Associação de MedicinaIntensiva Brasileira, the AssociaçãoBrasileira de Medicina de Emergência, and theSociedade Brasileira de Medicina Hospitalar formed a groupof 17 physicians to formulate questions relevant to the topic and discuss thepossibility of consensus for each of them. All questions were prepared using afive-point Likert scale. Consensus was defined a priori as at least 80% of theresponses between one and two or between four and five. The consideration of theissues involved two rounds of voting and debate among all participants. The 27questions prepared make up the present document and are divided into 4 majorassessment areas: left ventricular function, right ventricular function,diagnosis of shock, and hemodynamics. At the end of the process, there were 17positive (agreement) and 3 negative (disagreement) consensuses; another 7questions remained without consensus. Although areas of uncertainty persist,this document brings together consensus opinions on several issues related toechocardiography in critically ill patients and may enhance its development inthe national scenario.Echocardiography in critically ill patients has become essential in theevaluation of patients in different settings, such as the hospital. However,unlike for other matters related to the care of these patients, there are stillno recommendations from national medical societies on the subject. The objectiveof this document was to organize and make available expert consensus opinionsthat may help to better incorporate echocardiography in the evaluation ofcritically ill patients. Thus, the  Itsuse as a diagnostic or monitoring tool has gained acceptance in different settingsand is endorsed by several international medical entities.-4The echocardiography of critically ill patients has become an essential part of thecare provided in the most diverse contexts, from the prehospital environment to theintensive care unit (ICU).Zieleskiewicz et al. reportedeven higher prevalence rates in a similar European study. The wide use ofechocardiography by nonechocardiographers is related to several relevant aspects,both from the organizational and educational point of view and in terms of safetyand quality of care. Therefore, it is imperative that medical associationsrepresenting the specialties that use echocardiography for the care of criticallyill patients analyze the available evidence so that recommendations can be generatedthat take into account the particularities of the national scenario.Echocardiographic evaluation is the second most frequent application of ultrasound inBrazilian intensive care units. the demand by the different medical entities involved thatthere be guidance on the teaching practices and respective competencies for the useof ultrasound by the nonechocardiographer physician, with a presumed gain in carequality; the scarcity of high-quality evidence to guide the process of escalation ofrecommendations; and the lack of a similar position in the national scenario thatrepresents the Brazilian reality, in terms of health system organization,professional training, and availability of equipment.The choice of elaborating a document in consensus format is due to several factors,such as the wide use of echocardiography by nonechocardiographers in the mostdiverse settings in which critically ill patients are cared for; the wide variationin regional practice in several aspects;The objective of this document is to organize and make available expert consensusopinions that may help clarify the role of bedside echocardiography performed bynonechocardiographers responsible for the care and evaluation of critically illpatients. The present text is complementary to the one that primarily addresses therecommended skills for the use of this tool. Despite related and importantintentions, the authors understood that a better definition of the scope of thiswork would bring agility and consistency to the final document.Associação deMedicina Intensiva Brasileira (AMIB), theAssociação Brasileira de Medicina deEmergência (ABRAMEDE), and the Sociedade Brasileira deMedicina Hospitalar (SOBRAMH).This is a collaborative initiative between the The committee was initially composed of representatives of each of the entities andlater was structured through the appointment of representatives of each of theentities involved. Each member nominated had to be a medical professional and haverecognized experience in the use of ultrasound for cardiovascular evaluation intheir daily clinical practice. The publication of clinical research in this area andthe practice of teaching ultrasound to medical professionals or students in trainingwere recommended criteria, although not mandatory. The final group was formed inFebruary 2019, consisting of 17 consultants representing the collaborativespecialties and from different regions of Brazil. All group members completed adeclaration of potential conflicts of interest. Two of the authors prepared a set of questions thatwere submitted electronically to three cycles of judgment by the group. Afacilitator assessed the agreement between the individuals and provided individualfeedback to each of the consultants about their responses and any questions theymight have. Between the second and third consultation cycles, there were no changesin the content of the questions, thus validating them. There were no face-to-face orvirtual meetings for this purpose. The 27 validated questions were divided into fourbroad areas according to the similarity between the specific topics: assessment ofleft ventricular (LV) function, assessment of right ventricular (RV) function,diagnostic evaluation of shocks, and hemodynamic evaluation. To follow up on theconsensus process, the modified Delphi method was used, as described below.The questions were selected using the Delphi method.To compile a theoretical basis for obtaining answers to the chosen questions, asystematic review was independently performed in the PubMed database for each of thefour major areas by two authors. The structured search strategy for one of the majorareas can be found in full in A priori consensus was defined as at least 80%of responses being 1 - 2 or 4 - 5.The questions were made available to the committee through an electronic form (GoogleForms). All questions were answered on a five-point Likert scale: strongly disagree(1), disagree (2), neutral (3), agree (4), and strongly agree (5). For each questionanalyzed, the committee members took into account aspects such as consistency of theavailable evidence, analysis of risks, and benefits, associated costs, learningcurve and other barriers to the implementation of bedside echocardiography in eachspecific scenario. The facilitator assessed the coherence of the responses obtained from each member. Incase of the identification of inconsistency between the responses that suggested anerror in the understanding of the statement or a mistake in filling out thequestionnaire, he sent individual responses by e-mail as a form of conference. Theissues that did not generate consensus in the first round of submissions wereforwarded to the members of the advisory committee for a second round, performed 4weeks after the first round. At the end of each round, all participants received acomplete summary of the group voting results for each question evaluated, as well astheir own responses. The individual responses of each member were kept confidentialfrom the other members of the committee at all stages of the process.The issues that still had no consensus after this stage were subjected to onlinevoting in two virtual meetings held in October and November 2020, which broughttogether all the members of the committee. In this stage, the participants had theopportunity to discuss the particularities of each of the questions and argue fortheir position. The duties of the facilitator in the first stage consisted ofclarifying any doubts the participants had and allowing all participants who wishedto do so to have the opportunity to express their views, without the need to reach aconsensus on any questions, and to compile the results of the votes obtained on eachof the questions.www.mentimeter.com). After theonline voting results, questions that had not yet reached consensus were put to anew vote only once if the absolute majority of participants agreed.In the virtual meetings, the questions lacking consensus after the first two stageswere presented to the participants in a grouped manner in two groups: first,questions close to consensus, meaning those that had more than 60% of the answersconcentrated in 1 - 2 or 4 - 5); and second, the questions far from consensus, whichhad responses that were less than 60% 1 - 2 or 4 - 5. The votes were also obtainedanonymously through the online platform Mentimeter and three negative (disagreement) consensuses; another seven questions never reachedconsensus among the participants, overrepresented in the domains LV function andhemodynamic evaluation (three questions each) .To enable the reader to become familiar with the technique for obtaining images bymeans of echocardiography to better understand the aspects discussed here, we willbriefly describe the main echocardiographic windows used in the bedsideexamination.With the transducer positioned near the left sternal border, in the second orthird intercostal space, and with the marker directed to the patient’s rightshoulder, the main structures visualized in this window can be identified: RV,interventricular septum, LV, inferolateral wall, mitral and aortic valves, andleft atrium . ThroughKeeping the transducer positioned in the same location where the longitudinalview was obtained, the examiner performs a rotation of approximately 90°, nowdirecting the marker to the patient’s left shoulder . DependiBy placing the transducer close to the cardiac apex, or approximately in thefifth or sixth intercostal spaces, with the marker pointing to the patient’sleft arm, the apical view is obtained. The four chambers of the heart areidentified: the two atria and the two ventricles . The apiWith the transducer positioned approximately 1 to 2 cm below the xiphoid processand the index finger still directed toward the patient’s left arm, afour-chamber subcostal view can be obtained, in which the two atria and twoventricles are also identified, although in a different orientation than thatobtained in the apical sections .The evaA light caudal sweep can identify the inferior vena cava (IVC) in cross-sectionalview. On the other hand, starting from the subcostal view with the right atriumat the center of the image, a rotation of the transducer positioning the indexfinger toward the sternal notch, the IVC can be visualized in a longitudinalposition . These v1. Qualitative assessment of global LV function is the preferred way ofassessing critically ill patients by nonspecialist physicians - 100%agreement.2. The quantitative assessment of LV function in critically illpatients can be performed by a nonspecialist physician in selectedsituations - 81.25% agreement. while eliminating the delineation of theendocardial border, which can be laborious and time-consuming, even inpatients with a favorable echocardiographic window.The qualitative assessment of LV global function is often used in theevaluation of critically ill patients. Several authors called eye-ballingthe act of determining ventricular function through visual inspection,without the use of any quantitative method. Eye-balling can be performedmore quickly than quantitative reference methodsMelamed et al. identified a good correlation between the categorization intoejection fraction levels of intensivists with brief immersion training usingportable equipment and that of echocardiographers