Atrial Structure and Function

New Method for Noninvasive Quantification of Central

Venous Pressure by Ultrasound
Chang-Yang Xing, MD; Yuan-Ling Liu, MD; Mei-Ling Zhao, MD; Rui-Jing Yang, MD;
Yun-You Duan, MD; Lian-Hua Zhang, MD; Xu-De Sun, MD; Li-Jun Yuan, MD; Tie-Sheng Cao, MD
BackgroundThe central venous pressure (CVP) is essential for assessing the cardiac preload and circulating blood volume
in clinic. The invasive CVP measurement by central venous catheter has been reported with various complications. The
aim of this study was to develop a new noninvasive method for quantification of CVP by ultrasound.
Methods and ResultsSeventy-six patients who had their CVP monitored for intraoperative or postoperative management
were recruited. By accurate location of the collapse point of the internal jugular vein and the center of the right atrium
using ultrasound imaging, the height of the fluid column between those 2 points was measured as the noninvasive CVP
(CVPn). A total of 118 measurements were performed and compared with the invasive CVP (CVPi). Linear correlation
analysis revealed a significant correlation between CVPi and CVPn (preoperative measurements, r=0.90; P<0.01 and
postoperative measurements, r=0.93; P<0.01). BlandAltman plots showed a good agreement between CVPi and CVPn
with the mean difference of 0.22 mmHg (preoperative measurements) and 0.09 mmHg (postoperative measurements),
respectively.
ConclusionsThe new noninvasive CVP quantification method based on the location of both the collapse point of internal
jugular vein and the center of right atrium by ultrasound could be used as a reliable approach for monitoring the hemodynamic
status in clinic.(Circ Cardiovasc Imaging. 2015;8:e003085. DOI: 10.1161/CIRCIMAGING.114.003085.)
Key Words:central venous pressure ultrasonography

entral venous pressure (CVP) is frequently used in clinical practice for the assessment of volume status and
cardiac preload.1 Accurate determination of CVP is essential for the management of a variety of critical illnesses and
monitoring hemodynamics during the surgery.2,3 CVP can be
measured directly via central venous catheterization, but it is
invasive with potential complications.4,5

See Clinical Perspective

Since first proposed by Sir Thomas Lewis in 1930, the noninvasive determination of CVP using the physical examination
has not been widely used all along.6 This is mainly because it
is hard to accurately locate the 2 end points of the fluid column
whose height represents CVP.7,8 Even though some investigators proposed that ultrasound could be used to identify the
highest point of oscillation of the jugular vein,9,10 however, the
other end point, that is, the center of the right atrium (RA),
still could not be identified precisely. Obviously, the key factor
for the disagreement and inaccuracy between studies of CVP
measurement is the failure to locate the external reference
point of RA in patients with various positions.1,11
We thus sought to explore a new echocardiographic method
to locate the center of RA precisely based on solid geometry,

and to develop a noninvasive method of quantification of CVP

by combination with the location of the collapse point of the
jugular vein by ultrasound.

Methods
Preliminary Validation of the Echocardiographic
Location of RA Center by Comparison With
Computed Tomography
Patients and Data Collection

This study was performed at our institution, a tertiary medical center. Patients who were candidates for multi-slice three-dimensional
computed tomography (3D-CT) of the chest were recruited. Age,
sex, height, body mass index, and clinical diagnosis were recorded
for all patients. Informed consent was obtained from all patients and
the study was approved by the ethics committee of Fourth Military
Medical University.

CT Examination

Chest 3D-CT were performed on the patients with the use of a General
Electric Light-Speed VCT scanner (General Electric, Milwaukee,
WI). The data were further reconstructed into 3D images with the
General Electric Advantage Windows 3D workstation (General
Electric, version 4.5). These reconstructed images were then processed at the workstation into color-shade surface display and shaded
volume render images. With the 3D volume rendering images and the

Received November 16, 2014; accepted March 26, 2015.

