Reliability of Bioreactance and Pulse-Power Analysis in Measuring Cardiac Index in Patients Undergoing Cardiac Surgery With Cardiopulmonary Bypass

Published:December 03, 2021DOI:


      Less-invasive and continuous cardiac output monitors recently have been developed to monitor patient hemodynamics. The aim of this study was to compare the accuracy, precision, and trending ability of noninvasive bioreactance-based Starling SV and miniinvasive pulse-power device LiDCOrapid to bolus thermodilution technique with a pulmonary artery catheter (TDCO) when measuring cardiac index in the setting of cardiac surgery with cardiopulmonary bypass (CPB).


      A prospective method-comparison study.


      Oulu University Hospital, Finland.


      Twenty patients undergoing cardiac surgery with CPB.


      Cardiac index measurements were obtained simultaneously with TDCO intraoperatively and postoperatively, resulting in 498 measurements with Starling SV and 444 with LiDCOrapid.

      Measurements and Main Results

      The authors used the Bland-Altman method to investigate the agreement between the devices and four-quadrant plots with error grids to assess the trending ability. The agreement between TDCO and Starling SV was qualified with a bias of 0.43 L/min/m2 (95% confidence interval [CI], 0.37-0.50), wide limits of agreement (LOA, –1.07 to 1.94 L/min/m2), and a percentage error (PE) of 66.3%. The agreement between TDCO and LiDCOrapid was qualified, with a bias of 0.22 L/min/m2 (95% CI 0.16-0.27), wide LOA (–0.93 to 1.43), and a PE of 53.2%. With both devices, trending ability was insufficient.


      The reliability of bioreactance-based Starling SV and pulse-power analyzer LiDCOrapid was not interchangeable with TDCO, thus limiting their usefulness in cardiac surgery with CPB.

