307D. De Backer et al. (eds.), Hemodynamic Monitoring Using Echocardiography in the Critically Ill, DOI: 10.1007/978-3-540-87956-5, © Springer-Verlag Berlin Heidelberg 2011

AAcute aortic regurgitation (AR), 124–128Acute aortic syndrome (AAS)

classic aortic dissectiondiagnosis, 251–263evolutive patterns, 253–255pathology, 250–251

classifications, 247–248incomplete aortic dissection

diagnosis, 265, 269evolutive patterns, 267pathology, 263–265

intramural aortic hematomadiagnosis, 256–257, 264, 265evolutive patterns, 257–258pathology, 255–256, 263

management strategy, 267–268patient, risk identification, 248–253penetrating aortic ulcer

diagnosis, 260–262evolutive patterns, 262–263pathology, 258–260

Acute circulatory failure (ACF)acute therapy, efficacy and safety, 106cardiogenic shock, 117-129, 144–145Complicating cardiac surgery, 239–244Differential diagnosis, 100–105echocardiography, steps, 101–102mechanisms, 101Monitoring effects of therapy, 106pulmonary venous congestion, 103–104Septic shock, 109-115systemic venous congestion, 104–105Tamponade, 152-160

Acute cor pulmonale (ACP)clinical scenarios

acute respiratory distress syndrome (ARDS), 145acute RV failure, of sepsis, 145massive pulmonary embolism, 144–145preload/volume responsiveness, 146RV infarction, 145

definition, 135and pulmonary hypertension, 140RV diastolic overload, 138–139RV systolic overload, 135–137vs. subacute chronic cor pulmonale, 139–140

Acute myocardial infarction, cardiogenic shockcause, 118diagnosis, 118mechanical complications

acute MR, 121–123ventricular free-wall rupture, 121ventricular septal rupture, 119–121

pulmonary artery systolic pressure, 119Acute respiratory distress syndrome (ARDS), 145, 187–189.

See also Pulmonary edemaechocardiography use, 195–197PEEP effect, monitor, 199–200prone positioning role, 200, 201tidal volume and PP adaptation, 198–199

Acute right ventricular failure, 237–238Alveolar pressure, 43Aortic blood flow, 85Aortic dissection, 126, 237–240Aortic stenosis (AS), 126–127, 129Arrhythmias

atrial fibrillation (AF), hemodynamic consequencescardiac output effects, 90–91diastolic function effects, 90systolic function effects, 90

echocardiographic evaluation, of patientsDoppler assessment, 94LV diastolic pressure, 92–93LV strain and strain rate, 94stroke volume, 91–92systolic function, 91

Atrial fibrillation (AF), hemodynamic consequencescardiac output effects, 90–91diastolic function effects, 90systolic function effects, 90

BBlunt cardiac trauma

cardiac rupture, 227–228mechanisms of injury, 226segmental/global ventricular systolic function, 227septal defects, 228–229valvular injuries, 228–229

Blunt chest traumamanagement, 222–226traumatic aortic injury

angiography, 209–210

Index

308 Index

chest radiography, 208–209clinical presentation, 207–208computed tomography, 210–212incidence and natural history, 205–206mechanism of injury, 206pathology, 206–207TAI screening, 221–222transesophageal echocardiography (TEE), 212–221

CCardiac depression, septic shock

incidence, 110pathophysiology, 110treatment and prognosis impact, 110–111

Cardiac function alterationaortic blood flow, 85contractility, 83–84LV external mechanical power, 85–86LV wall stress relationship, 85maximal elastance, 86–87mitral regurgitation jet acceleration time, 85speckle tracking, 87velocity of circumferential fiber (VCF) shortening, 84–85

