>Year 2018, Issue 6
Rodríguez SAY, Rugenio CA, Sauza SJ, Franco GJ, Aguirre SJ, Camarena AG
Association of mortality, global longitudinal deformation of the left ventricle and circumferential deformation of the left ventricle in patients with sepsis in the intensive care unit
Rev Asoc Mex Med Crit y Ter Int 2018; 32 (6)
PDF: 547.77 Kb.
Introduction: Sepsis is one of the main causes of morbidity and mortality in the ICU, and when associated with SCM, the prognosis worsens; it can occur in up to 68% of patients. ECHO parameters have been proposed useful for the assessment of the LV systolic function, such as STRAIN-GLS and STRAIN-CS. In this study, the association of these with mortality in patients with sepsis in the ICU was assessed.
Material and methods: A prospective, cross-sectional, cohort study was conducted in patients with sepsis admitted to the ICU of a hospital center in Mexico City from January 1st to July 31st, 2018. Transthoracic ECHO was taken within the first 24 hours of the diagnosis of sepsis.
Results: Thirty patients were included, 17 were male (56.7%); the median age was 68.5 years (RIQ 56-84); the median hospital stay was 12 days (RIQ 7-17). The death rate was of 23.3%. The average length of stay in the ICU was 19.1 days (3-185 days). Independently assessed by CS, it was found that 36% of the population presented LV systolic dysfunction, while assessed by GLS, it was 40%. When comparing non-survivors and survivors, there were no significant demographic differences; a difference of proportions was observed in the number of patients with diabetes. Differences in medians of systolic pulmonary artery
pressure (SPAP), VAI, CS and GLS were observed. When testing the ability to discriminate survivors against non-survivors, it was found that CS was marginally superior to GLS, APACHE (Acute Physiology Age and Chronic Health Evaluation) II, SAPS (Simplified Acute Physiology Score) II, and SOFA (Sequential Organ Failure Assessment). When testing the ability of CS and GLS to discriminate hospital stay greater than seven days, it was observed that the echocardiographic measures were superior. Cut-off points were selected for discrimination of survivors against non-survivors by analyzing sensitivity and specificity for the following echocardiographic measurements: CS ≥ -15.1 (S: 71.43%, E: 83.33%, LR(+) 4.3, LR(-) 0.34) and GLS ≥ -15.4 (S: 85.71%, E: 73.91%, LR(+) 3.3, LR(-) 0.19). In the multivariate analysis, it was found that a CS ≥ -15.1 was predictive of mortality during hospitalization in the study period and population, adjusted for other echocardiographic variables such as LVEF ‹ 55%, GLS ≥ -15.4 and confounders such as sex [RM = 10.23 (95% CI, 1.01-103.2), p ‹ 0.049]. In linear regression models, no predictive echocardiographic variables were found for days of hospital stay in the study period and population.
Conclusions: The development of new ECHO techniques such as speckle tracking echocardiography (STE) has facilitated the ability to evaluate LV function through the quantitative evaluation of myocardial deformation; although they are complex techniques, if performed and interpreted appropriately, they are very useful in different clinical conditions. MD can be an early marker of mortality in patients with sepsis; obtained by measuring the GLS and CS, it could be a reliable predictor of the outcomes of patients in the ICU, and it can also potentiate scales such as APACHE II, SOFA and SAPS II to allow early identification of septic patients at high risk. There are still some obstacles to the regular clinical application of GLS and CS in septic patients in the ICU. The optimal GLS limit for the prediction of mortality in these patients remains uncertain, and the intrinsic differences between the populations could contribute to the observed differences. However, it is known to be an effective parameter for the quantification of left ventricular function, even more sensitive than the LVEF by bidimensional ECHO, depending relatively less on the operator and loading conditions. Current results should be confirmed in additional large-scale and multi-center studies. Therefore, it still remains in the field of clinical research for patients in critical condition.
||Cardiomyopathy, longitudinal global deformation, circumferential deformation.
Vincent JL, Sakr Y, Sprung CL, Ranieri VM, Reinhart K, Gerlach H, et al. Sepsis in European intensive care units: results of the SOAP study. Crit Care Med. 2006;34(2):344-353.