using conventionalequipment. Theevaluation performed using this approach tends to be more accurate thanquantitative assessment.Most published curricula for training in the ultrasonography of criticallyill patients recommend the qualitative evaluation of LV function  as the method ofchoice. in a systematic review of 15 studies that evaluatedultrasound curricula for critically ill patients, reported that the meancorrelation found between nonspecialists and echocardiographers for thequalitative assessment of LV systolic function was 0.67.The participants unanimously agreed that the preferred method for assessingLV systolic function should be qualitative, but 81.25% agreed thatnonspecialist physicians can use quantitative assessment in selectedsituations. Kanji et al.,3. The Simpson method is the method of choice for the quantitativeassessment of LV function in critically ill patients by nonspecialistphysicians - 81.25% disagreement.4. The rate of change of pressure per time interval (dP/dT) should beused by a nonspecialist physician for semiquantitative evaluation of LVsystolic function - 87.5% disagreement.5. The Teichholz method is the method of choice for the quantitativeassessment of LV function in critically ill patients by nonspecialistphysicians - without consensus.6. Mitral annular plane systolic excursion (MAPSE) should be used bynonspecialist physicians for semiquantitative evaluation of LV systolicfunction - without consensus.7. The S’ wave should be used by nonspecialist physicians forsemiquantitative evaluation of LV systolic function - withoutconsensus.The evidence regarding the evaluation of the LV in critically ill patients isquite limited, as most of the available studies included patients withstructural heart disease, not necessarily in the presence of acutedisease.evaluated several parameters for the evaluation of LV systolic function in apopulation of mechanically ventilated critically ill patients in shock. Allthe parameters studied were feasible in this population, although theuniplanar Simpson method was not obtainable in 7% of the individuals (and itshowed an intraobserver variability of 10.6%). The qualitative estimates byeye-balling and MAPSE were obtained in 100% of the patients, and theeye-balling method correlated well with Simpson’s method throughout thestudy period.Bergenzaun et al.,15Although it may provide useful information for the proper assessment of LVfunction, it is a time-consuming method, requires acquisition ofechocardiographic images that are precise enough to delineate theendocardial border, presents significant intraand interobserver variabilityin critically ill patients, and demands a near-specialist level of expertise fromthe examiner. The uniplanar method can be considered an alternative withgood correlation with the biplanar method. and greater agility in obtainingthem.The biplanar Simpson method is widely considered the standard forquantitative assessment of LV ejection fraction.The Teichholz formula, although previously widely used to convert diametersinto systolic and diastolic volumes (and therefore the ejection fraction),also requires good image resolution and proper alignment of the LV walls forits measurement, and it tends to underestimate the repercussion of regionalimpairment of ventricular function, especially in patients with structuralheart disease. Acute changes in blood volume or in preandafterload, for example, can significantly alter ejection fraction withoutnecessarily implying an effective change in systolic function. For the abovereasons, the committee did not reach consensus on issues related to themeasurement of ejection fraction.The use of any of the techniques should take into account the inherentlimitations of the ejection fraction itself as a measure of systolicfunction in critically ill patients. theyare mostly tested in studies of noncritical patients,21 and demand an adequate alignment of the image toavoid underestimation. The MAPSE measurement may constitute a viablealternative in patients with unfavorable acoustic windows. In patients in shock, thereduction in MAPSE was correlated with mortality at 28 days. Despite the favorableaspects considered above, both the acquisition of the MAPSE and the S’ waverequire a certain degree of expertise on the part of the operator, so thatthere are no errors in the acquisition of the image and thus in itsinterpretation and in the subsequent decision-making. We believe that thelack of consensus observed on these topics is related to the fact that theyare inherently quantitative measures, in contrast to those qualitativeparameters and subjective global assessments that characterize the essenceof bedside echocardiography by the nonechocardiographer physician.Regarding the other evaluation parameters of LV function, neither the use ofMAPSE nor the measurement of the S’ wave by means of tissue Doppler  was met ,25requires the identification of mitral regurgitation flow and lacks evidencein acutely ill patients, in addition to demanding from the operator all theabove-described requirements of adequate alignment and image resolution.Thus, the committee members took a position contrary to the routineemployment of this parameter by the nonspecialist physician (87.5%disagreement).The evaluation by means of the dP/dT, although validated for a long time inthe population of noncritical individuals,8. An assessment of RV function should be routinely performed insituations of severe hypoxemia and acute respiratory distress syndrome(ARDS) - 93.75% agreement.9. An assessment of RV function should be routinely performed in casesof pulmonary thromboembolism (PTE) - 100% agreement.the evaluation of RV function has received greater attention due to itsfundamental role in different scenarios commonly encountered in the care ofcritically ill patients. The first decade of the 2000s marked an exponentialincrease in publications involving echocardiographic evaluation of the RV incritically ill patients, as the greater availability of portable machines inintensive care units raised interest in its role.Since Jardin et al.,Right ventricular failure should be considered a heterogeneous syndrome, nota specific condition. Although the generic prevalence of RV failure incritically ill patients has not been established, some contexts seem to bemore frequently present: Patients who are hypoxemic of any nature, patientswith myocardial dysfunction associated with sepsis, and patients in shockare at increased risk of RV failure. The magnitude of the effects of invasiveMV (IMV) on the RV is related to chest compliance, tidal volume, and rightventricular positive end-expiratory pressure (PEEP) applied, among otherfactors. Fougères et al. demonstrated that the increase in PEEP from5cmH2O to the mean value of 13cmH2O  was accompaniedby an increase in RV end-diastolic diameter and vascular resistance lungfunction and a decrease in CO.Mechanical ventilation with positive pressure, by itself, is associated withimpairment of RV function, and among the effects on the RV, the increase inafterload and reduction of preload stand out. The prevalence of acutecor pulmonale has been reported as up to 25% inpatients with ARDS,,33 although it was 60% whenthe MV protocol used higher inspiratory volumes and pressures than thecurrent practice.Acute respiratory distress syndrome is one of the clinical situations thatmost commonly poses challenges to RV function due to the acute increase inafterload. These patients present not only alveolar involvement andhypoxemia but also structural changes in the pulmonary circulation thatprogress with inflammation, vasoconstriction, edema and microthrombi,culminating in an increase in pulmonary artery pressure. The fact that theventilatory strategy seems to interfere with RV performance led the authorsto put forth strategies designated “RV protection”, limiting the plateaupressure, driving pressure, and partial pressure of carbon dioxide(PaCO2), in addition to limiting the plateau pressure,driving pressure, and partial pressure of carbon dioxide (PaCO2),resorting to prone ventilation when these goals are not achieved. Proneventilation seems to be associated with relief of pressures on the rightside of the heart, as demonstrated by Vieillard-Baron et al. in a study that included42 individuals with severe ARDS and that found that both the RV dimensionsand septal dyskinesia are attenuated after an 18-hour session in the proneposition. Accordingly, Joswiak et al. reported a reduction in the RV:LV ratio, areduction in the eccentricity index, and an increase in CO.Hypercapnia, elevation of driving pressure above 18 mmHg and plateau pressureare associated with the development of RV failure.,38Dynamic parameters should be used to assess fluid responsiveness with cautionin patients with RV dysfunction, as the chance of false-positives increasesin this situation, and volume expansion can result in hemodynamicdeterioration through the mechanisms of ventricular interdependence. Theevaluation of echocardiographic parameters of RV function before and aftervolume delivery can be used to rule out the development of acute RVfailure. Up to one-third of patients withpulmonary embolism will have signs of RV distress. A similar prevalence canbe found in inferior infarction.  Regardless of the etiology, the identification ofRV distress in critically ill patients has prognostic relevance in settingssuch as ARDS,PTE andmyocardial infarction,,43 resulting in highermortality.Patients with chronic obstructive pulmonary disease (COPD) are at increasedrisk of developing RV overload, especially when the COPD is exacerbated andthey are subjected to MV. Up to 80% of COPD patients will show signs ofoverload, whether of a chronic or a acute nature.There was a consensus that the RV should be evaluated by a nonspecialistphysician in ARDS and PTE situations .However, the evaluation of RV functionality may be important in severalscenarios often found in ICUs and emergency rooms. The present document isnot intended to exhaust the diagnostic possibilities of bedsideechocardiography; the narrowing of the scope of the questions favored theunderstanding of the committee members and allowed for a consistent positionon several questions in this and other evaluated domains; and specificsituations, such as RV infarction, pulmonary hypertension, and congenitalheart disease, although also frequent, may require specialized evaluation ofRV function, being at the border of the possibilities of bedsideechocardiography by a nonechocardiographer physician. reportedfailure rates of up to 27% of individuals to obtain adequatemeasurements.Not surprisingly, in a considerable number of critically ill patients, itwill not be possible to assess RV function using the transthoracic approach:Huang et al.Furthermore, RV function may be directly influenced by ventilatorystrategies, volume expansion, or vasoactive drugs, making its evaluationessential for the best treatment of critically ill patients.The functional approach to the RV is challenging, both because of itspyramidal shape and because of its retrosternal anatomical location and itscondition that depends on the preload of most parameters used for itsevaluation.Ideally, right heart chamber pressures are measured invasively, eitherthrough conventional right catheterization in the hemodynamics laboratory orby insertion of a pulmonary artery catheter, even allowing continuousmonitoring of pulmonary artery pressure. Echocardiography is a useful (andeven complementary) alternative for the evaluation of the right chambers,both because of its noninvasive nature and because it allows the integrationof morphological aspects, chamber dimensions, and functional parameters. recentlypublished an