Doppler Recognition of Low or Normal Central Venous Pressure from Continuous Flow from Inferior Vena Cava Into Right Atrium

      Estimation of right atrial (RA) or central venous pressure (CVP) is a critical component of a comprehensive transthoracic echocardiographic (TTE) examination. We hypothesize that continuous inflow from the inferior vena cava (IVC) into the RA is a surrogate for low/normal CVP and can be reliably imaged in standard echocardiographic parasternal short and right ventricular inflow views. We retrospectively studied 200 patients who underwent right heart catheterization (RHC) within 8 hours of TTE between 2012 and 2016, and selected 60 patients in whom the continuous wave Doppler beam incidentally interrogated IVC inflow into RA during evaluation of the tricuspid valve. From these studies, we sought an uninterrupted Doppler wave (DW) inflow signal. CVP on RHC were then compared in patients with continuous and interrupted DW. Other TTE and RHC parameters were also noted and compared in these 2 groups. The average time interval between TTE and RHC was 266 ± 151 minutes. Of 60 patients (males = 39 (65%); age 63 ± 14 years), 12 patients (20%) had continuous DW and 48 (80%) had interrupted DW inflow signal from IVC into the RA. Of the 12 patients with continuous flow, 11 had RA pressure of ≤7 mm Hg. Similarly, of 48 patients with interrupted flow, RA pressure was >7 mm Hg in 45, and less than ≤7 mm Hg in 3 patients (two-sided p value 0.0001). The continuous DW signal predicted RA of ≤7 mm Hg with a sensitivity and specificity of 98% and 78%, respectively. Additionally, when combined with IVC size and collapsibility (normal-sized collapsible IVC), the sensitivity and specificity of DW signal to predict RA of ≤ 7 mmHg were enhanced to 94% and 92%, respectively. In conclusion, IVC flow pattern can be reliably studied to estimate CVP in standard echocardiographic views. Continuous and interrupted IVC flow predicts normal and elevated RA pressure, respectively.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to American Journal of Cardiology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Thomas SS
        • Nohria A
        Hemodynamic classifications of acute heart failure and their clinical application.
        Circ J. 2012; 76: 278-286
        • Beigel R
        • Cercek B
        • Luo H
        • Siegel RJ
        Noninvasive evaluation of right atrial pressure.
        J Am Soc Echocardiogr. 2013; 26: 1033-1042
        • Rudski LG
        • Lai WW
        • Afilalo J
        • Hua L
        • Handschumacher MD
        • Chandrasekaran K
        • Solomon SD
        • Louie EK
        • Schiller NB
        Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography.
        J Am Soc Echocardiogr. 2010; 23 (quiz 786-688): 685-713
        • Ranjan R
        • Gucuk Ipek E
        • Mostafavi Toroghi H
        • Schiller N
        Continuous flow from inferior vena cava into the right atrium predicts normal central venous pressure.
        Int Cardiovasc Res J. 2018; 12: e67163
        • Lang RM
        • Badano LP
        • Mor-Avi V
        • Afilalo J
        • Armstrong A
        • Ernande L
        • Flachskampf FA
        • Foster E
        • Goldstein SA
        • Kuznetsova T
        • Lancellotti P
        • Muraru D
        • Picard MH
        • Rietzschel ER
        • Rudski L
        • Spencer KT
        • Tsang W
        • Voigt JU
        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
        • Nagueh SF
        • Smiseth OA
        • Appleton CP
        • Byrd 3rd, BF
        • Dokainish H
        • Edvardsen T
        • Flachskampf FA
        • Gillebert TC
        • Klein AL
        • Lancellotti P
        • Marino P
        • Oh JK
        • Alexandru Popescu B
        • Waggoner AD
        Recommendations for the evaluation of left ventricular diastolic function by echocardiography: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging.
        Eur Heart J Cardiovasc Imaging. 2016; 17: 1321-1360
        • Zoghbi WA
        • Adams D
        • Bonow RO
        • Enriquez-Sarano M
        • Foster E
        • Grayburn PA
        • Hahn RT
        • Han Y
        • Hung J
        • Lang RM
        • Little SH
        • Shah DJ
        • Shernan S
        • Thavendiranathan P
        • Thomas JD
        • Weissman NJ
        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: 303-371
        • Lewis JF
        • Kuo LC
        • Nelson JG
        • Limacher MC
        • Quinones MA
        Pulsed Doppler echocardiographic determination of stroke volume and cardiac output: clinical validation of two new methods using the apical window.
