Speckle tracking echocardiography and right ventricle dysfunction in acute respiratory distress syndrome: A pilot study

Right Ventricular Dysfunction in Acute Respiratory Distress Syndrome and Its Quantification by Tricuspid Annular Plane Systolic Excursion on Transthoracic Echocardiography

Background Right ventricular (RV) dysfunction is a typical complication of acute respiratory distress syndrome (ARDS), which is an independent predictor of poor prognosis in ARDS. Thus, evaluation of RV function is a crucial component of ARDS patient management. The present study aimed to determine the incidence of RV dysfunction by 2D echocardiography in mechanically ventilated ARDS patients in the ICU and assess the serial changes in tricuspid annular plane systolic excursion (TAPSE) among these patients in the intensive care unit (ICU) of a tertiary care cancer institute of Eastern India. Methods The prospective observational study included 40 patients aged 18-80 years who were admitted to the critical care unit with ARDS and put on mechanical ventilation. Patients meeting eligibility criteria underwent routine investigations on admission to the ICU. Key parameters included recording of the partial pressure of oxygen/fraction of inspired oxygen (PaO2/FiO2) oxygenation index, TAPSE on 2D transthoracic echocardiography, and plasma B-type (or brain) natriuretic peptide (BNP) level estimation conducted on day 0, day 2, and day 5. A TAPSE value <17 mm was considered to indicate RV dysfunction. Weaning outcomes, ventilator days, length of ICU stay, length of hospital stay, and in-ICU mortality were noted. Results Among the 40 study participants, the mean (± SD) age was 52.6 (± 14.3) years, and 52.5% were male patients. The incidence of RV dysfunction in ARDS was 17.5%. These patients were observed to have a progressive worsening of hypoxia along with a significant elevation of plasma BNP levels on day 2 and day 5 as compared to baseline. Weaning outcomes, ventilator days, length of hospital stay, and in-ICU mortality were comparable between the two groups. Conclusion The present study reports a 17.5% incidence of RV dysfunction in ARDS and quantifies a longitudinal deterioration in RV function with the onset of ARDS using TAPSE. The inclusion of objective indices on two-dimensional echocardiography, such as TAPSE, facilitates their regular application at the bedside and equips clinicians with a means to detect and quantify RV dysfunction in its early stages in ARDS.

The Effect of Lower Tidal Volume Ventilation Facilitated by Extracorporeal Carbon Dioxide Removal Compared With Conventional Lung Protective Ventilation on Cardiac Function

OBJECTIVES

Lower tidal volume ventilation (targeting 3 mL/kg predicted body weight, PBW) facilitated by extracorporeal carbon dioxide removal (ECCO2R) has been investigated as a potential therapy for acute hypoxemic respiratory failure (AHRF) in the pRotective vEntilation with veno-venouS lung assisT in respiratory failure (REST) trial. We investigated the effect of this strategy on cardiac function, and in particular the right ventricle.

DESIGN

Substudy of the REST trial.

SETTING

Nine U.K. ICUs.

PATIENTS

Patients with AHRF (Pao2/Fio2 < 150 mm Hg [20 kPa]).

INTERVENTION

Transthoracic echocardiography and N-terminal pro-B-type natriuretic peptide (NT-proBNP) measurements were collected at baseline and postrandomization in patients randomized to ECCO2R or usual care.

MEASUREMENTS

The primary outcome measures were a difference in tricuspid annular plane systolic excursion (TAPSE) on postrandomization echocardiogram and difference in NT-proBNP postrandomization.