Cardiac tamponadeechocardiographic identification

clinical context, 158Doppler analysis, 157–158two-dimensional, 157

pathophysiology, 152Cardiogenic shock

acute myocardial infarctioncause, 118diagnosis, 118mechanical complications, 119–123pulmonary artery systolic pressure, 119

diagnosis, 117–118myocarditis, 124stress cardiomyopathy, 123–124valvular disease

acute aortic regurgitation (AR), 124–128aortic stenosis (AS), 126–127, 129mitral stenosis (MS), 128–130

Cardiopulmonary bypass (CBP)postoperative period

localized tamponade, 243mechanical valve thrombosis, 244transesophageal echo, 244transthoracic echo, 244

prior toacute right ventricular failure, 237–238aortic dissection, 237–240hypovolemia, 235–237intraoperative TEE, recommendations, 235, 236

weaning fromdynamic left ventricular outflow tract obstruction,

241–242injuries, surgical procedure, 242–243ischemic disorders, 240–241

Circulatory failureacute therapy, efficacy and safety, 106definitions, 100

diagnostic algorithmsacute circulatory failure, 101–102conditions, 101LV systolic function, 102–103pulmonary venous congestion, 103–104RV systolic function, 103systemic venous congestion, 104–105

echocardiographyadvantages, 100indications, 100

Classic aortic dissectiondiagnosis, 251–263evolutive patterns, 253–255pathology, 250–251

Critical care echocardiography (CCE)competence level

advanced, 277–278basic, 276–277

curriculumadvanced, 278–280basic, 278

definition, 275–276history, 1–2indications, 3–4specificities, 2

heart–lung interactions, 3hemodynamic assessment, 3nonscheduled management and care, 3

TEE, tolerance of, 4–5therapeutic impact, 5–6TTE vs. TEE, 4

DDestination therapy. See Extracorporeal life support, ICUDoppler echocardiography, principles of

color doppler, 20, 22continuous-wave (CW) doppler, 17, 21, 22pulsed-wave (PW) doppler, 19, 22

EEjection fraction

evaluationLV volume estimation, 81short-axis area measurements, LV, 81unidimensional approach, M-mode, 80–81

measurement, 81–83RV systolic dysfunction assessment, 142

Extracorporeal life support, ICUmonitoring assistance, echo and

circulatory failure, 167–170contraindications, 166IABP, 166Impella, 166, 167principles, 165respiratory failure, 171–172

short-term circulatory assistanceaxial pumps, 164catecholamine-resistant cardiac failure, 163centrifugal pumps, 164–165intra-aortic balloon pump (IABP), 164

weaning from assistance, 172–174

309Index

FFluid challenge

cutoffs, 71–72guidance, echocardiography, 75hydrostatic pressure changes, 72indications

response evaluation, 56-57, 74–76tolerance evaluation, 73–74type and administration rate, 73

Fluid requirements assessmentfluid challenge

cutoffs, 71–72hydrostatic pressure changes, 72indications, 72–76

fluid responsivenessclinical application, 67definition, 61–62dynamic parameters, 64–67Frank–Starling relationship, 62hypovolemia, 61static parameter, 62–63

Fractional area contractionLV, 80-81RV, 142

Frank–Starling curve, 62

HHeart–lung interactions, in mechanical ventilation

intravascular vs. transmural pressures, 44pressures types, 43–44reverse pulsus paradoxus

dDown component, 45–47definition, 45dUp component, 47–49

Hemodynamic assessmentalternative hemodynamic measurements

cardiac output, 285flow and global tissue perfusion, 285PAC monitoring, 286pulmonary artery pressure, 285stroke volume variation, 285

echocardiography meritscardiac function, 106, 284transesophageal echocardiography (TEE), 278, 285transthoracic echocardiography, 284

Hemodynamic instability. See acute circulatory failureHydrostatic pulmonary edema, 188–191Hypovolemia, 61

cardiopulmonary bypass (CBP), 235–237septic shock, 109–110

IICU applications, echocardiographic technologies

hand-carried ultrasound (HCU), 301, 303intracardiac echocardiography (ICE), 299–301

