Optimal right heart filling pressure in acute respiratory distress syndrome determined by strain echocardiography

Garcia‐Montilla, Romel; Imam, Faryal; Miao, Mi; Stinson, Kathryn; Khan, Akram; Heitner, Stephen B.

doi:10.1111/echo.13546

Cited by 10 publications

(11 citation statements)

References 72 publications

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“…Interobserver reproducibility assessed by ICC was > 0.75 for all LSS indices, which indicates good reliability [12], much higher than for RV FAC. The same findings were recently reported in ARDS patients by Garcia-Montilla et al, with high ICC coefficients for RV lateral strain but a low interobserver agreement for RVFAC [13]. This could be explained by the software-based automated tracing of the endocardial border, which limits operator dependency.…”

Section: Table 4 Correlation Coefficients (Pearson) Between Echocardisupporting

confidence: 85%

Feasibility, reproducibility and diagnostic usefulness of right ventricular strain by 2-dimensional speckle-tracking echocardiography in ARDS patients: the ARD strain study

Lemarié¹,

Maigrat

Kimmoun³

et al. 2020

Ann. Intensive Care

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Background: Right ventricular (RV) function evaluation by echocardiography is key in the management of ICU patients with acute respiratory distress syndrome (ARDS), however, it remains challenging. Quantification of RV deformation by speckle-tracking echocardiography (STE) is a recently available and reproducible technique that provides an integrated analysis of the RV. However, data are scarce regarding its use in critically ill patients. The aim of this study was to assess its feasibility and clinical usefulness in moderate-severe ARDS patients.Results: Forty-eight ARDS patients under invasive mechanical ventilation (MV) were consecutively enrolled in a prospective observational study. A full transthoracic echocardiography was performed within 36 h of MV initiation. STE-derived and conventional parameters were recorded. Strain imaging of the RV lateral, inferior and septal walls was highly feasible (47/48 (98%) patients). Interobserver reproducibility of RV strain values displayed good reliability (intraclass correlation coefficients (ICC) > 0.75 for all STE-derived parameters) in ARDS patients. ROC curve analysis showed that lateral, inferior, global (average of the 3 RV walls) longitudinal systolic strain (LSS) and global strain rate demonstrated significant diagnostic values when compared to several conventional indices (TAPSE, S′, RV FAC). A RV global LSS value > − 13.7% differentiated patients with a TAPSE < vs > 12 mm with a sensitivity of 88% and a specificity of 83%. Regarding clinical outcomes, mortality and cumulative incidence of weaning from MV at day 28 were not different in patients with normal versus abnormal STE-derived parameters. Conclusions:Global STE assessment of the RV was highly achievable and reproducible in moderate-severe ARDS patients under MV and additionally correlated with several conventional parameters of RV function. In our cohort, STE-derived parameters did not provide any incremental value in terms of survival or weaning from MV prediction. Further investigations are needed to evaluate their theranostic usefulness. Trial registration NCT02638844: NCT

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Section: Table 4 Correlation Coefficients (Pearson) Between Echocardisupporting

confidence: 85%

Feasibility, reproducibility and diagnostic usefulness of right ventricular strain by 2-dimensional speckle-tracking echocardiography in ARDS patients: the ARD strain study

Lemarié¹,

Maigrat

Kimmoun³

et al. 2020

Ann. Intensive Care

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“…These analyses demonstrated that an RVFWS of −21% (Figure 3, point A) corresponded to an LVEF of approximately 55% (vertical blue dotted arrow), and an LVGLS of −12% (Figure 3, point B) corresponded to an LVEF of approximately 42% (vertical red dotted arrow), and with an RVFWS close to −16% (Figure 3, point C). In a previous report, we demonstrated that in this group of patients with ARDS, the CVP values corresponding to points A and C on the RVFWS curve were approximately 13 mm Hg and 17 mm Hg, respectively 35 . The analyses of Figure 1 also suggested that points A and B represent two different inflection areas in the strain function curves of RV and LV correspondingly, and the distance and slope between these two points signify a period of progressive biventricular contractile deterioration.…”

Section: Resultssupporting

confidence: 51%

“…From a practical perspective, our results indicate that in moderate–severe ARDS, the sole presence of a nondilated IVC is associated with a preserved cardio‐circulatory function and, in this circumstance, intravenous fluids may be confidently given with an potentially expected good clinical response and tolerance. However the development of a dilated IVC, more if associated with a significantly elevated CVP, 35,46,48 may be a marker of imminent circulatory failure, and should signal the necessity to stop fluid expansion, initiate diuretic administration, 47 or renal replacement therapy 12,13 and consider the initiation/escalation of vasoactive drugs, 14 while fine tuning other cardiac (particularly right ventricle) protecting interventions such as ventilatory optimization, hypercarbia limitation, and/or the initiation of prone position ventilation 31,57,58 …”

