1
|
Catena E, Volontè A, Rizzuto C, Bergomi P, Gambarini M, Fossali T, Ottolina D, Perotti A, Veronese A, Colombo R. The value of a dynamic echocardiographic approach to diastolic dysfunction in intensive care medicine. JOURNAL OF CLINICAL ULTRASOUND : JCU 2024; 52:95-102. [PMID: 37962285 DOI: 10.1002/jcu.23610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 10/31/2023] [Accepted: 11/02/2023] [Indexed: 11/15/2023]
Abstract
Diastolic dysfunction is an underestimated feature in the context of the critically ill setting and perioperative medicine. Advances in echocardiography, its noninvasive, safe and easy use, have allowed Doppler echocardiography to become a cornerstone for diagnosing diastolic dysfunction in clinical practice. The diagnosis of diastolic dysfunction and increased filling pressures is nevertheless complex. Using an echocardiographic assessment and the routine application of preload stress maneuvers during echocardiographic examination can help identify early stages of diastolic dysfunction leading to better management of patients at risk of acute heart decompensation in the perioperative period or during ICU stay.
Collapse
Affiliation(s)
- Emanuele Catena
- Anesthesia and Intensive Care Unit, "Luigi Sacco" Hospital of Milan, University of Milan, Milan, Italy
| | - Alessandra Volontè
- Anesthesia and Intensive Care Unit, "Papa Giovanni XXIII" Hospital of Bergamo, University of Milan, Milan, Italy
| | - Chiara Rizzuto
- Anesthesia and Intensive Care Unit, "Luigi Sacco" Hospital of Milan, University of Milan, Milan, Italy
| | - Paola Bergomi
- Anesthesia and Intensive Care Unit, "Luigi Sacco" Hospital of Milan, University of Milan, Milan, Italy
| | - Matteo Gambarini
- Anesthesia and Intensive Care Unit, "Luigi Sacco" Hospital of Milan, University of Milan, Milan, Italy
| | - Tommaso Fossali
- Anesthesia and Intensive Care Unit, "Luigi Sacco" Hospital of Milan, University of Milan, Milan, Italy
| | - Davide Ottolina
- Anesthesia and Intensive Care Unit, "Luigi Sacco" Hospital of Milan, University of Milan, Milan, Italy
| | - Andrea Perotti
- Anesthesia and Intensive Care Unit, "Luigi Sacco" Hospital of Milan, University of Milan, Milan, Italy
| | - Alice Veronese
- Anesthesia and Intensive Care Unit, "Luigi Sacco" Hospital of Milan, University of Milan, Milan, Italy
| | - Riccardo Colombo
- Anesthesia and Intensive Care Unit, "Luigi Sacco" Hospital of Milan, University of Milan, Milan, Italy
| |
Collapse
|
2
|
Ginsburg S, Conlon T, Himebauch A, Glau C, Weiss S, Weber MD, O'Connor MJ, Nishisaki A. Left Ventricular Diastolic Dysfunction in Pediatric Sepsis: Outcomes in a Single-Center Retrospective Cohort Study. Pediatr Crit Care Med 2021; 22:275-285. [PMID: 33534389 DOI: 10.1097/pcc.0000000000002668] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVES Left ventricular diastolic dysfunction is associated with difficulty in ventilator weaning and increased mortality in septic adults. We evaluated the association of left ventricular diastolic dysfunction with outcomes in a cohort of children with severe sepsis and septic shock. DESIGN Retrospective cohort study. SETTING Single-center noncardiac PICU. PATIENTS Age greater than 1 month to less than 18 years old with severe sepsis or septic shock from January 2011 to June 2017 with echocardiogram within 48 hours of sepsis onset. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Echocardiograms were retrospectively assessed for mitral inflow E (early) and A (atrial) velocity and e' (early mitral annular motion) septal and lateral velocity. Left ventricular diastolic dysfunction was defined as E/e' greater than 10, E/A less than 0.8, or E/A greater than 1.5. Left ventricular diastolic dysfunction was present in 109 of 204 patients (53%). The data did not demonstrate an association between the presence of left ventricular diastolic dysfunction and the proportion of children requiring invasive mechanical ventilation at the time of echocardiogram (difference in proportion, +5% [72% vs 67%; 95% CI, -8% to 17%]; p = 0.52). The duration of mechanical ventilation was median 192.9 hours (interquartile range, 65.0-378.4 hr) in the left ventricular diastolic dysfunction group versus 151.0 hours (interquartile range, 45.7-244.3 hr) in the group without left ventricular diastolic dysfunction. The presence of left ventricular diastolic dysfunction was not significantly associated with ICU length of stay or mortality. Exploratory analyses revealed that an alternative definition of left ventricular diastolic dysfunction, solely defined by E/e' greater than 10, was found to have an association with mechanical ventilation requirement at the time of echocardiogram (difference in proportion, +15%; 95% CI, 3-28%; p = 0.02) and duration of mechanical ventilation (median, 207.3 vs 146.9 hr). CONCLUSIONS The data failed to show an association between the presence of left ventricular diastolic dysfunction defined by both E/e' and E/A and the primary and secondary outcomes. When an alternative definition of left ventricular diastolic dysfunction with E/e' alone was used, there was a significant association with respiratory outcomes.