RESULTS

There were 21 patients included in the echocardiography cohort (ECCO2R, n = 13; usual care, n = 8). Patient characteristics were similar in both groups at baseline. Median (interquartile range) tidal volumes were lower in the ECCO2R group compared with the usual care group postrandomization; 3.6 (3.1-4.2) mL/kg PBW versus 5.2 (4.9-5.7) mL/kg PBW, respectively (p = 0.01). There was no difference in the primary outcome measure of mean (sd) TAPSE in the ECCO2R and usual care groups postrandomization; 21.3 (5.4) mm versus 20.1 (3.2) mm, respectively (p = 0.60). There were 75 patients included in the NT-proBNP cohort (ECCO2R, n = 36; usual care, n = 39). Patient characteristics were similar in both groups at baseline. Median (interquartile range [IQR]) tidal volumes were lower in the ECCO2R group than the usual care group postrandomization; 3.8 (3.3-4.2) mL/kg PBW versus 6.7 (5.8-8.1) mL/kg PBW, respectively (p < 0.0001). There was no difference in median (IQR) NT-proBNP postrandomization; 1121 (241-5370) pg/mL versus 1393 (723-4332) pg/mL in the ECCO2R and usual care groups, respectively (p = 0.30).

CONCLUSIONS

In patients with AHRF, a reduction in tidal volume facilitated by ECCO2R, did not modify cardiac function.

Right ventricular free wall longitudinal strain is independently associated with mortality in mechanically ventilated patients with COVID-19

BACKGROUND

Right ventricular (RV) dysfunction has been commonly reported in patients with Coronavirus disease 2019 (COVID-19), and is associated with mortality in mixed cohorts of patients requiring and not requiring invasive mechanical ventilation (IMV). Using RV-speckle tracking echocardiography (STE) strain analysis, we aimed to identify the prevalence of RV dysfunction (diagnosed by abnormal RV-STE) in patients with COVID-19 that are exclusively undergoing IMV, and assess association between RV dysfunction and 30 day mortality. We performed a prospective multicentre study across 10 ICUs in Scotland from 2/9/20 to 22/3/21. One-hundred-and-four echocardiography scans were obtained from adult patients at a single timepoint between 48 h after intubation, and day 14 of intensive care unit admission. We analysed RV-STE using RV free-wall longitudinal strain (RVFWLS), with an abnormal cutoff of  > -20%. We performed survival analysis using Kaplan-Meier, log rank, and multivariate cox-regression (prespecified covariates were age, gender, ethnicity, severity of illness, and time since intubation).

RESULTS

Ninety-four/one-hundred-and-four (90.4%) scans had images adequate for RVFWLS. Mean RVFWLS was -23.0% (5.2), 27/94 (28.7%) of patients had abnormal RVFWLS. Univariate analysis with Kaplan-Meier plot and log-rank demonstrated that patients with abnormal RVFWLS have a significant association with 30-day mortality (p = 0.047). Multivariate cox-regression demonstrated that abnormal RVFWLS is independently associated with 30-day mortality (Hazard-Ratio 2.22 [1.14-4.39], p = 0.020).

CONCLUSIONS

Abnormal RVFWLS (> -20%) is independently associated with 30-day mortality in patients with COVID-19 undergoing IMV. Strategies to prevent RV dysfunction, and treatment when identified by RVFWLS, may be of therapeutic benefit to these patients.

TRIAL REGISTRATION

Retrospectively registered 21st Feb 2021.

CLINICALTRIALS

gov Identifier: NCT04764032.

Block Matching Pyramid Algorithm-Based Analysis on Efficacy of Shexiang Baoxin Pills Guided by Echocardiogram (ECG) on Patients with Angina Pectoris in Coronary Heart Disease

