Intensive Care Medicine

, Volume 42, Issue 8, pp 1223–1233 | Cite as

Systematic review of cardiac output measurements by echocardiography vs. thermodilution: the techniques are not interchangeable

  • Mik Wetterslev
  • Hasse Møller-Sørensen
  • Rasmus Rothmann Johansen
  • Anders PernerEmail author
Systematic Review



Echocardiography is frequently used in the hemodynamic evaluation of critically ill patients, but inaccurate measurements may lead to wrong clinical decisions. The aim of our systematic review was to investigate the interchangeability of echocardiography with thermodilution technique in measuring cardiac output and its changes.


In August 2015 we systematically searched electronic databases and included studies investigating the echocardiographic measurement of cardiac output compared with thermodilution technique using the Bland–Altman method. Two authors independently reviewed the studies and extracted data on type of measurements, clinical setting and characteristics, and those of the Bland–Altman and trending ability analyses.


We identified 13,834 citations and included 24 studies in the final analysis. The median number of participants was 32 (range 8–65). Most of the studies assessed left-sided heart structures and the majority had small bias, wide limits of agreement, and high percentage error between echocardiography and thermodilution. In only two of the 24 studies the precision of each technique (echocardiography and thermodilution) was assessed before comparing them. In the single study evaluating trending ability using valid methodology, agreement was observed between echocardiography and thermodilution in detecting the directional changes in cardiac output, but the magnitude of changes varied considerably.


The majority of studies comparing echocardiography with thermodilution were difficult to interpret, but current evidence does not support interchangeability between these techniques in measuring cardiac output. The techniques may be interchangeable in tracking directional changes in cardiac output, but this has to be confirmed in large high-quality studies.


Cardiac output Critical care Echocardiography Hemodynamic monitoring Intensive care unit Thermodilution technique 


Compliance with ethical standards

Conflicts of interest

None of the authors have potential conflicts of interest.


Department funds only.