extensive systematic review addressing all the parameters of RVfunction described in critically ill patients in the ICU, operating room, oremergency department, including, for the most part, patients with PTE, ARDS,postoperative cardiac surgery, and myocardial dysfunction combined withsepsis. Studies of prognosis (28%) and associations between variables (27%)prevailed. Most studies (69%) used a combination of parameters to assess RVfunction. Although the use of a single parameter results in greatersimplicity, each parameter has specific advantages and limitations and maynot be ideal for the clinical situation or patient in question.Huang et al.The parameters of RV function can be classified as global function,longitudinal function, and right chamber pressure.10. The assessment of RV function by nonspecialists should be performedusing the parameters of global systolic function  - 100% agreement.Although reference values for RV dimensions are not adequately validated forpatients under VM, their comparison with the left side can serve as areference. Therelationship between the RV and LV areas is commonly used in the definitionof cor pulmonale with anomalous septal movement. Under physiologicalconditions, the RV diastolic area will be up to 60% of the LV diastolic area(RV/EV up to 0.6). When the RV area exceeds 60% of the LV, there will be RVdilation, which is considered severe if the RV/LV ratio is greater than 1(RV greater than LV). Vieillard-Baron et al. found a mortality rate of 25% in patientswith ARDS and an RV area ratio/EV greater than 1.The planimetry of the endocardial edge of both ventricles in the apicalfour-chamber view to measure their respective areas can be used for thispurpose.Additionally, using the apical four-chamber view, it is possible to measurethe distance between the interventricular septum and the lateral insertionsof the tricuspid and mitral rings, yielding the RV and LV diameters,respectively. The same parameters for RV/EVs used for the area may be usedwith their diameters. One-dimensional measurements, however, may havelimited accuracy under conditions of increased RV preandafterload.In obtaining these measurements, special care should be taken to measure thelargest possible RV dimensions, as window angle distortions are frequentcauses of underestimation. These measurements should be performed at the endof ventricular diastole, with the atrioventricular valves at their maximumopenness.The interventricular septum is part of the anatomical structure of the LV andshould maintain, together with the other LV walls, a symmetrical conformation,with synchronous contractility in the transverse axis. This, however, depends onthe maintenance of physiological pressure relationships.In situations of an increase in pressure on the right side of the heart, theinterventricular septum may be pushed back toward the LV, becoming straightenedin some or all of the cardiac cycle. Dyssynchronous contraction of the septumrelative to the remainder of the LV is termed paradoxical movement and should beconsidered a specific sign of increased RV afterload. Up to 22% of patients withARDS exhibit paradoxical septal movement within the first 3 days ofARDS.11. The assessment of RV function by a nonspecialist should be performed bymeasuring the fractional area change (FAC) - 81.25% disagreement. Thereduced rate also has prognostic importance: independent of other factors, itwas associated with all-cause mortality in patients after myocardialinfarction. Forproper measurement, it is necessary to carefully and manually delimit theendocardial border, starting from the lateral tricuspid annulus, following theRV free wall to the medial tricuspid annulus, which can be technicallychallenging in situations of inadequate positioning , IMV, and use of dedicated bedside equipment, which isnot always sufficient to perform advanced echocardiographic measurements.Furthermore, it should be noted that while the measurement incorporates septalcontractility (and is therefore influenced by the LV), the contribution of theRV outflow tract will not be taken into account. For these reasons, thecommittee members opposed the routine use of this parameter.Based on the planimetry of the RV endocardial border at end-systole andend-diastole, its fractional change can be calculated as (diastolic area -systolic area)/diastolic area. Fractional area change values < 35% indicateRV dysfunction. Fractional area change is associated with RV ejection fractionand is even used in some studies as a parameter of comparison for otherindices.12. The assessment of RV function by nonspecialists should be performed bymeasuring the parameters of longitudinal function  - 87.5% agreement.The arrangement of the myocardial fibers in the RV follows a predominantlylongitudinal orientation, as opposed to the LV, which is transversal. Thus,the main mechanism of RV contraction occurs in the long axis, from the basetoward the apex. The maximum displacement of the tricuspid plane toward theRV apex can be measured using the M-mode .When below 17 mm, it suggests RV dysfunction and has prognostic impact indifferent scenarios,-53 being an isolatedpredictor of mortality in a recent study of patients with ARDS. TAPSE does not provideinformation on regional contractility and may be inaccurate in cases ofsegmental dysfunction.The TAPSE value is related to the RV ejection fraction measured by myocardialscintigraphy.Tricuspid annular plane systolic excursion is the parameter most frequentlystudied in critically ill patients, possibly due to the simplicity of itsmeasurement. It is, however, subject to distortions, especially in relationto the measurement axis and movement artifacts of the heart and the patienthimself. It is essential to pay attention to the correct alignment of theultrasound beam with the axis of longitudinal contraction of the RV to avoidunderestimation. In this way, good intraand interoperator reproducibilitycan be obtained.In addition to TAPSE, the application of tissue Doppler imaging on thetricuspid annulus, together with its insertion into the RV free wall, allowsthe measurement of the maximum velocity of myocardial displacement towardthe apex, representing a parameter of systolic function . An S’ wAs with TAPSE, attention should be paid to artifacts of movement andangulation of the longitudinal axis. The S’ wave value depends less on thequality of the image obtained in B-mode, allowing measurements even withlimited windows. In critically ill patients, S’ wave measurement is notas widely used as TAPSE, but it has been associated with prolongedMV, theseverity of sepsis, and its prognosis.Although correlated with pulmonary artery systolic pressure (PASP)measurements obtained using the tricuspid regurgitation jet, this methodstill lacks validation against invasive measurements using right heartcatheterization.13. The assessment of RV function by nonspecialists can be performed bymeasuring right chamber pressures in selected situations - withoutconsensus. Theevaluation of the tricuspid regurgitant jet provides information about thedegree of elevation of the pressures in the pulmonary arterial bed: as arule, the maximum velocity of tricuspid regurgitation is directlyproportional to the pulmonary arterial pressure. A regurgitation velocity ofless than 2 m/s is considered normal max)2] allows thecalculation of the pressure gradient from the direct measurement of themaximum regurgitant velocity. This gradient should then be added to the right atrialpressure (RAP) to result in the estimation of PASP .With the use of continuous Doppler aligned to the axis of the regurgitantjet, the simplified Bernoulli formula [4 into kinetic energy(peak velocity of the tricuspid regurgitation jet). In situations where thisrelationship is altered, the pressure estimate may be consequently affected.Eccentric regurgitant jets or patients with a small RA may have anunderestimated peak pressure. Furthermore, factors such as marked dilationof the tricuspid annulus , as well as RV systolic dysfunction,imply a risk of underestimation if the measures dependent on the analysis oftricuspid regurgitation flow. Likewise, polycythemia or severe anemia caninterfere with blood viscosity and result in underestimation oroverestimation, respectively. Considering that the regurgitation velocity factorwill be squared, small measurement errors will result in substantiallydifferent measurements.The agreement between the PASP measurement using the Bernoulli equation andright catheterization is moderate, reported significant deviations from this measure inpatients with advanced lung disease on the list for lung transplantation. Incritically ill patients undergoing IMV and monitoring with a pulmonaryartery catheter, Bouhemad et al. reported a significant correlation (r = 0.74)between tricuspid regurgitation and PASP. More recently, Mercado etal. reported asignificant correlation (r = 0.87) with PASP and 100% accuracy for theidentification of pulmonary hypertension.Most of the studies that analyzed the agreement between echocardiographicparameters and invasive measures of PASP were performed in stable patientsunder spontaneous ventilation. In situations where there is lunghyperinflation , the accuracy of these parametersis less known. Arcasoy et al. and between 60 and 70%among critically ill patients on MV,64 due tothe presence of obstacles such as an insufficient cardiac window andhyperinflation. The effective absence of tricuspid regurgitation,despite making this approach impossible, does not rule out elevation ofpulmonary artery pressure: approximately 20% of patients with PASP above35mmHg will not have tricuspid regurgitation; among those with PASP above50, up to 95% will have a detectable regurgitant jet.The proportion of patients in whom it is feasible to evaluate tricuspidregurgitation is approximately 75% among outpatientsMean pulmonary artery pressure (MPAP) is an essential parameter for thecalculation of pulmonary vascular resistance, in addition to beingrepresentative in the evaluation of scenarios in which pulmonary hypertension issuspected. This pressure can be measured in different ways by means ofechocardiography, mainly the evaluation of the pulmonary regurgitant jet, theacquisition of the VTI through planimetry of the tricuspid regurgitant jet, andthe measurement of the acceleration time of the pulmonary valve.,68 However,this measure will be feasible only in approximately 25% of situations involvingcritically ill patients.In the parasternal short-axis view, at the level of the heart base, theapplication of color Doppler can identify a regurgitant jet starting from thepulmonary valve. The application of continuous Doppler imaging will thus allowthe calculation of the maximum regurgitation velocity and of the gradientbetween the pulmonary artery and the RV. This gradient, added to the RAP, willresult in the estimate of MPAP.,70 The MPAP can be estimated using the formula 90 - (0.62× acceleration time). Changes in heart rate may limit the accuracy ofthis measurement, although for MPAP values above 25mmHg, accuracy seems to bemaintained. Theidentification of a systolic notch in the ejection flow indicates an increase inpulmonary vascular resistance and suggests the possibility of a precapillarymechanism.In the same section, the acceleration time of the pulmonary valve, defined as thetime required for the RV outflow tract flow to reach its maximum velocity, canbe obtained by applying pulsed Doppler imaging immediately proximal to thepulmonary valve. The shorter the acceleration time, the higher the pulmonaryartery pressure. A value above 130 milliseconds will be considered normal, whilea value below 105 milliseconds suggests pulmonary hypertension. Inthe