Impella® system, 164Incomplete aortic dissection

diagnosis, 265, 269evolutive patterns, 267pathology, 263–265

Inotropes/vasodilators, 57, 59

Intra-aortic balloon pump (IABP), 164, 166Intracardiac echocardiography (ICE), 299–301Intramural aortic hematoma (IAH)

diagnosis, 256–257, 264, 265evolutive patterns, 257–258pathology, 255–256, 263

Intrathoracic pressure, 43–44Intravascular pressure, 44Ischemic disorders, CBP, 240–241

KKnobology, TTE

artifact, 15–16image resolution, 14–15ultrasound, 14

LLeft ventricular (LV) diastolic pressure

volume, 181evaluation, 92–93

Left ventricular strain (LVSt), 94Left ventricular (LV) systolic function evaluation

cardiac function alterationaortic blood flow, 85contractility, 83–84LV external mechanical power, 85–86LV wall stress relationship, 85maximal elastance, 86–87mitral regurgitation jet acceleration time, 85speckle tracking, 87velocity of circumferential fiber (VCF) shortening,

84–85ejection fraction

evaluation, 80–81measurement, 81–83

systolic function evaluation, 79–81Left ventricular wall area index (LVWAI), 172Localized tamponade, 243LV filling pressures estimation

Doppler assessment validation, 182–183, 185, 188Doppler patterns evolution, 181–182, 185, 186principles and technique, 180, 182, 183

MMassive pulmonary embolism, 144–145Maximal elastance, 86–87Mechanical valve thrombosis, 244Mechanical ventilation, 195Mitral inflow, 74Mitral regurgitation jet acceleration time, 85Mitral stenosis (MS), 128–130M-mode echocardiography, 16–17Myocardial depression, septic shock

incidence, 110pathophysiology, 110treatment and prognosis impact, 110–111

Myocardial performance index (MPI), 144Myocarditis, 124

NNitric oxide inhalation, 57–58

310 Index

PPassive leg-raising (PLR) test, 66–67Penetrating aortic ulcer

diagnosis, 260–262evolutive patterns, 262–263pathology, 258–260

Pericardial effusion. See also Cardiac tamponade; Pericardiocentesis

anatomy, 151identification, 152–156pathophysiology, 152

Pericardiocentesisequipment requirements, 158–159identification, 158site selection, 159–160

Pericardiumanatomy, 151pathophysiology, 152

Pulmonary artery occluded pressure (PAOP), 74Pulmonary artery pressures. See Right ventricular functionPulmonary edema

definitions, 177–179diagnostic algorithm

acute respiratory distress syndrome vs. hydrostatic pulmonary edema, 187–189

hydrostatic pulmonary edema, 188–191ongoing therapy influence, 191–192

LV diastolic function and filling pressures, 179LV filling pressures estimation

Doppler assessment validation, 182–183, 185, 188Doppler patterns evolution, 181–182, 185, 186principles and technique, 180, 182, 183

pathophysiologyleft ventricular (LV) diastolic pressure volume, 181systolic and diastolic left ventricular failure, 178–181

RReal-time 3D echocardiography (RT3DE)

applications, 296–301full-volume data, 295limitations, 296prototype software, 297texture tracking, 297, 298three-dimensional volumetric rendering, 299

Real-time 3D TEE (RT3D TEE), 299, 302Reverse pulsus paradoxus

dDown component, 45, 47hemodynamic effect, mechanical ventilation, 47RV afterload, 46–47systemic venous return, 45–46

definition, 45dUp component, 47–49

Right ventricular functionacute cor pulmonale (ACP)

cor pulmonale and pulmonary hypertension, 140definition, 135RV diastolic overload, 138–139RV systolic overload, 135–137vs. subacute chronic cor pulmonale, 139–140

anatomy and functioncontraction manners, 133–134

pathophysiological changes, 134–135PHT and right-heart dysfunction evaluation, 134pressure/volume loop technique, 134

clinical scenariosacute respiratory distress syndrome (ARDS), 145acute RV failure, of sepsis, 145massive pulmonary embolism, 144–145preload/volume responsiveness, 146RV infarction, 145

echocardiographic estimates, pulmonary artery pressure, 140–141

systolic dysfunction assessmentcontractile function, 141dP/dt, 143–144ejection fraction, 142fractional area contraction, 142myocardial performance index (MPI), 144tissue doppler, 143tricuspid annular motion, 142–143