  1. 1.
    Rhodes A, Cecconi M, Hamilton M, Poloniecki J, Woods J, Boyd O, Bennett D, Grounds RM (2010) Goal-directed therapy in high-risk surgical patients: a 15-year follow-up study. Intensive Care Med 36:1327–1332CrossRefPubMedGoogle Scholar
  2. 2.
    Nilsson LB, Nilsson JC, Skovgaard LT, Berthelsen PG (2004) Thermodilution cardiac output—are three injections enough? Acta Anaesthesiol Scand 48:1322–1327CrossRefPubMedGoogle Scholar
  3. 3.
    Berthelsen PG, Eldrup N, Nilsson LB, Rasmussen JP (2002) Thermodilution cardiac output. Cold vs. room temperature injectate and the importance of measuring the injectate temperature in the right atrium. Acta Anaesthesiol Scand 46:1103–1110CrossRefPubMedGoogle Scholar
  4. 4.
    Monnet X, Persichini R, Ktari M, Jozwiak M, Richard C, Teboul JL (2011) Precision of the transpulmonary thermodilution measurements. Crit Care 15:R204CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Moller-Sorensen H, Graeser K, Hansen KL, Zemtsovski M, Sander EM, Nilsson JC (2014) Measurements of cardiac output obtained with transesophageal echocardiography and pulmonary artery thermodilution are not interchangeable. Acta Anaesthesiol Scand 58:80–88CrossRefPubMedGoogle Scholar
  6. 6.
    Moller-Sorensen H, Hansen KL, Ostergaard M, Andersen LW, Moller K (2012) Lack of agreement and trending ability of the endotracheal cardiac output monitor compared with thermodilution. Acta Anaesthesiol Scand 56:433–440CrossRefPubMedGoogle Scholar
  7. 7.
    Polanczyk CA, Rohde LE, Goldman L, Cook EF, Thomas EJ, Marcantonio ER, Mangione CM, Lee TH (2001) Right heart catheterization and cardiac complications in patients undergoing noncardiac surgery: an observational study. JAMA 286:309–314CrossRefPubMedGoogle Scholar
  8. 8.
    Sandham JD, Hull RD, Brant RF, Knox L, Pineo GF, Doig CJ, Laporta DP, Viner S, Passerini L, Devitt H, Kirby A, Jacka M (2003) A randomized, controlled trial of the use of pulmonary-artery catheters in high-risk surgical patients. N Engl J Med 348:5–14CrossRefPubMedGoogle Scholar
  9. 9.
    Haji DL, Royse A, Royse CF (2013) Review article: clinical impact of non-cardiologist-performed transthoracic echocardiography in emergency medicine, intensive care medicine and anaesthesia. Emerg Med Australas 25:4–12CrossRefPubMedGoogle Scholar
  10. 10.
    Romero-Bermejo FJ, Ruiz-Bailen M, Guerrero-De-Mier M, Lopez-Alvaro J (2011) Echocardiographic hemodynamic monitoring in the critically ill patient. Curr Cardiol Rev 7:146–156CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Guarracino F, Baldassarri R (2009) Transesophageal echocardiography in the OR and ICU. Minerva Anestesiol 75:518–529PubMedGoogle Scholar
  12. 12.
    Figueiredo A, Germano N, Guedes P, Marcelino P (2011) The evolving concepts of haemodynamic support: from pulmonary artery catheter to echocardiography and theragnostics. Curr Cardiol Rev 7:136–145CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Quinones MA, Otto CM, Stoddard M, Waggoner A, Zoghbi WA (2002) Recommendations for quantification of Doppler echocardiography: a report from the Doppler Quantification Task Force of the Nomenclature and Standards Committee of the American Society of Echocardiography. J Am Soc Echocardiogr 15:167–184CrossRefPubMedGoogle Scholar
  14. 14.
    Bland JM, Altman DG (1986) Statistical methods for assessing agreement between two methods of clinical measurement. Lancet 1:307–310CrossRefPubMedGoogle Scholar
  15. 15.
    Berthelsen PG, Nilsson LB (2006) Researcher bias and generalization of results in bias and limits of agreement analyses: a commentary based on the review of 50 Acta Anaesthesiologica Scandinavica papers using the Altman–Bland approach. Acta Anaesthesiol Scand 50:1111–1113CrossRefPubMedGoogle Scholar
  16. 16.
