostic of flow obstruction CO and LV filling pressures are being performed rapidly at the
from thrombosis or mechanical obstruction in the LVAD tubing. bedside in an acute setting. In the setting of septic shock, goal-
Echocardiographic guidance has also been used to determine if pa- directed therapy has been shown to improve patient outcome.43
tients can be weaned from their LVADs. Once the LVIDD decreases Although this study used central venous pressure, mean arterial
to <60 mm and mitral regurgitation is reduced in severity on chronic pressure, and central venous oxygen saturation to guide fluid, blood,
LVAD therapy, the patient is scheduled for an echocardiographically and vasopressor management, echocardiographic parameters might
guided study in which the LVAD is turned off. LVIDD, LVIDS, and RV be substituted for most parameters. IVC collapse could be used to
size and function are then assessed; maintenance of LV function assess central venous pressures and LVOT stroke distance to monitor
(LVEF > 50%) without the development of worsening RV dilatation CO. These noninvasive assessments could be combined with blood
during off-pump trials are used as criteria for LVAD removal.12 A lack pressure monitoring to guide therapy in this setting. In small
of change in LVEF or RV size at end-diastole was also associated with numbers of critically ill patients, an increase in LVOT VTI of
good clinical outcomes after LVAD removal. >12.5% during passive leg raising predicted increases in SV in
response to intravenous fluids with 77% sensitivity and 100% spec-
Critical Care Monitoring ificity.44 The change in LVOT VTI with passive leg raising was more
Although echocardiography plays an invaluable role in assessing the accurate than changes in LV dimensions or mitral inflow patterns in
cause of hemodynamic compromise in critically ill patients, its role predicting fluid responsiveness.
48 Porter et al Journal of the American Society of Echocardiography
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Table 4 Methods by which critical monitoring parameters are assessed with a PA catheter versus serial echocardiographic
measurements

*
Monitoring technique PA catheter Echocardiography Advantage

Filling pressures RAP, PCWP directly measured RAP, PCWP indirectly measured PA catheter
Cardiac output Thermodilution Doppler derived Equal
Valve assessment Not possible Anatomic/Doppler Echocardiography
Systolic/diastolic function Estimated from PCWP/CO Table 1 parameters Echocardiography
Risks Invasive technique Noninvasive Echocardiography
Speed of assessment Immediate changes detected Operator dependent PA catheter
PCWP, Pulmonary capillary wedge pressure.
*Advantage refers to which monitoring parameter the writing group considered better suited for the particular application.

