Analysis of factors affecting the variability of fick versus indicator dilution measurements of cardiac output

doi:10.1016/0002-9149(85)91132-4

The American Journal of Cardiology

Volume 56, Issue 12, 1 November 1985, Pages 764-768

https://doi.org/10.1016/0002-9149(85)91132-4 Get rights and content

Abstract

This study was performed to assess the relation between Fick and indicator dilution measurements of cardiac output (CO) in a large number of subjects and to evaluate this relation in patients with a low CO, a high CO, and left-sided cardiac regurgitation. In 808 patients (428 men, 380 women, mean age 50 ± 11), CO was measured by Fick and either thermodilution (right atrium to pulmonary artery (n = 252) or indocyanine green dye (“dye”) (pulmonary artery to systemic artery) (n = 556) within 10 minutes of each other. There was excellent agreement between Fick and both thermodilution and dye. The difference between Fick and indicator dilution measurements was 9 ± 9%; it was 10% or less in 67% and 20% or less in 91% of patients. The disparity between Fick and indicator dilution measurements was increased in patients with a low CO (less than 2 liters/min/m²) (n = 152) (difference 14 ± 11%, p < 0.001) and those with aortic or mitral regurgitation (n = 83) (difference 13 ± 11%, p < 0.001). In these groups, the disparity between Fick and thermodilution measurements was not exaggerated, but the disparity between Fick and dye measurements was greater. Thus, although there is excellent agreement between Fick and both thermodilution and dye measurements of CO, thermodilution is preferable to dye in patients with a low CO and those with aortic or mitral regurgitation.

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Cited by (121)