      Key Words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic and Personal
      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 Journal of Cardiothoracic and Vascular Anesthesia
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Marik PE.
        Noninvasive cardiac output monitors: A state-of the-art review.
        J Cardiothorac Vasc Anesth. 2013; 27: 121-134
        • Peeters Y
        • Bernards J
        • Mekeirele M
        • et al.
        Hemodynamic monitoring: To calibrate or not to calibrate? Part 1 - Calibrated techniques.
        Anaesthesiol Intensive Ther. 2015; 47: 487-500
        • Swan HJC
        • Ganz W
        • Forrester J
        • et al.
        Catheterization of the heart in man with use of a flow-directed balloon-tipped catheter.
        N Engl J Med. 1970; 283: 447-451
        • Evans DC
        • Doraiswamy VA
        • Prosciak MP
        • et al.
        Complications associated with pulmonary artery catheters: A comprehensive clinical review.
        Scand J Surg. 2009; 98: 199-208
        • Connors AF
        • Speroff T
        • Dawson N.V.
        • et al.
        The effectiveness of right heart catheterization in the initial care of critically ill patients.
        J Am Med Assoc. 1996; 276: 889-897
        • Ramsey S
        • Saint S
        • Sullivan S
        • et al.
        Clinical and economic effects of pulmonary artery cathetrization in nonemergent coronary artery bypass graft surgery.
        J Cardiothorac Vasc Anesth. 2000; 14: 113-118
        • Rajaram SS
        • Desai NK
        • Kalra A
        • et al.
        Pulmonary artery catheters for adult patients in intensive care.
        Cochrane Database Syst Rev. 2013; 2013CD003408
        • Sandham JD
        • Hull RD
        • Brant RF
        • et al.
        A randomized, controlled trial of the use of pulmonary-artery catheters in high-risk surgical patients.
        N Engl J Med. 2003; 348: 5-14
        • Harvey S
        • Harrison DA
        • Singer M
        • et al.
        Assessment of the clinical effectiveness of pulmonary artery catheters in management of patients in intensive care (PAC-Man): A randomised controlled trial.
        Lancet. 2005; 366: 472-477
        • VanDyck TJ
        • Pinsky MR.
        Hemodynamic monitoring in cardiogenic shock.
        Curr Opin Crit Care. 2021; 27: 454-459
        • Garan AR
        • Kanwar M
        • Thayer KL
        • et al.
        Complete hemodynamic profiling with pulmonary artery catheters in cardiogenic shock is associated with lower in-hospital mortality.
        JACC Heart Fail. 2020; 8: 903-913
        • Hernandez GA
        • Lemor A
        • Blumer V
        • et al.
        Trends in utilization and outcomes of pulmonary artery catheterization in heart failure with and without cardiogenic shock.
        J Card Fail. 2019; 25: 364-371
        • Jakovljevic DG
        • Trenell MI
        • MacGowan GA.
        Bioimpedance and bioreactance methods for monitoring cardiac output.
        Best Pract Res Clin Anaesthesiol. 2014; 28: 381-394
        • Bernards J
        • Mekeirele M
        • Hoffmann B
        • et al.
        Hemodynamic monitoring: To calibrate or not to calibrate? Part 2 - Non-calibrated techniques.
        Anaesthesiol Intensive Ther. 2015; 47: 501-516
        • Broch O
        • Renner J
        • Höcker J
        • et al.
        Uncalibrated pulse power analysis fails to reliably measure cardiac output in patients undergoing coronary artery bypass surgery.
        Crit Care. 2011; 15: R76
        • Fischer GW
        • Levin MA.
        Vasoplegia during cardiac surgery: Current concepts and management.
        Semin Thorac Cardiovasc Surg. 2010; 22: 140-144
        • Barnes TJ
        • Hockstein MA
        • Jabaley CS.
        Vasoplegia after cardiopulmonary bypass: A narrative review of pathophysiology and emerging targeted therapies.
        SAGE Open Med. 2020; 8: 1-8
        • Lomivorotov VV
        • Efremov SM
        • Kirov MY
        • et al.
        Low-cardiac-output syndrome after cardiac surgery.
        J Cardiothorac Vasc Anesth. 2017; 31: 291-308
        • Costa MG
        • Chiarandini P
        • Scudeller L
        • et al.
        Uncalibrated continuous cardiac output measurement in liver transplant patients: LiDCOrapidTM system versus pulmonary artery catheter.
        J Cardiothorac Vasc Anesth. 2014; 28: 540-546
        • Yamashita K
        • Nishiyama T
        • Yokoyama T
        • et al.
        Effects of vasodilation on cardiac output measured by PulseCOTM.
        J Clin Monit Comput. 2007; 21: 335-339
        • Raval NY
        • Squara P
        • Cleman M
        • et al.
        Multicenter evaluation of noninvasive cardiac output measurement by bioreactance technique.
        J Clin Monit Comput. 2008; 22: 113-119
        • Stetz CW
        • Miller RG
        • Kelly GE
        • et al.
        Reliability of the thermodilution method in the determination of cardiac output in clinical practice.
        Am Rev Respir Dis. 1982; 126: 1001-1004
        • McMillan RW
        • Morris DM.
        Effect of respiratory cycle on measurements of cardiac output by thermodilution.
        Surg Gynecol Obstet. 1988; 167: 420-422
        • Julious SA.
        Sample sizes for clinical trials.
        CRC Press, Boca Raton, FL2009
      1. Ylikauma LA, Ohtonen PP, Erkinaro TM, et al. Bioreactance and fourth-generation pulse contour methods in monitoring cardiac index during off-pump coronary artery bypass surgery [e-pub ahead of print]. J Clin Monit Comput. doi: 10.1007/s10877-021-00721-0. Accessed May 26, 2021.