Pericardial Tamponade Monitoring assess whether thrombus within the main PA is present, which may
Echocardiographic guidance has played a critical role in decision mak- warrant surgical embolectomy. Most important, it is useful to
ing for patients presenting with significant pericardial effusion and monitor RV function and PA systolic pressure when thrombolysis is
guiding pericardiocentesis and postpericardiocentesis management. administered.52
Echocardiographic monitoring plays a vital role in patients presenting Patients with suspected pulmonary embolism often present with
with pericardial effusion when the rate of accumulation is unknown signs and symptoms that are nonspecific, which can make it difficult
and the patients have nonspecific symptoms. Approximately 33% to distinguish the diagnosis from other life-threatening disorders.
of large idiopathic pericardial effusions may suddenly develop tampo- Although not diagnostic of pulmonary embolism, initial TTE can
nade physiology.45 Along with monitoring for increase in pericardial help in identifying when pulmonary embolism may be the cause by
effusion size, monitoring for the development of right atrial collapse detecting RV dilation (RVIDD/LVIDD ratio > 0.9) and assist with
(lasting for greater than one-third of the cardiac cycle), early RV dia- ruling out other causes, such as pericardial effusion or myocardial
stolic collapse, and IVC plethora have been used for determining infarction.50,51 Once the diagnosis of pulmonary embolus is
when pericardiocentesis may be indicated.45 established, these patients can be risk-stratified according to the ef-
For pericardiocentesis, echocardiographic monitoring has replaced fects of elevated RV afterload: hypotensive patients and those with
fluoroscopy at many centers because of its ability to detect and guide elevated cardiac biomarkers or echocardiographic indices of RV strain
needle and catheter placement for loculated effusions.46-48 Using are at an increased risk, and thrombolysis is considered a class II indi-
echocardiographic guidance has resulted in more apical, rather than cation.52 Patients with massive pulmonary embolism can have serial
subxiphoid, approaches to pericardiocentesis, mainly because the assessments of RV size and FAC (Figure 5), assessments of RV systolic
distance to effusion from the skin surface is smallest in this location. pressure, and IVC assessments using ASE RV guidelines for normal
The use of saline contrast administered through the ranges.31 The writing group recommends that considerable attention
pericardiocentesis needle confirms pericardial entry (Figure 4, be given to maintaining the same identical imaging plane of the right
Video 1; available at www.onlinejase.com). After this confirmation, ventricle when serially examining RV size and FAC, as slight devia-
echocardiography can be used to confirm both guidewire and pigtail tions in the imaging plane may alter these values.
catheter placement into the pericardial space.48 Drainage then pro-
ceeds until there is near disappearance of pericardial effusion on
Prosthetic Valve Thrombosis Monitoring
echocardiography (Video 1). The ultrasound transducer can be either
sterilized by placing a gel-filled sterile sleeve over the transducer or Both TTE and TEE have been used to detect prosthetic valve throm-
placed in an imaging area that is outside the sterile field. This echocar- bosis and monitor therapy effectiveness.53-56 Fibrinolytic therapy is
diographically guided procedure has a >95% success rate, with a large recommended if left-sided prosthetic valve thrombus area (planime-
single-site study demonstrating minimal complications.46 After tered on a 2D image) is <0.8 cm2, with serial Doppler echocardio-
drainage of the effusion, repeat echocardiography within 24 hours graphic monitoring of mean gradients across the valve to assess
is indicated to examine for reaccumulation. At this point, IVC collapse effectiveness of either fibrinolytic or unfractionated heparin treat-
can be reevaluated to see if RAPs have decreased or if RAPs remain ment.55 A significant reduction in the transvalvular gradient at
elevated, as may occur in effusive constrictive pericarditis.45 24 hours is indicative of effective therapy. TEE and TTE are comple-
mentary in these settings, with serial TEE giving better visualization of
residual thrombus burden, but both are equally effective at moni-
Pulmonary Embolism Therapy Monitoring toring for reductions in transvalvular gradients.
Despite the widespread use of echocardiography in assisting in the
diagnosis and initial management of pulmonary embolism, there
are very few published data on the usefulness of monitoring RV sys- Echocardiographic Monitoring in Trauma
tolic function or PA pressures in this setting. Nonetheless, echocardi- TTE and TEE have been proposed as methods to monitor volume sta-
ography plays a significant role in making therapeutic decisions in tus and regional and global systolic function in a wide variety of trau-
patients with pulmonary embolism and can facilitate a change in man- matic settings. Although they have proved useful in the immediate
agement by identifying those at high risk who might otherwise be assessment of LV and RV systolic function, volume status, and detec-
treated with less aggressive therapies.49-51 In addition, it can help tion of significant pericardial or aortic pathology, their role in
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Figure 4 Demonstration of an echocardiographically guided apical approach to pericardiocentesis. Once needle entry into a fluid
filled space was confirmed, agitated saline contrast was administered (C–F) to confirm that the needle was in the pericardial space.
Reproduced from Ainsworth and Salehian.48

