Impedance cardiography

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Impedance cardiography is a hemorheology technique of using sensors to detect the properties of the blood flow in the Thorax.

Introduction

Impedance cardiography (ICG), also referred to as thoracic electrical bioimpedance (TEB) and electrical impedance plethysmography (EIP), has been researched since the 1940’s. With ICG, the placement of four dual disposable sensors on the neck and chest are used to transmit and detect electrical and impedance changes in the thorax, which are used to measure and calculate hemodynamic parameters.

How ICG Works

• Current is transmitted through the chest

• Current seeks path of least resistance: the blood filled aorta

• ICG measures the baseline impedance (resistance) to this current

• With each Heartbeat, blood volume and velocity in the aorta change

• ICG measures the corresponding change in impedance

• ICG uses the baseline and changes in impedance to measure and calculate hemodynamic parameters

Hemodynamics

Main Article: Hemodynamics

Hemodynamics is defined as the forces affecting the flow of blood throughout the body. Human beings cannot survive without adequate oxygenation, and the primary function of the cardiopulmonary system is to deliver an appropriate amount of oxygen and nutrients to meet the metabolic demands of the body and then to remove metabolic waste products.

A healthy body constantly regulates the amount of blood ejected by the heart, cardiac output, to maintain adequate tissue perfusion. In disease states, however, hemodynamic imbalances occur and the body is forced to compensate, often severely, for cardiovascular and systemic vascular dysfunction. Most (if not all) cardiac drugs administered for both acute and chronic conditions, affect either directly and indirectly one of the four factors that comprise cardiac output:

Component: Meaning

Preload: Volume of blood in the ventricle at the end of diastole

Contractility: Rate of shortening of myocardial muscle fibers

Afterload: Force heart must overcome to expel blood into the vasculature

Heart Rate: Number heart beats per minute

The measurement of cardiac output and its derivatives allow clinicians to make timely patient assessment, diagnosis, prognosis, and treatment decisions. It has been well established that both trained and untrained physicians alike are unable to estimate cardiac output through physical assessment alone.

Invasive Hemodynamic Monitoring

Clinical measurement of cardiac output has been available since the 1970’s. However, this blood flow measurement is highly invasive, utilizing a flow-directed, thermodilution catheter (also known as the Swan-Ganz catheter), which represents significant risks to the patient. In addition, this technique is costly (several thousand dollars per procedure) and requires a skilled physician and a sterile environment for catheter insertion. As a result, it has been used only in very narrow strata (less than 2%) of critically ill and high-risk patients in whom the knowledge of blood flow and oxygen transport outweighed the risks of the method. In the United States, it is estimated that at least two million pulmonary artery catheter monitoring procedures are performed annually, most often in peri-operative cardiac and vascular surgical patients, decompensated heart failure, multi-organ failure, and trauma.

Noninvasive Hemodynamic Monitoring

In theory, a noninvasive way to monitor hemodynamics would provide exceptional clinical value because data similar to invasive hemodynamic monitoring methods could be obtained with much lower cost and no risk. While noninvasive hemodynamic monitoring can be used in patients who previously required an invasive procedure, the largest impact can be made in patients and care environments where invasive hemodynamic monitoring was neither possible nor worth the risk or cost. Because of its safety and low cost, the applicability of vital hemodynamic measurements could be extended to significantly more patients, including outpatients with chronic diseases. Heart failure, hypertension, pacemaker, and dyspnea patients are four conditions in which outpatient noninvasive hemodynamic monitoring can play an important role in the assessment, diagnosis, prognosis, and treatment.

ICG Parameters

The electrical and impedance signals are processed to determine fiducial points, which are then utilized to measure and calculate hemodynamic parameters, such as cardiac output, stroke volume, systemic vascular resistance, thoracic fluid content, acceleration index, and systolic time ratio.

Parameter	Definition
Heart Rate	Number of heart beats each minute
Cardiac Output	Amount of blood pumped by the left ventricle each minute
Cardiac Index	Cardiac output normalized for body surface area
Stroke Volume	Amount of blood pumped by the left ventricle each heartbeat
Stroke Index	Stroke volume normalized for body surface area
Systemic Vascular Resistance	The resistance to the flow of blood in the vasculature (often referred to as “Afterload”)
Systemic Vascular Resistance Index	Systemic vascular resistance normalized for body surface area
Acceleration Index	Peak acceleration of blood flow in the aorta
Velocity Index	Peak velocity of blood flow in the aorta
Thoracic Fluid Content	The electrical conductivity of the chest cavity, which is primarily determined by the intravascular, intraalveolar, and interstitial fluids in the thorax
Left Cardiac Work	An indicator of the amount of work the left ventricle must perform to pump blood each minute
Left Cardiac Work Index	Left cardiac work normalized for body surface area
Systolic Time Ratio	The ratio of the electrical and mechanical systole
Pre Ejection Period	The time interval from the beginning of electrical stimulation of the ventricles to the opening of the aortic valve (electrical systole)
Left Ventricular Ejection Time	The time interval from the opening to the closing of the aortic valve (mechanical systole)