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The diaphragm affects echocardiographic measurement of inferior vena cava diameter to predict right atrial pressure

  • Original Article–Cardiology
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Abstract

Purpose

It is recommended in current guidelines that the inferior vena cava (IVC) diameter should be measured at 1.0–2.0 cm from the junction with the right atrium. However, right atrial pressure (RAP) is underestimated in some patients who have a small IVC diameter (IVCD) because of a high-echo structure compressing the IVC from the back at that portion. The aim of this study was to identify the structure behind the IVC and to evaluate its influence on RAP.

Methods

We retrospectively studied 116 patients who underwent right-heart catheterization. We reviewed computed tomography (CT) scans and analyzed the relation between RAP and IVCD measured by echocardiography not only in the way recommended in the guidelines, but also in a way that avoided the structure.

Results

CT scans revealed that the diaphragm, not the vertebra, was located just behind the IVC in most patients. Sixteen patients (13.8%) had RAP ≥ 10 mmHg. In those patients, when IVCs were measured in a way that avoided the diaphragm, IVCDmax diameter was larger and IVC collapsibility index (IVCCI) tended to be smaller than those when IVCDs were measured according to the guideline methods. The sensitivity of IVCD to predict RAP ≥ 10 mmHg (IVCDmax > 21 mm, IVCCI < 50%) increased from 31.3% to 68.8% with our method.

Conclusions

The high-echo structure pushing the IVC from the back is the diaphragm in most patients. It might be better to measure IVCD using a method that avoids the diaphragm to accurately estimate RAP.

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References

  1. Ponikowski P, Voors AA, Anker SD, et al. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC) Developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur Heart J. 2016;37:2129–200.

    Article  Google Scholar 

  2. Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA guideline for the management of heart failure: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation. 2013;128:1810–52.

    Article  Google Scholar 

  3. Lang RM, Badano LP, Mor-Avi V, et al. Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr. 2015;28(1–39):e14.

    Google Scholar 

  4. Tucker WD, Burns B. Anatomy, abdomen and pelvis, inferior vena cava. In: StatPearls. Treasure Island (FL): StatPearls; 2019.

  5. Zoghbi WA, Adams D, Bonow RO, et al. Recommendations for Noninvasive Evaluation of Native Valvular Regurgitation: A Report from the American Society of Echocardiography Developed in Collaboration with the Society for Cardiovascular Magnetic Resonance. J Am Soc Echocardiogr. 2017;30:303–71.

    Article  Google Scholar 

  6. Simonson JS, Schiller NB. Sonospirometry: a new method for noninvasive estimation of mean right atrial pressure based on two-dimensional echographic measurements of the inferior vena cava during measured inspiration. J Am Coll Cardiol. 1988;11:557–64.

    Article  CAS  Google Scholar 

  7. Jue J, Chung W, Schiller NB. Does inferior vena cava size predict right atrial pressures in patients receiving mechanical ventilation? J Am Soc Echocardiogr. 1992;5:613–9.

    Article  CAS  Google Scholar 

  8. Pearson AA, Sauter RW, Oler RC. Relationship of the diaphragm to the inferior vena cava in human embryos and fetuses. Thorax. 1971;26:348–53.

    Article  CAS  Google Scholar 

  9. Downey R. Anatomy of the normal diaphragm. Thorac Surg Clin. 2011;21(273–9):ix.

    Google Scholar 

  10. du Plessis M, Ramai D, Shah S, et al. The clinical anatomy of the musculotendinous part of the diaphragm. Surg Radiol Anat. 2015;37:1013–20.

    Article  Google Scholar 

  11. Boriek AM, Rodarte JR. Effects of transverse fiber stiffness and central tendon on displacement and shape of a simple diaphragm model. J Appl Physiol. 1985;1997:1626–36.

    Google Scholar 

  12. Teismann NA, Ching B, Shyy W, et al. Technical Pitfalls in Sonography of the Inferior Vena Cava: Beware the Diaphragm. J Ultrasound Med. 2017;36:1071–2.