Vallabhajosyula S, Jentzer JC, Geske JB, Kumar M, Sakhuja A, Singhal A, et al. New-onset heart failure and mortality in hospital survivors of sepsis-related left ventricular dysfunction. choque. 2018;49(2):144-149.
Russell JA, Boyd J, Nakada T, Thair S, Walley KR. Molecular mechanisms of sepsis. Contrib Microbiol. 2011;17:48-85.
Conway-Morris A, Wilson J, Shankar-Hari M. Immune activation in sepsis. Crit Care Clin. 2018;34(1):29-42.
Kakihana Y, Ito T, Nakahara M, Yamaguchi K, Yasuda T. Sepsis-induced myocardial dysfunction: pathophysiology and management. J Intensive Care. 2016;4:22.
Bruni FD, Komwatana P, Soulsby ME, Hess ML. Endotoxin and myocardial failure: role of the myofibril and venous return. Am J Phys. 1978;235(2):H150-H156.
Cunnion RE, Schaer GL, Parker MM, Natanson C, Parrillo JE. The coronary circulation in human septic shock. Circulation. 1986;73(4):637-644.
Sato R, Nasu M. A review of sepsis-induced cardiomyopathy. J Intensive Care. 2015;3:48.
Madorin WS, Rui T, Sugimoto N, Handa O, Cepinskas G, Kvietys PR. Cardiac myocytes activated by septic plasma promote neutrophil transendothelial migration: role of platelet-activating factor and the chemokines LIX and KC. Circ Res. 2004;94(7):944-951.
Rudiger A, Singer M. Mechanisms of sepsis-induced cardiac dysfunction. Crit Care Med. 2007;35(6):1599-1608.
Ehrman RR, Sullivan AN, Favot MJ, Sherwin RL, Reynolds CA, Abidov A, et al. Pathophysiology, echocardiographic evaluation, biomarker findings, and prognostic implications of septic cardiomyopathy: a review of the literature. Crit Care. 2018;22(1):112.
Bednarczyk JM, Fridfinnson JA, Kumar A, Blanchard L, Rabbani R, Bell D, et al. Incorporating dynamic assessment of fluid responsiveness into goal-directed therapy: a systematic review and meta-analysis. Crit Care Med. 2017;45(9):1538-1545.
Cherpanath TG, Hirsch A, Geerts BF, Lagrand WK, Leeflang MM, Schultz MJ, et al. Predicting fluid responsiveness by passive leg raising: a systematic review and meta-analysis of 23 clinical trials. Crit Care Med. 2016;44(5):981-991.
Ma IWY, Caplin JD, Azad A, Wilson C, Fifer MA, Bagchi A, et al. Correlation of carotid blood flow and corrected carotid flow time with invasive cardiac output measurements. Crit Ultrasound J. 2017;9(1):10.
Jardin F, Fourme T, Page B, Loubieres Y, Vieillard-Baron A, Beauchet A, et al. Persistent preload defect in severe sepsis despite fluid loading: A longitudinal echocardiographic study in patients with septic shock. Chest. 1999;116(5):1354-1359.
Blanco J, Muriel-Bombín A, Sagredo V, Taboada F, Gandía F, Tamayo L, et al. Incidence, organ dysfunction and mortality in severe sepsis: a Spanish multicentre study. Crit Care. 2008;12(6):R158.
Calvin JE, Driedger AA, Sibbad WJ. Una evaluación de la función del miocardio en la sepsis humana mediante gammagrafía cardiaca controlada. Chest. 1981;80:579-586.
Parker MM, Shelhamer JH, Bacharach SL, Green MV, Natanson C, Frederick TM, et al. Profound but reversible myocardial depression in patients with septic shock. Ann Intern Med. 1984;100(4):483-490.
Vallabhajosyula S, Pruthi S, Shah S, Wiley BM, Mankad SV, Jentzer JC. Basic and advanced echocardiographic evaluation of myocardial dysfunction in sepsis and septic shock. Anaesth Intensive Care. 2018;46(1):13-24.
