Estimation of cardiac output variations induced by hemodynamic interventions using multi-beat analysis of arterial waveform: a comparative off-line study with transesophageal Doppler method during non-cardiac surgery

Abstract

Multi-beat analysis (MBA) of the radial arterial pressure (AP) waveform is a new method that may improve cardiac output (CO) estimation via modelling of the confounding arterial wave reflection. We evaluated the precision and accuracy using the trending ability of the MBA method to estimate absolute CO and variations (ΔCO) during hemodynamic challenges. We reviewed the hemodynamic challenges (fluid challenge or vasopressors) performed when intra-operative hypotension occurred during non-cardiac surgery. The CO was calculated offline using transesophageal Doppler (TED) waveform (COTED) or via application of the MBA algorithm onto the AP waveform (COMBA) before and after hemodynamic challenges. We evaluated the precision and the accuracy according to the Bland & Altman method. We also assessed the trending ability of the MBA by evaluating the percentage of concordance with 15% exclusion zone between ΔCOMBA and ΔCOTED. A non-inferiority margin was set at 87.5%. Among the 58 patients included, 23 (40%) received at least 1 fluid challenge, and 46 (81%) received at least 1 bolus of vasopressors. Before treatment, the COTED was 5.3 (IQR [4.1–8.1]) l min−1, and the COMBA was 4.1 (IQR [3–5.4]) l min−1. The agreement between COTED and COMBA was poor with a 70% percentage error. The bias and lower and upper limits of agreement between COTED and COMBA were 0.9 (CI95 = 0.82 to 1.07) l min−1, −2.8 (CI95 = −2.71 to−2.96) l min−1 and 4.7 (CI95 = 4.61 to 4.86) l min−1, respectively. After hemodynamic challenge, the percentage of concordance (PC) with 15% exclusion zone for ΔCO was 93 (CI97.5 = 90 to 97)%. In this retrospective offline analysis, the accuracy, limits of agreements and percentage error between TED and MBA for the absolute estimation of CO were poor, but the MBA could adequately track induced CO variations measured by TED. The MBA needs further evaluation in prospective studies to confirm those results in clinical practice conditions.

Agreement between the Multi-Beat Analysis algorithm for cardiac output estimation and 2D echocardiography in the ICU

“…[4][5][6] In patients undergoing abdominal or neuro surgery, the MBA method was able to track changes in CO accurately after vasopressor or uid interventions, when using the esophageal Doppler as a reference. 7 To our knowledge, this is the rst study comparing CO and SV values from the MBA algorithm to 2D echocardiography in non-cardiac patients in the ICU with a wide range of diagnoses.…”

“…Previous validation studies in cardiac, abdominal and neuro surgery patients show promising results, but the MBA algorithm accuracy remains to be validated in noncardiac ICU patients. [4][5][6][7] We used the Critchley and Critchley criterion to determine if the agreement between the two methods of CO estimation was clinically acceptable. 8 This criterion states that the two methods are clinically interchangeable if the percentage error between them is less than 30%.…”

Agreement between cardiac output estimation by multi-beat analysis of arterial blood pressure waveforms and continuous thermodilution in post cardiac surgery intensive care unit patients

“…However, both devices were not interchangeable with thermodilution for absolute CO measurement due to high percentage errors of 50%. In non-cardiac surgery, the MBA method was 93% concordant with the transesophageal Doppler method during both fluid and vasopressor administration [ 24 ].…”

Bias, trending ability and diagnostic performance of a non-calibrated multi-beat analysis continuous cardiac output monitor to identify fluid responsiveness in critically ill patients

“… 3 The device had the advantage of connecting directly to the AP module of the ICU monitor, without requiring changing the arterial catheter. The device analyses the AP waveform over multiple heartbeats to account for confounding wave reflections and was identified as having a percentage error >30% in a post-cardiac surgery population, [4] , [5] , [6] , [7] , [8] but its diagnostic performance to predict fluid responsiveness remains to date unknown. On the other hand, devices calibrated using transpulmonary thermodilution assess CCO with potentially higher precision (below the 30% percentage error) using pulse-contour analysis of AP waveform, at the price of requiring the placement of specific catheters and frequent recalibration.…”