Collapse
Affiliation(s)
- Sarah Ginsburg
- Division of Critical Care Medicine, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX
| | - Thomas Conlon
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA.,Department of Anesthesiology, Critical Care, and Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Adam Himebauch
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA.,Department of Anesthesiology, Critical Care, and Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Christie Glau
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA.,Department of Anesthesiology, Critical Care, and Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Scott Weiss
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA.,Department of Anesthesiology, Critical Care, and Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.,Children's Hospital of Philadelphia Pediatric Sepsis Program, Philadelphia, PA
| | - Mark D Weber
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Matthew J O'Connor
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Akira Nishisaki
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA.,Department of Anesthesiology, Critical Care, and Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| |
Collapse
|
3
|
Zhang F, Liang Y, Chen X, Xu L, Zhou C, Fan T, Yan J. Echocardiographic evaluation of left ventricular end diastolic pressure in patients with diastolic heart failure: A comparative study with real-time catheterization. Medicine (Baltimore) 2020; 99:e22683. [PMID: 33285675 PMCID: PMC7717788 DOI: 10.1097/md.0000000000022683] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 08/12/2020] [Accepted: 09/08/2020] [Indexed: 02/06/2023] Open
Abstract
To evaluate the left ventricular end diastolic pressure (LVEDP) in patients with diastolic heart failure by echocardiography and explore the clinical value of echocardiography.From July 2017 to January 2018, 120 patients were prospectively selected from the affiliated hospital of Jiangsu university diagnosed as diastolic heart failure (York Heart Association class ≥II, LVEF ≥50%). The patients were divided into group with LVEDP ≤15 mm hg (1 mm hg = 0.133 kpa) (43 cases) and the group with LVEDP >15 mm hg (77 cases) according to the real-time measurement of LVEDP. Receiver operator characteristic curves of each parameter of echocardiography in diagnosis of LVEDP were compared between the 2 groups.Common ultrasonic parameters such as left ventricular inflow tract blood flow propagation velocity, mitral valve diastole e peak velocity/mitral valve diastole a peak velocity, e peak deceleration time, a peak duration, and early diastole interventricular septum bicuspid annulus velocity e' (e'sep) were used to evaluate LVEDP elevation with low accuracy (AUC is only between 0.5 and 0.7). Other ultrasonic parameters such as left atrial volume index (LAVI), tricuspid regurgitation maximum flow rate (TRmax), early diastole left ventricular sidewall bicuspid annulus velocity e' (e'lat), average e', E/e'sep, E/e'lat, average E/e' were used to evaluate LVEDP elevation with a certain improvement in accuracy (AUC between 0.7 and 0.9). Propagation velocity, mitral valve diastole e peak velocity/mitral valve diastole a peak velocity, e peak deceleration time, a peak duration, e'sep, average e', E/e'sep have very low correlation with LVEDP (r = -0.283 to 0.281); LAVI, TRmax, e'lat, E/e'lat, average E/e' and LVEDP are not highly correlated (r = 0.330-0.478). Through real-time left ventricular manometry, multiple regression analysis showed that TRmax, average e', e'lat, LAVI were independently correlated with the actual measured LVEDP.Echocardiography can recognize the increase of LVEDP in patients with heart failure preserved by LVEF, and estimate the value of LVEDP roughly, which can reflect LVEDP to a certain extent, with high feasibility and accuracy.
