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In cardiac patients, pulmonary capillary wedge pressure (PCWP) is estimated using color M-mode Doppler study of left ventricular filling and Doppler tissue imaging. The goal of this study was to assess whether echocardiography accurately estimates PCWP in critically ill patients.Sixty ventilated patients admitted for septic shock and acute lung injury were prospectively studied using simultaneously transesophageal echocardiography and pulmonary artery catheterization. Initial PCWP values and their changes measured invasively were compared to initial values and corresponding changes of early diastolic velocity of mitral annulus displacement measured by Doppler tissue imaging (Ea), flow propagation velocity of early diastolic mitral inflow measured by color M-mode Doppler (Vp), and their respective ratio to early mitral inflow velocity (E) measured by conventional Doppler: E/Ea and E/Vp. Relations between E/Ea, E/Vp, and PCWP were prospectively tested in 20 additional patients.E/Ea and E/Vp gave a rough estimate of initial PCWP values with mean biases of 0.4 ± 2.2 and 0.1 ± 2.9 mmHg, respectively. Receiving operating characteristic curves demonstrated that an E/Ea of 6 or greater is an accurate predictor of a PCWP of 13 mmHg or greater and that an E/Ea of 5.4 is a good predictor of a PCWP of 8 mmHg or less. Changes in PCWP were significantly correlated to changes in E/Ea (Rho = 0.84, P < 0.0001).In patients with postoperative circulatory shock and acute lung injury, transesophageal echocardiography estimates noninvasively PCWP. However, echocardiographic estimation of PCWP may not be accurate enough for adjusting therapy.