From the Departments of Ultrasound Diagnostics (C.-Y.X., Y.-L.L., M.-L.Z., R.-J.Y., Y.-Y.D., L.-J.Y., T.-S.C.) and Anesthesiology (L.-H.Z., X.-D.S.),
Tangdu Hospital, Fourth Military Medical University, Xian, China.
The Data Supplement is available at http://circimaging.ahajournals.org/lookup/suppl/doi:10.1161/CIRCIMAGING.114.003085/-/DC1.
Correspondence to Tie-Sheng Cao, MD or Li-Jun Yuan, MD, Department of Ultrasound Diagnostics, Tangdu Hospital, Fourth Military Medical
University, No. 569, Xinsi Rd, Baqiao District, Xian 710038, Shaanxi, China. E-mail caotsxcy@hotmail.com or yuanljxcy@gmail.com
2015 American Heart Association, Inc.
Circ Cardiovasc Imaging is available at http://circimaging.ahajournals.org

DOI: 10.1161/CIRCIMAGING.114.003085

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by guest on August 19, 2016
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2 Xing et al Noninvasive Measurement of CVP

Figure 1. Location of the center of right atrium.
A, Adjusted apical 4-chamber view. This view is
acquired by adjusting the standard apical 4-chamber to make the right atrium in the middle of the sector image. The length of line segment AB represents
the distance between the probe contact point and
the center of the right atrium. B, Location procedure.
The probe is fixed after acquiring the image shown
in A. A pencil is put next to the probe and make it
perpendicular to the anterior chest wall. The ruler is
made to be in parallel with the long-axis central line
of the probe and to intersect with both the stick and
the anterior chest wall. The distance between the 2
intersections is equal to segment AB in A. The intersection of the ruler and the anterior chest wall is the
surface projection of the center of the right atrium.

corresponding 2D images, the center of RA was located by the scanner technician. When necessary, we rotated the 3D volume rendering
image to display the standard coronal view. After locating the center
of RA in the corresponding 2D images, we acquired the same point
in the 3D image by autoprocessing at the workstation. The accurate
position of that point in the coronal plane was recorded as shown in
Figure I in the Data Supplement.

Echocardiography

Patients were kept in the same supine position as done during the
previous CT examination. A commercially available echocardiography system equipped with a 3.5 MHz transducer (Vivid E9; General
Electric Healthcare, Milwaukee, WI) was used to scan the heart. First,
an adjusted apical 4-chamber view in which the RA was placed in the
middle of the sector image was acquired. The distance from the top
of image to the center of RA was measured and recorded. Then the
probe was fixed at the image acquired direction and position by the
operator. The assistant put a pencil next to the probe and made it perpendicular to the coronal plane. After that, a ruler with its direction
parallel with the long-axis of the probe was used to locate the surface
projection of the center of RA. The ruler was made intersected with
both the pencil and the anterior chest wall, and distance between the 2
intersections was kept the same distance as previously recorded. The
intersection of the ruler and the anterior chest wall was the surface
projection of the center of RA (Figure1). The time needed for the
locating process was recorded.

Comparison and Analysis

After the surface projection of the center of RA located by echocardiography was marked, the surface projection point acquired
with CT was also marked in the anterior chest wall. Then the
absolute distance (Da) and vertical distance (Dv) between the 2
points in the direction of coronal plane were measured. As the
point marked according to CT location was the standard point, if
the echo-location point was superior to it, Dv was defined as +,
otherwise (Figure S2).
To evaluate the accuracy of the echo-location method, mean value and 95% confidence interval (CI) of Da, Dv were calculated. To
evaluate the feasibility, data in both men and women were obtained
and compared using Student unpaired t test, and the time spent on the
ultrasound location was also recorded.

Fifteen patients were randomly selected to assess the inter- and

intraobserver reproducibility. For the interobserver reproducibility
assessment, location point marked by 1 of the 2 investigators was
identified as the standard point, if the other point was superior to
it, Dv was defined as +, otherwise . For the intraobserver reproducibility assessment, the first-time location point was identified
as the standard point. Mean value and 95% CI of Da, Dv were
calculated.

