Bedside ultrasound to assess acute central venous pressure change during treatment of decompensated heart failure.

Abstract

Accurate volume status assessment is crucial for the treatment of acute decompensated heart failure (ADHF). Volume status assessment by physical exam is often inaccurate, necessitating invasive measurement with right heart catheterization (RHC), which carries safety, pragmatic (scheduling, holding anticoagulants, etc.), and financial burdens. Therefore, a reliable, non-invasive, cost-effective alternative is desired. Previously, we developed an ultrasound (US) based technique to measure internal jugular vein (IJV) compliance during RHC which was used for single time point central venous pressure (CVP) predictions. We now aim to apply this technique to track acute changes in CVP during diuresis for ADHF in patients with an in-dwelling pulmonary artery catheter (PAC). We used an observational, prospective study design and recruited 15 patients from the cardiac critical unit (CCU) being treated for ADHF (systolic or diastolic) with intravenous (IV) diuretics with/without inotropic agents who underwent Swan- Ganz catheter/PAC insertion for continuous CVP monitoring. 13 of 15 patients received milrinone infusions. US images of the IJV were obtained at end-expiration and during the strain phase of Valsalva at multiple 2-3 hours intervals. Change in IJV cross-sectional area (CSA) (ImageJ) was used as a measure of IJV compliance. Patients unable to perform the Valsalva maneuver were excluded. Calculated percentage change (%Δ) in CSA of IJV was plotted against CVP. An inverse relationship was observed between CVP and %Δ in CSA of IJV. The data was fit with a polynomial regression curve (R2=0.36, root mean square error=3.19). Fivefold cross-validation showed a stable model for predicting CVP based on CSA (R2=0.31, root mean square error=3.18). Serial portable US assessment of IJV compliance can act as a surrogate measure of CVP and, therefore, can provide reliable information on acute hemodynamic changes in ADHF.