Novel point-of-care ultrasound (POCUS) technique to modernize the JVP exam and rule out elevated right atrial pressures

Abstract

Accurate assessment of the jugular venous pressure (JVP) and right atrial pressure (RAP) has relied on the same bedside examination method since 1930. While this technique provides a rough estimate of right-sided pressures, it is limited by poor sensitivity and overall diagnostic inaccuracy. The internal jugular vein (IJV) is difficult to visualize in many patients and relies on an incorrect assumption that the right atrium lies 5 centimeters below the sternum. Point-of-care ultrasound (POCUS) offers an alternative method for more precisely estimating JVP and RAP. We propose a novel method of measuring the right atrial depth (RAD) using a sonographic measurement of the depth of the posterior left ventricular outflow tract as a surrogate landmark to the center of the right atrium when viewed in the parasternal long axis view. This is combined with determination if JVD was present at the supraclavicular point. Sensitivity, specificity, PPV, NPV of JVD at the supraclavicular point was 70%, 76%, 59%, 91% respectively. These values were confounded by the lack of standardization of zero reference landmarks (ZRLs) used during the right heart catheterizations. When the RAD estimate was adjusted to account for measurement error the sensitivity of JVD at supraclavicular point for elevated RAP improved to 90% with negative predictive value of 96%. This may offer a rapid and reliable method for ruling out elevated RAP and increase objectivity in our volume status assessment.

Novel method for estimating right atrial pressure with point-of-care ultrasound (POCUS)

“…In our study, using the non-coronary cusp attachment to the posterior LVOT as a proxy, the average distance to the right atrium at the 45-degree position was 9.2 cm. This is similar to the RAD in our previous study of 10.16 cm, 15 as well as to the 9 centimeters in Kovacs et al 10 and the 9.9 cm found by Seth et al 11 which both relied on measurements from CT scans.…”

“…Previously we compared this POCUS method to RAP obtained from RHC performed by multiple interventional cardiologists without standardized zeroing technique between them, resulting in less accurate results. 15 When the RHC zero level was standardized to the mid-thoracic level, both the corrected and uncorrected RAP U measurements strongly correlated with gold-standard RAP i measurements, and was within 3 mmHg 74% of the time. This is compared to an R 2 of 0.19 and overall accuracy of 34% seen with standard IVC measurements.…”