transthoracic approach of a patient under MV, the correct alignment with theRV outflow tract may be problematic, and the transesophageal approach mayconstitute a viable alternative.The acceleration time is a measure that depends on RV preload, contractility,pulmonary vascular resistance, and the intricate mechanisms between thesefactors. The reproducibility of acceleration time in critically ill patients is,therefore, limited to specific studies with unsatisfactoryperformance. proposed an additional methodfor estimating MPAP using regurgitant jet planimetry. The resulting meangradient is simply added to the RAP, yielding an estimate of MPAP withapproximately 80% accuracy against measurements obtained by pulmonary arterycatheter. Thismethod was later reproduced by Laver et al. in a population of 53 critically ill patientsundergoing pulmonary artery catheterization. Although the mean differencebetween the MPAP measurements was only 1.9mmHg, jet planimetry for applicationof this technique could be obtained in only 43% of the patients, limiting itsapplicability.Evaluating the tricuspid regurgitant jet, Aduen et al. The members of the committee did not reach a consensus about the estimation ofright chamber pressures by means of bedside echocardiography by anonechocardiographer physician. On the one hand, there is recognition that theseparameters have long been used in clinical practice and are directly related tothe physiology of critically ill patients and even to the calculation oftraditional hemodynamic variables . On theother hand, there are uncertainties about their accuracy in the specificscenarios of emergency and intensive care and the lack of validation of many ofthese findings on these parameters in unstable patients. In addition, factorssuch as insufficient echocardiographic windows, frequent use of IMV, and theneed for advanced skills on the part of the examiner to perform differentquantitative measures limit the applicability of these measures in acomprehensive manner.14. Bedside echocardiography should be routinely used in the initialevaluation of shock - 100% agreement.15. Bedside echocardiography should be routinely used in the follow-upof shock and in the reassessment after institution of therapies - 100%agreement.16. Bedside echocardiography contributes to the recognition of severehypovolemia as the cause of shock - 100% agreement.cor pulmonale as the cause of shock - 100%agreement.17. Bedside echocardiography contributes to the recognition of18. Bedside echocardiography contributes to the recognition of cardiactamponade as the cause of shock - 100% agreement.19. Bedside echocardiography contributes to the recognition of severeleft ventricular dysfunction as the cause of shock - 100%agreement.cor pulmonale,severe LV dysfunction, or significant pericardial effusion, making it a toolthat can potentially reduce the time to diagnosis.,77This domain was the only one to reach a positive consensus of 100% on all sixquestions evaluated - all of them in the first round of responses byelectronic form. The use of bedside echocardiography is useful in the studyof shock and should be used in the initial evaluation to help understand themechanisms of hemodynamic instability. Ultrasound analysis will allow theevaluation of signs of severe hypovolemia, Hypovolemic shock is characterized by a low CO due to reduced stroke volume.Cavities with reduced dimensions and low filling pressures are visualized,and sometimes, at the end of each systole, the walls touch each other, asign described as kissing walls or systolic obliteration sign. The IVC isusually collapsed and varies greatly in diameter in the respiratorycycle.The RV undergoes dilation and systolic dysfunction after these gradualincreases in afterload pressures, ultimately leading to obstructive shock.If the pressure on the right side becomes greater than that on the leftside, there will be a paradoxical movement of the interventricular septum tothe left, in addition to increasing dilation of the right chamber. These twofindings together make up what we call cor pulmonale. Incases of acute cor pulmonale, we can also observe thepresence of segmental alteration of the RV walls with the presence ofhypokinesia or akinesia of the lateral wall with normal contraction of theapex. In cases of shock with suspected pulmonary embolism, the combined useof venous ultrasound and right ventricular dilation on echocardiogramincreases the specificity of the diagnosis of PTE.Right ventricular failure can occur in some critical situations, such asmassive pulmonary embolism and adult respiratory distress syndrome, due tothe use of high ventilatory pressures to maintain an oxygenation levelcompatible with life.The presence of hypoechoic content around the heart is indicative of theaccumulation of pericardial fluid. The rate of accumulation of thispericardial fluid dictates how much accumulated fluid will be required tocause circulatory collapse due to tamponade. Chronic effusions rely onpericardial compliance adjustment and can reach large effusion volumesbefore collapse. Acute effusions, such as hemopericardium, lead to collapsemore quickly due to tamponade, and approximately 50 - 100mL of blood isenough to cause shock. The timely identification of tamponade cansignificantly alter the treatment of patients in shock. The RA systoliccollapse, added to RV diastolic collapse, is the earliest sign. The IVCbecomes turgid and unchanging. Other signs that can be identified includevariation in aortic, mitral, and tricuspid flow. An inspiratory variationgreater than 25% measured on pulsed Doppler ultrasound at the mitral valvelevel and an inspiratory variation greater than 40% at the tricuspid valvelevel indicate the diagnosis of pericardial tamponade. Another sign that maybe present is the swinging of the heart in the midst of the fluid, calledswinging heart, indicating that cardiac tamponade most likely occurs in thepresence of hemodynamic instability.The use of parameters related to LV function - notably by eye-balling - inpatients with shock can quickly rule out the cardiogenic mechanism. Whenassociated with high-output states and reduced afterload, however, LVdysfunction may remain undetected, becoming evident only afterreestablishment of blood volume. This can significantly change thetreatment of patients with hemodynamic instability, directing the line oftreatment toward systemic vasoconstrictors and inotropic and chronotropicagents, for example, for heart rate control and maintenance of euvolemia, oreven administration of volume expansion aliquots. Sometimes unknowna priori or even having an acute onset at the time ofcritical illness, itsrecognition becomes essential for the intensivist qualified inadvanced-level echocardiography.A clinical situation that deserves mention is the dynamic obstruction of theLV outflow tract. Found in up to 20% of patients with septic shock, it isassociated with high mortality in the ICU. Bagheri-Hariri et al., evaluating patients inshock in the emergency room, reported a correlation coefficient of 0.84between the result of the RUSH protocol and the final reference diagnosis. Arecent systematic review identified four original studies that evaluated thediagnostic performance of the RUSH protocol. The positive likelihood ratio rangedbetween 8.25 (for hypovolemic shock) and 40.54 for obstructive shock; thenegative likelihood ratio was between 0.13 (for obstructive shock) and 0.32(for shock of mixed etiology). In general, the protocol performed better atcorroborating than excluding possible mechanisms of shock.The rapid ultrasound for shock and hypotension (RUSH) protocol consists ofthe evaluation of fluid collections in the costophrenic sinuses and pelvis,in addition to the abdominal aorta and cardiac function itself, throughparasternal, apical, and subxiphoid views.,86 The use ofechocardiography in patients with shock has even been associated with betterclinical outcomes in observational studies.,87The use of echocardiography in the evaluation of patients in shock cansignificantly alter the procedures adopted. Echocardiography-guided therapyof patients in shock tends to be associated with lower fluid use and greaterrecognition of LV dysfunction - and, consequently, the use ofinotropes.The assessment of blood volume in critically ill patients is a complex taskthat requires an integrative and multimodal approach. The use of ultrasoundin this context should be viewed in the same way: The examiner should seekdifferent tools that, through the clinical-echocardiographic correlation,will yield the most representative information. This topic may be the onethat has undergone the most changes over the past few years in relation tothe assessment of blood volume status and regarding how to use ultrasoundparameters to assess fluid responsiveness.Important components of blood volume that can be evaluated are the estimateof filling pressures, both on the right side  andon the left side of the heart (pulmonary artery occlusion pressure - PAOP),and the estimate of extravascular pulmonary water (EVPW).,89 and thatreflect complex interactions of cardiopulmonary physiology. Examples ofstatic variables are RAP and PAOP. Specific (dynamic) parameters should beused to assess fluid responsiveness, which will be discussed in latersections.As a rule, the assessment of blood volume status takes into account variablescollectively known as static, obtained at a given time, providing data oncardiac chamber pressures that do not directly inform about theresponsiveness potential to fluids20. The estimation of central venous pressure by echocardiography by anonspecialist physician is recommended as part of the hemodynamicevaluation of critically ill patients - 81.25% agreement. and forthe determination of pressures on the right side of the heart, since theRV-RA gradient is imposed on it.The estimation of central venous pressure - or RAP - is part of theunderstanding of the volume and hemodynamic status of critically illpatients and is mainly determined by venous return and right ventricularfunction. As a rule, the RAP measurement should be incorporated into theclinical context not in isolation but taking into account all the rest ofthe hemodynamic evaluation. Among other scenarios, knowledge of the RAPvalue is relevant both for the hemodynamic management of the patient inshock Furthermore, the mechanics of the IVC remainunchanged by compensatory responses to a loss of circulating volume or theinfusion of vasoconstrictors.The RAP can be estimated by echocardiography of the IVC, according to thephase of the respiratory cycle. Because it is a highly compliant,collapsible, and contiguous vessel, the IVC directly reflects changes in thevolume and filling pressure of the RA. Someauthors evaluated the indexation of the IVC diameter to the body surface,with inconsistent results.-99 Theinterobserver correlation of IVC diameter ranges between 0.56 and 0.81 andtends to be more precise as the examiner accumulates experience.