This paper was aimed to explore the application of the block matching pyramid (BMP) algorithm in echocardiographic spot tracking in patients with coronary heart disease (CHD) and angina pectoris, as well as the effect of Shexiang Baoxin pills (a kind of drug containing musk, which is good for cardiac diseases) on blood lipids, cardiac function, and curative effect. 206 patients with CHD angina pectoris in the hospital from July 2018 to May 2020 were selected as the research subjects and were enrolled into the control (Ctrl) group (conventional treatment, n = 103) and the observation group (the Shexiang Baoxin pill was given on the basis of conventional treatment, n = 103) in random. Then, the patients' echocardiograms were obtained, and the BMP algorithm was used to track the echocardiograms. At 12 months after treatment, the total cholesterol (TC), triglycerides (TG), low-density lipoprotein cholesterol (LDL-C), and high-density lipoprotein cholesterol (HDL-C) were compared. Besides, the differences between left ventricular end-systolic volume (LVESV), left ventricular end-systolic diameter (LVESD), left ventricular end-diastolic volume (LVEDV), left ventricular end-diastolic dimension (LVEDD), cardiac index (CI), cardiac output (CO), and LVEF were observed. Finally, the efficacy of angina pectoris and electrocardiogram was calculated. It was found that the BMP algorithm can track the echocardiograms and display the movement and displacement of the patients' left ventricle. After treatment, in contrast with the Ctrl, the levels of TC, TG, and LDL-C in the observation group were obviously lower (P < 0.05); the LVESV, LVEDV, and LVEF were obviously lower (P < 0.05), the LVESD, LVEDD, CO, and CI were obviously higher (P < 0.05), the total score of angina after treatment was obviously lower (P < 0.05), and the total effective rates of angina pectoris and echocardiogram were obviously higher (P < 0.05). In conclusion, echocardiographic spot tracking can realize the diagnosis of patients with CHD angina pectoris, and Shexiang Baoxin pill can regulate the blood lipid level and improve the echocardiographic indicators and the clinical efficacy is obvious.

Utility of echocardiographic right ventricular subcostal strain in critical care

AIMS

Right ventricular (RV) strain is a known predictor of outcomes in various heart and lung pathologies but has been considered too technically challenging for routine use in critical care. We examined whether RV strain acquired from the subcostal view, frequently more accessible in the critically ill, is an alternative to conventionally derived RV strain in intensive care.

METHODS AND RESULTS

RV strain data were acquired from apical and subcostal views on transthoracic echocardiography (TTE) in 94 patients (35% female), mean age 50.5 ± 15.2 years, venovenous extracorporeal membrane oxygenation (VVECMO) (44%). RV strain values from the apical (mean ± standard deviation; -20.4 ± 6.7) and subcostal views (-21.1 ± 7) were highly correlated (Pearson's r -0.89, P < 0.001). RV subcostal strain correlated moderately well with other echocardiography parameters including tricuspid annular plane systolic excursion (r -0.44, P < 0.001), RV systolic velocity (rho = -0.51, P < 0.001), fractional area change (r -0.66, P < 0.01), and RV outflow tract velocity time integral (r -0.49, P < 0.001). VVECMO was associated with higher RV subcostal strain (non-VVECMO -19.6 ± 6.7 vs. VVECMO -23.2 ± 7, P = 0.01) but not apical RV strain. On univariate analysis, RV subcostal strain was weakly associated with survival at 30 days (R2 = 0.04, P = 0.05, odds ratio =1.08) while apical RV was not (P = 0.16).

CONCLUSION 

RV subcostal deformation imaging is a reliable surrogate for conventionally derived strain in critical care and may in time prove to be a useful diagnostic marker in this cohort.

Mortality of right ventricular dysfunction in patients with acute respiratory distress syndrome subjected to lung protective ventilation: A systematic review and meta-analysis

BACKGROUND

The impact of right ventricular dysfunction(RVD) on the prognosis of acute respiratory distress syndrome(ARDS) patients is controversial.

OBJECTIVES

The objectives of this systematic review and meta-analysis was to investigate whether RVD or pulmonary vascular dysfunction are associated with increased mortality in patients with ARDS.

METHODS

We searched Pubmed, Embase, Cochrane Library, Wanfang Data, CNKI, and the WHO Clinical Trial Registry for studies of RVD or pulmonary vascular dysfunction in patients with ARDS.

