title: Mitral Doppler indices are superior to two-dimensional echocardiographic and hemodynamic variables in predicting responsiveness of cardiac output to a rapid intravenous infusion of colloid.
abstract: We hypothesized that mitral flow (MF) Doppler measurements could be used to predict cardiac output (CO) responsiveness to fluid challenge. Fourteen patients with normal systolic and diastolic function, scheduled for coronary artery bypass graft surgery, were evaluated as part of a pilot study in which preload was varied immediately before the beginning of cardiopulmonary bypass. A Validation group of 36 patients with different levels of systolic and diastolic function received a rapid infusion of 500 mL of 10% pentastarch. By use of transesophageal echocardiography, we measured left ventricular end-diastolic area, pulsed Doppler indices of the MF and pulmonary venous flow, and standard hemodynamic variables during acute volemic variations. A baseline measurement was first recorded, followed by measurements taken after a decrease (211 +/- 87 mL) and then an increase (176 +/- 149 mL) in preload (pilot study) and before and after 500 mL of pentastarch (validation study). In the pilot study, we found that a low velocity/time integral (VTI) E wave/A wave (E/A) ratio was associated with a larger increase in CO secondary to an increase in preload (r = 0.64, P < 0.05). Stepwise linear regression identified Doppler measurements of the mitral VTI E/A ratio as the most important variable to predict the increase in CO after fluid infusion. In the validation study, a mitral E/A ratio <1.26 before fluid infusion best predicted a 20% increase in stroke volume (receiver operating characteristic curve, 71%; P < 0.05), whereas no other hemodynamic or echocardiographic variable predicted preload responsiveness. We conclude that the MF Doppler filling pattern is an important factor to predict the increase in CO after intravascular fluid challenge in patients undergoing coronary artery bypass grafting.
  
  
  CONCLUSIONS
  In the presence of low cardiac output, the clinician's ability to identify which patients are more likely to benefit from volume administration to improve hemodynamic status while avoiding fluid overload is important. The analysis of Doppler measurement of the mitral flow as an indirect indicator of the individual diastolic pressure/volume relationship may be useful to predict the intravascular volume responsiveness in patients undergoing coronary artery bypass graft surgery.
authors.affiliation: Department of Anesthesiology, Montreal Heart Institute, Montreal, Quebec, Canada.
authors.forename: Robert
authors.initials: R
authors.lastname: Lattik
authors.forename: Pierre
authors.initials: P
authors.lastname: Couture
authors.forename: André Y
authors.initials: AY
authors.lastname: Denault
authors.forename: Michel
authors.initials: M
authors.lastname: Carrier
authors.forename: François
authors.initials: F
authors.lastname: Harel
authors.forename: Jean
authors.initials: J
authors.lastname: Taillefer
authors.forename: Jean-Claude
authors.initials: JC
authors.lastname: Tardif
mesh_terms: D000328:Adult; D000368:Aged; D002302:Cardiac Output; D003102:Colloids / Q000008:administration & dosage*; D001026:Coronary Artery Bypass; D003971:Diastole; D018619:Echocardiography, Doppler, Pulsed; D017548:Echocardiography, Transesophageal; D005260:Female; D006439:Hemodynamics; D006801:Humans; D007262:Infusions, Intravenous; D008297:Male; D008875:Middle Aged; D010865:Pilot Projects; D011669:Pulmonary Wedge Pressure
chemical_list: D003102:Colloids