Comparison of the Noninvasive and Invasive

Measurements of CVP
Patients and Data Collection

Patients who would have their CVP monitored for intraoperative or

postoperative management were eligible for enrollment. Exclusion
criteria were neck injury at the measurement site, mass of neck that
could compress the internal jugular vein (IJV), thrombosis or altered
blood flow in the IJV, uncontrollable exaggerated or irregular respiration, incapability of semireclining position, significant tricuspid regurgitation, and poor echocardiographic windows. Informed consent
was obtained from all patients before the measurement. The study
was approved by the ethics committee of our university.

Noninvasive Measurement of CVP by Ultrasound

The noninvasive measurements of CVP were performed before or

after the surgical operation.
Location of the Center of RA. Patients were kept in a supine position.
A commercially available portable ultrasound machine (M-Turbo;
SonoSite Inc, Bothell, Washington, DC) equipped with a 3.5 MHz
transducer (P21x/5-1 MHz) was used. The location procedures were
the same as described in the preliminary validation study above. After
the surface projection of the center of RA on the anterior chest wall
was located, the transverse plane that contained the RA center point
was also obtained. The intersections of the bilateral midaxillary lines
and that plane were marked.
Location of the Collapse Point of IJV. A broadband linear array transducer (L38xi/10-5 MHz) was used to visualize the IJV. The probe was
moved gently on the neck rotating between longitudinal and transverse views to locate the region of vein collapse. The bed angle was

Figure 2. Collapse region of the internal jugular

vein. A, Longitudinal view of internal jugular vein
(IJV). The skin surface is at the top of the figure and
the total depth of the image is 2.5 cm. The left side
is cephalad. The arrow shows the highest point of
oscillation of the IJV. This is where the jugular pulsations are present in real-time. B, Corresponding
transverse view of IJV. ICA indicates internal carotid
artery.

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3 Xing et al Noninvasive Measurement of CVP

Table 1. Patient Characteristics
Variable

Value

Men/Women

46/30

Age, y

54.313.2

BMI, kg/m2

23.03.5

Right internal jugular vein

catheterization, n

70

Right subclavian vein catheterization, n

Data are given as meanSD unless otherwise mentioned. BMI indicates body
mass index.

adjusted to yield the best view. The highest point of oscillation of IJV
was marked on the neck using the longitudinal view (Figure2).
Measurement of CVP. Without changing the bed angle, the height
between the collapse point of IJV and the previous marked point in
midaxillary line was measured, and the value was recorded as noninvasive CVP (CVPn, cm H2O) and converted to millimeters of mercury (1 mmHg=1.36 cm H2O). The measurements were made at the
right IJV before the surgical operation and at the left IJV after the
operation. The time for noninvasive measurement was recorded.

Invasive Measurement of CVP by Central Venous Catheter

The central venous catheterization measurement of CVP was done

within 15 minutes after the noninvasive measurement by ultrasound.
The central venous catheters were inserted into the right IJV or subclavian vein by an experienced anesthesiologist after the standard
procedures.12,13 Then the catheters were connected to the multimodular monitor (S/5; GE Datax-Ohmeda, Helsinki, Finland) via a pressure transducer. After the transducer had been zeroed to the level of
the heart, the mean value of CVP (mmHg) over time was displayed
real time on the monitor and recorded as invasive CVP (CVPi). The
CVPi was continuously monitored after operation. The ultrasound investigator was blinded to the CVPi results and vice versa.

Statistical Analysis

Statistical analysis was performed using SPSS 20.0 (SPSS, Inc,

Chicago, IL). Normality distribution of continuous variables was assessed using the KolmogorovSmirnov test. Data were presented as
meanSD. Student paired t test was used to compare CVPi versus
CVPn for the preoperative and postoperative measurements separately. Correlations between CVPi and CVPn were estimated using
Pearson correlation. BlandAltman analysis was performed to quantify the agreement between CVPi and CVPn. The data from patients
who underwent both the preoperative and postoperative measurements were used to verify the ability of the noninvasive method in
tracking changes in CVP. Where appropriate, 95% CIs were reported.
For all analysis, a 2-sided P<0.05 was considered significant.