RESULTS

The presence of RVD or pulmonary vascular dysfunction in patients with ARDS was associated with an increase in mortality (OR = 1.68, 95% CI = 1.21-2.32, P = 0.069, I² = 40.8%). Subgroup analyses obtained similar results. Funnel plots and the Egger's test indicated no publication bias, and sensitivity analyses determined that the results were stable.

CONCLUSION

The prognosis of patients with ARDS and RVD or pulmonary vascular dysfunction is worse than that of ARDS patients without RVD or pulmonary vascular dysfunction.

The Right Ventricle in COVID-19

Infection with the novel severe acute respiratory coronavirus-2 (SARS-CoV2) results in COVID-19, a disease primarily affecting the respiratory system to provoke a spectrum of clinical manifestations, the most severe being acute respiratory distress syndrome (ARDS). A significant proportion of COVID-19 patients also develop various cardiac complications, among which dysfunction of the right ventricle (RV) appears particularly common, especially in severe forms of the disease, and which is associated with a dismal prognosis. Echocardiographic studies indeed reveal right ventricular dysfunction in up to 40% of patients, a proportion even greater when the RV is explored with strain imaging echocardiography. The pathophysiological mechanisms of RV dysfunction in COVID-19 include processes increasing the pulmonary vascular hydraulic load and others reducing RV contractility, which precipitate the acute uncoupling of the RV with the pulmonary circulation. Understanding these mechanisms provides the fundamental basis for the adequate therapeutic management of RV dysfunction, which incorporates protective mechanical ventilation, the prevention and treatment of pulmonary vasoconstriction and thrombotic complications, as well as the appropriate management of RV preload and contractility. This comprehensive review provides a detailed update of the evidence of RV dysfunction in COVID-19, its pathophysiological mechanisms, and its therapy.

The impact of right ventricular injury on the mortality in patients with acute respiratory distress syndrome: a systematic review and meta-analysis

BACKGROUND

Previous studies have found various incidences of right ventricular (RV) injury and its association with clinical outcome in patients with acute respiratory distress syndrome (ARDS). In this systematic review and meta-analysis, we aimed to investigate the impact of the presence of RV injury on mortality in patients with ARDS.

METHOD

We searched Medline, Embase, and the Cochrane Central Register of Controlled Trials for studies investigating the association between RV injury and mortality. Two authors independently evaluated whether studies meet eligibility criteria and extracted the selected patients' and studies' characteristics and outcomes. RV injury was diagnosed by trans-thoracic echocardiogram (TTE), trans-esophageal echocardiogram (TEE) and PAC (pulmonary artery catheter) in the included studies. The primary outcome was the association between mortality and the presence of RV injury in patients with ARDS. The overall reported mortality was defined as either the intensive care unit (ICU) mortality, in-hospital mortality, or mortality within 90 days, and short-term mortality was defined as ICU-mortality, in-hospital mortality, or mortality within 30 days.

RESULTS

We included 9 studies (N = 1861 patients) in this meta-analysis. RV injury that included RV dysfunction, RV dysfunction with hemodynamic compromise, RV failure, or acute cor-pulmonale was present in 21.0% (391/1,861). In the pooled meta-analysis, the presence of RV injury in patients with ARDS was associated with significantly higher overall mortality (OR 1.45, 95% CI 1.13-1.86, p-value = 0.003, I² = 0%), as well as short-term mortality (OR 1.48, 95% CI 1.14-1.93, p-value = 0.003, I² = 0%).

CONCLUSION

In this systematic review and meta-analysis including 1861 patients with ARDS, the presence of RV injury was significantly associated with increased overall and short-term mortality.

TRIAL REGISTRATION

The protocol was registered at PROSPERO (CRD42020206521).

Cardiac biomarkers in acute respiratory distress syndrome: a systematic review and meta-analysis

BACKGROUND

Acute respiratory distress syndrome (ARDS) is a leading cause of morbidity and mortality in the intensive care unit. Biochemical markers of cardiac dysfunction are associated with high mortality in many respiratory conditions. The aim of this systematic review is to examine the link between elevated biomarkers of cardiac dysfunction in ARDS and mortality.