Levy RJ, Piel DA, Acton PD, Zhou R, Ferrari VA, Karp JS, et al. Evidence of myocardial hibernation in the septic heart. Crit Care Med. 2005;33(12):2752-2756.
Lanspa MJ, Pittman JE, Hirshberg EL, Wilson EL, Olsen T, Brown SM, et al. Association of left ventricular longitudinal strain with central venous oxygen saturation and serum lactate in patients with early severe sepsis and septic shock. Crit Care. 2015;19:304.
Del Castillo JM, Herszkowicz N, Ferreira C. Speckle tracking—A contratilidade miocárdica em sintonia fina. Rev Bras Ecocardiogr Imagem Cardiovasc. 2010;23(3):46-54.
Lanspa MJ, Gutsche AR, Wilson EL, Olsen TD, Hirshberg EL, Knox DB, et al. Application of a simplified definition of diastolic function in severe sepsis and septic shock. Crit Care. 2016;20(1):243.
Sevilla Berrios RA, O’Horo JC, Velagapudi V, Pulido JN. Correlation of left ventricular systolic dysfunction determined by low ejection fraction and 30-day mortality in patients with severe sepsis and septic shock: a systematic review and meta-analysis. J Crit Care. 2014;29(4):495-499.
Boissier F, Razazi K, Seemann A, Bedet A, Thille AW, de Prost N, et al. Left ventricular systolic dysfunction during septic shock: the role of loading conditions. Intensive Care Med. 2017;43(5):633-642.
Cosín-Aguilar J, Hernándiz-Martínez A. La disposición de las fibras miocárdicas en una banda condiciona la morfología y la función del corazón. Rev Esp Cardiol. 2013;66(10):768-700.
Gorcsan J 3rd, Tanaka H. Echocardiographic assessment of myocardial strain. J Am Coll Cardiol. 2011;58(14):1401-1413.
Holly G, Giuseppe C, Haruhiko A, Susan W, Scipione C, Federico G, et al. Assessment of myocardial mechanics using speckle tracking echocardiography: fundamentals and clinical applications. J Am Soc Echocardiogr. 2010;23:351-369.
Dandel M, Lehmkuhl, Knosalla C, Suramelashvili N, Hetzer R. Strain and strain rate imaging by echocardiography. Basic concepts and clinical applicability. Curr Cardiol Rev. 2009;5:133-148.
Amundsen BH, Helle-Valle T, Edvardsen T, Torp H, Crosby J, Lyseggen E, et al. Noninvasive myocardial strain measurement by speckle tracking echocardiography: validation against sonomicrometry and tagged magnetic resonance imaging. J Am Coll Cardiol. 2006;47:789-793.
Manovel A, Dawson D, Smith B, Nihoyannopoulos P. Assessment of left ventricular function by different speckle-tracking software. Eur J Echocardiogr. 2010;11:417-421.
Belghitia H, Brette S, Lafitte S, Reant P, Picard F, Serri K, et al. Automated function imaging: a new operator-independent strain method for assessing left ventricular function. Arch Cardiovasc Dis. 2008;101(3):163-169.
Marwick TH. Measurement of strain and strain rate by echocardiography: ready for prime time? J Am Coll Cardiol. 2006;47:1313-1327.
Leitman M, Lysyansky P, Sidenko S, Shir V, Peleg E, Binenbaum M, et al. Two-dimensional strain—a novel software for real-time quantitative echocardiographic assessment of myocardial function. J Am Soc Echocardiogr. 2004;17(10):1021-1029.
Mor-Avi V, Lang RM, Badano LP, Belohlavek M, Cardim NM, Derumeaux G, et al. Current and evolving echocardiographic techniques for the quantitative evaluation of cardiac mechanics: ASE/EAE consensus statement on methodology and indications endorsed by the Japanese Society of Echocardiography. Eur J Echocardiogr. 2011;12(3):167-205.
Voigt JU, Pedrizzetti G, Lysyansky P, Marwick TH, Houle H, Baumann R, et al. Definitions for a common standard for 2D speckle tracking echocardiography: consensus document of the EACVI/ASE/Industry Task Force to standardize deformation imaging. Eur Heart J Cardiovasc Imaging. 2015;16(1):1-11.