    Cecconi M, De Backer D, Antonelli M, Beale R, Bakker J, Hofer C, Jaeschke R, Mebazaa A, Pinsky MR, Teboul JL, Vincent JL, Rhodes A (2014) Consensus on circulatory shock and hemodynamic monitoring. Task force of the European Society of Intensive Care Medicine. Intensive Care Med 40:1795–1815CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Moher D, Liberati A, Tetzlaff J, Altman DG (2009) Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ 339:b2535CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Hahn RT, Abraham T, Adams MS, Bruce CJ, Glas KE, Lang RM, Reeves ST, Shanewise JS, Siu SC, Stewart W, Picard MH (2014) Guidelines for performing a comprehensive transesophageal echocardiographic examination: recommendations from the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists. Anesth Analg 118:21–68CrossRefPubMedGoogle Scholar
  19. 19.
    Muhiudeen IA, Kuecherer HF, Lee E, Cahalan MK, Schiller NB (1991) Intraoperative estimation of cardiac output by transesophageal pulsed Doppler echocardiography. Anesthesiology 74:9–14CrossRefPubMedGoogle Scholar
  20. 20.
    Savino JS, Troianos CA, Aukburg S, Weiss R, Reichek N (1991) Measurement of pulmonary blood flow with transesophageal two-dimensional and Doppler echocardiography. Anesthesiology 75:445–451CrossRefPubMedGoogle Scholar
  21. 21.
    Shimamoto H, Kito H, Kawazoe K, Fujita T, Shimamoto Y (1992) Transoesophageal Doppler echocardiographic measurement of cardiac output by the mitral annulus method. Br Heart J 68:510–515CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Ryan T, Page R, Bouchier-Hayes D, Cunningham AJ (1992) Transoesophageal pulsed wave Doppler measurement of cardiac output during major vascular surgery: comparison with the thermodilution technique. Br J Anaesth 69:101–104CrossRefPubMedGoogle Scholar
  23. 23.
    Darmon PL, Hillel Z, Mogtader A, Mindich B, Thys D (1994) Cardiac output by transesophageal echocardiography using continuous-wave Doppler across the aortic valve. Anesthesiology 80:796–805CrossRefPubMedGoogle Scholar
  24. 24.
    Pinto FJ, Siegel LC, Chenzbraun A, Schnittger I (1994) On-line estimation of cardiac output with a new automated border detection system using transesophageal echocardiography: a preliminary comparison with thermodilution. J Cardiothorac Vasc Anesth 8:625–630CrossRefPubMedGoogle Scholar
  25. 25.
    Izzat MB, Regragui IA, Wilde P, Angelini GD, Bryan AJ (1994) Transesophageal echocardiographic measurements of cardiac output in cardiac surgical patients. Ann Thorac Surg 58:1486–1489CrossRefPubMedGoogle Scholar
  26. 26.
    Feinberg MS, Hopkins WE, Davila-Roman VG, Barzilai B (1995) Multiplane transesophageal echocardiographic doppler imaging accurately determines cardiac output measurements in critically ill patients. Chest 107:769–773CrossRefPubMedGoogle Scholar
  27. 27.
    Descorps-Declere A, Smail N, Vigue B, Duranteau J, Mimoz O, Edouard A, Samii K (1996) Transgastric, pulsed Doppler echocardiographic determination of cardiac output. Intensive Care Med 22:34–38CrossRefPubMedGoogle Scholar
  28. 28.
    Axler O, Tousignant C, Thompson CR, Dall’ava-Santucci J, Phang PT, Russell JA, Walley KR (1996) Comparison of transesophageal echocardiographic, fick, and thermodilution cardiac output in critically ill patients. J Crit Care 11:109–116CrossRefPubMedGoogle Scholar
  29. 29.
    Maslow A, Comunale ME, Haering JM, Watkins J (1996) Pulsed wave Doppler measurement of cardiac output from the right ventricular outflow tract. Anesth Analg 83:466–471PubMedGoogle Scholar
  30. 30.
    Estagnasie P, Djedaini K, Mier L, Coste F, Dreyfuss D (1997) Measurement of cardiac output by transesophageal echocardiography in mechanically ventilated patients. Comparison with thermodilution. Intensive Care Med 23:753–759CrossRefPubMedGoogle Scholar
  31. 31.
    Perrino AC Jr, Harris SN, Luther MA (1998) Intraoperative determination of cardiac output using multiplane transesophageal echocardiography: a comparison to thermodilution. Anesthesiology 89:350–357CrossRefPubMedGoogle Scholar
  32. 32.
    Poelaert J, Schmidt C, Van Aken H, Hinder F, Mollhoff T, Loick HM (1999) A comparison of transoesophageal echocardiographic Doppler across the aortic valve and the thermodilution technique for estimating cardiac output. Anaesthesia 54:128–136CrossRefPubMedGoogle Scholar
  33. 33.
    Zhao X, Mashikian JS, Panzica P, Lerner A, Park KW, Comunale ME (2003) Comparison of thermodilution bolus cardiac output and Doppler cardiac output in the early post-cardiopulmonary bypass period. J Cardiothorac Vasc Anesth 17:193–198CrossRefPubMedGoogle Scholar