METHODS

A systematic review of MEDLINE, EMBASE, Web of Science and CENTRAL databases was performed. We included studies of adult intensive care patients with ARDS that reported the risk of death in relation to a measured biomarker of cardiac dysfunction. The primary outcome of interest was mortality up to 60 days. A random-effects model was used for pooled estimates. Funnel-plot inspection was done to evaluate publication bias; Cochrane chi-square tests and I² tests were used to assess heterogeneity.

RESULTS

Twenty-two studies were included in the systematic review and 18 in the meta-analysis. Biomarkers of cardiac stretch included NT-ProBNP (nine studies) and BNP (six studies). Biomarkers of cardiac injury included Troponin-T (two studies), Troponin-I (one study) and High-Sensitivity-Troponin-I (three studies). Three studies assessed multiple cardiac biomarkers. High levels of NT-proBNP and BNP were associated with a higher risk of death up to 60 days (unadjusted OR 8.98; CI 4.15-19.43; p<0.00001). This association persisted after adjustment for age and illness severity. Biomarkers of cardiac injury were also associated with higher mortality, but this association was not statistically significant (unadjusted OR 2.21; CI 0.94-5.16; p= 0.07).

CONCLUSION

Biomarkers of cardiac stretch are associated with increased mortality in ARDS.

Preoperative echocardiographic parameters predict primary graft dysfunction following pediatric lung transplantation

The importance of preoperative cardiac function in pediatric lung transplantation is unknown. We hypothesized that worse preoperative right ventricular (RV) systolic and worse left ventricular (LV) diastolic function would be associated with a higher risk of primary graft dysfunction grade 3 (PGD 3) between 48 and 72 hours. We performed a single center, retrospective pilot study of children (<18 years) who had echocardiograms <1 year prior to lung transplantation between 2006 and 2019. Conventional and strain echocardiography parameters were measured, and PGD was graded. Area under the receiver operating characteristic (AUROC) curves and logistic regression were performed. Forty-one patients were included; 14 (34%) developed PGD 3 and were more likely to have pulmonary hypertension (PH) as the indication for transplant (P = .005). PGD 3 patients had worse RV global longitudinal strain (P = .01), RV free wall strain (FWS) (P = .003), RV fractional area change (P = .005), E/e' (P = .01) and lateral e' velocity (P = .004) but not tricuspid annular plane systolic excursion (P = .61). RV FWS (AUROC 0.79, 95% CI 0.62-0.95) and lateral e' velocity (AUROC 0.87, 95% CI 0.68-1.00) best discriminated PGD 3 development and showed the strongest association with PGD 3 (RV FWS OR 3.87 [95% CI 1.59-9.43], P = .003; lateral e' velocity OR 0.10 [95% CI 0.01-0.70], P = .02). These associations remained when separately adjusting for age, weight, primary PH diagnosis, ischemic time, and bypass time. In this pilot study, worse preoperative RV systolic and worse LV diastolic function were associated with PGD 3 and may be modifiable recipient risk factors in pediatric lung transplantation.

Cardiac involvement in COVID-19 patients: mid-term follow up by cardiovascular magnetic resonance

BACKGROUND

Coronavirus disease 2019 (COVID-19) induces myocardial injury, either direct myocarditis or indirect injury due to systemic inflammatory response. Myocardial involvement has been proved to be one of the primary manifestations of COVID-19 infection, according to laboratory test, autopsy, and cardiovascular magnetic resonance (CMR). However, the middle-term outcome of cardiac involvement after the patients were discharged from the hospital is yet unknown. The present study aimed to evaluate mid-term cardiac sequelae in recovered COVID-19 patients by CMR METHODS: A total of 47 recovered COVID-19 patients were prospectively recruited and underwent CMR examination. The CMR protocol consisted of black blood fat-suppressed T2 weighted imaging, T2 star mapping, left ventricle (LV) cine imaging, pre- and post-contrast T1 mapping, and late gadolinium enhancement (LGE). LGE were assessed in mixed both recovered COVID-19 patients and healthy controls. The LV and right ventricle (RV) function and LV mass were assessed and compared with healthy controls.