Collapse
|
4
|
Patel R, Desai AR, Patel P, Vanka V, Ghadiam H, Kizhakekuttu T. Physician Variability in Diastology Reporting in Patients With Preserved Ejection Fraction: A Single Center Experience. Cureus 2020; 12:e9062. [PMID: 32782880 PMCID: PMC7413311 DOI: 10.7759/cureus.9062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
To help standardize the assessment of diastolic dysfunction in the United States, the American Society of Echocardiography (ASE) released criteria for the assessment of diastology in patients with normal and abnormal ejection fraction. As heart failure with preserved ejection fraction (HFpEF) is a leading cause of morbidity and mortality in cardiac patients, it is imperative to assess diastology appropriately. Echocardiography is the mainstay in the assessment of diastolic function; with the new ASE guidelines, diagnosis is simplified especially in patients that have preserved baseline ejection fraction. Our study aimed to determine the extent of physician variability in diastology reporting at our medical center after the release of the new ASE criteria.
Collapse
|
5
|
Yin W, Li Y, Wang S, Zeng X, Qin Y, Wang X, Chao Y, Zhang L, Kang Y, (CCUSG) CCUSG. The PIEPEAR Workflow: A Critical Care Ultrasound Based 7-Step Approach as a Standard Procedure to Manage Patients with Acute Cardiorespiratory Compromise, with Two Example Cases Presented. BIOMED RESEARCH INTERNATIONAL 2018; 2018:4687346. [PMID: 29992144 PMCID: PMC6016228 DOI: 10.1155/2018/4687346] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Revised: 03/04/2018] [Accepted: 05/16/2018] [Indexed: 02/05/2023]
Abstract
Critical care ultrasound (CCUS) has been widely used as a useful tool to assist clinical judgement. The utilization should be integrated into clinical scenario and interact with other tests. No publication has reported this. We present a CCUS based "7-step approach" workflow-the PIEPEAR Workflow-which we had summarized and integrated our experience in CCUS and clinical practice into, and then we present two cases which we have applied the workflow into as examples. Step one is "problems emerged?" classifying the signs of the deterioration into two aspects: acute circulatory compromise and acute respiratory compromise. Step two is "information clear?" quickly summarizing the patient's medical history by three aspects. Step three is "focused exam launched": (1) focused exam of the heart by five views: the assessment includes (1) fast and global assessment of the heart (heart glance) to identify cases that need immediate life-saving intervention and (2) assessing the inferior vena cava, right heart, diastolic and systolic function of left heart, and systematic vascular resistance to clarify the hemodynamics. (2) Lung ultrasound exam is performed to clarify the predominant pattern of the lung. Step four is "pathophysiologic changes reported." The results of the focused ultrasound exam were integrated to conclude the pathophysiologic changes. Step five is "etiology explored" diagnosing the etiology by integrating Step two and Step four and searching for the source of infection, according to the clues extracted from the focused ultrasound exam; additional ultrasound exams or other tests should be applied if needed. Step six is "action" supporting the circulation and respiration sticking to Step four. Treat the etiologies according step five. Step seven is "recheck to adjust." Repeat focused ultrasound and other tests to assess the response to treatment, adjust the treatment if needed, and confirm or correct the final diagnosis. With two cases as examples presented, we insist that applying CCUS with 7-step approach workflow is easy to follow and has theoretical advantages. The coming research on its value is expected.