monitoring specific parameters has not been validated sufficiently, The specific surgical settings that would benefit from transesophageal
even in single-center, unblinded studies. Therefore, no recommenda- guidance are discussed below.
tions can be given regarding the use of transesophageal or transtho-
racic echocardiographic monitoring at this time.
Echocardiographic Monitoring During Liver, Kidney, and
Lung Transplantation
Perioperative management of liver transplantation patients pre-
IV. PERIOPERATIVE MEDICINE sents unique challenges in a population at risk for volume overload
or tissue hypoperfusion. Underlying cardiac dysfunction from
The American Society of Anesthesiologists endorses the use of TEE cirrhotic cardiomyopathy and abnormal SVR make fluid and
when surgery or the patient’s cardiovascular pathology may result drug management of these patients difficult.57 TEE diagnosis of
in severe hemodynamic, pulmonary, or neurologic compromise.1 intracardiac thrombus, pulmonary embolism, myocardial ischemia,
Although the basic perioperative transesophageal echocardiographic cardiac tamponade, acute right heart failure, and systolic anterior
examination consensus statement outlines the specific views required motion of the anterior MV have all been described during
to obtain these measurements,8 the use of echocardiography as a liver transplantation in situations in which other hemodynamic
monitoring tool in this setting requires quantitative transesophageal monitoring tools failed to detect these phenomena.58-62 TEE
echocardiographic monitoring of specific Doppler hemodynamics guidance in detecting and managing these problems during liver
(transmitral E and e0 , tissue Doppler s0 measurements in the right transplantation has led to its use by >85% of transplantation
ventricle) and RV and LV size and systolic function in the immediate anesthesiologists surveyed at 30 transplantation programs in the
preoperative, perioperative, and postoperative setting. Figure 6 de- United States.63 Doppler echocardiography can play a role in
picts the changes in transmitral E/A ratio and E/e0 ratio that occurred the ongoing assessment of cardiac filling status using transmitral
with echocardiographic monitoring in the operating room that guided E and e0 , LVOT VTI, and assessment of pulmonary pressures.
fluid management in a patient with underlying diastolic dysfunction. Doppler-derived SVR and LV end-systolic dimensions may be
 50 Porter et al Journal of the American Society of Echocardiography
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Figure 5 Serial echocardiograms in a patient with a pulmonary embolus treated with fibrinolytic therapy. FAC improved significantly
after fibrinolytic therapy, and RVIDD decreased. RV systolic pressure decreased by >50 mm Hg.