RESULTS

A total of 44 recovered COVID-19 patients and 31 healthy controls were studied. LGE was found in 13 (30%) of COVID-19 patients. All LGE lesions were located in the mid myocardium and/or sub-epicardium with a scattered distribution. Further analysis showed that LGE-positive patients had significantly decreased LV peak global circumferential strain (GCS), RV peak GCS, RV peak global longitudinal strain (GLS) as compared to non-LGE patients (p < 0.05), while no difference was found between the non-LGE patients and healthy controls.

CONCLUSION

Myocardium injury existed in 30% of COVID-19 patients. These patients have depressed LV GCS and peak RV strains at the 3-month follow-up. CMR can monitor the COVID-19-induced myocarditis progression, and CMR strain analysis is a sensitive tool to evaluate the recovery of LV and RV dysfunction.

A pilot study on right ventricular longitudinal strain as a predictor of outcome in COVID‐19 patients with evidence of cardiac involvement

AIMS

The aim of this investigation was to evaluate echocardiographic parameters of cardiac function and in particular right ventricular (RV) function as a predictor of mortality in patients with coronavirus disease-2019 (COVID-19) pneumonia.

METHODS AND RESULTS

This prospective observational study included 35 patients admitted to a UK district general hospital with COVID-19 and evidence of cardiac involvement, that is, raised Troponin I levels or clinical evidence of heart failure during the first wave of the COVID-19 pandemic (March-May 2020). All patients underwent echocardiography including speckle tracking for right ventricular longitudinal strain (RVLS) providing image quality was sufficient (30 out of 35 patients). Upon comparison of patients who survived COVID-19 with non-survivors, survivors had significantly smaller RVs (basal RV diameter 38.2 vs 43.5 mm P = .0295) with significantly better RV function (Tricuspid annular plane systolic excursion (TAPSE): 17.5 vs 15.3 mm P = .049; average RVLS: 24.3% vs 15.6%; P = .0018). Tricuspid regurgitation (TR) maximal velocity was higher in survivors (2.75 m/s vs 2.11 m/s; P = .0045) indicating that pressure overload was not the predominant driver of this effect and there was no significant difference in left ventricular (LV) ejection fraction. Kaplan-Meier and log-rank analysis of patients split into groups according to average RVLS above or below 20% revealed significantly increased 30-day mortality in patients with average RVLS under 20% (HR: 3.189; 95% CI: 1.297-12.91; P = .0195).

CONCLUSION

This study confirms that RVLS is a potent and independent predictor of outcome in COVID-19 patients with evidence of cardiac involvement.

Prognostic utility of quantitative offline 2D-echocardiography in hospitalized patients with COVID-19 disease

PURPOSE

To assess the prognostic utility of quantitative 2D-echocardiography, including strain, in patients with COVID-19 disease.

METHODS

COVID-19-infected patients admitted to the San Paolo University Hospital of Milan that underwent a clinically indicated echocardiographic examination were included in the study. To limit contamination, all measurements were performed offline. Quantitative measurements were obtained by an operator blinded to the clinical data.