Comparison of Accuracy of Estimation of Cardiac Output by Thermodilution Versus the Fick Method Using Measured Oxygen Uptake
2022, American Journal of Cardiology
Citation Excerpt :
The TD method is often performed in concert with indirect Fick Q̇C measurements, and TD recently was shown in a large observational cohort to predict mortality more accurately as compared with the indirect Fick method.15 However, there are few previous studies comparing the accuracy of the TD method versus the gold standard Direct Fick method, where agreement between the 2 methods demonstrated acceptable correlation (R > 0.8),16–18 including in a subset of patients with pulmonary hypertension, severe tricuspid regurgitation and low Q̇C.18 This larger study cohort contrasts with these findings indicating the potential error of TD measurements when compared with the Fick method.
The thermodilution (TD) method is routinely used for the estimation of cardiac output (Q̇_C). However, its accuracy, compared with the gold-standard Fick method, where systemic oxygen uptake (V̇O₂) is directly measured, and Q̇_C calculated from V̇O₂ and the arterio-venous oxygen difference (“direct” Fick), has not been well validated. The present study determined the agreement between TD and Fick methods in consecutive patients who underwent pulmonary artery catheterization for a broad range of clinical conditions. This is a subanalysis of a previous study comparing the indirect versus Fick method based on a prospective, consecutive patient registry of 253 patients who underwent pulmonary artery catheterization for clinical indications at a single center between 1999 and 2005. We included patients that had an estimation of Q̇_C both by the Fick method using measured V̇O₂ by exhaled gas analyses from timed Douglas bag collections and by TD. Cardiac index was classified as low when ≤2.2 L/min/m² or normal when >2.2 L/min/m². The median (25th, 75th percentile) age of the cohort was 59 (50,67) years, and 50% were female. A total of 43.5% had normal left ventricular function by ventriculography, and 25.7% had ischemic heart disease. Median overall Fick and TD Q̇_C were 4.4 (3.5, 5.5) and 4.3 (3.7, 5.2) L/min, respectively (p = 0.04). The median absolute percent error between Fick and TD Q̇_C was 17.5 (7.7, 28.4)%, with a typical error of 0.88 L/min (95% confidence interval [CI] 0.82 to 0.95). Median absolute percent error was comparable in the low (n = 118) and normal Q̇_CI (n = 135) groups (16.9% vs 18.9%, respectively, p = 0.88). typical error was 0.3 (95% CI 0.27 to 0.33) and 0.49 (95% CI 0.45 to 0.55) L/min/m² in that comparison. Percent error >25% between Fick and TD Q̇_C was observed in over 30% of patients. Overall, Fick and TD Q̇_C modestly correlated (R_s = 0.64, p <0.001), with a nondirectional error introduced by TD Q̇_C [mean bias of 0.21 (−2.2, 2.7) L/min].
There was poor agreement between TD and the gold-standard Fick method, highlighting the limitations of making clinical decisions based on TD.
Resting Oxygen Consumption and Heart Failure: Importance of Measurement for Determination of Cardiac Output With the Use of the Fick Principle
2020, Journal of Cardiac Failure
Citation Excerpt :
In that study, Td CO better predicted mortality.33 Given the importance of CO in the clinical decision making and management of patients with HF, the potential inaccuracy of Td CO introduced by TR and low CO, both of which are often present in end-stage HF, remains a concern.2–5 In addition, it does not appear that using Td-derived VO2 is preferential because it also overestimated VO2 in this HF population.
Resting oxygen consumption (VO₂) is often estimated and frequently used to guide therapeutic decisions in symptomatic heart failure (HF) patients. The relationship between resting VO₂ and symptomatic HF and the accuracy of estimations of VO₂ in this population are unknown.
We performed a cross-sectional study of HF patients (n = 691) and healthy control subjects (n = 77). VO₂ was measured with the use of a metabolic cart, and estimated VO₂ was calculated with the use of the Dehmer, LaFarge, and Bergstra formulas and the thermodilution method. The measured and estimated VO₂ were compared and the potential impact of estimations determined. In the multivariable model, resting VO₂ decreased with increasing New York Heart Association (NYHA) functional class in a stepwise fashion (β NYHA functional class IV vs control = −36 mL O₂/min; P < .001). Estimations of VO₂ with the use of derived equations diverged from measured values, particularly for patients with NYHA functional class IV limitations. The percentage difference of measured VO₂ versus estimated VO₂ was >25% in 39% (n = 271), 25% (n = 170), 82% (n = 566), and 39% (n = 271) of HF patients when using the Dehmer, LaFarge, Bergstra, and thermodilution-derived estimations of VO₂ respectively.
Resting VO₂ decreases with increasing NYHA functional class and is lower than in control subjects. Using estimations of VO₂ to calculate CO may introduce clinically important error.
Pediatric Interventional Cardiovascular Magnetic Resonance
2018, Cardiovascular Magnetic Resonance: A Companion to Braunwald’s Heart Disease
Magnetic resonance image guidance for cardiovascular interventions has grown in recent years from a research tool to translation into clinical practice. The scope of improved visualization of cardiovascular anatomy, tissue characterization, physiologic information, and reduced ionizing radiation from cardiovascular magnetic resonance (CMR) is attractive compared to conventional fluoroscopic cardiac catheterization techniques. This is particularly relevant to a pediatric population who are more at risk from radiation, and more likely to need repeat interventions in the future.
Industry support has increased the development of interventional CMR systems. New generation scanners allow for faster scanning protocols, which translate into improved catheter visualization and tracking. The platforms for interacting with these images are also more intuitive. CMR conditional hardware in the form of catheters and guidewires is more available, although more work is still needed in this area.