  34. 34.
    Bettex DA, Hinselmann V, Hellermann JP, Jenni R, Schmid ER (2004) Transoesophageal echocardiography is unreliable for cardiac output assessment after cardiac surgery compared with thermodilution. Anaesthesia 59:1184–1192CrossRefPubMedGoogle Scholar
  35. 35.
    Parra V, Fita G, Rovira I, Matute P, Gomar C, Pare C (2008) Transoesophageal echocardiography accurately detects cardiac output variation: a prospective comparison with thermodilution in cardiac surgery. Eur J Anaesthesiol 25:135–143CrossRefPubMedGoogle Scholar
  36. 36.
    Missant C, Rex S, Wouters PF (2008) Accuracy of cardiac output measurements with pulse contour analysis (PulseCO) and Doppler echocardiography during off-pump coronary artery bypass grafting. Eur J Anaesthesiol 25:243–248CrossRefPubMedGoogle Scholar
  37. 37.
    Mayer SA, Sherman D, Fink ME, Homma S, Solomon RA, Lennihan L, Beckford A, Klebanoff LM (1995) Noninvasive monitoring of cardiac output by Doppler echocardiography in patients treated with volume expansion after subarachnoid hemorrhage. Crit Care Med 23:1470–1474CrossRefPubMedGoogle Scholar
  38. 38.
    McLean AS, Needham A, Stewart D, Parkin R (1997) Estimation of cardiac output by noninvasive echocardiographic techniques in the critically ill subject. Anaesth Intensive Care 25:250–254PubMedGoogle Scholar
  39. 39.
    Marcelino P, Germano N, Marum S, Fernandes AP, Ribeiro P, Lopes MG (2006) Haemodynamic parameters obtained by transthoracic echocardiography and Swan-Ganz catheter: a comparative study in liver transplant patients. Acta Med Port 19:197–205PubMedGoogle Scholar
  40. 40.
    Temporelli PL, Scapellato F, Eleuteri E, Imparato A, Giannuzzi P (2010) Doppler echocardiography in advanced systolic heart failure: a noninvasive alternative to Swan-Ganz catheter. Circ Heart Fail 3:387–394CrossRefPubMedGoogle Scholar
  41. 41.
    Tian Z, Liu YT, Fang Q, Ni C, Chen TB, Fang LG, Gao P, Jiang XC, Li MT, Zeng XF (2011) Hemodynamic parameters obtained by transthoracic echocardiography and right heart catheterization: a comparative study in patients with pulmonary hypertension. Chin Med J 124:1796–1801PubMedGoogle Scholar
  42. 42.
    Huang SJ, McLean AS (2012) Appreciating the strengths and weaknesses of transthoracic echocardiography in hemodynamic assessments. Cardiol Res Pract 2012:894308PubMedPubMedCentralGoogle Scholar
  43. 43.
    van den Berg PC, Grimbergen CA, Spaan JA, Pinsky MR (1997) Positive pressure inspiration differentially affects right and left ventricular outputs in postoperative cardiac surgery patients. J Crit Care 12:56–65CrossRefPubMedGoogle Scholar
  44. 44.
    Pinsky MR (2007) Heart–lung interactions. Curr Opin Crit Care 13:528–531CrossRefPubMedGoogle Scholar
  45. 45.
    Hansen KL, Udesen J, Thomsen C, Jensen JA, Nielsen MB (2009) In vivo validation of a blood vector velocity estimator with MR angiography. IEEE Trans Ultrason Ferroelectr Freq Control 56:91–100CrossRefPubMedGoogle Scholar
  46. 46.
    Hansen KL, Moller-Sorensen H, Kjaergaard J, Jensen, MB, Lund, JT, Pedersen MM, Olesen JB, Jensen JA, Nielsen MB (2015) Vector flow imaging compared with conventional Doppler ultrasound and thermodilution for estimation of blood flow in the ascending aorta. Ultrason Imaging. doi: 10.1177/0161734615620137
  47. 47.
    Dubrey SW, Falk RH (1997) Optimal number of beats for the Doppler measurement of cardiac output in atrial fibrillation. J Am Soc Echocardiogr 10:67–71CrossRefPubMedGoogle Scholar
  48. 48.
    Nishikawa T, Dohi S (1993) Errors in the measurement of cardiac output by thermodilution. Can J Anaesth 40:142–153CrossRefPubMedGoogle Scholar
  49. 49.
    Vincent JL, Rhodes A, Perel A, Martin GS, Della Rocca G, Vallet B, Pinsky MR, Hofer CK, Teboul JL, de Boode WP, Scolletta S, Vieillard-Baron A, De Backer D, Walley KR, Maggiorini M, Singer M (2011) Clinical review: update on hemodynamic monitoring—a consensus of 16. Crit Care 15:229CrossRefPubMedPubMedCentralGoogle Scholar
  50. 50.