RESULTS

Among the 49 patients, nonsurvivors (33%) had worse respiratory parameters, index of multiorgan failure, and worse markers of lung involvement. Right ventricular (RV) dysfunction (as assessed by conventional and 2-dimensional speckle tracking) was a common finding and a powerful independent predictor of mortality. At the ROC curve analyses, RV free wall longitudinal strain (LS) showed an AUC 0.77 ± 0.08 in predicting death, P = .008, and global RV LS (RV-GLS) showed an AUC 0.79 ± 0.04, P = .004. This association remained significant after correction for age (OR = 1.16, 95%CI 1.01-1.34, P = .029 for RV free wall LS and OR = 1.20, 95%CI 1.01-1.42, P = .033 for RV-GLS), for oxygen partial pressure at arterial gas analysis/fraction of inspired oxygen (OR = 1.28, 95%CI 1.04-1.57, P = .021 for RV free wall-LS and OR = 1.30, 95%CI 1.04-1.62, P = .020 for RV-GLS) and for the severity of pulmonary involvement measured by a computed tomography lung score (OR = 1.27, 95%CI 1.02-1.19, P = .034 for RV free wall LS and OR = 1.30, 95%CI 1.04-1.63, P = .022 for RV-GLS).

CONCLUSIONS

In patients hospitalized with COVID-19, offline quantitative 2D-echocardiographic assessment of cardiac function is feasible. Parameters of RV function are frequently abnormal and have an independent prognostic value over markers of lung involvement.

Heart, COVID-19, and echocardiography

Although clinical manifestations of coronavirus disease of 2019 (COVID-19) mainly consist of respiratory symptoms, a severe cardiovascular damage may occur. Moreover, previous studies reported a correlation of cardiovascular metabolic diseases with severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS), and actually, many COVID-19 patients show comorbidities (systemic hypertension, cardio-cerebrovascular disease, and diabetes) and have a raised risk of death. The purpose of this review is to focus the cardiovascular effects of 2019-nCoV on the base of the most recent specific literature and previous learnings from SARS and MERS and analyze the potential role of echocardiography during the current critical period and short- and long-term follow-up.

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

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.

New or Persistent Right Ventricular Systolic Dysfunction Is Associated With Worse Outcomes in Pediatric Acute Respiratory Distress Syndrome

OBJECTIVES

The trajectory and importance of right ventricular systolic function and pulmonary hypertension during the course of pediatric acute respiratory distress syndrome are unknown. We hypothesized that new or persistent right ventricular systolic dysfunction and pulmonary hypertension would be associated with worse patient outcomes.

DESIGN

Retrospective, single-center cohort study.

SETTING

Tertiary care, university-affiliated PICU.

PATIENTS

Children who had at least two echocardiograms less than 8 days following pediatric acute respiratory distress syndrome diagnosis.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Between July 1, 2012, and April 30, 2018, 74 children met inclusion criteria. The first echocardiogram was performed a median of 0.61 days (interquartile range, 0.36-0.94 d) and the second echocardiogram was performed a median of 2.57 days (interquartile range, 1.67-3.63 d) after pediatric acute respiratory distress syndrome diagnosis. Univariate analyses showed that new or persistent right ventricular systolic dysfunction as defined by global longitudinal strain or free wall strain was associated with a greater number of ICU days in survivors (global longitudinal strain p = 0.04, free wall strain p = 0.04), lower ventilator-free days at 28 days (global longitudinal strain p = 0.03, free wall strain p = 0.01), and higher rate of PICU death (global longitudinal strain p = 0.046, free wall strain p = 0.01). Mixed-effects multivariate modeling showed that right ventricular global longitudinal strain and right ventricular fractional area change stayed relatively constant over the course of the first 8 days in nonsurvivors and that there was a linear improvement in global longitudinal strain (p = 0.037) and fractional area change (p = 0.05) in survivors. Worsening right ventricular dysfunction at the time of repeat echocardiogram as defined by global longitudinal strain and free wall strain were independently associated with decreased probability of extubation (subdistribution hazard ratio, 0.30 [0.14-0.67]; p = 0.003 and subdistribution hazard ratio, 0.47 [0.23-0.98]; p = 0.043, respectively). In univariate and multivariate analyses, pulmonary hypertension had no significant associations with outcomes in his cohort.

CONCLUSIONS

New or persistent right ventricular systolic dysfunction over the first week following pediatric acute respiratory distress syndrome onset is associated with worse patient outcomes, including decreased probability of extubation and higher PICU mortality.