-101The diameter of the IVC should be measured with the patient in the supineposition, through a four-chamber subcostal view, from its longitudinal view,at a distance of 0.5 to 2cm from its insertion in the RA, taking care tomaintain the most perpendicular alignment possible with the walls of the IVCto obtain the most faithful measurement. Measurements in the right or leftlateral decubitus position can significantly change the diameter of theIVC.,102-104others evaluated the so-called collapse index (maximum diameter - minimumdiameter/maximum diameter).,105,106 The correlationcoefficients (r) reported between RAP and diastolic diameter are between0.72 and 0.86; between RAP. and the collapsibility index, they are between0.57 and 0.76. Stawicki et al. reported an negative correlation between a 3.3%variation in the collapsibility index and 1mmHg in RAP.The precise method used to measure the IVC diameter has varied considerablybetween the studies that has evaluated the performance of this technique.While some authors sought to relate the IVC diastolic diameter withRAP,,106,108 due to the significant overlap of patients withnormal and elevated RAP and dilated IVC, as well as the limited ability ofthe IVC to dilate in response to RAP increases. The identification ofdilated IVC may suggest high RAP but cannot identify the magnitude of thisincrease.Extreme values of IVC diameter, however, may be useful in selectedsituations. When lower than 12mm, they are correlated with RAP lower than10mmHg in patients under IMV, with high specificity, albeit at the expense oflow sensitivity.The accuracy of these parameters for predicting the specific RAP value,however, is limited  or patients with a large body surface area maysimilarly have spurious dilation of the IVC. In addition, portal orintra-abdominal hypertension of another nature, such as from asthma orexacerbated COPD,may limit our ability to properly evaluate the behavior of the IVC.A number of clinical situations can result in IVC dilation without associatedelevation of RAP. Athletes Therefore, the RAP estimate by means ofIVC analysis should be primarily used in spontaneously ventilated patients(negative inspiratory intrathoracic pressure). In this population, Dipti etal., in ameta-analysis of five studies conducted in the emergency room, reported thatthe maximum IVC diameter is consistently smaller in hypovolemic patientsthan in euvolemic patients. In dyspneic patients in the emergency room, theanalysis of the diameter of the IVC was the most accurate ultrasoundmeasurement for the identification of the cardiac etiology.Notably, patients under IMV may have a dilated IVC only as a result ofpositive intrathoracic pressure. The correlation between IVC diameter andRAP was greater in spontaneously ventilated patients (r = 0.97) than inmechanically ventilated patients (r = 0.59). and the exact precision of this strategy is notadequately documented.The guidelines of the American Society of Echocardiography propose that byintegrating the degree of inspiratory collapse and its diameter, a certainRAP value can be assigned. The degree of IVC collapse should be expressed asa percentage and as a dichotomous variable (less than or greater than 50%).This technique will allow the arbitrary assignment of one of threepredetermined values . It is not possible through this methodto determine the exact value of RAP,Hepatic venous flow is directly related to venous flow through theatrio-caval system, thus sharing much of its behavior in differenthemodynamic situations. The left and right hepatic veins drain into the IVCat the level of the diaphragm and can be evaluated by means of afour-chamber subcostal view.Although studied mainly in MV patients ,this technique requires greater expertise on the part of the operator toobtain the appropriate window and apply Doppler imaging.The evaluation of hepatic venous flow can be used as a complementary tool inthe estimation of RAP. In conditions of low or intermediate RAP, there willbe a predominance of systolic flow in the liver (the systolic wave velocity- Vs - will be higher than the diastolic wave velocity - Vd). When RAPincreases, systolic predominance is lost, and the Vs/Vd ratio will be lessthan 1. Similarly, the systolic filling fraction of the hepatic vein(systolic VTI/systolic VTI + diastolic VTI) can be calculated. A value lowerthan 55% is correlated with a RAP above 8mmHg with 86% sensitivity and 90%specificity.-119 Several other techniques have beendescribed for the evaluation of RAP, but in the understanding of this group,they are beyond the scope of the nonechocardiographer.,120,121The evaluation of jugular vein dynamics through different techniques has beenproposed to estimate RAP, with conflicting results.21. The estimation of left atrial pressure (LAP) by means ofechocardiography by a nonspecialist physician should be part of thehemodynamic evaluation of critically ill patients - withoutconsensus.PAOP is a hemodynamic parameter related to LV filling and therefore to LVdiastolic function and LAP. It can be measured through cardiaccatheterization or, more commonly in clinical practice, through theinsertion of a pulmonary artery catheter and the occlusion of a main branchof the pulmonary artery by insufflation of its distal cuff. Echocardiographyis a noninvasive alternative for the evaluation of PAOP because severalechocardiographic parameters related to ventricular diastole can be used forits estimation. Among the relevant parameters, the most frequently used arethe E wave, the E/A ratio, the e’ wave and the E/e’ ratio.The E wave corresponds to the first phase of ventricular diastole (rapidventricular filling - early filling), a consequence of the pressure gradientgenerated between the atrium and the LV, from the isovolumetric relaxationof the LV. In this phase of the cardiac cycle, approximately 60 - 65% ofdiastolic filling occurs. The peak E-wave velocity is measured by placingthe pulsed Doppler sample volume immediately above the opening of the mitralleaflets in the apical four-chamber view. Under physiological conditions,the expected value of the E wave is 80 - 100cm/s. In healthy individuals,the E wave measurement alone may be a predictor of PAOP. in a population ofcritically ill patients, identified a significant correlation (r = 0.75)between the E/A value and the PAOP measured by pulmonary arterycatheterization. Boussuges et al. evaluated E/A in mechanically ventilatedpatients, among other hemodynamic parameters, and found a positivepredictive value of 100% for LAP above 18mmHg when E/A was greater than2.After equalization of the pressure gradient between the LA and LV, theremainder of the LV filling will occur by atrial contraction, represented ontransmitral Doppler as the A wave. The E/A ratio, under physiologicalconditions, therefore remains above 1. In situations in which LV relaxationis compromised, the LA-LV pressure gradient becomes narrower, lowering theamplitude of the E wave (E/A less than 1). In clinical situations in whichthere is a consequent compensatory increase in LAP, this pattern willreverse, returning E/A to greater than 1  or even togreater than 2 (restrictive pattern). Nagueh et al., Ommen et al., using invasivehemodynamic parameters as a reference in patients referred for cardiaccatheterization, found that the accuracy of E/e’ was 76% in relation to LVdiastolic pressure, with even better results when using the septal mitralannulus lateral (or even the average between these point measurements) tomeasure the velocity of myocardial tissue displacement. Applying a bimodalanalysis, the authors reported that 23 of 27 patients with E/e’ lower than 8had normal diastolic pressures; similarly, all patients with E/e’ above 15had high diastolic pressures.The most studied parameter for the evaluation of left diastolic pressuresmight be E/e’, which is an indexing of the E wave by its tissue equivalent(e’), a variable that is less subject to preload variations .(125) Omthrough a systematic review, indicated that there is not enough evidence toproperly evaluate the correlation of E/e’ with changes in LV diastolicpressure in response to exercise or pharmacological interventions, furtherincreasing the uncertainty regarding patient instability. Also noteworthyare the frequent technical limitations related to the measurement of the e’parameter: pathologies that affect the structure of the mitral annulus,severe mitral regurgitation, ventricular dyssynchrony, and regionalcontractile abnormalities. Although specific studies suggest the accuracy ofthis measurement even in patients undergoing MV and in septic shock, reference values havenot yet been adequately validated in the population of critically illpatients.These results were obtained in hemodynamically stable patients, so theirgeneralizability to critically ill patients remains a matter of doubt.Sharifov et al., Likewise, a recentmeta-analysis of studies in patients with preserved LV systolicfunctionevaluated the correlation of invasive measurements with echocardiographicparameters of diastolic dysfunction. The best accuracy was found with E/e’,although with wide variability (r = 0.19 - 0.84) and predominantly moderatecorrelation. The studies were underpowered  and included mostlyoutpatients and hemodynamically stable patients.The positive and negative predictive value of E/e’ greater than 14 were onlymoderate  in a recent cross-sectional study thatcompared echocardiographic parameters with invasive measurements.Furthermore, the combined use of diastolic function assessment withpulmonary ultrasound,134 may provide moreconsistent information about the underlying mechanism in scenarios of acuterespiratory failure.Although these measurements are frequently taken in clinical practice and arerelatively simple to obtain, taking into account the still inconsistentfindings regarding the use of these parameters in critically ill patients,there was no consensus on their use. Aside from the limitations of theseparameters for measuring filling pressures in critically ill patients, theprognostic power of the assessment of diastolic function has gottenattention.22. The estimation of EVPW by means of chest ultrasound by anonspecialist physician should be part of the hemodynamic evaluation ofcritically ill patients - 87.5% agreement.In situations of hemodynamic instability, the decision to administer aliquotsof expander solutions may be indicated, although the aggressiveness of thisstrategy has been a matter of debate. The increase in pulmonary capillarypermeability in critically ill patients, however, can result in fluidleakage into the extravascular compartment and a consequent increase in EVPWand hypoxemia, further complicating the daily decision-making processregarding volume expansion in the ICU.-137Transpulmonary thermodilution is the method of choice for clinicalevaluation of the amount of EVPW, although it requires the use ofspecialized and invasive equipment, limiting its availability at the bedsidein selected settings. Through thermodilution, the expected values of EVPWare between 3 and 7mL/kg of ideal weight, while values above 10mL/kg arecharacteristic of pulmonary edema.Chest X-ray continues to be used for EVPW monitoring, although its accuracyfor this purpose is not ideal. Theincrease in EVPW is linearly correlated with the increase in the amount ofpulmonary B lines.,141 The amount of EVPWestimated by ultrasound is correlated with a worse prognosis in patientswith ARDS; valuesabove 14mL/kg are associated with higher mortality when detected on ICUadmission.In this scenario, chest ultrasonography is an option because the presence ofenough EVPW provides enough acoustic impedance for the propagation of theultrasonic beams, triggering the formation of artifacts known as Blines.analyzed 73 critically ill patients regarding the correlation between thepulmonary sonographic pattern  and the PAOP and EVPW levels. Although theaccuracy of pulmonary sonographic pattern A for the prediction of PAOP <18mmHg was limited (sensitivity of 85.7% and specificity of 40%), theresults for EVPW were promising (sensitivity of 81% and specificity of 90.9%for PLE < 10mL/kg). These findings are in agreement with previousfindings,possibly reflecting the complexity of hemodynamic phenomena in the contextof critical illness.Volpicelli et al.-146 and when interpreted in the appropriateclinical setting, this finding may reflect real-time fluctuations in bloodvolume status. The dynamism of the findings may make it feasible to use lungultrasound to monitor EVPW in the context of trauma or in the perioperativeperiod of major thoracic surgery.