medigraphic.com
ISSN 2448-8909 (Print)

2024, Number 6

<< Back Next >>

Med Crit 2024; 38 (6)

Precision medicine; left atrial strain predictor of diastolic dysfunction in refractory septic shock, in search of the silent killer

López FJ, Olguin HJM, Alfaro LCI, Cortes RJS, Gasca AJC

Language: Spanish
References: 39
Page: 453-564
PDF size: 466.76 Kb.


ABSTRACT

Introduction: sepsis and septic shock remain one of the main causes of mortality and morbidity in the Intensive Care Unit. Myocardial dysfunction related to sepsis and septic shock is expressed as systolic or diastolic dysfunction of the left and/or right ventricle, isolated or combined, associated with an unavoidable short- and long-term outcome, compared to patients with preserved cardiac function; during its approach we will face a complex and difficult decision-making process, this is where transthoracic echocardiography becomes relevant as a diagnostic tool. Left atrial strain (LAS) allows early detection of left ventricular (LV) dysfunction before LVEF decline, assessing atrial function throughout the cardiac cycle by measuring reservoir, conduction, and pump functions. Reservoir phase left atrial strain (RSLS) could provide early recognition of clinical implications that facilitate risk stratification and prognosis of adverse events. Objective: to analyze whether reservoir phase left atrial strain could be an early predictor of diastolic dysfunction in refractory septic shock in the Intensive Care Unit of the ISSSTE Veracruz High Specialty Regional Hospital B. Material and methods: observational, descriptive, retrospective, unidirectional, single-center, homodemic study. It was carried out in the Intensive Care Unit of the ISSSTE Veracruz High Specialty Regional Hospital B, between May 2023 and July 2024. In a finite, non-probabilistic convenience sample with a record of 35 patients. Results: in a population of 35 patients, a binary logistic regression model was used to evaluate that RSLS < 19% is associated as a risk factor for death with an OR 1.62 (95% CI 1.215-2.113), which generates an estimated score of 68%, being a strong relationship of variability in the occurrence of complications through the Nagelkerke R² coefficient of determination and representing with a p-value of 0.001, the survival rate was determined using the Kaplan-Meier curve where we can see that the survival rate is higher in patients with a RSLS > 20% compared to those with a RSLS < 19%. Regarding the RSLS mortality probability analysis, it turned out to be non-inferior to PSAP and fluid balance, however, with PVC it ??does not show statistical significance in the mortality outcome, presenting a p-value of 0.69. Conclusions: RSLS could be feasible to predict the prognosis of adverse events associated with morbidity and mortality, therefore, justifying its gradual implementation in routine clinical practice, which makes it important as part of the evaluation in patients with refractory septic shock. However, it is important to consider that more studies should be carried out and thus establish a new line of research.


REFERENCES

  1. Singer M, Deutschman CS, Seymour CW, Shankar-Hari M, Annane D, Bauer M, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315(8):801-810. doi: 10.1001/jama.2016.0287.

  2. Seymour CW, Liu VX, Iwashyna TJ, Brunkhorst FM, Rea TD, Scherag A, et al. Assessment of clinical criteria for sepsis: for the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315(8):762-774. doi: 10.1001/jama.2016.0288.

  3. Sato R, Kuriyama A, Takada T, Nasu M, Luthe SK. Prevalence and risk factors of sepsis induced cardiomyopathy: a retrospective cohort study. Medicine (Baltimore). 2016;95(39):e5031.

  4. 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.

  5. Kotfis K, Wittebole X, Jaschinski U, Solé-Violán J, Kashyap R, Leone M, et al. A worldwide perspective of sepsis epidemiology and survival according to age: observational data from the ICON audit. J Crit Care. 2019;51:122-32. doi: 10.1016/j.jcrc.2019.02.015.

  6. Bauer M, Gerlach H, Vogelmann T, Preissing F, Stiefel J, Adam D. Mortality in sepsis and septic shock in Europe, North America and Australia between 2009 and 2019- results from a systematic review and meta-analysis. Crit Care. 2020;24(1):239. doi: 10.1186/s13054-020-02950-2.

  7. 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. doi: 10.1186/s13054-018-2043-8.

  8. Landesberg G, Gilon D, Meroz Y, Georgieva M, Levin PD, Goodman S, et al. Diastolic dysfunction and mortality in severe sepsis and septic shock. Eur Heart J. 2012;33(7):895-903. doi: 10.1093/eurheartj/ehr351.