    Rhodes A, Cusack RJ, Newman PJ, Grounds RM, Bennett ED (2002) A randomised, controlled trial of the pulmonary artery catheter in critically ill patients. Intensive Care Med 28:256–264CrossRefPubMedGoogle Scholar
  51. 51.
    Jansen JR (1995) The thermodilution method for the clinical assessment of cardiac output. Intensive Care Med 21:691–697CrossRefPubMedGoogle Scholar
  52. 52.
    Jullien T, Valtier B, Hongnat JM, Dubourg O, Bourdarias JP, Jardin F (1995) Incidence of tricuspid regurgitation and vena caval backward flow in mechanically ventilated patients. A color Doppler and contrast echocardiographic study. Chest 107:488–493CrossRefPubMedGoogle Scholar
  53. 53.
    Artucio H, Hurtado J, Zimet L, de Paula J, Beron M (1997) PEEP-induced tricuspid regurgitation. Intensive Care Med 23:836–840CrossRefPubMedGoogle Scholar
  54. 54.
    Balik M, Pachl J, Hendl J (2002) Effect of the degree of tricuspid regurgitation on cardiac output measurements by thermodilution. Intensive Care Med 28:1117–1121CrossRefPubMedGoogle Scholar
  55. 55.
    Thiele RH, Bartels K, Gan TJ (2015) Cardiac output monitoring: a contemporary assessment and review. Crit Care Med 43:177–185CrossRefPubMedGoogle Scholar
  56. 56.
    Ostergaard M, Nilsson LB, Nilsson JC, Rasmussen JP, Berthelsen PG (2005) Precision of bolus thermodilution cardiac output measurements in patients with atrial fibrillation. Acta Anaesthesiol Scand 49:366–372CrossRefPubMedGoogle Scholar
  57. 57.
    Reuter DA, Huang C, Edrich T, Shernan SK, Eltzschig HK (2010) Cardiac output monitoring using indicator-dilution techniques: basics, limits, and perspectives. Anesth Analg 110:799–811CrossRefPubMedGoogle Scholar
  58. 58.
    Leibowitz AB, Oropello JM (2007) The pulmonary artery catheter in anesthesia practice in 2007: an historical overview with emphasis on the past 6 years. Semin Cardiothorac Vasc Anesth 11:162–176CrossRefPubMedGoogle Scholar
  59. 59.
    Lee AJ, Cohn JH, Ranasinghe JS (2011) Cardiac output assessed by invasive and minimally invasive techniques. Anesthesiol Res Pract 2011:475151PubMedPubMedCentralGoogle Scholar
  60. 60.
    Cecconi M, Rhodes A, Poloniecki J, Della Rocca G, Grounds RM (2009) Bench-to-bedside review: the importance of the precision of the reference technique in method comparison studies—with specific reference to the measurement of cardiac output. Crit Care 13:201CrossRefPubMedPubMedCentralGoogle Scholar
  61. 61.
    Critchley LA, Critchley JA (1999) A meta-analysis of studies using bias and precision statistics to compare cardiac output measurement techniques. J Clin Monit Comput 15:85–91CrossRefPubMedGoogle Scholar
  62. 62.
    Critchley LA, Lee A, Ho AM (2010) A critical review of the ability of continuous cardiac output monitors to measure trends in cardiac output. Anesth Analg 111:1180–1192CrossRefPubMedGoogle Scholar
  63. 63.
    Critchley LA, Yang XX, Lee A (2011) Assessment of trending ability of cardiac output monitors by polar plot methodology. J Cardiothorac Vasc Anesth 25:536–546CrossRefPubMedGoogle Scholar
  64. 64.
    Squara P, Cecconi M, Rhodes A, Singer M, Chiche JD (2009) Tracking changes in cardiac output: methodological considerations for the validation of monitoring devices. Intensive Care Med 35:1801–1808CrossRefPubMedGoogle Scholar
  65. 65.
    Geisen M, Spray D, Nicholas Fletcher S (2014) Echocardiography-based hemodynamic management in the cardiac surgical intensive care unit. J Cardiothorac Vasc Anesth 28:733–744CrossRefPubMedGoogle Scholar
  66. 66.
    Huttemann E (2006) Transoesophageal echocardiography in critical care. Minerva Anestesiol 72:891–913PubMedGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg and ESICM 2016

Authors and Affiliations

  • Mik Wetterslev
    • 1
  • Hasse Møller-Sørensen
    • 2
  • Rasmus Rothmann Johansen
    • 1
  • Anders Perner
    • 1
    Email author
  1. 1.Department of Intensive Care, Section 4131Copenhagen University Hospital, RigshospitaletCopenhagenDenmark
  2. 2.Department of Cardiothoracic AnaesthesiologyCopenhagen University Hospital, RigshospitaletCopenhagenDenmark

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