-149The dynamics of identification of B lines reflect both their precocity andfugacity. When there are significant variations in blood volume,150 The use of simplifiedprotocols isrelated to comparable diagnostic accuracy, even using fewermeasurements.Extravascular pulmonary water volume can be estimated by means of thequantification of pulmonary B lines using one of several protocolsavailable. proposed the automation of this quantification bydedicated software, although these findings still lack validation indifferent populations. The low specificity of B lines should be taken intoaccount in relation to the presence of previous parenchymal diseases, which may limit the use ofthis tool in an unselected population of individuals.Although many studies have evaluated the correlation between the number of Blines and both the development of clinical pulmonary edema and the directincrease in EVPW, it must be kept in mind that these were small studies (19- 73 patients) and that it is still uncertain what is the most appropriatetechnique for monitoring the number of B lines and how to deal with thesubjectivity in the quantification of this artifact in the eyes of theoperator. Corradi et al.23. The use of B lines in lung ultrasound can be used as a safetymeasure for the provision of fluids - 81.25% agreement. suggest that the supply of fluids, whennecessary, should be guided by lung ultrasound up to the point at which thepatient begins to develop B lines, indicating that the inflection point ofthe Frank-Starling curve has been reached. From that point on, additionalfluids would only have deleterious effects.Based on the rationale of the relationship between EVPW and the increase inpulmonary B lines, some authors demonstrated that theappearance of pulmonary B lines occurs early in the induction of lung injuryafter administration of oleic acid, with concomitant worsening ofcompliance, but much earlier than the onset of hypoxemia. Caltabeloti etal.evaluated 32 patients with sepsis and ARDS and reported that the B-lineultrasound score increased by 23% when measured 40 minutes afteradministration of a 1,000mL aliquot of crystalloid in relation to thebaseline. In contrast, the relationship between the partial pressure ofoxygen and the fraction of inspired oxygen (PaO2/FiO2)remained stable at this point, suggesting that the findings by Gargani etal. may bemirrored in clinical studies involving critically ill patients. Theerawit etal., in astudy that included 20 patients admitted to the ICU, reported that theB-line ultrasound score was correlated with the increase in water balance 48hours after admission.In a study of experimental models of ARDS, Gargani et al.applied a structured volume expansion protocol using ultrasound parametersto replace the classic hemodynamic variables used by Rivers etal. B linesappeared in nine patients, warranting additional investigation ofechocardiography and administration of inotropes or vasoconstrictors.However, there was no control group or differentiation between thecharacteristics of patients who developed and did not develop B lines.Furthermore, the mean amount of fluid administered was greater than 5L inthe first 6 hours of treatment, limiting the external applicability of thesefindings.In a study that evaluated 47 patients with septic shock in the emergencyroom, Coen et al.,157 orsimply dynamic parameters. These are maneuvers that affect cardiac functionand/or the heart-lung interaction, resulting in hemodynamic disturbances.The maneuvers may consist of postural changes, respiratory cycle phases, oreven infusion of small aliquots. The magnitude of the resulting hemodynamicdisturbance will determine whether the individual has a greater or lesserchance of responding to fluids by increasing their CO.Fluid responsiveness is evaluated based on the use of hemodynamic testscollectively called “functional” Numerous studies have associated unfavorableoutcomes both to administration of too little (with consequent impairment oftissue perfusion) and too much administration of fluids,,160 leading to weight gain, fluid overload,and several deleterious effects in different systems.Fluid administration should follow the rationale of other pharmacologicalinterventions for critically ill patients, respecting the establishedindication, presentation, and dosage.-163 For these reasons, the search for the answer towhether a particular patient benefits from an additional supply of fluids isone of the main issues in the routine care of the critically illpatient.Under the most commonly used definitions of fluid responsiveness , it is estimated that the proportion of fluid responders in emergencyrooms and ICUs is not greater than 50%.The use of echocardiographic variables may noninvasively provide informationon the potential benefit of offering fluids through various parameters.These measurements can be repeated as many times as necessary to reassessthe patient’s behavior over time, with variations in the clinical context,and after any interventions are performed.24. Inferior vena cava variability should be used as a tool forassessing fluid responsiveness - without consensus.The IVC is a compliant vessel, with its caliber altered by volume status,right ventricular function, and respiratory cycle. The behavior of the IVCwill differ according to the patient’s ventilation - in positive pressure,it will be controlled, while under negative pressure, it will bespontaneous. The positive pressure applied to the airway in the inspiratoryphase of MV will determine the engorgement of the intrahepatic portion ofthe IVC, which is reversed in the exhalation phase. In spontaneousventilation, the reverse phenomenon will be observed (inspiratory collapse).The greater the impact of pressure changes in the airways on the IVC, thegreater the potential for fluid responsiveness.The transverse diameter of the IVC should be measured in the longitudinalview, through the subcostal window, caudal to the course of the suprahepaticvein. The suggested distance for a better approach to the IVC diameter isapproximately 0.5-2 cm from the atrio-vena cava junction. The M mode iscommonly used to facilitate the measurement process. Inpatients on MV, the most common calculation method is the distensibilityindex: /mean diameter × 100%, whose ideal cutoff pointwould be 12%. The qualitative assessment of IVC distensibility is analternative to the quantitative approach and was the subject of the study byDuwat et al.  Inthose patients situated in the extremes of distensibility (< 15 and >30%), the accuracy of the qualitative evaluation was similar to thequantitative one. In the distensibility range between 15 and 30%, however,the error rate of the qualitative evaluation reached 35%.For patients breathing spontaneously, the most frequently used index is thecollapsibility index: (maximum diameter - minimum diameter/maximum diameter× 100%). reported that the diagnostic accuracy of IVCdistensibility is higher in ventilated patients with a TV of > 8mL/kgpredicted weight or PEEP below 5cmH2O. Similarly, almost all of thepublished studies included patients in sinus rhythm. Bortolotti etal.published the only study to date that exclusively evaluated patients witharrhythmia , reporting an area under thereceiver operating characteristic (ROC) curve of 0.93 for the collapseindex. Barbier and Feissel published their results independently butconcurrently,,166 both evaluatingpatients undergoing IMV, reporting sensitivity of 96 - 90% and specificityof 75 - 90%, respectively. Several other studies are available in thiscontext, most of them single-center and with highly selected and limitedsamples (n = 15 to 90).It is important to pay attention to the ventilatory parameters in thosepatients on MV. Si et al. IVC distensibility hadonly moderate accuracy in predicting fluid responsiveness, with lowsensitivity. The authors also evaluated the end-expiratory diameter of theIVC; when evaluated at its extremes, it had a specificity of 80% for <13mm (responders) and > 25mm (nonresponders). However, patients in thesesituations made up only 30% of the study population.In the largest study to date evaluating the behavior of the IVC,-173 were performed toevaluate the aggregate performance of IVC variability for fluidresponsiveness prediction. The reported sensitivity and specificity arebetween 63 - 76% and 73 - 86%, respectively. This diagnostic accuracy refersto a heterogeneous group of patients, including individuals under MV andspontaneous ventilation, although their physiology is different. Muller andAirapetian,,174 evaluating onlyspontaneously breathing patients, reported that a collapsibility value ofapproximately 40% is associated with fluid responsiveness with goodspecificity but poor sensitivity. Préau et al., through rigorousstandardization of the inspiratory effort maneuver, obtained a sensitivityof 84% and specificity of 90% for a cutoff point of 48%. The application ofa similar maneuver in a population of dyspneic or confused patientsrepresents a significant obstacle to the external validity of these results.Das et al. conducteda recent systematic review and reported the diagnostic accuracy separatelyaccording to the ventilation modality. Among mechanically ventilatedpatients, the pooled sensitivity was 79%, and the specificity was 70%,resulting in an area under the ROC curve of 0.75 . In those patients on spontaneous ventilation, they identifieda sensitivity of 80% and specificity of 79%, with an area under the ROCcurve of 0.857 . The measurement of IVC variability inthe spontaneously ventilated patient population agrees with previousmeta-analyses,172 but should beinterpreted with caution. The ideal cutoff point varied considerably in thearticles reviewed by Das et al.; excluding two outlier studies in each group, atrend was identified for a higher cutoff point in patients on spontaneousventilation: 31 to 50% compared to 12 to 22% for mechanically ventilatedpatients.Several meta-analyses recently described thedistensibility index using the IVC cross-sectional area and diameter ratio,reporting areas under the ROC curve of 0.749 and 0.829, respectively. Thesedata still lack the validation needed for greater applicability.In a study of 67 mechanically ventilated patients, Yao et al.Situations related to changes in central venous pressure and therefore inIVC variability should be ruled out to make the data more reliable. Amongthese variables, the presence of RV infarction, RV overload, or evenventilatory changes associated with the mechanical ventilator  or with the patient himself (severeinspiratory effort) stand out. Furthermore, patients ventilated using methodssuch as pressure support or patients with intra-abdominal hypertension arenot well suited to the regular use of this tool.,179 We believe these reasons explain the lack ofconsensus among the committee members despite its wide use in clinicalpractice.The evaluation of the IVC is subject to a number of technical limitations,including an adequate window, movement artifacts, and large respiratoryincursions.25. Functional hemodynamic tests (minibolus and end-expiratoryocclusion test (EOT)) should be used as a tool for assessing fluidresponsiveness - without consensus. The maneuver consists of performing 12 to 15 secondsof occlusion at the end of expiration. Hemodynamic measurements (includingmeasurement of stroke volume or its correlates) should be performed beforeand at the end (in the last seconds) of the maneuver. The expiratory pausewill induce an increase in venous return and therefore an increase in strokevolume in fluid-responsive patients.