  9. Nagueh SF. Left ventricular diastolic function: understanding pathophysiology, diagnosis, and prognosis with echocardiography. JACC Cardiovasc Imaging. 2020;13(1 Pt 2):228-244. doi: 10.1016/j.jcmg.2018.10.038.

  10. Thomas L, Marwick TH, Popescu BA, Donal E, Badano LP. Left atrial structure and function, and left ventricular diastolic dysfunction: JACC State-of-the-Art Review. J Am Coll Cardiol. 2019;73(15):1961-1977. doi: 10.1016/j.jacc.2019.01.059.

  11. Farsalinos KE, Daraban AM, Unlu S, Thomas JD, Badano LP, Voigt JU. Head-to-head comparison of global longitudinal strain measurements among nine different vendors: the EACVI/ASE InterVendor Comparison Study. J Am Soc Echocardiogr. 2015;28(10):1171-1181.

  12. Stanton T, Leano R, Marwick TH. Prediction of all-cause mortality from global longitudinal speckle strain: comparison with ejection fraction and wall motion scoring. Circ Cardiovasc Imaging. 2009;2(5):356-364.

  13. Smiseth OA, Baron T, Marino PN, Marwick TH, Flachskampf FA. Imaging of the left atrium: pathophysiology insights and clinical utility. Eur Heart J Cardiovasc Imaging. 2021;23(1):2-13. doi: 10.1093/ehjci/jeab191.

  14. D'Elia N, Caselli S, Kosmala W, Lancellotti P, Morris D, Muraru D, et al. Normal global longitudinal strain: an individual patient meta-analysis. JACC Cardiovasc Imaging. 2020;13(1 Pt 1):167-169.

  15. Mondillo S, Galderisi M, Mele D, Cameli M, Lomoriello VS, Zacà V, et al. Speckle-tracking echocardiography: a new technique for assessing myocardial function. J Ultrasound Med. 2011;30(1):71-83.

  16. Cameli M, Lisi M, Focardi M, Reccia R, Natali BM, Sparla S, et al. Left atrial deformation analysis by speckle tracking echocardiography for prediction of cardiovascular outcomes. Am J Cardiol. 2012;110(2):264-269.

  17. Nyberg J, Jakobsen EO, Ostvik A, Holte E, Stolen S, Lovstakken L, et al. Echocardiographic reference ranges of global longitudinal strain for all cardiac chambers using guideline-directed dedicated views. JACC Cardiovasc Imaging. 2023;16(12):1516-1531. doi: 10.1016/j.jcmg.2023.08.011.

  18. Badano L, Kolias T, Muraru D, Abraham T, Aurigemma G, Edvardsen T, et al. Standardization of left atrial, right ventricular, and right atrial deformation imaging using two-dimensional speckle tracking echocardiography: a consensus document of the EACVI/ASE/Industry Task Force to standardize deformation imaging. Eur Heart J Cardiovasc Imaging. 2018;19(6):591-600. doi: 10.1093/ehjci/jey042.

  19. Pavlopoulos H, Nihoyannopoulos P. Strain and strain rate deformation parameters: from tissue Doppler to 2D speckle tracking. Int J Cardiovasc Imaging. 2008;24(5):479-491.

  20. Langeland S, D'hooge J, Wouters P, Leather H, Claus P, Bijnens B, et al. Experimental validation of a new ultrasound method for the simultaneous assessment of radial and longitudinal myocardial deformation independent of insonation angle. Circulation. 2005;112(14):2157-2162.

  21. Mor-Avi V, Lang R, Badano L, Belohlavek M, Cardim N, 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.

  22. Singh A, Medvedofsky D, Mediratta A, Balaney B, Kruse E, Ciszek B, et al. Peak left atrial strain as a single measure for the non-invasive assessment of left ventricular filling pressures. Int J Cardiovasc Imaging. 2019;35(1):23-32.

  23. Hosseinsabet A, Mahmoudian R, Jalali A, Mohseni-Badalabadi R, Davarpasand T. Normal ranges of right atrial strain and strain rate by two dimensional speckle-tracking echocardiography: a systematic review and meta-analysis. Front Cardiovasc Med. 2021;8:771647.

  24. Donal E, Lip G, Galderisi M, Goette A, Shah D, Marwan M, et al. EACVI/EHRA Expert Consensus Document on the role of multi-modality imaging for the evaluation of patients with atrial fibrillation. Eur Heart J Cardiovasc Imaging. 2016;17(4):355-383.