Results
Preliminary Validation of the Echocardiographic
Location of RA Center
A total of 40 patients were recruited into this study. Patient
characteristics were given in Table I in the Data Supplement.
By 3D-CT location, levels of the mid-RA varied from the third
intercostal space at the sternum to the upper limb of the sixth
costal cartilage.
Accuracy and Feasibility of Echo-Location
Mean Da and Dv of the whole subjects were 0.77 cm, 0.04 cm,
and the mean time spending on the locating process was 42.52
s, with no significant difference between the men and women
groups (Table S2). The points located by CT and echocardiography were almost at the same level in the vertical direction of
the coronal plane with the 95% CI of Dv (0.13 to 0.21 cm).

Reproducibility
Inter- and intraobserver reproducibility for echocardiographic
method were summarized in Table S3. With respect to the
degree of accuracy for location of RA, the echocardiographic
method was found to be highly reproducible in terms of both
inter- and intraobserver variability.

Comparison of the Noninvasive and Invasive

Measurements of CVP
Seventy-six patients were recruited into this study. Patient
characteristics were given in Table1. Details of clinical diagnoses were given in Table S4. A total of 118 noninvasive
measurements by ultrasound were performed (74 preoperative measurements and 44 postoperative measurements). The
mean time for noninvasive measurement was 3 minutes
(18247 s).
The values of CVPi and CVPn were compared in Table2.
No statistically significant difference was found for both
preoperative and postoperative measurements. The correlation and BlandAltman plots between CVPi and CVPn were
shown in Figure3. Linear correlation analysis revealed a significantly positive correlation between CVPi and CVPn (preoperative measurements, r=0.90; P<0.01 and postoperative
measurements, r=0.93; P<0.01). BlandAltman plots showed
that the mean bias between CVPi and CVPn was 0.22 mmHg
with the limits of agreement being 2.16 to 2.59 mmHg (preoperative measurements) and 0.09 mmHg with the limits of
agreement being 2.12 to 1.94 mmHg (postoperative measurements). There was no systematic bias between CVPi and
CVPn. The bias in preoperative measurements was slightly
larger than postoperative measurements (0.22 mmHg; 95%
CI, 0.06 to 0.50 mmHg versus 0.09 mmHg; 95% CI, 0.41
to 0.22 mmHg).
There were 42 patients who had 2 sets of measurements.
The mean bias between changes in CVPi and CVPn was
0.08 mmHg (95% CI, 0.43 to 0.26 mmHg) with the limits
of agreement being 2.25 to 2.08 mmHg. Correlation analysis
showed a high degree of correlation between changes in CVPi
and CVPn (r=0.91; P<0.01).

Discussion
In this study, a new noninvasive method for CVP quantification was developed by location of both the collapse point of
IJV and the center of RA using ultrasound. CVPn determined
using our new method has been proven to have a strong correlation and high agreement with the CVPi measured by the
central venous catheterization.
CVP is essential for monitoring hemodynamics in critically
ill patients and estimating the cardiac preload and circulating
Table 2. Student Paired t Test of CVPi and CVPn
Preoperative
Measurements (n=74)

Postoperative
Measurements (n=44)

CVPi, mmHg

8.12.8

8.62.6

CVPn, mmHg

7.92.5

8.72.8

>0.10

>0.10

Data are given as meanSD. CVPi indicates invasive central venous pressure;
and CVPn, noninvasive central venous pressure.