used to monitor dynamic changes in vasodilated states. Detection RV contractility must be identified early, so that inotropic support
of intracardiac thrombus, ventricular function, pericardial effusion, or inhaled PA vasodilators can be initiated before overt hemodynamic
and monitoring for systolic anterior motion of the mitral valve can compromise occurs. TEE is also used to monitor the pulmonary veins
all be detected with serial 2D TEE monitoring in this population for any stenoses that may develop from thrombosis at the anasto-
(Figure 7, Video 2; available at www.onlinejase.com), in which motic sites.70
changes in hemodynamic and prothrombotic conditions occur
rapidly.64-67 As long as a patient is not receiving positive
pressure ventilation, IVC collapsibility and size can be used to Major Vascular Surgery
predict fluid responsiveness for postoperative fluid management Direct clamping of major vessels causes a sudden significant increase
along with ongoing 2D and Doppler hemodynamic and function in cardiac loading conditions, which may lead to hemodynamic insta-
assessment. Before considering TEE as a monitoring tool during bility from ventricular failure, myocardial ischemia, and end-organ hy-
liver transplantation, it is important to note that esophageal poperfusion. Echocardiography indices can be used to monitor effects
varices may be present and that this is considered a relative of cross-clamping of the aorta or the vena cava on both diastolic and
contraindication to performing TEE.39 Therefore, the writing group systolic function.71-75 Previous studies have shown TEE to be more
recommends lubrication and careful probe insertion to minimize sensitive than PA catheters in the detection of alterations in systolic
esophageal variceal bleeding. and diastolic function during cross-clamping of the thoracic and thor-
Large systematic evaluations of the role of TEE monitoring in acoabdominal aorta.73,74 Echocardiographic indices that are
kidney transplantation are lacking, and there are only limited data recommended to detect these dynamic changes include changes in
to demonstrate that it can add to central venous pressure monitoring CO, LV ejection fraction, LV end-diastolic dimensions, regional wall
in volume assessment and management of ischemia reperfusion motion in the transgastric SAX view, and transmitral Doppler flow
injury.68 The writing group recommends that the use of TEE as a patterns.
monitoring tool of LV and RV systolic and diastolic function be consid- Complete occlusion of the vena cava can also cause significant
ered only if coexisting cardiovascular disease is present. changes in preload and afterload. Intraoperative assessment of ven-
With regard to echocardiographic monitoring during lung trans- tricular filling, wall motion, and both diastolic and systolic function
plantation, there is a consensus that TEE is essential to monitoring may be used to guide medical intraoperative therapy during vena
RV systolic function during and after transplantation.69 Changes in cava cross-clamping.
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Figure 6 Intraoperative transesophageal echocardiographic monitoring in two different liver transplantation cases. In the top panel,
one sees a normal relatively low E/e0 ratio before liver transplantation, followed by an increase to 8 (C,D) after IVC clamp removal. This
led to a cessation of intravenous fluid administration. In the bottom panels, one sees a decrease in the E/A ratio during IVC clamping
during liver transplantation (B, bottom panel) but a dramatic increase in the E/A ratio after clamp removal (C, bottom panel). This led to
an immediate reduction in fluid administration.
 52 Porter et al Journal of the American Society of Echocardiography
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Figure 7 Transesophageal echocardiographic images during liver transplantation demonstrating acute RV dilation due to emboliza-
tion of debris during the initial dissection (left). After the procedure was aborted and anticoagulation given, there was dissolution of
debris, and RV size decreased (right). See Video 2 (available at www.onlinejase.com).