Section: Discussionmentioning

confidence: 99%

Inferior vena cava dilation predicts global cardiac dysfunction in acute respiratory distress syndrome: A strain echocardiographic study

et al. 2021

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Purpose Limited data exist on the utility of ultrasonographic evaluation of inferior vena cava (IVC) in acute respiratory distress syndrome (ARDS). We studied the value of IVC diameter in assessing cardio‐circulatory performance in ARDS using strain echocardiography. Materials and Methods Retrospective cross‐sectional analysis of Doppler echocardiograms of patients with moderate–severe ARDS was performed. Right ventricle (RV) parameters, IVC diameter, and left ventricle (LV) systolic and diastolic parameters were collected. RV free wall strain (RVFWS) and LV global longitudinal strain (LVGLS) were calculated. Results Fifty‐one patients were dichotomized into two groups: with IVC > 2.1 cm (dilated) and with IVC ≤ 2.1 cm (nondilated). The dilated IVC group presented worse hypoxemic profile, hypotension, and poor perfusion markers. No significant associations with positive end‐expiratory pressure or lung mechanics were observed. Dilated IVC was associated with impaired RV function, high central venous pressure, elevated pulmonary artery pressure, and LV systolic and diastolic dysfunctions. Strongest predictors of a dilated IVC were RVFWS, LVGLS, and tissue Doppler mitral annular early diastolic velocity. Dilated IVC predicted a global cardiac dysfunction defined by strain echocardiography (GCDS) with high sensitivity and specificity. Conclusions In ARDS, strain echocardiography analyses demonstrated that a dilated IVC is associated with GCDS and impaired hemodynamics independent of lung mechanics. A dilated IVC should be considered a marker of circulatory distress, signaling the potential necessity for improved hemodynamic optimization.

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“…It has also demonstrated a close association with invasively measured cardiac index (54) and RV stroke work index (53,54). Recently, Garcia-Montilla and colleagues (55) evaluated whether RVFWS was able to predict an optimal RV filling pressure in patients with ARDS receiving lung protective MV (55). These authors concluded that in terms of RV mechanics, the optimal RV filling pressure in moderate-severe ARDS may typically average CVP of ~13 mmHg, and correlating with a RVFWS of ~20% (normal reference value) (55).…”

Section: The Role Of Echocardiographymentioning

confidence: 99%

“…Recently, Garcia-Montilla and colleagues (55) evaluated whether RVFWS was able to predict an optimal RV filling pressure in patients with ARDS receiving lung protective MV (55). These authors concluded that in terms of RV mechanics, the optimal RV filling pressure in moderate-severe ARDS may typically average CVP of ~13 mmHg, and correlating with a RVFWS of ~20% (normal reference value) (55). Once this technology becomes more widely available and standardized, STE may provide critical care practitioners with an important and objective metric to help with hemodynamic management of patients with ARDS, potentially allowing, for example, realtime PEEP titration based on RV strain.…”

Section: The Role Of Echocardiographymentioning

confidence: 99%

Physiology-guided management of hemodynamics in acute respiratory distress syndrome

Cortes-Puentes¹,

Oeckler²,

Marini³

2018

Ann. Transl. Med.

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Skillfully implemented mechanical ventilation (MV) may prove of immense benefit in restoring physiologic homeostasis. However, since hemodynamic instability is a primary factor influencing mortality in acute respiratory distress syndrome (ARDS), clinicians should be vigilant regarding the potentially deleterious effects of MV on right ventricular (RV) function and pulmonary vascular mechanics (PVM). During both spontaneous and positive pressure MV (PPMV), tidal changes in pleural pressure (P PL), transpulmonary pressure (P TP , the difference between alveolar pressure and P PL), and lung volume influence key components of hemodynamics: preload, afterload, heart rate, and myocardial contractility. Acute cor pulmonale (ACP), which occurs in 20-25% of ARDS cases, emerges from negative effects of lung pathology and inappropriate changes in P PL and P TP on the pulmonary microcirculation during PPMV. Functional, minimally invasive hemodynamic monitoring for tracking cardiac performance and output adequacy is integral to effective care. In this review we describe a physiology-based approach to the management of hemodynamics in the setting of ARDS: avoiding excessive cardiac demand, regulating fluid balance, optimizing heart rate, and keeping focus on the pulmonary circuit as cornerstones of effective hemodynamic management for patients in all forms of respiratory failure.

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Optimal right heart filling pressure in acute respiratory distress syndrome determined by strain echocardiography

Abstract: Our data are the first to show that an RV filling pressure of 13±2 mm Hg-as by CVP-correlates with optimal RV mechanics as evaluated by strain echocardiography in patients with moderate-severe ARDS.

Cited by 10 publications

References 72 publications

Feasibility, reproducibility and diagnostic usefulness of right ventricular strain by 2-dimensional speckle-tracking echocardiography in ARDS patients: the ARD strain study

Feasibility, reproducibility and diagnostic usefulness of right ventricular strain by 2-dimensional speckle-tracking echocardiography in ARDS patients: the ARD strain study

Inferior vena cava dilation predicts global cardiac dysfunction in acute respiratory distress syndrome: A strain echocardiographic study

Physiology-guided management of hemodynamics in acute respiratory distress syndrome

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