  25. Singh A, Carvalho Singulane C, Miyoshi T, Prado AD, Addetia K, Bellino M, et al. Normal values of left atrial size and function and the impact of age: results of the World Alliance Societies of Echocardiography Study. J Am Soc Echocardiogr. 2022;35(2):154-164.

  26. Robinson S, Ring L, Oxborough D, Harkness A, Bennett S, Rana B, et al. The assessment of left ventricular diastolic function: guidance and recommendations from the British Society of Echocardiography. Echo Res Pract. 2024;11(1):16. doi: 10.1186/s44156-024-00051-2.

  27. Sun BJ, Park JH. Echocardiographic measurement of left atrial strain? a key requirement in clinical practice. Circ J. 2021;86(1):6-13. doi: 10.1253/circj.CJ-21-0373.

  28. Inoue K, Khan FH, Remme EW, Ohte N, García-Izquierdo E, Chetrit M, et al. Determinants of left atrial reservoir and pump strain and use of atrial strain for evaluation of left ventricular filling pressure. Eur Heart J Cardiovasc Imaging. 2021;23(1):61-70. doi: 10.1093/ehjci/jeaa415.

  29. Krittanawong C, Maitra NS, Hassan Virk HU, Farrell A, Hamzeh I, Arya B, et al. Normal ranges of right atrial strain: a systematic review and meta-analysis. J Am Coll Cardiol Img. 2023;16(3):282-294.

  30. Lang RM, Badano LP, Mor-Avi V, Afilalo J, Armstrong A, Ernande L, et al. Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr. 2015;28(1):1-39e14. doi: 10.1016/j.echo.2014.10.003.

  31. Yan X, Li Y, Liu J, Zhou T, Zhou Y, Sun W, et al. Serial changes in left ventricular myocardial deformation in sepsis or septic shock using three-dimensional and two-dimensional speckle tracking echocardiography. Front Cardiovasc Med. 2022;9:925367. doi: 10.3389/fcvm.2022.925367.

  32. Sugimoto T, Dulgheru R, Bernard A, Ilardi F, Contu L, Addetia K, et al. Echocardiographic reference ranges for normal left ventricular 2D strain: results from the EACVI NORRE study. Eur Heart J Cardiovasc Imaging. 2017;18(8):833-840.

  33. Pathan F, D'Elia N, Nolan M, Marwick T, Negishi K. Normal ranges of left atrial strain by speckle-tracking echocardiography: a systematic review and meta-analysis. J Am Soc Echocardiogr. 2017;30(1):59-70.e8.

  34. Morris D, Takeuchi M, Krisper M, Kohncke C, Bekfani T, Carstensen T, et al. Normal values and clinical relevance of left atrial myocardial function analysed by speckle-tracking echocardiography: multicentre study. Eur Heart J Cardiovasc Imaging. 2015;16(4):364-372.

  35. Beyls C, Hermida A, Daumin C, Delmotte MP, Nsiku A, Huette P, et al. Left and right atrial strain analysis to predicting new-onset atrial fibrillation in patients with septic shock: a single-center retrospective echocardiography study. Crit Care. 2024;28(1):233. doi: 10.1186/s13054-024-05024-9.

  36. Malaescu GG, Mirea O, Capota R, Petrescu AM, Duchenne J, Voigt JU. Left atrial strain determinants during the cardiac phases. J Am Coll Cardiol Img. 2022;15(3):381-391.

  37. Raafs AG, Vos JL, Henkens MTHM, Slurink BO, Verdonschot JAJ, Bossers D, et al. Left atrial strain has superior prognostic value to ventricular function and delayed-enhancement in dilated cardiomyopathy. J Am Coll Cardiol Img. 2022;15(6):1015-1026.

  38. Park JH, Hwang IC, Park JJ, Park JB, Cho GY. Prognostic power of left atrial strain in patients with acute heart failure. Eur Heart J Cardiovasc Imaging. 2021;22(2):210-219. doi: 10.1093/ehjci/jeaa013.

  39. Lundberg A, Johnson J, Hage C, Back M, Merkely B, Venkateshvaran A, et al. Left atrial strain improves estimation of filling pressures in heart failure: a simultaneous echocardiographic and invasive haemodynamic study. Clin Res Cardiol. 2019;108(6):703-715. doi: 10.1007/s00392-018-1399-8.




2020     |     www.medigraphic.com