Orthopedic and Spinal Surgery earlier pharmacologic or surgical interventions. Although TEE moni-
Intraoperative TEE is used in this setting primarily as a rescue proce- toring is useful for neurosurgery in the sitting position, it should be
dure. Hip arthroplasty, spinal surgery, and knee arthroplasty are all noted that TEE monitoring in the sitting position has been associated
associated with significant risk for intraoperative cement and fat with posterior tongue edema and even necrosis.87 Further controlled
emboli. Hypotension, ventilation-perfusion mismatch, hypoxemia, studies are needed to define the beneficial role of transesophageal
pulmonary embolism, and cardiac collapse can all occur during intra- monitoring in this setting.
medullary reaming and release of microparticulate matter.76
Intraoperative rescue TEE can be used to monitor microemboli and
detect intracardiac shunting using color-flow Doppler through a pat- V. WHEN HAS A MEANINGFUL CHANGE IN A MONITORING
ent foramen ovale.77 Both TEE and TTE have been reported to be PARAMETER OCCURRED?
useful hemodynamic monitors for lengthy orthopedic and spinal sur-
gery.78-81 However, it should be noted that the majority of spinal On the basis of available evidence, the use of echocardiography for
surgery is done in the prone position, and TEE is not used. Changes monitoring purposes is justified when categorical changes have
in RV function due to increases in acute pulmonary vascular occurred, such as an increase in LAP from normal to abnormal (an in-
resistance can be detected using TAPSE, pulmonic valve VTI, and crease in E/e0 ratio from <8 to >13 in the setting of normal systolic
peak tricuspid regurgitant jet velocity measurements. Fat emboli function). It can be used for continuous monitoring in settings in
can be visualized with TEE during hip arthroplasty; its identification which LVIDD, RV FAC, or PA systolic pressure are being reevaluated
has been associated with neurologic dysfunction and a subsequent in ramp or weaning protocols. In both of these settings, it is important
higher American Society of Anesthesiologists physical status to note what degree of change must occur before one can say the
($III).81 Despite its limited use, TEE has detected thromboembolic given change is beyond the interobserver variability of the measure-
events during cervical spine surgery.82 ment (Table 588-93). Although only small numbers of patients are
included in these studies of variability measurements, they do
Neurosurgery provide assistance in determining what cutoffs to use when
deciding whether a change in a parameter is beyond what would
The vast majority of all neurosurgery (other than spinal) in the United
be expected on the basis of interobserver variability or coefficients
States is done in the supine position, and TEE monitoring is used pri-
of variation. In the specific areas of IVC collapsibility index, E/e0 , E/
marily in a rescue setting. The potential for venous air embolism dur-
A, and PA systolic pressure changes, we have added categorical
ing neurosurgery has led to the ‘‘equivocal’’ endorsement of the use of
changes (on the basis of guidelines) that should be used when
intraoperative TEE as category B by the American Society of
guiding management. These categorical changes are well within the
Anesthesiologists during such procedures.1 Evaluation of the intera-
published data regarding coefficient of variation and interobserver
trial septum by color-flow Doppler and agitated saline contrast to
variability of the monitoring parameter.
assess the risk for paradoxical emboli associated with a patent fora-
men ovale can be performed during intraoperative monitoring.
Doppler assessment of right-sided pulmonary pressures and 2D
assessment of RV function can detect changes secondary to venous VI. CONCLUSIONS REGARDING TRAINING AND USE OF
air embolic load, especially in procedures done in the sitting posi- ECHOCARDIOGRAPHY AS A MONITORING TOOL
tion.83,84 TEE has been used to guide the placement of right atrial
aspiration catheters to an optimal location at the junction of the The writing committee emphasizes that a minimum of level II training
superior vena cava and right atrium.85,86 Ongoing intraoperative experience94 is required to use echocardiography as a quantitative
assessment for air entrapment into right-sided cardiac chambers is monitoring tool, regardless of the clinical scenario for which it is being
recommended when the risk for paradoxical emboli is high. applied. Although level II Core Cardiology Training Symposium
Identification of these complications early, along with careful qualita- training experience in TTE is sufficient to monitor LV dimensions
tive and quantitative assessments of RV systolic function, may assist and IVC collapsibility, additional level III Core Cardiology Training
significantly in preventing hemodynamic deterioration and permit Symposium training experience with both TTE and TEE is required
Journal of the American Society of Echocardiography Porter et al 53
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Table 5 Interobserver variability and coefficients of variation for specific echocardiographic monitoring parameters, with
recommended meaningful changes that must occur in a clinical scenario (monitoring setting)

Echocardiographic monitoring Meaningful changes from baseline

parameter IOV/CV Monitoring setting in a monitoring setting

IVC collapsibility index Not demonstrated CHF, trauma, perioperative >10%32

Change from <50% to >50%31
E/A ratio 6% CV88 CHF, perioperative Change from <1 to 1–2 to 2
Depressed LV systolic function
E/e0 8% CV CHF, perioperative >8%89
Normal LV systolic function Change from <8 to 9–14 to
$1515
LVOT VTI 6% IOV CHF, perioperative setting >6% change in VTI or SV90
LVOT area 4 % IOV
PASP 3% IOV Pulmonary embolus, >3%91
perioperative, CHF Change from <40 to 40–60 to
>60 mm Hg31
LVIDD, LVIDS 8% IOV Perioperative, CHF ramp/weaning >8%92
0
RV FAC, S , and TAPSE RV FAC:10% (IOV) Pulmonary embolus RV FAC > 10%93
RV s0 : 1.6 mm/sec (IOV) Perioperative RV s0 > 1.6 mm/sec93
TAPSE: 1.9 mm (IOV) Pulmonary hypertension TAPSE > 1.9 mm93
CHF LVAD
CV, Coefficient of variation; IOV, interobserver variability; PASP, PA systolic pressure.