SSeptic shock

bacteremia/fungemia, 115echocardiographic evaluation

cardiac function, 114–115cardiac output, 112clinical management, 111, 112response to fluids, 113–114

hypovolemia, 109–110myocardial depression, 115

incidence, 110pathophysiology, 110treatment and prognosis impact, 110–111

Speckle tracking, 87applications, 292–295limitations, 292strain calculation, 292systolic contraction, 292

Stress cardiomyopathy, 123–124Stroke volume and cardiac output measurement

echocardiography and dopplerlimitations, 55mitral/pulmonary valves, 55step-by-step procedure, 53–55

heart rate, 53systemic arterial pressure, 52therapeutic maneuver effects

fluids, 56–57inotropes/vasodilators, 57, 59nitric oxide inhalation, 57–58

tissue perfusion, 51venous return determinants, 52–53

Systolic and diastolic left ventricular failure, 178, 180

TTamponade

echocardiographic identificationclinical context, 158Doppler analysis, 157–158two-dimensional, 157pathophysiology, 152

311Index

TEE. See Transesophageal echocardiographyThoracic trauma

blunt cardiac traumacardiac rupture, 227–228mechanisms of injury, 226segmental/global ventricular systolic function, 227septal defects, 228–229valvular injuries, 228–229

blunt chest traumamanagement, 222–226traumatic aortic injury, 205–222

Tissue Doppler imaging (TDI), 143constrictive vs. restrictive cardiomyopathy, 290dobutamine stress echocardiography, 291for the evaluation of PAOP 181-189hypertrophic, nonobstructive cardiomyopathy

(HNOCM), 292left ventricular ejection fraction (LVEF), 291pulsed wave Doppler, 289RV function, 141, 143velocity and strain limitations, 290in weaning from assist cardiac devices, 173

Transesophageal echocardiography (TEE)acute respiratory distress syndrome (ARDS), 196advantages, 32blunt chest trauma, 212–221equipment, 31–32hemodynamic assessment, in ICU, 37–38hemodynamic instability, 235safety considerations, 32two-dimensional imaging

aortic views, 36–37deep transgastric views, 33, 34mid-esophageal views, 34–35transgastric short-axis views, 32–33upper esophageal views, 35–36

Transmural pressure, 44Transpulmonary pressure (TPP), 44

Transthoracic echocardiography (TTE)apical four-and five-chamber views, 23–24apical two-and three-chamber views, 26hemodynamic assessment, 28knobology

artifact, 15–16image resolution, 14–15ultrasound, 14

limitations of, 28–29parasternal long-axis view, 21–23parasternal short-axis view, 23–25subcostal view, 24–25, 27suprasternal view, 25–26, 28ultrasound modalities

applications, in intensive care unit, 18doppler echocardiography, 17–22M-mode echocardiography, 16–17two-dimensional echocardiography, 17

uses, 26–28Tricuspid annular motion, 142–143Two-dimensional echocardiography, 17Two-dimensional imaging, TEE

aortic views, 36–37deep transgastric views, 33, 34mid-esophageal views, 34–35transgastric short-axis views, 32–33upper esophageal views, 35–36

UUltrasound, principles, 14

VValvular disease, cardiogenic shock

acute aortic regurgitation (AR), 124–128aortic stenosis (AS), 126–127, 129mitral stenosis (MS), 128–130