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4 Xing et al Noninvasive Measurement of CVP

Figure 3. Comparison of invasive and noninvasive central venous pressure values. Left, BlandAltman plots are presented. Right,
Regression plots with coefficient of correlation are presented. Note there are several points overlapped in these figures. A, Preoperative
measurements. Correlation coefficient is 0.90. The bias is 0.22 mmHg (95% confidence interval [CI], 0.06 to 0.50 mmHg) with the limits
of agreement being 2.16 to 2.59 mmHg. B, Postoperative measurements. Correlation coefficient is 0.93. The bias is 0.09 mmHg (95%
CI, 0.41 to 0.22 mmHg) with the limits of agreement being 2.12 to 1.94 mmHg. C, Changes in CVPn and CVPi. Correlation coefficient
is 0.91. The bias is 0.08 mmHg (95% CI, 0.43 to 0.26 mmHg) with the limits of agreement being 2.25 to 2.08 mmHg. cCVPi indicates
changes in invasive CVP between the pre- and postoperative measurements; cCVPn, changes in noninvasive CVP between the pre- and
postoperative measurements; CVPi, invasive central venous pressure; and CVPn, noninvasive central venous pressure.

blood volume in surgery.13 The current standard technique

for measurement of CVP is invasive, requiring insertion
of a catheter into the subclavian or IJV, and has potential

complications.4,5,14 Therefore, a noninvasive, simple and accurate method of CVP quantification is greatly needed, especially in cases of hemodynamic emergencies.

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5 Xing et al Noninvasive Measurement of CVP

The noninvasive estimation of CVP by physical examination has been described by Sir Thomas Lewis, and refined by
a lot of investigators.6,11,15,16 However, because this method is
difficult to master and lack of accuracy, it has not been widely
used all along. In recent years, some investigators tried to
improve the accuracy of this noninvasive method by identifying the collapse point using ultrasound, but the improvement was limited for their significant bias after comparing
with the invasive measurement.9,10 Indeed, the height of the
blood column in the jugular veins that represents CVP could
not be precisely quantified only if both the collapse point of
IJV and the center of RA are accurately located. Thus, the
key obstacle to the noninvasive CVP measurement is the failure to accurately locate the external reference point of RA in
patients with different positions. There are a few methods that
have been proposed for locating the center of RA (or midRA). The most widely used method is to assume that the distance between the sternal angle and the center of RA is 5 cm
regardless of the posture of the patients.13,11 While by rigorous assessment of the sternal angleRA distance, Seth et al17
had proven that the vertical distance from sternal angle to the
level of mid-RA varies considerably between individuals and
with patients different positions. Another method to mark
the mid-RA is to find the intersection of the midaxillary line
and a perpendicular extended to the fourth intercostal space
at the sternum.11 However, the levels of mid-RA varied from
the third intercostal space at the sternum to the upper limb
of the sixth costal cartilage verified by 3D-CT examination.
Obviously, both of these 2 methods ignored the differences of
patients clinical status and position, and thus neither of them
could serve as a reliable method for locating the center of RA,
and accordingly, for the assessment of CVP.
Ultrasound has been widely used as an optimal tool of
localization and guidance in clinic.18,19 However, the main
part of RA is sheltered by the sternum, making it difficult
to directly locate the RA center by echocardiography. To
solve this problem, we proposed this geometric method to
locate the surface projection of the center of RA under the
guidance of echocardiography. Figure4 illustrates the spatial relationship in the RA location procedure. The line segment between points A and B is in the same direction with the
probe long-axis, and the 2 end points represent the center of
RA and the contact point between the probe and the anterior
chest wall, respectively. Line segment CD that represents the