Duncan AE, Alfirevic A, Sessler DI, Popovic ZB, Thomas JD. Perioperative assessment of myocardial deformation. Anesth Analg. 2014;118(3):525-544.
Notomi Y, Lysyansky P, Setser RM, Shiota T, Popović ZB, Martin-Miklovic MG, et al. Measurement of ventricular torsion by two-dimensional ultrasound speckle tracking imaging. J Am Coll Cardiol. 2005;45(12):2034-2041.
Pavlopoulos H, Nihoyannopoulos P. Strain and strain rate deformation parameters: from tissue Doppler to 2D speckle tracking. Int J Cardiovasc Imaging. 2008;24:479-491.
Sengupta PP, Krishnamoorthy VK, Korinek J, Narula J, Vannan MA, Lester SJ, et al. Left ventricular form and function revisited: applied translational science to cardiovascular ultrasound imaging. J Am Soc Echocardiogr. 2007;20(5):539-551.
Teske AJ, De Boeck B, Melman PG, Sieswerda GT, Doevendas PA, Cramer JM. Echocardiographic quantification of myocardial function using tissue deformation imaging, a guide to image acquisition and analysis using tissue Doppler and speckle tracking. Cardiovasc Ultrasound. 2007;5:27.
Marwick TH, Leano RL, Brown J, Sun JP, Hoffmann R, Lysyansky P, et al. Myocardial strain measurement with 2-dimensional speckle-tracking echocardiography: definition of normal range. JACC Cardiovasc Imaging. 2009;2(1):80-84.
Yingchoncharoen T, Agarwal S, Popović ZB, Marwick TH. Normal ranges of left ventricular strain: a meta-analysis. J Am Soc Echocardiogr. 2013;26(2):185-191.
Cheng S, Larson MG, McCabe EL, Osypiuk E, Lehman BT, Stanchev P, et al. Age- and sex-based reference limits and clinical correlates of myocardial strain and synchrony: the Framingham Heart Study. Circ Cardiovasc Imaging. 2013;6(5):692-699.
Kuznetsova T, Herbots L, Richart T, D’hooge J, Thijs L, Fagard RH, et al. Left ventricular strain and strain rate in a general population. Eur Heart J. 2008;29:2014-2023.
Dalen H, Thorstensen A, Aase SA, Ingul CB, Torp H, Vatten LJ, et al. Segmental and global longitudinal strain and strain rate based on echocardiography of 1266 healthy individuals: the HUNT study in Norway. Eur J Echocardiogr. 2010;11:176-183.
Sun JP, Lee AP, Wu C, Lam YY, Hung MJ, Chen L, et al. Quantification of left ventricular regional myocardial function using two-dimensional speckle tracking echocardiography in healthy volunteers—a multi-center study. Int J Cardiol. 2013;167:495-501.
Fonseca CG, Oxenham HC, Cowan BR, Occleshaw CJ, Young AA. Aging alters patterns of regional nonuniformity in LV strain relaxation: a 3-D MR tissue tagging study. Am J Physiol Heart Circ Physiol. 2003;285:621-630.
Hurlburt HM, Aurigemma GP, Hill JC, Narayanan A, Gaasch WH, Vinch CS, et al. Direct ultrasound measurement of longitudinal, circumferential, and radial strain using 2-dimensional strain imaging in normal adults. Echocardiography. 2007;24(7):723-731.
Rosner A, Bijnens B, Hansen M, How OJ, Aarsaether E, Muller S, et al. Left ventricular size determines tissue Doppler-derived longitudinal strain and strain rate. Eur J Echocardiogr. 2009;10:271-277.
Ferferieva V, Van den Bergh A, Claus P, Jasaityte R, Veulemans P, Pellens M, et al. The relative value of strain and strain rate for defining intrinsic myocardial function. Am J Physiol Heart Circ Physiol. 2012;302(1):H188-H195.
