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Original Investigation
September 6, 2017

Thermodilution vs Estimated Fick Cardiac Output Measurement in Clinical PracticeAn Analysis of Mortality From the Veterans Affairs Clinical Assessment, Reporting, and Tracking (VA CART) Program and Vanderbilt University

Author Affiliations
  • 1Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
  • 2Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts
  • 3Veterans Affairs Eastern Colorado Health Care System, Denver
  • 4Veterans Affairs Boston Healthcare System, Boston, Massachusetts
  • 5Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
  • 6Vanderbilt Translational and Clinical Cardiovascular Research Center, Vanderbilt University Medical Center, Nashville, Tennessee
  • 7University of Colorado School of Medicine, Denver
  • 8Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
  • 9Department of Biostatistics, Vanderbilt University, Nashville, Tennessee
  • 10Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
  • 11Division of Cardiology, Department of Medicine, Northwestern University, Chicago, Illinois
  • 12Providence Veterans Affairs Medical Center, Providence, Rhode Island
  • 13Alpert Medical School of Brown University, Providence, Rhode Island
  • 14Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston
JAMA Cardiol. Published online September 6, 2017. doi:10.1001/jamacardio.2017.2945
Key Points

Question  Which commonly applied method to measure cardiac output, thermodilution or Fick using estimated oxygen consumption, performs better in routine clinical practice?

Findings  Among more than 15 000 adults in this cohort study who underwent right heart catheterization, thermodilution and estimated Fick cardiac output measurements agreed poorly, with estimates differing by greater than 20% in well over one-third of patients. Thermodilution estimates of cardiac output were more strongly associated with mortality than estimated Fick cardiac output estimates.

Meaning  Thermodilution and estimated Fick cardiac output estimates should not be considered interchangeable; thermodilution is preferable for most situations in clinical practice.

Abstract

Importance  Thermodilution (Td) and estimated oxygen uptake Fick (eFick) methods are widely used to measure cardiac output (CO). They are often used interchangeably to make critical clinical decisions, yet few studies have compared these approaches as applied in medical practice.

Objectives  To assess agreement between Td and eFick CO and to compare how well these methods predict mortality.

Design, Setting, and Participants  This investigation was a retrospective cohort study with up to 1 year of follow-up. The study used data from the Veterans Affairs Clinical Assessment, Reporting, and Tracking (VA CART) program. The findings were corroborated in a cohort of patients cared for at Vanderbilt University, an academic referral center. Participants were more than 15 000 adults who underwent right heart catheterization, including 12 232 in the Veterans Affairs cohort between October 1, 2007, and September 30, 2013, and 3391 in the Vanderbilt cohort between January 1, 1998, and December 31, 2014.

Exposures  A single cardiac catheterization was performed on each patient with CO estimated by both Td and eFick methods. Cardiac output was indexed to body surface area (cardiac index [CI]) for all analyses.

Main Outcomes and Measures  All-cause mortality over 90 days and 1 year after catheterization.

Results  Among 12 232 VA patients (mean [SD] age, 66.4 [9.9] years; 3.3% female) who underwent right heart catheterization in this cohort study, Td and eFick CI estimates correlated modestly (r = 0.65). There was minimal mean difference (eFick minus Td = −0.02 L/min/m2, or −0.4%) but wide 95% limits of agreement between methods (−1.3 to 1.3 L/min/m2, or −50.1% to 49.4%). Estimates differed by greater than 20% for 38.1% of patients. Low Td CI (<2.2 L/min/m2 compared with normal CI of 2.2-4.0 L/min/m2) more strongly predicted mortality than low eFick CI at 90 days (Td hazard ratio [HR], 1.71; 95% CI, 1.47-1.99; χ2 = 49.5 vs eFick HR, 1.42; 95% CI, 1.22-1.64; χ2 = 20.7) and 1 year (Td HR, 1.53; 95% CI, 1.39-1.69; χ2 = 71.5 vs eFick HR, 1.35; 1.22-1.49; χ2 = 35.2). Patients with a normal CI by both methods had 12.3% 1-year mortality. There was no significant additional risk for patients with a normal Td CI but a low eFick CI (12.9%, P = .51), whereas a low Td CI but normal eFick CI was associated with higher mortality (15.4%, P = .001). The results from the Vanderbilt cohort were similar in the context of a more balanced sex distribution (46.6% female).

Conclusions and Relevance  There is only modest agreement between Td and eFick CI estimates. Thermodilution CI better predicts mortality and should be favored over eFick in clinical practice.

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