Left Ventricular Longitudinal Systolic Function in Septic Shock Patients with Normal Ejection Fraction: A Case-control Study

Mitral Annular Plane Systolic Excursion (MAPSE): A Review of a Simple and Forgotten Parameter for Assessing Left Ventricle Function

Mitral annular plane systolic excursion (MAPSE) was a widely used and simple M-mode echocardiographic parameter for determining the left ventricle (LV) longitudinal systolic function. The purpose of this review is to analyze the use of MAPSE as a simple LV systolic function marker in different clinical scenarios, especially given the recent paradox of choices in ultrasound markers assessing cardiac performance. Recent data on the use of MAPSE in the assessment of LV function in different settings seem to be relatively scarce, given the wide variety of possible causes of cardiovascular pathology. There remain significant possible clinical applications of MAPSE utilization. This review included all major articles on the topic of mitral annular plane systolic excursion published and indexed in the PubMed, Google Scholar, and Scopus databases. We analyzed the potential implications of using simpler ultrasonographical tools in heart failure diagnosis, prediction, and treatment. MAPSE is a dependable, robust, and easy-to-use parameter compared to ejection fraction (EF) or global longitudinal strain (GLS) for the quick assessment of LV systolic function in various clinical settings. However, there may be a gap of evidence in certain scenarios such as conventional cardiac pacing.

Seven-day and In-hospital Mortality According to Left and Right Ventricular Dysfunction in Patients With Septic Shock

BACKGROUND AND OBJECTIVES

The prognostic implications of septic cardiomyopathy have not been clearly demonstrated. We evaluated serial changes in left ventricular (LV) and right ventricular (RV) function in patients with septic shock and their prognostic value on 7-day and in-hospital mortality.

METHODS

Transthoracic echocardiography was performed within 48 hours of the diagnosis of septic shock and 7 days after the initial evaluation. In addition to traditional echocardiographic parameters, LV and RV function was evaluated using global longitudinal strain (GLS), and tricuspid annular plane systolic excursion (TAPSE).

RESULTS

A total of 162 patients (men, 83, 51.5%; 70.7±13.4 years; Acute Physiology and Chronic Health Evaluation [APACHE] II, 30.6±9.2) were enrolled. Initial GLS and TAPSE were -14.9±5.2% and 16.9±5.5 mm, and improved in the follow-up evaluation (GLS, -17.6±4.9%; TAPSE, 19.2±5.4 mm). Seven-day and in-hospital mortality were 24 (14.9%) and 64 (39.8%). Seven-day mortality was significantly associated with initial GLS >-16% (odds ratio [OR], 14.066, 95% confidence interval [CI], 1.178-167.969, p=0.037) and APACHE II score (OR, 1.196, 95% CI, 1.047-1.365, p=0.008). The in-hospital mortality of 7-day survivors was associated with follow-up TAPSE <16 mm (OR, 10.109, 95% CI, 1.640-62.322, p=0.013) and Sequential Organ Failure Assessment score (OR, 1.340, 95% CI, 1.078-1.667, p=0.008). GLS was not associated with in-hospital mortality of 7-day survivors.

CONCLUSIONS

Fluctuation of both ventricular function was common in septic shock. Seven-day mortality of patients with septic shock was related to GLS, whereas in-hospital mortality of 7-day survivors was related to TAPSE, not to GLS.

The relation of echo-derived lateral MAPSE to left heart functions and biochemical markers in patients with preserved ejection fraction: Short-term prognostic implications

OBJECTIVE

Mitral annular plane systolic excursion (MAPSE) is a simple way to evaluate-left ventricle (LV) function. Our aim was to explain the relationship of MAPSE with LV function and biochemical markers in patients with preserved ejection fraction (EF), and to determine whether it has an effect on prognosis in echocardiography (echo) practice.

METHODS

Consecutive patients referred to the echo laboratory between November 2020 and March 2021 were included in the study. In addition to conventional parameters, MAPSE of the lateral mitral annulus was measured in all patients. Patients were divided into three groups according to lateral MAPSE: low (<12 mm), relatively preserved (12-15 mm), and high (≥15 mm).

