SESSION TITLE: Pulmonary & Critical Care Imaging
SESSION TYPE: Original Investigation Slide
PRESENTED ON: Tuesday, October 27, 2015 at 11:00 AM - 12:15 PM
PURPOSE: Assessment of right ventricular (RV) function in patients with acute respiratory distress syndrome (ARDS) is challenging. Novel echocardiographic indices for estimation RV systolic function (RVSF), such as tricuspid annular plane systolic excursion (TAPSE), tricuspid annular plane systolic velocity (St) and longitudinal strain of RV free wall (FWLS) using speckle tracking technology have been suggested. We analyzed the ability of these indices to reflect RVSF in patients with ARDS.
METHODS: We did a retrospective cross-sectional analysis of ventilated intensive care units (ICU) patients with ARDS who had a transthoracic Doppler echocardiogram at a tertiary academic medical center. TAPSE, St, FWLS and right ventricular fractional area change (RVFAC) were measured and pertinent hemodynamic and laboratory values collected.
RESULTS: A total of thirty patients with moderate-severe ARDS were included. There was direct correlation between TAPSE, St, FWLS and RVFAC, and inverse correlation with these variables and central venous pressure (CVP), systolic pulmonary artery pressure and serum creatinine (SCr). RV indices correlated negatively with tidal volume (Vt) and Fraction of Inspired Oxygen (FiO2), but not with other ventilatory parameters. There were no correlations with demographic variables, Simplified Acute Physiology Score II, length of ventilatory support, ICU or hospital stay. Stepwise analysis showed TAPSE and CVP as strong predictors of RVFAC (R2: 0.64, p=0.000); FWLS, St, Vt and FiO2 were excluded. Using ROC curves analysis, a cutoff for TAPSE of 1.6 cm and CVP of 13 mm Hg were identified as the best values to predict RVFAC<35% and FWLS>-21% (lower reference values).The combination of TAPSE<1.6 cm and CVP>13 mm Hg detected a subgroup with the lowest RVFAC, lowest FWLS and the highest SCr.
CONCLUSIONS: ARDS negatively impacted RVSF through increase in right side pressures and was associated with renal impairment, suggesting a cardiorenal effect with systemic venous hypertension. These findings were independent of ventilatory parameters. The combination of TAPSE<1.6 cm and CVP>13 mm Hg was able to identified the group of patients with the worst RV performance.
CLINICAL IMPLICATIONS: Despite difficulties in the management of RV systolic dysfunction in the setting of ARDS, there are no clinical guidelines available. The adoption and integration of novel and readily available indices such TAPSE and CVP may provide objective and useful metrics for the hemodynamic management of these patients.
DISCLOSURE: The following authors have nothing to disclose: Romel Garcia-Montilla, Faryal Imam, Mi Miao, Kathryn Stinson, Stephen Heitner, Akram Khan
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