Collapse
Affiliation(s)
- Wanhong Yin
- Department of Critical Care Medicine, West China School of Medicine/West China Hospital, Sichuan University, 37 Guoxue Avenue, Chengdu 610041, China
| | - Yi Li
- Department of Critical Care Medicine, West China School of Medicine/West China Hospital, Sichuan University, 37 Guoxue Avenue, Chengdu 610041, China
| | - Shouping Wang
- Department of Critical Care Medicine, West China School of Medicine/West China Hospital, Sichuan University, 37 Guoxue Avenue, Chengdu 610041, China
| | - Xueying Zeng
- Department of Critical Care Medicine, West China School of Medicine/West China Hospital, Sichuan University, 37 Guoxue Avenue, Chengdu 610041, China
| | - Yao Qin
- Department of Critical Care Medicine, West China School of Medicine/West China Hospital, Sichuan University, 37 Guoxue Avenue, Chengdu 610041, China
| | - Xiaoting Wang
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Yangong Chao
- Department of Critical Care Medicine, The First Hospital of Tsinghua University, Beijing 100016, China
| | - Lina Zhang
- Department of Critical Care Medicine, Xiangya Hospital, Central South University, Changsha, Hunan 410008, China
| | - Yan Kang
- Department of Critical Care Medicine, West China School of Medicine/West China Hospital, Sichuan University, 37 Guoxue Avenue, Chengdu 610041, China
| | | |
Collapse
|
6
|
Preliminary Exploration of Epidemiologic and Hemodynamic Characteristics of Restrictive Filling Diastolic Dysfunction Based on Echocardiography in Critically Ill Patients: A Retrospective Study. BIOMED RESEARCH INTERNATIONAL 2018; 2018:5429868. [PMID: 29682549 PMCID: PMC5841041 DOI: 10.1155/2018/5429868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Revised: 01/07/2018] [Accepted: 01/15/2018] [Indexed: 02/05/2023]
Abstract
Objective To preliminarily describe the epidemiologic and hemodynamic characteristics of critically ill patients with restrictive filling diastolic dysfunction based on echocardiography. Setting A retrospective study. Methods Epidemiologic characteristics of patients with restrictive filling diastolic dysfunction in ICU were described; clinical and hemodynamic data were preliminarily summarized and compared between patients with and without restrictive filling diastolic dysfunction; most of the data were based on echocardiography. Results More than half of the patients in ICU had diastolic dysfunction and about 16% of them had restrictive filling pattern. The patients who had restrictive filling diastolic dysfunction were more likely to have wider diameter of IVC (2.18 ± 0.50 versus 1.92 ± 0.43, P = 0.037), higher extravascular lung water score (15.9 ± 9.2 versus 13.2 ± 9.1, P = 0.014), lower left ventricular ejection fraction (EF-S: 53.0 ± 16.3 versus 59.3 ± 12.5, P = 0.014), and lower percentage of normal LAP that was estimated by E/e′ (8.9% versus 90.0%, P = 0.001) when compared with those of patients without restrictive filling diastolic dysfunction. Conclusion Our results suggest that critically ill patients with restrictive filling diastolic dysfunction may experience rising volume status, increasing extravascular lung water ultrasonic score, reducing long-axis systolic dysfunction, and less possibility of normal left atrial pressure. Intensivists are advised to pay more attention to patients with diastolic dysfunction, especially the exquisite fluid management of patients with restrictive filling pattern due to the close relationship of restrictive filling diastolic dysfunction with volume status and extravascular lung water in our study.
Collapse
|
7
|
Yin W, Li Y, Zeng X, Qin Y, Wang D, Zou T, Su L, Kang Y. The utilization of critical care ultrasound to assess hemodynamics and lung pathology on ICU admission and the potential for predicting outcome. PLoS One 2017; 12:e0182881. [PMID: 28806783 PMCID: PMC5555697 DOI: 10.1371/journal.pone.0182881] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 07/26/2017] [Indexed: 02/05/2023] Open
Abstract
Aim Critical care ultrasound (CCUS) has been used by many Intensive Care Units(ICUs) worldwide, so as to guiding the diagnosis and the treatment. However, none of the publications currently systematically describe the utilization of CCUS to analyze the characteristics of hemodynamics and lung pathology upon the new admission to ICU and its potential role in patients’ prognosis prediction. In this retrospective clinical study, we have demonstrated and analyzed the characteristics of hemodynamics and lung pathology assessed by CCUS and investigated its potential to predict patient outcome. Methods We have described and analyzed the epidemic characteristics of hemodynamics and lung pathology assessed by CCUS on ICU admission, which based on our database of 451 cases from the biggest medical center in Western China, between November 2014 and October 2015. The patients’ demographics, clinical characteristics, prognosis and ultrasonic pattern of hemodynamics and lung pathology had been analyzed. A bivariate logistic regression model was established to identify the correlation between the ultrasonic variables on admission and the ICU mortality. Results The mean age of the 451 patients was 56.7±18.7 years; the mean APACHE II score was 19.0±7.9, the ICU mortality was 30.6%. Patients received CCUS examination of pericardial, right ventricle (RV) wall motion, left ventricle (LV) wall motion, LV systolic function, LV diastolic function, lung and volume of inferior vena cava (IVC) were 423(93.8%), 418(92.7%), 392(86.9%), 389(86.3%), 383(84.9%), 440(97.6%), 336(74.5%), respectively; The univariate analysis revealed that length of mechanical ventilation was significantly correlated with the diameter of IVC, tricuspid annular plane systolic excursion(TAPSE), mitral annular plane systolic excursion(MAPSE), early diastolic transmitral velocity to early mitral annulus diastolic velocity(E/e’) (p = 0.016, 0.011, 0.000, 0.049, respectively); The TAPSE, ejection fraction(EF), MAPSE, lung ultrasound score (LUS score) (p = 0.000, 0.028, 0.000, 0.011, respectively) were significantly related to ICU mortality. The multivariate analysis demonstrated that APACHE II, age, TAPSE, E/e’ are the independent risk factors for ICU mortality in our study. Conclusion CCUS examination on ICU admission which performed by the experienced physician provide valuable information to assist the caregivers in understanding the comprehensive outlook of the characteristics of hemodynamics and lung pathology. Those key variables obtained by CCUS predict the possible prognosis of patients, hence deserve more attention in clinical decision making.