-182 Thismaneuver was first described by Monnet et al. in a study that evaluated 34 patientson positive-pressure MV using transpulmonary thermodilution for COmeasurement. It had an accuracy of 97% for the prediction of fluidresponsiveness, even in patients with arrhythmia or with moderatespontaneous respiratory activity.The EOT is based on heart-lung interactions and changes in respiratorydynamics that alter CO. included studies that evaluated the performance of“alternative” functional hemodynamic tests  for predicting fluid responsiveness. The EOT had an aggregatesensitivity of 86%, specificity of 91%, and area under the curve of 96%,with a positivity threshold of 5% for increased stroke volume or itssubstitutes. The exclusion criteria varied between the studies, but it isnoteworthy that the exclusion was due to an unsatisfactory echocardiographicwindow, spontaneous breathing during the test, complex arrhythmias(ventricular tachycardia), and cor pulmonale.,183 The methods for measuring CO werevaried, with transpulmonary thermodilution predominating.A recent meta-analysisevaluated 30 patients under positive-pressure MV and reported that theaccuracy of the maneuver was 93.8% with a cutoff point of 5% in the VTIincrement. Georges et al. evaluated 50 neurocritical patients and found a 9%increase in VTI as the ideal cutoff point, with a sensitivity of 89% andspecificity of 95% (area under the ROC curve 96%).Two recent studies evaluated whether the measurement of VTI byechocardiography can serve as a response variable to EOT. Jozwiak etal.The EOT may be appropriate in different clinical scenarios, especially whenthe passive leg lift test is not applicable, such as when there isintra-abdominal or intracranial hypertension or traumatic fracture of thehip or leg. after theadministration of 100mL of colloid solution in 1 minute, each 10% increasein VTI had a specificity of 78% and sensitivity of 95% at discriminatingresponders from nonresponders. Along the same lines, Wu et al. used an even smallerinfusion volume (50mL) and crystalloid solution. These authors reportedlower sensitivity and higher specificity than the previous study. Otherauthors have validated the minibolus technique in other contexts, usingother methods to measure CO,-189predominantly pulse contour analysis and transpulmonarythermodilution, with similar diagnostic performance.Perhaps the functional test closest to a conventional fluid challenge with asimpler mechanism is the so-called minibolus test, in which a small aliquotis administered to the patient in question, and the hemodynamic effects ofthis intervention are monitored in real time. Regarding the other functionaltests, the minibolus test was initially proposed to use echocardiography asthe method of response measurement. In its original description,Aspects such as the need for high precision on the part of the examiner toidentify differences of the order of 5 to 10% , as well as the lack ofreproducibility of studies in larger populations of critically ill patients,may explain why there was no consensus on the regular use of functionalhemodynamic tests to predict fluid responsiveness.26. The passive leg elevation maneuver should be used as a tool forassessing fluid responsiveness - 93.75% agreement.-192 Itsgoal is to drain blood held in the venous system of the leg to the RA, thusoptimizing venous return and, consequently, CO. Approximately 300mL ofblood-195 will be mobilizedthrough gravitational transfer, which constitutes an endogenous - andreversible - volume challenge, countering the effects of water overload andits deleterious consequences in the most diverse of contexts. If the ventricles areoperating in the Frank-Starling preload-dependent region, CO willtransiently increase, most evidently approximately 60 to 90 seconds afterthe maneuver. Thus,an essential component of the maneuver is to verify its effect on CO in realtime. The ideal tool for this purpose should allow the detection of quickvariations in CO, ideally in a continuous manner. Echocardiographicevaluation, although essentially intermittent, has been evaluated as analternative in this context, with consistent results.-201 Wrist contour analysis has become oneof the most commonly used tools to verify the response to leg elevation.When compared to pulse contour analysis or esophageal Doppler examinations,for example,,203 transthoracicechocardiography has similar performance.Elevation of the legs in response to hypotension has been empiricallyemployed in different contexts.,203 The reportedsensitivity and specificity were 0.85 - 0.86 and 0.91-0.92, respectively,with an area under the ROC curve of 0.95 in both studies and an ideal cutoffpoint of 10%. Thediagnostic accuracy was similar regardless of the initial position (supineor elevated headboard) and whether the individual was on spontaneous orcontrolled ventilation.Two meta-analyses of more than 20 studies, comprising approximately 1,000patients, evaluated the performance of passive leg raising as a predictor offluid responsiveness. evaluatedonly patients with atrial fibrillation in the postoperative period ofcardiac surgery and reported an accuracy of up to 77% for predicting fluidresponsiveness, although thermodilution was used as a tool for monitoring COvariations. The use of alternative ultrasound parameters to evaluate theresponse to the maneuver has been described, with similar results usingfemoral orcarotid Doppler ultrasound. These are viable options in case of difficulty inobtaining aortic outflow tract flow measurement.Although most studies have been conducted in patients with regular rhythm,Kim et al.,207 Inaddition to these aspects, severe hypoxemia, high risk of aspiration ofgastric contents, and intracranial hypertension should prompt caution in theapplication of the maneuver.The use of echocardiography as the response variable of the maneuver by meansof the VTI measurement has the fundamental limitation of obtaining anadequate window and angle in a timely manner. Also noteworthy isintra-abdominal hypertension; compression of the IVC may limit the drainageof fluid from the lower limbs to the RA, resulting in compromised testaccuracy due to false-negatives.27. The estimation of CO from VTI measurement should be used as a toolfor hemodynamic evaluation - 100% agreement.,209 Theproduct of the VTI and the area of the LV outflow tract equals the strokevolume, which, multiplied by the heart rate, equals CO.The estimate of CO will be relevant in situations in which there isdiagnostic doubt about the mechanisms of hemodynamic deterioration or whenintervening in CO is considered, such as with inotropic drugs.Echocardiography is the first option for discerning the mechanism of shock,as well as for its evaluation. evaluatedthe accuracy of emergency physicians with limited and focusedechocardiographic training to obtain the VTI measurement in determining theCO of 100 emergency room patients. In all patients, it was possible tomeasure the LVOT diameter, although in three individuals it was not possibleto measure the VTI. When validated by a cardiologist, the LVOT diametermeasurements were optimal in 90% of the cases. Regarding the VTImeasurements, 78% were classified as such (numbers similar to those obtainedby certified echocardiographers). The mean difference in VTI measurementbetween emergency physicians and echocardiographers was 8%, with a Pearson’scorrelation coefficient of 0.87.Dinh et al.Echocardiography has some advantages over continuous invasive methods: It isnoninvasive; has lower cost; is not influenced by hypothermia; allowsmorphological evaluation of the heart, with analysis of valves, chamber, andpericardium size; allows the quantification of global and segmentalfunctionality; and can be integrated, for example, with lung ultrasound.Several aspects may limit the accuracy of echocardiographic measurement,especially due to visualization limitations thar arise from too-smallcardiac windows and deviation of the alignment of the Doppler interrogationaxis from the real blood flow. The presence of pathologies that affect theaortic valve - both stenosis and regurgitation - interfere with the accuracyand often make measurement impossible. Atrial fibrillation requires takingseveral VTI measurements to obtain a reliable mean value, due to thevariability of the measurements from heartbeat to heartbeat. The patient populations have consistedmostly of individuals in sinus rhythm, without significant valvularpathologies. Crossingham et al., in a recent systematic review, reported marginalto acceptable agreement between echocardiography and conventionalthermodilution using a pulmonary artery catheter. transpulmonary bypass, andpulse contour analysis, among other tools. Mercado et al. recently reviewed theagreement between intermittent thermodilution and echocardiography. In astudy that included 38 mechanically ventilated, sedated patients in sinusrhythm, the authors verified the accuracy and precision of echocardiographyfor estimating CO, with narrow deviation and acceptable limits of agreement,in addition to its good ability to detect trends. In that study, thevariation in CO estimated by echocardiography had a sensitivity of 88% andspecificity of 66% to detect a 10% variation in CO measured bythermodilution.Most studies that have evaluated the agreement of CO estimation byechocardiography with intermittent thermodilution have used transesophagealechocardiography in patients in the perioperative period of cardiac surgery,in conditions of hemodynamic stability and IMV.The purpose of this document is to synthesize information and discuss points ofinterest that may improve the performance of bedside echocardiography by physicianswho are not specialists in echocardiography. Using the Delphi method, participantsfrom medical associations representing different practice areas responsible for thecare of critically ill patients reached consensus on most questions pertinent to theuse of bedside echocardiography by physicians who are not specialists inechocardiography.The positions described in this document reflect the goals of bedside ultrasound bynonspecialist physicians and prioritize direct qualitative parameters that mayaffect decision-making. Essentially quantitative parameters that require strictlyprecise measurements or lack validation in the literature in critically ill patientsengendered rejection or even lack of consensus among the committee members.Furthermore, there was a particular trend in the ability to reach consensus inrelation to each of the domains addressed. The domain related to the assessment ofshock enjoyed consensus on all questions from the beginning of the process, whiledomains such as assessment of left ventricular systolic function and hemodynamicassessment concentrated questions that remained without consensus at the end of theprocess.Consensus documents are not guidelines and have the ultimate goal of creatingopportunities for improving the quality of care in a given area. They are based onthe opinion of experts and are primarily informative and educational. The issuesaddressed throughout this text may reflect uncertainties and be influenced bypersonal points of view. The rigorous method used to obtain this consensus aims tomitigate personal biases and identify the position of a group of people dedicated tothe optimization of bedside echocardiography.