        • Montenij LJ
        • Buhre WF
        • Jansen JR
        • et al.
        Methodology of method comparison studies evaluating the validity of cardiac output monitors: A stepwise approach and checklist.
        Br J Anaesth. 2016; 116: 750-758
        • Bland JM
        • Altman DG.
        Measuring agreement in method comparison studies.
        Stat Methods Med Res. 1999; 8: 135-160
        • Bland JM
        • Altman DG.
        Statistical methods for assessing agreement between two methods of clinical measurement.
        Lancet. 1986; 1: 307-310
        • Bland JM
        • Altman DG.
        Agreement between methods of measurement with multiple observations per individual.
        J Biopharm Stat. 2007; 17: 571-582
        • Abu-Arafeh A
        • Jordan H
        • Drummond G.
        Reporting of method comparison studies: A review of advice, an assessment of current practice, and specific suggestions for future reports.
        Br J Anaesth. 2016; 117: 569-575
        • Gerke O.
        Reporting standards for a bland-altman agreement analysis: A review of methodological reviews.
        Diagnostics. 2020; 10: 334
        • Zou GY.
        Confidence interval estimation for the Bland-Altman limits of agreement with multiple observations per individual.
        Stat Methods Med Res. 2013; 22: 630-642
        • Critchley LAH
        • Critchley JAJH.
        A meta-analysis of studies using bias and precision statistics to compare cardiac output measurement techniques.
        J Clin Monit Comput. 1999; 15: 85-91
        • Saugel B
        • Grothe O
        • Wagner JY.
        Tracking changes in cardiac output: Statistical considerations on the 4-quadrant plot and the polar plot methodology.
        Anesth Analg. 2015; 121: 514-524
        • Lamia B
        • Kim HK
        • Severyn DA
        • et al.
        Cross-comparisons of trending accuracies of continuous cardiac-output measurements: pulse contour analysis, bioreactance, and pulmonary-artery catheter.
        J Clin Monit Comput. 2018; 32: 33-43
        • Squara P
        • Denjean D
        • Estagnasie P
        • et al.
        Noninvasive cardiac output monitoring (NICOM): A clinical validation.
        Intensive Care Med. 2007; 33: 1191-1194
        • Kupersztych-Hagege E
        • Teboul JL
        • Artigas A
        • et al.
        Bioreactance is not reliable for estimating cardiac output and the effects of passive leg raising in critically ill patients.
        Br J Anaesth. 2013; 111: 961-966
        • Phan TD
        • Kluger R
        • Wan C
        • et al.
        A comparison of three minimally invasive cardiac output devices with thermodilution in elective cardiac surgery.
        Anaesth Intensive Care. 2011; 39: 1014-1021
        • de Wilde RBP
        • Schreuder JJ
        • van den Berg PCM
        • et al.
        An evaluation of cardiac output by five arterial pulse contour techniques during cardiac surgery.
        Anaesthesia. 2007; 62: 760-768
        • Hadian M
        • Kim HK
        • Severyn DA
        • et al.
        Cross-comparison of cardiac output trending accuracy of LiDCO, PiCCO, FloTrac and pulmonary artery catheters.
        Crit Care. 2010; 14: R212
        • Mora B
        • Ince I
        • Birkenberg B
        • et al.
        Validation of cardiac output measurement with the LiDCOTM pulse contour system in patients with impaired left ventricular function after cardiac surgery.
        Anaesthesia. 2011; 66: 675-681
        • Broch O
        • Bein B
        • Gruenewald M
        • et al.
        Accuracy of cardiac output by nine different pulse contour algorithms in cardiac surgery patients: A comparison with transpulmonary thermodilution.
        Biomed Res Int. 2016; 20163468015
        • De Waal EEC
        • Wappler F
        • Buhre WF.
        Cardiac output monitoring.
        Curr Opin Anaesthesiol. 2009; 22: 71-77
        • Cecconi M
        • Rhodes A
        • Poloniecki J
        • et al.
        Bench-to-bedside review: The importance of the precision of the reference technique in method comparison studies – with specific reference to the measurement of cardiac output.
        Crit Care. 2009; 13: 201
        • Le Manach Y
        • Collins GS
        Disagreement between cardiac output measurement devices: Which device is the gold standard?.
        Br J Anaesth. 2016; 116: 451-453
        • Bazaral MG
        • Petre J
        • Novoa R.
        Errors in thermodilution cardiac output mesurements caused by rapid pulmonary artery temperature decreases after cardiopulmonary bypass.
        Anesthesiology. 1992; 77: 31-37
        • Yang XX
        • Critchley LA
        • Joynt GM.
        Determination of the precision error of the pulmonary artery thermodilution catheter using an in vitro continuous flow test rig.
        Anesth Analg. 2011; 112: 70-77