to ensure accurate Doppler and advanced hemodynamic pressure and basic clinical trials are lacking on the use of echocardiography in
measurements in intensive care units, emergency departments, and guiding trauma management or other critical care and surgical appli-
surgical suites. Because echocardiographic monitoring is currently cations. Although a sufficient amount of data have been published
used in a wide range of clinical settings, it is imperative that the person using interventional echocardiography to guide percutaneous cardiac
using quantitative echocardiography to guide therapeutic decision interventions,95 it is a strong consensus recommendation from the
making (whether an anesthesiologist, a cardiologist, or an emergency writing group that additional clinical trials be performed that docu-
room physician with level II or level III experience) understand the ment the utility of both TTE and TEE as dynamic monitoring modal-
interobserver variability of each of the quantitative measurements ities to aid in the treatment of several acute medical and surgical
(as displayed and referenced in Table 5) and have the technical exper- conditions.
tise required to ensure the serial measurements are obtained accu-
rately. Although high-quality images can be obtained by those with
lesser experience, as outlined in the basic perioperative transesopha- NOTICE AND DISCLAIMER
geal echocardiography consensus statement and focused cardiac ul-
trasound recommendations,8,13 the interpretation and use of the This report is made available by the ASE as a courtesy reference
quantitative parameters to guide therapeutic decision making source for its members. This report contains recommendations only
outlined in this document should be done only by level II and III and should not be used as the sole basis to make medical practice de-
trained personnel. For example, is there a significant global wall cisions or for disciplinary action against any employee. The statements
motion abnormality in the left or right ventricle that has developed and recommendations contained in this report are based primarily on
during the intraoperative monitoring? Such detection would be the opinions of experts rather than on scientifically verified data. The
required for basic perioperative or critical care monitoring, but does ASE makes no express or implied warranties regarding the complete-
not require a quantitative assessment of LVIDD or LVIDS or the ness or accuracy of the information in this report, including the war-
IVC to guide fluid resuscitation and does not require a ranty of merchantability or fitness for a particular purpose. In no event
measurement of RV FAC in the setting of monitoring or guiding shall the ASE be liable to you, your patients, or any other third parties
interventions in pulmonary embolus or intraoperative embolism for any decision made or action taken by you or such other parties in
after the release of IVC cross-clamping. Quantitative measurements, reliance on this information. Nor does your use of this information
when used to guide therapeutic decision making, require a minimum constitute the offering of medical advice by the ASE or create any
of level II training. physician-patient relationship between the ASE and your patients
In conclusion, a sufficient body of literature exists, originating from or anyone else.
critical care, anesthesiology, and emergency medicine, demonstrating
the potential role of echocardiographic monitoring. Clinical studies
have demonstrated the role of echocardiographic monitoring in ACKNOWLEDGMENTS
guiding management of pulmonary emboli, pericardial effusions,
thrombosed prosthetic valves, and acute heart failure management. The writing committee would like to thank Dr. Feng Xie, Julie
However, large-scale clinical trials documenting the effectiveness of Sommer, and Stacey Therrien for their assistance with manuscript
echocardiography as a monitoring tool are lacking in all of these areas, and figure preparation.
54 Porter et al Journal of the American Society of Echocardiography
January 2015

SUPPLEMENTARY DATA 18. Broch O, Renner J, Gruenewald M, Meybohm P, Hocker J, Schottler J, et al.
Variation of left ventricular outflow tract velocity and global end-diastolic
Supplementary data related to this article can be found at http://dx. volume index reliably predict fluid responsiveness in cardiac surgery pa-
doi.org/10.1016/j.echo.2014.09.009. tients. J Crit Care 2012;27:e7-325.
19. Shah MR, Hasselblad V, Stevenson LW, Binanay C, O’Connor CM,
Sopko G, et al. Impact of the pulmonary artery catheter in critically ill pa-
tients. JAMA 2005;294:1664-70.
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