        Circulation. 1984; 70: 425-431
        • Rokey R
        • Sterling LL
        • Zoghbi WA
        • Sartori MP
        • Limacher MC
        • Kuo LC
        • Quinones MA
        Determination of regurgitant fraction in isolated mitral or aortic regurgitation by pulsed Doppler two-dimensional echocardiography.
        J Am Coll Cardiol. 1986; 7: 1273-1278
        • Austin C
        • Alassas K
        • Burger C
        • Safford R
        • Pagan R
        • Duello K
        • Kumar P
        • Zeiger T
        • Shapiro B
        Echocardiographic assessment of estimated right atrial pressure and size predicts mortality in pulmonary arterial hypertension.
        Chest. 2015; 147: 198-208
        • Drazner MH
        • Rame JE
        • Stevenson LW
        • Dries DL
        Prognostic importance of elevated jugular venous pressure and a third heart sound in patients with heart failure.
        N Engl J Med. 2001; 345: 574-581
        • Simon MA
        • Kliner DE
        • Girod JP
        • Moguillansky D
        • Villanueva FS
        • Pacella JJ
        Detection of elevated right atrial pressure using a simple bedside ultrasound measure.
        Am Heart J. 2010; 159: 421-427
        • Kircher BJ
        • Himelman RB
        • Schiller NB
        Noninvasive estimation of right atrial pressure from the inspiratory collapse of the inferior vena cava.
        Am J Cardiol. 1990; 66: 493-496
        • Brennan JM
        • Blair JE
        • Goonewardena S
        • Ronan A
        • Shah D
        • Vasaiwala S
        • Kirkpatrick JN
        • Spencer KT
        Reappraisal of the use of inferior vena cava for estimating right atrial pressure.
        J Am Soc Echocardiogr. 2007; 20: 857-861
        • Moreno FL
        • Hagan AD
        • Holmen JR
        • Pryor TA
        • Strickland RD
        • Castle CH
        Evaluation of size and dynamics of the inferior vena cava as an index of right-sided cardiac function.
        Am J Cardiol. 1984; 53: 579-585
        • Tsutsui RS
        • Borowski A
        • Tang WH
        • Thomas JD
        • Popovic ZB
        Precision of echocardiographic estimates of right atrial pressure in patients with acute decompensated heart failure.
        J Am Soc Echocardiogr. 2014; 27: 1072-1078.e1072
        • Yildirimturk O
        • Tayyareci Y
        • Erdim R
        • Ozen E
        • Yurdakul S
        • Aytekin V
        • Demiroglu IC
        • Aytekin S
        Assessment of right atrial pressure using echocardiography and correlation with catheterization.
        J Clin Ultrasound. 2011; 39: 337-343
        • Merrer J
        • De Jonghe B
        • Golliot F
        • Lefrant JY
        • Raffy B
        • Barre E
        • Rigaud JP
        • Casciani D
        • Misset B
        • Bosquet C
        • Outin H
        • Brun-Buisson C
        • Nitenberg G
        • French Catheter Study Group in Intensive C
        Complications of femoral and subclavian venous catheterization in critically ill patients: a randomized controlled trial.
        JAMA. 2001; 286: 700-707
        • Johnson JR
        Complications and failures of subclavian-vein catheterization.
        N Engl J Med. 1995; 332: 1580-1581
        • Lorente L
        • Henry C
        • Martin MM
        • Jimenez A
        • Mora ML
        Central venous catheter-related infection in a prospective and observational study of 2,595 catheters.
        Crit Care. 2005; 9: R631-R635
        • Zoghbi WA
        • Enriquez-Sarano M
        • Foster E
        • Grayburn PA
        • Kraft CD
        • Levine RA
        • Nihoyannopoulos P
        • Otto CM
        • Quinones MA
        • Rakowski H
        • Stewart WJ
        • Waggoner A
        • Weissman NJ
        • American Society of Echocardiography
        Recommendations for evaluation of the severity of native valvular regurgitation with two-dimensional and Doppler echocardiography.
        J Am Soc Echocardiogr. 2003; 16: 777-802
        • Scapellato F
        • Eleuteri E
        • Temporelli PL
        • Imparato A
        • Corra U
        • Giannuzzi P
        Doppler-derived acceleration rate of right ventricular early filling as a measurement of right atrial pressure in chronic heart failure secondary to ischemic or idiopathic dilated cardiomyopathy.
        Am J Cardiol. 1998; 81: 513-515