ruler parallels and has equal length with segment AB. Thus,
quadrilateral ABCD is a parallelogram. Because segment BC
is perpendicular to the coronal plane that contains the contact point B, segment CD is also perpendicular to the coronal
plane. Finally, point D is the surface projection of point A,
that is, the center of RA.
Thus, the precise measurement of CVP was realized by
accurately locating the collapse point of IJV and the center
of RA by ultrasound using our new method, and the results
were confirmed by comparison with the central venous catheterization. The BlandAltman plot revealed no tendency for
a systematic bias and the linear correlation analysis showed
a high degree of correlation between CVPi and CVPn. With
respect to the ability of the noninvasive method in tracking
changes in CVP, BlandAltman analysis revealed a good
agreement between changes of CVPi and CVPn (mean bias,
0.08 mmHg), which indicated that the new method could
track changes in CVP reliably. The slight discrepancy in bias
between the preoperative and postoperative measurements
(0.22 versus 0.09 mmHg) might be caused by several factors, such as the observation point of the noninvasive measurements and the time interval between the invasive and
noninvasive measurements.
Even though there were some other noninvasive methods of
CVP measurement, such as controlled compression sonography on the peripheral vein,20,21 forearm volume plethysmography,22,23 and neck inductive plethysmography,24 they relied
on additional instruments that are not readily available in routine clinical practice. By contrast, the instruments that we use
in the new method of quantification of CVP are just a ruler
and a pencil besides a portable ultrasound machine, which is
widely available. Thus, this method is applicable for bedside
measurement.
Furthermore, because CVP is equal to the right atrial pressure
as long as there is no obstruction of the vena cava, the noninvasive measurement of CVP could be useful in noninvasive estimation of the pulmonary arterial pressure. In comparison with
currently used semiquantitative Doppler echocardiographic
methods for estimation of the right atrial pressure,3 our new
quantitative method might be a better choice.

Limitations
There are several limitations to this new method that may limit
its clinical application. First, the presence of any mass that
Figure 4. Illustration of the spatial geometric relationship in the location progress. A, Perspective
drawing of the spatial relationship from the anterior
view. B, Abstract geometric drawing of the spatial
relationship from the lateral view. Point A represents
the center point of the right atrium; point B represents the probe contact point; point C represents
the intersection of the ruler and the pencil; point D
represents the intersection of the ruler and the anterior chest wall, which is also the surface projection
point of the right atrium. Plane is the transverse
plane, in which the center point of the right atrium
locates; plane is the transverse plane, in which
the probe contact point locates; plane is the
coronal plane that contains the anterior chest wall.
Quadrilateral ABCD is a parallelogram. Segment AD
and BC both are perpendicular to the chest wall.

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6 Xing et al Noninvasive Measurement of CVP

compresses the IJV, thrombosis, or altered blood flow in the
central vein that impedes venous return will cause a false measurement. Previous neck injury, IJV cannulation will interfere
the measurement. Second, uncontrollable exaggerated or
irregular respiration and significant tricuspid regurgitation
will disturb the measurement of CVP. Third, this new method
for noninvasive measurement of CVP may not be practical to
monitor the CVP continuously, but could be repeatedly performed if needed with no harm to the patient.

Conclusions
The new method for noninvasive quantification of CVP based
on the ultrasound location of the collapse point of the IJV and
the center of RA might be an alternative approach for monitoring the volume status and cardiac preload in clinic.

Sources of Funding
This study was supported by the National Natural Science Foundation
of China (NSFC 81171348 and NSFC 31400803).

Disclosures
None.

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Clinical Perspective
Knowledge of central venous pressure (CVP) is essential for monitoring hemodynamics in critically ill patients and estimating cardiac preload and circulating blood volume in surgery. The current standard technique for measuring CVP is invasive,
requiring insertion of a catheter into the subclavian or internal jugular vein, and has potential complications. The noninvasive
estimation of CVP by physical examination has been described by Sir Thomas Lewis, and refined by subsequent investigators. However, because of the challenges of mastering the technique and its lack of accuracy, this approach is not used quantitatively. In this study, precise and noninvasive measurement of CVP was achieved by accurately locating the collapse point
of the internal jugular vein and the center of the right atrium by ultrasound using our new method, with the results confirmed
by comparison with invasively measured CVP. The instruments used in this new method are widely available and portable,
making it applicable for bedside measurement in critically ill and emergency room patients. Furthermore, because CVP is
equal to the right atrial pressure as long as there is no obstruction of the vena cava, this new noninvasive and quantitative
measurement of CVP is also a crucial step toward an accurate noninvasive determination of the pulmonary arterial pressure
based on the right ventricleright atrium gradient calculated by echocardiography.

