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Jinyang Yu Profile picture
@dritsyk
Feb 11 • 10 tweets • 7 min read • Read on X
Scrolly
The RVOT or PA Doppler has a lot of underutilized potential for hemodynamic monitoring of the RV #ThePeoplesVentricle

🧵On the physiology of the RVOT/PA Doppler. Simplified understandings. Corrections are welcome!😃
#FOAMcc #EchoFirst #Cardiotwitter #FOAMed #Medtwitter #POCUS Image
VTI reflects stroke volume, but values are much lower than for LVOT. Lower cut-off for 60-79 year olds is actually around 10 cm.
Monitoring changes are likely more useful. doi.org/10.1016/j.jcmg…
Image
AcT and Vmax/AT both reflects RV afterload. Increased afterload reduces AT and Vmax/AT.
➡️AcT correlates with mPAP and PVR.
doi.org/10.1161/01.CIR…
Image
➡️Vmax/AcT detects increased RV afterload with lung inflation.
➡️Vmax/AcT does not change after fluid bolus in fluid responsive patients
➡️Vmax/AcT is improved when PEEP = optimal respiratory compliance doi.org/10.1152/jappl.…
doi.org/10.1097/000005…
doi.org/10.1097/000032…
Image
Notching in the Doppler waveform represents wave reflections from vascular stiffening and the "vascular source" of RV afterload.
➡️For details on waveforms & physiology➡️
➡️DT is a potential quantitative metric of wave reflections doi.org/10.1164/rccm.2…
doi.org/10.1016/j.jcmg…
Image
PET reflects the time the RV takes to overcome PA diastolic pressure.
➡️PET is increased in PHT, likely due to RV-PA uncoupling
➡️PET correlates well with RVFAC
➡️PET increases during mechanical inspiration doi.org/10.1161/01.CIR…
doi.org/10.1093/ejecho…
doi.org/10.1016/1053-0…
Image
ET reflects the ratio of displacement/velocity of fiber shortening - at least for the LV
➡️ET is decreased in PHT
➡️ET does not ⬆️after fluids, but decreases during inspiration in fluid responsive patients. doi.org/10.1161/01.CIR…
doi.org/10.1161/01.CIR…
doi.org/10.1097/000005…
Image
(PET+ET) reflects inotropic state (at least for the LV. )
➡️(PET+ET) is correlated with RVFAC; better than PET alone
➡️(PET+ET) is also increased for RV volume overloaded ASD patients doi.org/10.1161/01.CIR…
doi.org/10.1093/ejecho…
doi.org/10.1161/01.CIR…
Image
Lastly, PET/ET-ratio is also a robust marker for ventricular function (higher ratio is bad).
➡️PET/ET-ratio increases during increased RV afterload from inspiration doi.org/10.1016/1053-0…
Image
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More from @dritsyk

Jinyang Yu Profile picture
Jul 20
🧵1/
A very interesting RCT by @MirjanaCihoric & @BangFoss in @BJSurgery show the importance of dexamethasone (DXM) in acute abdominal surgery! DXM ⬇️inflammation,⬇️vasodilation,⬇️pressor dependency, and improves fluid balance and even 90-day ☠️
doi.org/10.1093/bjs/zn…

Image
Image
2/
 DXM shows positive effects on various secondary endpoints with different levels of significance. Also, less fatigue, pain, immobilization and better peak exp flow.
https://doi.org/10.1093/bjs/znae130
Image
3/
 Interestingly, there were no more infections in the DXM-group; in fact, there were fewer infections of various subtypes, though statistically insignificant. However, DXM had more hyperglycemia. Image
Read 7 tweets
Jinyang Yu Profile picture
Jul 10
1/
 🧵Can the pulmonary artery catheter (PAC) guide massive transfusion?
Key ideas:
1⃣Continuous SvO2 may be useful for optimizing O2-delivery.
2⃣Continuous SvO2 & CO aids in detecting distributive shock physiology.
#FOAMed #MedTwitter #CritCare #ICU
2/ 1⃣Optimizing DO2
The goal of transfusion is to improve O2-delivery. SvO2 is an excellent measure O2-delivery. PAC allows continuous SvO2 monitoring.
3/ 1⃣Optimizing DO2
🩸SvO2 > 65% during bleeding suggests a need for transfusion.
🩸SvO2 > 65% suggests that resuscitation is adequate, avoiding unnessecary transfusions and potentially preventing transfusion-associated complications.
Read 9 tweets
Jinyang Yu Profile picture
Jun 14
1/🧵The history of #EchoFirst for hemodynamic monitoring in #ICU to put this new study on continuous #AutoMAPSE in perspective!