RESULTS

A total of 512 patients with preserved EF were included in the study. MAPSE was low in 44 patients (9%), relatively preserved in 231 patients (45%), and high in 237 patients (46%). The mean age was higher in the low group compared to the other two groups (p < 0.001) and the body mass index was increased in the low group compared to the high group (p = 0.010). Atrial fibrillation and hypertension were more common in patients with low MAPSE. The rate of diastolic dysfunction (DD) and all-cause hospitalization were higher in the low and relatively preserved groups than in the high group (p < 0.001, p = 0.002; respectively). The pro-BNP level and mortality rate were higher in the low group compared to the relatively preserved and high groups (p = 0.007, p = 0.005; respectively). MAPSE was identified as independent predictor of hospitalization (OR: 0.284, 95% CI: 0.093-0.862, p = 0.026) via multivariate analysis and independent predictor of in-hospital mortality (HR: 0.002, 95% CI: 0-0.207, p = 0.008).

CONCLUSIONS

Analysis of LV longitudinal function by echo-derived lateral MAPSE when LV ejection fraction is normal provides important information about DD and related heart failure and may predict prognosis in echo practice.

Septic Cardiomyopathy: From Basics to Management Choices

Septic cardiomyopathy (SCM) is increasingly recognized as a potential complication of septic shock; it is understood to be a reversible left ventricular systolic dysfunction. The presence of SCM in septic shock, in previous studies, infer a poorer prognosis as it significantly increases the mortality rate of patients to 70%-90% and its incidence varies from 18% to 40% of septic shock patients. The pathogenesis is unclear, but believed to be a combination of bacterial toxins, cytokines, nitric oxide, and cardiac mitochondrial dysfunction, that depresses intrinsic cardiac contractility. The presence of SCM can be diagnosed in patients using a bedside transthoracic echocardiogram which typically shows left ventricular ejection fraction <45% and right ventricular dilatation. For management, levosimendan provides a good hemodynamic response without increasing cardiac oxygen demand when compared to dobutamine, while more invasive techniques such as extracorporeal membrane oxygenation, and intra-aortic balloon pulsation are being explored as well as potential rescue strategies for patients with severe SCM.

Left ventricular longitudinal strain is associated with mitral annular fractional area change in healthy subjects-Results from the three-dimensional speckle tracking echocardiographic MAGYAR-Healthy Study

Background

The mitral annulus (MA) plays a significant role in promoting left atrial and left ventricular (LV) filling and emptying, which is dependent on LV functional properties. The present study aimed to investigate the relationship between LV strains, quantitative features of longitudinal contractility and MA size and function in healthy subjects.

Methods

The present study comprised 295 healthy adults; 117 subjects were excluded due to inferior image quality (40%). Finally, 178 healthy adults (mean age: 32.0±11.3 years, 92 males). Complete two-dimensional Doppler echocardiography and three-dimensional speckle-tracking echocardiography were performed in all cases.

Results

The global and mean segmental left ventricular longitudinal strain (LV-LS) proved to be -16.1%±2.5% and -16.9%±2.4%, respectively. In the present study, LV-LS ≤-13% was considered to be reduced. In ROC analysis, the cut-off value for MA fractional area change (MAFAC) to predict impaired LV-LS was ≤44%, with 67% sensitivity and 69% specificity and ROC area under curve 0.73 (P=0.0005). Significantly increased LV volumes and LV mass and reduced MAFAC could be demonstrated in healthy subjects with global LV-LS ≤-13%. Significantly larger ratio of subjects with global LV-LS ≤-13% had MAFAC ≤44% (31% vs. 67%, P=0.009). Patients with MAFAC ≤44% had significantly reduced global and mean segmental LV-LS. Significantly larger ratio of subjects with MAFAC ≤44% had global LV-LS ≤-13% (4% vs. 16%, P=0.009).