Weidemann F, Jamal F, Kowalski M, Kukulski T, D’Hooge J, Bijnens B, et al. Can strain rate and strain quantify changes in regional systolic function during dobutamine infusion, B-blockade, and atrial pacing—implications for quantitative stress echocardiography. J Am Soc Echocardiogr. 2002;15:416-424.
Kovács A, Oláh A, Lux Á, Mátyás C, Németh BT, Kellermayer D, et al. Strain and strain rate by speckle-tracking echocardiography correlate with pressure-volume loop-derived contractility indices in a rat model of athlete’s heart. Am J Physiol Heart Circ Physiol. 2015;308(7):H743-H748.
Rodríguez-Bailón I, Jiménez-Navarro MF, Pérez-González R, García-Orta R, Morillo-Velarde E, de Teresa-Galván E. Deformación ventricular izquierda en ecocardiografía bidimensional: valores y tiempos en sujetos normales. Rev Esp Cardiol. 2010;63(10):1195-1199.
Landesberg G, Jaffe AS, Gilon D, Levin PD, Goodman S, Abu-Baih A, et al. Troponin elevation in severe sepsis and septic shock: the role of left ventricular diastolic dysfunction and right ventricular dilatation. Crit Care Med. 2014;42(4):790-800.
Orde SR, Pulido JN, Masaki M, Gillespie S, Spoon JN, Kane GC, et al. Outcome prediction in sepsis: speckle tracking echocardiography based assessment of myocardial function. Crit Care. 2014;18(4):R149.
De Geer L, Engvall J, Oscarsson A. Strain echocardiography in septic shock—a comparison with systolic and diastolic function parameters, cardiac biomarkers and outcome. Crit Care. 2015;19:122.
Chang WT, Lee WH, Lee WT, Chen PS, Su YR, Liu PY, et al. Left ventricular global longitudinal strain is independently associated with mortality in septic shock patients. Intensive Care Med. 2015;41(10):1791-1799.
Palmieri V, Innocenti F, Guzzo A, Guerrini E, Vignaroli D, Pini R. Left ventricular systolic longitudinal function as predictor of outcome in patients with sepsis. Circ Cardiovasc Imaging. 2015;8(11):e003865.
Ng PY, Sin WC, Ng AK, Chan WM. Speckle tracking echocardiography in patients with septic shock: a case control study (SPECKSS). Crit Care. 2016;20(1):145.
Zaky A, Gill EA, Lin CP, Paul CP, Bendjelid K, Treggiari MM. Characteristics of sepsis-induced cardiac dysfunction using speckle-tracking echocardiography: a feasibility study. Anaesth Intensive Care. 2016;44(1):65-76.
De Geer L, Oscarsson A, Engvall J. Variability in echocardiographic measurements of left ventricular function in septic shock patients. Cardiovasc Ultrasound. 2015;13:19.
Dalla K, Hallman C, Bech-Hanssen O, Haney M, Ricksten SE. Strain echocardiography identifies impaired longitudinal systolic function in patients with septic shock and preserved ejection fraction. Cardiovasc Ultrasound. 2015;13:30.
Kalam K, Otahal P, Marwick TH. Prognostic implications of global LV dysfunction: a systematic review and meta-analysis of global longitudinal strain and ejection fraction. Heart. 2014;100(21):1673-1680.
Innocenti F, Palmieri V, Guzzo A, Stefanone VT, Donnini C, Pini R. SOFA score and left ventricular systolic function as predictors of short-term outcome in patients with sepsis. Intern Emerg Med. 2018;13(1):51-58.
Lang RM, Badano LP, Mor-Avi V, Afilalo J, Armstrong A, Ernande L, et al. Recomendaciones para la cuantificación de las cavidades cardiacas por ecocardiografía en adultos: actualización de la Sociedad Americana de Ecocardiografía y de la Asociación Europea de Imagen Cardiovascular. Asociación de Ecocardiografía de la Sociedad Interamericana de Cardiología (ECOSIAC); 2018.
Liu YW, Su CT, Huang YY, Yang CS, Huang JW, Yang MT, et al. Left ventricular systolic strain in chronic kidney disease and hemodialysis patients. Am J Nephrol. 2011;33(1):84-90.
>Year 2018, Issue 6