🫀📜

@ICMexperimental #POCUS #TEE #MAPSE #MedTwitter #CardioTwitter #FOAMed #CriticalCare rdcu.be/dKPgA
Image
2/
1⃣st report of TEE was in 1980, using M-mode from TGSAX during cardiac surgery. The rationale for this was: "Currently used monitoring techniques such as measurements of pressure and cardiac output provide an incomplete picture of LV function..."
doi.org/10.1016/0002-9…

Image
Image
3/
 A serious limitation is that all measurements required manual image acquisition and measurements.

Imagine using Korotkoff sounds for "monitoring" BP; manual methods requires too much time and attention to effectively serve as monitoring and guide patient management⏱️🧠 Image
Read 14 tweets
Jinyang Yu Profile picture
May 16
1/ 🎯Bland-Altman analysis is the common way to evaluate AI in #EchoFirst. However, BA analyses can be tricky to interpret. 🧵On the paradox of BA analysis for AI in #EchoFirst with examples from our studies on #AutoMAPSE 📜
#Foamed #Cardiotwitter rdcu.be/dH8aR
Image
2/ BA analysis is an important approach used for comparing 2⃣measuement methods for measuring the same unit, like #MAPSE (mm) and #AutoMAPSE (mm). ‼️Correlation (r) is inappropriate yet commonly used because it is seductive. Read the reasoning in their📜: doi.org/10.1016/S0140-…

Image
Image
3/ The output in BA analysis is 1⃣bias &2⃣limits of agreement (LOA). Bias is the avg difference across all paired measurements of manual MAPSE and autoMAPSE. LOA=+/- 2SD of the bias in the study. The bias and LOA is presented in a BA plot from 📜: rdcu.be/dH0mY
Image
Read 16 tweets
Jinyang Yu Profile picture
May 13
🧵1/ #AutoMAPSE had high feasibility for estimating MAPSE from ≥1⃣wall. Many worry that #MAPSE is limited by RWMA, such as acute MI - however, evidence suggests that regional MAPSE reflects global LV function.

#EchoFirst #POCUS #FOAMed #CardioTwitter rdcu.be/dHLxx
2/ Several studies have shown that in AMI, MAPSE is ⬇️even in walls remote to MI. This was confirmed experimentally by Berg et al, in an experiment occluding the LAD in pigs and measuring #MAPSE by #WhyCMR.
First paper:
Berg et al: doi.org/10.1080/140174…
doi.org/10.1152/japplp…
Image
3/ ⬇️MAPSE in remote walls is explained through the distribution of afterload. For a specific region to shorten, that region must overcome the opposing afterload imposed by its neighboring region, which is shortening in the opposite direction.
Read 9 tweets
Jinyang Yu Profile picture
Mar 25
🧵We have now refined AutoMAPSE.!
🔓
⬆️New paper on #autoMAPSE showing that the newest version achieves an optimal balance between feasibility, analysis speed, and agreement.
A🧵on the clinical importance of these findings
#echofirst #CardioTwitter #POCUS doi.org/10.1016/j.ultr…
1/ Our design involved measurements from 🔟beats per #EchoFirst recording. This is very different from the usual practice of measuring 1-3 beats. What are the advantages?
2/ Measuring 1-3 beats in #Echofirst involves huge physiological variability. How?
❤️🫁 interactions can cause serious beat-to-beat variations in any echo measurement. Often overlooked, these changes may be misinterpreted as real. Acting on wrong info ⬆️the risk of harm.
Read 9 tweets

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