These advances are balanced with the need to maintain safety issues in a CMR environment and any risks from heating. While there is some limitation in the available hardware options for sole CMR guidance, x-ray fused with CMR allows physiologic testing in the assessment of pulmonary avascular resistance as an example. There is now a growing body of early human experience or interventional cases, electrophysiology testing, and radiofrequency ablation in the CMR environment. These are discussed in the chapter.
Catheterisation as a tool in the diagnosis of pulmonary hypertension
2017, Revista Colombiana de Cardiologia
La evaluación de la condición hemodinámica del paciente con posible hipertensión pulmonar por medio de cateterismo derecho, ha ganado especial importancia durante los últimos años. Es fundamental contar con información completa al analizar los resultados con el objetivo de aclarar el diagnóstico, establecer el pronóstico, orientar la terapéutica y evaluar la respuesta de la misma. El cateterismo derecho por sí solo no llega al diagnóstico etiológico de la hipertensión pulmonar, pues debe estar enfocado por un estudio previo, organizado y estructurado, en el que se evalúen las causas posibles de la hipertensión enmarcadas en el contexto clínico de cada paciente.
Es fundamental recordar que todas las variables hemodinámicas deben ser evaluadas durante el procedimiento, con el fin de aportar la mayor cantidad de información posible al diagnóstico, tratamiento y seguimiento de este grupo de pacientes con una patología tan catastrófica y con implicaciones de costo tan relevantes para los sistemas de salud, no solo en cuanto al precio de medicamentos sino a la pérdida de años productivos ya que afecta de manera incapacitante a una población joven.
The assessment of the haemodynamic condition of the patient with possible pulmonary hypertension using right-heart catheterisation, has gained special importance in the last few years. It is essential to have full information on analysing the results, in order to clarify the diagnosis, establish the prognosis, the therapeutic approach, as well as the response to this. Right-heart catheterisation on its own does not provide a diagnosis of the origin of the pulmonary hypertension, since this must be approached by an organised and structured preliminary study, in which the possible causes of the hypertension are evaluated within the clinical context of each patient.
It must be remembered that all the haemodynamic variables should be evaluated during the procedure, with the aim of providing the best quality information possible for the diagnosis, treatment, and follow-up of this group of patients with such a catastrophic disease, and with such important costs for health services, not only as regards the price of the drugs, but also the productive years lost, since it affects and debilitates a young population.
Cardiac Outputs and Shunts
2017, Textbook of Clinical Hemodynamics, Second Edition
Advanced imaging tools rather than hemodynamics should be the primary approach for diagnosing, following, and managing pulmonary arterial hypertension
2015, Canadian Journal of Cardiology
Citation Excerpt :
Although O2 consumption can be measured accurately, that measurement is cumbersome, and many laboratories use standard tables for an assumed value instead of direct measurements. Such estimation may cause an error of as much as 40% in the assessment of CO.9 Most laboratories now use thermodilution based on an indicator dilution methodology to measure CO.10 When compared with the direct Fick method, thermodilution measurements show little bias, with a mean difference of 0.1 L/min and a confidence interval of 0.2 L/min, corresponding to excellent accuracy even in the presence of tricuspid regurgitation, but limits of agreement are ± 1 L/min, corresponding to moderate precision.11 Clinically significant information is gained from RHC that helps guide decisions.
Pulmonary hypertension (PH) is currently defined based on invasive measurements: a resting pulmonary artery pressure ≥ 25 mm Hg. For pulmonary arterial hypertension, a pulmonary arterial wedge pressure ≤ 15 mm Hg and pulmonary vascular resistance > 3 Wood units are also required. Thus, right heart catheterization is inevitable at present. However, the diagnosis, follow-up, and management of PH by noninvasive techniques is progressing. Significant advances have been achieved in the imaging of pulmonary vascular disease and the right ventricle. We review the current sensitivities and specificities of noninvasive imaging of PH and discuss its role and future potential to replace hemodynamics as the primary approach to screening, diagnosing, and following/managing PH.
L’hypertension pulmonaire (HP) est actuellement définie selon des méthodes effractives de mesure : une pression artérielle pulmonaire ≥ 25 mm Hg au repos. Pour définir l’hypertension artérielle pulmonaire, une pression artérielle pulmonaire d’occlusion ≤ 15 mm Hg et une résistance vasculaire pulmonaire > 3 unités Wood sont également requises. Par conséquent, le cathétérisme cardiaque droit est inévitable pour le moment. Malgré cela, le diagnostic, le suivi et la prise en charge de l’HP par des techniques non effractives évoluent. L’imagerie des maladies vasculaires pulmonaires et du ventricule droit a connu d’importants progrès. Nous passons en revue la sensibilité et la spécificité actuelles de l’imagerie non effractive de l’HP, et discutons de ses rôles et de son potentiel futur de remplacement de l’hémodynamique comme principale approche en matière de dépistage, de diagnostic, de prise en charge/suivi de l’HP.

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¹: Dr. Hillis is an Established Investigator of the American Heart Association, Dallas, Texas.

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Analysis of factors affecting the variability of fick versus indicator dilution measurements of cardiac output

Abstract

Am J Cardiol

Am J Cardiol

Am J Cardiol

Am J Cardiol

Comparison of the Fick and dye injection methods of measuring the cardiac output in man

Am J Physiol

Comparison of the dye dilution and the direct Fick methods for the measurement of cardiac output in man

Scand J Clin Lab Invest

Determinants of variation between Fick and indicator dilution estimates of cardiac output during diagnostic catheterization. Fick vs. dye cardiac outputs

J Lab Clin Med

Blood flow measurement: the cardiac output