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New Method for Noninvasive Quantification of Central Venous Pressure by Ultrasound

Chang-Yang Xing, Yuan-Ling Liu, Mei-Ling Zhao, Rui-Jing Yang, Yun-You Duan, Lian-Hua
Zhang, Xu-De Sun, Li-Jun Yuan and Tie-Sheng Cao
Circ Cardiovasc Imaging. 2015;8:
doi: 10.1161/CIRCIMAGING.114.003085
Circulation: Cardiovascular Imaging is published by the American Heart Association, 7272 Greenville Avenue,
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Copyright 2015 American Heart Association, Inc. All rights reserved.
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SUPPLEMENTAL MATERIAL
Supplemental Tables
Table S1. Characteristics of 40 patients in the preliminary validation of the echo-location
method
Demographic

Value

Age, y

46.1 11.1

Male (Female)

21 (19)

Height, cm

166.4 6.8

Weight, kg

59.7 9.6

BMI, kg/m2

21.5 2.7

Heart rate, bpm

72 11

Data are given as mean SD.

Table S2. Accuracy and feasibility of the echo-location method

All (n=40)

Male (n=21)

Female (n=19)

P Value

Da, cm

0.770.25 (0.69, 0.85)

0.740.24 (0.63, 0.85)

0.810.26 (0.68, 0.94)

> 0.10

Dv, cm

0.040.55 (-0.13, 0.21)

-0.070.54 (-0.31, 0.17)

0.160.53 (-0.09, 0.43)

> 0.10

Time, sec

42.529.65 (39.4, 45.6)

43.719.34 (39.46, 47.97)

41.21 10.06 (36.35, 46.06)

> 0.10

Data are given as mean SD and 95% CI (Lower bound, Upper bound). Values obtained in
males and females were compared using Students unpaired t-tests. Da, distance between points
located by CT and echocardiography in the direction of coronal plane. Dv, vertical distance between
the two points.

Table S3. Inter-observer and intra-observer reproducibility for the echo-location method
(n=15)
Da, cm

Dv, cm

Inter-observer

0.45 0.27 (0.29, 0.59)

0.05 0.41 (-0.18,0.27)

intra-observer

0.34 0.22 (0.22, 0.46)

-0.03 0.30 (-0.20, 0.13)

Data are given as mean SD and 95% CI (Lower bound, Upper bound). Da, distance between
the two points located either by two observers (inter-observer) or by one observer before and after
(intra-observer). Dv, vertical distance between the two points.

Table S4. Details of clinical diagnoses of the patients for the central venous pressure
measurements
Clinical diagnosis for surgery

Hepatic cirrhosis

22

Cholangiocarcinoma

10

Abdominal mass

Atrial fibrillation

Carcinoma of pancreas

Gastroenteric tumor

Carcinoma of gallbladder

Liver cancer

Subarachnoid hemorrhage

Common duct stones

Others

Others referred to intestinal obstruction and choledochectasia.

Supplemental Figures with Figure Legends

Figure S1. RA location by CT

After locating the center of the right atrium (RA) in coronal plane and transverse plane through
two-dimensional (2D) images (red dot), we got the same point (red dot) in the three-dimensional
(3D) image by auto-processing at the workstation. Images in the top panel and the bottom panel
were separately obtained from patients undergoing chest multislice 3D-CT with and without
angiography.

Figure S2. Illustration of the definition of the vertical distance and absolute distance.

Point A represents the center of the right atrium located by CT, i.e. the standard point. Point B
and D represent different positions of echo-location points related to the CT-location point. Segment
BC and CD represent the corresponding vertical distance (Dv) between the points marked by the
echocardiography and CT. If the echo-location point is superior (Point B), Dv is defined as +,
otherwise - (Point D). Segment AD represents the absolute distance (Da).