Collapse
Affiliation(s)
- Wanhong Yin
- Department of Critical Care Medicine, West China Hospital/West China School of Medicine, Sichuan University, Chengdu, Sichuan, People’s Republic of China
| | - Yi Li
- Department of Critical Care Medicine, West China Hospital/West China School of Medicine, Sichuan University, Chengdu, Sichuan, People’s Republic of China
| | - Xueying Zeng
- Department of Critical Care Medicine, West China Hospital/West China School of Medicine, Sichuan University, Chengdu, Sichuan, People’s Republic of China
| | - Yao Qin
- Department of Critical Care Medicine, West China Hospital/West China School of Medicine, Sichuan University, Chengdu, Sichuan, People’s Republic of China
| | - Dong Wang
- Critical Care Medicine Department, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Tongjuan Zou
- Department of Critical Care Medicine, West China Hospital/West China School of Medicine, Sichuan University, Chengdu, Sichuan, People’s Republic of China
| | - Ling Su
- Department of Critical Care Medicine, West China Hospital/West China School of Medicine, Sichuan University, Chengdu, Sichuan, People’s Republic of China
| | - Yan Kang
- Department of Critical Care Medicine, West China Hospital/West China School of Medicine, Sichuan University, Chengdu, Sichuan, People’s Republic of China
- * E-mail:
| |
Collapse
|
8
|
|
9
|
Suárez JC, López P, Mancebo J, Zapata L. Diastolic dysfunction in the critically ill patient. Med Intensiva 2016; 40:499-510. [PMID: 27569679 DOI: 10.1016/j.medin.2016.06.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Revised: 06/14/2016] [Accepted: 06/20/2016] [Indexed: 12/16/2022]
Abstract
Left ventricular diastolic dysfunction is a common finding in critically ill patients. It is characterized by a progressive deterioration of the relaxation and the compliance of the left ventricle. Two-dimensional and Doppler echocardiography is a cornerstone in its diagnosis. Acute pulmonary edema associated with hypertensive crisis is the most frequent presentation of diastolic dysfunction critically ill patients. Myocardial ischemia, sepsis and weaning failure from mechanical ventilation also may be associated with diastolic dysfunction. The treatment is based on the reduction of pulmonary congestion and left ventricular filling pressures. Some studies have found a prognostic role of diastolic dysfunction in some diseases such as sepsis. The present review aims to analyze thoroughly the echocardiographic diagnosis and the most frequent scenarios in critically ill patients in whom diastolic dysfunction plays a key role.
Collapse
Affiliation(s)
- J C Suárez
- Servicio de Medicina Intensiva, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Calle de Sant Quintí, 89, 08026 Barcelona, Spain
| | - P López
- Servicio de Medicina Intensiva, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Calle de Sant Quintí, 89, 08026 Barcelona, Spain
| | - J Mancebo
- Servicio de Medicina Intensiva, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Calle de Sant Quintí, 89, 08026 Barcelona, Spain
| | - L Zapata
- Servicio de Medicina Intensiva, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Calle de Sant Quintí, 89, 08026 Barcelona, Spain.
| |
Collapse
|