The study of trimethylamine oxide (TMAO), a metabolite of gut microbiota, and heart failure and chronic kidney disease has made preliminary achievements and been summarized by many researchers, but its research in the field of cardiorenal syndrome is just beginning. TMAO is derived from the trimethylamine (TMA) that is produced by the gut microbiota after consumption of carnitine and choline and is then transformed by flavin-containing monooxygenase (FMO) in the liver. Numerous research results have shown that TMAO not only participates in the pathophysiological progression of heart and renal diseases but also significantly affects outcomes in chronic heart failure (CHF) and chronic kidney disease (CKD), besides influencing the general health of populations. Elevated circulating TMAO levels are associated with adverse cardiovascular events such as HF, myocardial infarction, and stroke, patients with CKD have a poor prognosis as well. However, no study has confirmed an association between TMAO and cardiorenal syndrome (CRS). As a syndrome in which heart and kidney diseases intersect, CRS is often overlooked by clinicians. Here, we summarize the research on TMAO in HF and kidney disease and review the existing biomarkers of CRS. At the same time, we introduced the relationship between exercise and gut microbiota, and appropriately explored the possible mechanisms by which exercise affects gut microbiota. Finally, we discuss whether TMAO can serve as a biomarker of CRS, with the aim of providing new strategies for the detection, prognostic, and treatment evaluation of CRS. Cardiorenal syndrome (CRS) is commonly encountered in clinical practice and includes a range of diseases involving the heart and kidneys. This condition occurs when one organ is acutely or chronically dysfunctional, often resulting in other organ dysfunction as well. This syndrome was first described in 1836 by Robert Bright who observed that patients with advanced kidney disease often experience significant changes in the structure of the heart . Many stClostridium, Proteus, Shigella, and Aeromonas  . TMA maieromonas . Althougeromonas . It shoueromonas . TMAO iseromonas , and a seromonas . TMAO leeromonas . The proGut microbiota and its metabolites are involved in the pathogenesis of HF . The intin vitro FMO enzyme activity assay in mice suggested that non-dietary activation of FMO-mediated TMAO production may be a new biochemical mechanism (echanism . Patientechanism . A studyechanism . Howeverechanism . In CKD echanism . In patiechanism . Given techanism . Zhang Wechanism . A signiechanism . Human iechanism . In renaechanism . Serum Techanism . There iechanism . One stuechanism  showed techanism . The eluechanism . ResearcThe initial definition of CRS was that it is the outcome of interactions between the renal and other circulatory compartments that increased circulating volume, exacerbated symptoms, and disease progression of patients with HF . In 2008In order to explore whether TMAO can serve as a biomarker for CRS, we cannot ignore the existing biomarkers for CRS. The biomarkers related to the diagnosis and prognosis of CRS include both cardiac and renal markers. Here, we described the different biomarkers in detail of the heart and kidneys in CRS. BNP and NT-proBNP are widely used in the diagnosis and exclusion of HF in clinical practice . CompareSerum creatinine is a common indicator used to evaluate kidney function; however, it has limited value in assessing acute renal dysfunction and uremia . DespiteTMAO has made some progress in the study of heart failure and renal dysfunction. The research on CRS and TMAO has just begun. CRS is a clinical syndrome involving complex pathophysiological pathways and dysfunction of both the heart and kidneys . Recent At present, many issues remain unclear in the research on TMAO and CRS. First, the causal relationship between changes in TMAO concentration and heart and kidney failure and CRS is uncertain. This requires more researchers and institutions to carry out multi-center cooperation to establish an extensive and comprehensive database to monitor the continuous changes in TMAO levels in normal people with different dietary environments, different races, and people with heart and kidney failure. Only then can the causal relationship between TMAO and heart and kidney failure and cardiorenal syndrome be clarified. Secondly, the clinical diagnosis of CRS has not been taken seriously. This requires calling on clinicians to pay attention to the identification and diagnosis of CRS, pay attention to the role of intestinal flora metabolites in the progression of CRS, and encourage more clinicians to actively join TMAO Research related to CRS. At present, the accurate determination of TMAO relies on expensive LC-MS/ms, which limits the development of related research. The accuracy of existing TMAO detection kits has not been widely recognized. Whether the test performance of affordable TMAO detection kits is consistent with that of LC-MS/ms requires more research to confirm.Bacillus phylum ratio (Paying attention to changes in the gut microbiota derivative TMAO, we have to pay attention to the gut microbiota. Gut microbiota are similar to endocrine organs, and gut microbiota can receive stimulation and send signals. Appropriate exercise has beneficial effects on the gut microbiota, which may involve complex stress responses and neuroenteroendocrine activation . Approprum ratio . At presum ratio . SecondlMany researchers view TMAO as a new marker for assessing the prognosis of patients with HF and CKD, and its potential role in CRS diagnosis and prognosis cannot be underestimated. As more scholars conduct in-depth research, TMAO has the potential to serve as a valuable biomarker for the diagnosis and long-term prognostic evaluation of CRS patients.The gut microbiota and metabolite TMAO serve as a bridge connecting heart, kidney failure, and CRS. At present, there are certain limitations in evaluating the diagnostic and prognostic value of CRS using diagnostic/prognostic markers for heart failure or chronic kidney disease. If TMAO can serve as a biomarker for CRS, it will greatly improve the diagnosis and prognosis evaluation of CRS by clinical doctors.As a new uremic toxin and potential biomarker, TMAO is involved in changes in the heart-gut-kidney axis, including neuroendocrine activation, hemodynamic changes, alterations in gut microbiota, and intestinal congestion . Many re


Editorial on the Research TopicMultimodality imaging of left ventricular assist devices: applications in advanced heart failureIn the realm of medical advancements, long-term (durable) left ventricular assist devices (LVADs) have emerged as a crucial lifeline for individuals battling advanced left ventricular failure. As the prevalence of heart failure continues to rise, so does the need for innovative approaches to diagnose and manage this debilitating condition. Multimodality imaging has proven to be a game-changer, enabling clinicians to comprehensively assess durable LVAD function and optimize patient outcomes. This editorial delves into the applications of multimodality imaging in the context of durable LVADs, highlighting its importance in the management of advanced heart failure.Multimodality imaging techniques, such as echocardiography, computed tomography (CT), cardiac magnetic resonance imaging (MRI), and nuclear studies, offer distinctive advantages when it comes to assessing LVAD function. Echocardiography remains the primary modality for initial assessment due to its accessibility, real-time visualization, and ability to assess key parameters such as blood flow, device position, and the presence of complications like thrombosis, right heart failure, or tamponade etc. , 2. MoreEchocardiography remains a fundamental tool in LVAD assessment due to its real-time imaging capabilities, bedside availability, and ability to provide immediate insights into LVAD function, pump speed optimisation, inflow cannula/outflow graft velocities, and assessment of native heart structure and function. It aids in evaluating ventricular size, contractile function, valvular function, and can guide decision-making regarding the potential for myocardial recovery .Doppler echocardiography assists in evaluating blood flow patterns within the LVAD, quantifying valvular dysfunction severity, and non-invasively measuring various hemodynamic parameters. It contributes to evaluating the effectiveness of medical management and the need for valve interventions .Echocardiography is invaluable during LVAD implantation procedures, providing real-time guidance for surgeons regarding device positioning, cannula placement, ruling out intracardiac shunts or intracardiac thrombi. Moreover, echocardiography is vital in evaluating complications like pericardial effusion, cardiac tamponade and right ventricular failure . It is aSerial echocardiographic examinations are crucial for long-term follow-up and surveillance of LVAD patients, enabling the monitoring of LVAD function, assessment of ventricular size/function, and detection of complications. Multimodality integrated use of the aforementioned imaging modalities provides a comprehensive assessment of LVAD patients .Cardiac MRI has emerged as a potentially useful tool for evaluating LVAD patients before implantation and after explantation. It provides high-resolution images, allowing for precise assessment of myocardial function, and tissue characterization. By employing cine imaging and late Gadolinium enhancement, clinicians can evaluate for myocardial fibrosis or inflammation. Unfortunately, there are no MRI-compatible LVAD devices in use, therefore the role of MRI is limited to assessment before implantation and after explantation . MRI wouComputed tomography complements echocardiography and cardiac MRI by offering detailed anatomical visualization. It aids in the assessment of vascular anatomy, cannula position, and potential complications like outflow graft obstruction or kinking. Furthermore, CT assists in planning for LVAD implantation or explantation procedures, providing a roadmap for surgeons and optimizing patient outcomes.Nuclear scan assists in the diagnosis of infection in LVAD patients by assessing the uptake of the glucose-analoge and radiotracer 18-fluorodeoxyglucose (FDG). Several studies have demonstrated that FDG-PET/CT can accurately localize the site and extent of the late LVAD infection across the peripheral driveline and the involvement of the central portion of the pump. Moreover, it has a higher ability to predict outcomes of LVAD infection than CT scan .While multimodality imaging proves to be immensely valuable, certain considerations must be kept in mind. Standardization of protocols and reporting guidelines are crucial to ensure consistency and facilitate meaningful comparisons across studies. Additionally, efforts should be made to reduce radiation exposure associated with cardiac CT, especially in patients who may require multiple scans during their LVAD journey.Looking ahead, the integration of artificial intelligence (AI) and machine learning algorithms holds immense promise in refining LVAD assessment. These technologies can analyse large datasets, identify subtle changes in LVAD function, and predict adverse events. Additionally, advancements in imaging hardware and software will continue to enhance image quality, reducing acquisition times and patient discomfort.Multimodality imaging has revolutionised the assessment of long-term (durable) LVADs, empowering clinicians in their mission to optimize the care of patients with advanced heart failure. By combining the strengths of echocardiography, cardiac MRI, CT and nuclear studies, clinicians can comprehensively evaluate LVAD function, detect complications, and tailor treatment strategies accordingly. With ongoing advancements in imaging technology and the integration of AI, the future of multimodality imaging looks brighter than ever, promising improved outcomes and enhanced quality of life for those battling advanced heart failure.