    Article  Google Scholar 

  13. Goldhammer E, Mesnick N, Abinader EG, et al. Dilated inferior vena cava: a common echocardiographic finding in highly trained elite athletes. J Am Soc Echocardiogr. 1999;12:988–93.

    Article  CAS  Google Scholar 

  14. Brennan JM, Blair JE, Goonewardena S, et al. Reappraisal of the use of inferior vena cava for estimating right atrial pressure. J Am Soc Echocardiogr. 2007;20:857–61.

    Article  Google Scholar 

  15. Mannarino S, Bulzomi P, Codazzi AC, et al. Inferior vena cava, abdominal aorta, and IVC-to-aorta ratio in healthy Caucasian children: Ultrasound Z-scores according to BSA and age. J Cardiol. 2019;74:388–93.

    Article  Google Scholar 

  16. Taniguchi T, Ohtani T, Nakatani S, et al. Impact of Body Size on Inferior Vena Cava Parameters for Estimating Right Atrial Pressure: A Need for Standardization? J Am Soc Echocardiogr. 2015;28:1420–7.

    Article  Google Scholar 

  17. Kawata T, Daimon M, Lee SL, et al. Reconsideration of Inferior Vena Cava Parameters for Estimating Right Atrial Pressure in an East Asian Population- Comparative Simultaneous Ultrasound-Catheterization Study. Circ J. 2017;81:346–52.

    Article  Google Scholar 

  18. Ciozda W, Kedan I, Kehl DW, et al. The efficacy of sonographic measurement of inferior vena cava diameter as an estimate of central venous pressure. Cardiovasc Ultrasound. 2016;14:33.

    Article  Google Scholar 

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Acknowledgements

The authors thank Ms. Natsuki Yoshimoto, Ms. Saori Murata, Ms. Yasuko Jinzenji, Ms. Ayumi Shimizu, and Ms. Tomono Okada for their assistance with data collection. Y Baba, J Kawaguchi, Y Ochi, T Kubo, and H Kitaoka conceived the idea for the study and planned the investigations. Y Baba, J Kawaguchi, T Kubo, T Hirota, and N Yamasaki undertook clinical investigations of patients. Y Baba, J Kawaguchi, D Hirakawa, and Y Ochi examined echocardiography. Y Baba, J Kawaguchi, K Miyagawa, and T Noguchi performed right-heart catheterization. T Oryu performed CT scans and reconstructed three-dimensional CT imaging.

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Authors and Affiliations

  1. Department of Cardiology and Geriatrics, Kochi Medical School, Kochi University, Oko-cho, Nankoku-shi, Kochi, 783-8505, Japan

    Yuichi Baba, Juri Kawaguchi, Yuri Ochi, Tatsuya Noguchi, Takayoshi Hirota, Toru Kubo, Naohito Yamasaki & Hiroaki Kitaoka

  2. Department of Laboratory Medicine, Kochi Medical School, Kochi University, Kochi, Japan

    Daigo Hirakawa

  3. Department of Diagnostic Radiology, Kochi Medical School, Kochi University, Kochi, Japan

    Takafumi Oryu

Authors
  1. Yuichi Baba
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  2. Juri Kawaguchi
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  3. Yuri Ochi
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  4. Daigo Hirakawa
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  5. Takafumi Oryu
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  6. Tatsuya Noguchi
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  7. Takayoshi Hirota
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  8. Toru Kubo
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  9. Naohito Yamasaki
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  10. Hiroaki Kitaoka
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Corresponding author

Correspondence to Toru Kubo.

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The authors declare that there are no conflicts of interest.

Ethical approval

The study protocol was approved by the Ethical Review Board of Kochi Medical School, Kochi University. (approval number: 31–113).

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Baba, Y., Kawaguchi, J., Ochi, Y. et al. The diaphragm affects echocardiographic measurement of inferior vena cava diameter to predict right atrial pressure. J Med Ultrasonics 47, 565–573 (2020). https://doi.org/10.1007/s10396-020-01047-1

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  • DOI: https://doi.org/10.1007/s10396-020-01047-1

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