Conclusions

There is a strong relationship between MA and LV longitudinal function. MA fractional area change predicts global LV-LS.

Mitral Annular Plane Systolic Excursion as a Predictor of Mortality in Children With Septic Shock

OBJECTIVES

Myocardial dysfunction is well recognized in severe sepsis and septic shock. Echocardiography provides rapid, noninvasive, and bedside evaluation of cardiac function in patients with hemodynamic instability. Mitral annular plane systolic excursion is an M-mode-derived echocardiographic variable used to assess longitudinal left ventricular systolic function. No data are available about the uses of mitral annular plane systolic excursion in children with septic shock. Therefore, we aimed to assess the prognostic significance of mitral annular plane systolic excursion in children with septic shock and to correlate it with the most commonly used measures of left ventricular systolic function and myocardial injury.

DESIGN

A prospective cohort study.

SETTING

The study carried out at the PICU of Menoufia University Hospital in the period from March 2015 to September 2016.

PATIENTS

We serially enrolled 50 children with septic shock.

INTERVENTIONS

Complete diagnostic workup was performed for each patient including calculation of Pediatric Risk of Mortality III score. Transthoracic echocardiography was done to obtain mitral annular plane systolic excursion and the left ventricular ejection fraction measurement within 24 hours of inclusion then repeated on third and fifth days. Patients were followed up until hospital discharge or death. The predictive power of mitral annular plane systolic excursion was determined using the receiver operating characteristic curve.

MEASUREMENTS AND MAIN RESULTS

Mitral annular plane systolic excursion was significantly lower in nonsurvivors compared with survivors (p < 0.001). Receiver operating characteristic curve analysis showed an area under the curve of 0.892 for mitral annular plane systolic excursion on day 1. The cut-off point was 7.9 mm with 82.76% sensitivity and 80.95% specificity. Furthermore, follow-up of the patient's systolic function showed that mitral annular plane systolic excursion was significantly lower in nonsurvivors compared with survivors on days of follow-up, whereas left ventricular ejection fraction was not significantly different between survivors and nonsurvivors at any day. Mitral annular plane systolic excursion was positively correlated with left ventricular ejection fraction (p = 0.044) and duration of hospital stay (p < 0.001) and negatively correlated with Pediatric Risk of Mortality III score (p < 0.001) and cardiac troponin I level (p < 0.001).

CONCLUSIONS

Measurement of mitral annular plane systolic excursion at admission added a prognostic value in septic shock children. Compared with the left ventricular ejection fraction, longitudinal systolic function might be more sensitive in the detection of myocardial dysfunction in critically ill children and should receive more attention.

Pathophysiology, echocardiographic evaluation, biomarker findings, and prognostic implications of septic cardiomyopathy: a review of the literature

BACKGROUND

Sepsis is a common condition encountered by emergency and critical care physicians, with significant costs, both economic and human. Myocardial dysfunction in sepsis is a well-recognized but poorly understood phenomenon. There is an extensive body of literature on this subject, yet results are conflicting and no objective definition of septic cardiomyopathy exists, representing a critical knowledge gap.

OBJECTIVES

In this article, we review the pathophysiology of septic cardiomyopathy, covering the effects of key inflammatory mediators on both the heart and the peripheral vasculature, highlighting the interconnectedness of these two systems. We focus on the extant literature on echocardiographic and laboratory assessment of the heart in sepsis, highlighting gaps therein and suggesting avenues for future research. Implications for treatment are briefly discussed.

CONCLUSIONS

As a result of conflicting data, echocardiographic measures of left ventricular (systolic or diastolic) or right ventricular function cannot currently provide reliable prognostic information in patients with sepsis. Natriuretic peptides and cardiac troponins are of similarly unclear utility. Heterogeneous classification of illness, treatment variability, and lack of formal diagnostic criteria for septic cardiomyopathy contribute to the conflicting results. Development of formal diagnostic criteria, and use thereof in future studies, may help elucidate the link between cardiac performance and outcomes in patients with sepsis.