Echocardiographic Parameters of Right Ventricular Function Predict Mortality in Acute Respiratory Distress Syndrome: A Pilot Study

Abstract

Right ventricular (RV) dysfunction in acute respiratory distress syndrome (ARDS) contributes to increased mortality. Our aim is to identify reproducible transthoracic echocardiography (TTE) parameters of RV dysfunction that can be used to predict outcomes in ARDS. We performed a retrospective single-center cohort pilot study measuring tricuspid annular plane systolic excursion (TAPSE), Tei index, RV-fractional area change (RV-FAC), pulmonary artery systolic pressure (PASP), and septal shift, reevaluated by an independent blinded cardiologist (JK). Thirty-eight patients were included. Patients were divided on the basis of 30-day survival. Thirty-day mortality was 47%. Survivors were younger than nonsurvivors. Survivors had a higher pH, PaO 2 ∶ FiO 2 ratio, and TAPSE. Acute Physiology and Chronic Health Evaluation II (APACHE II), Simplified Acute Physiology Score II (SAPS II), and Sequential Organ Failure Assessment (SOFA) scores were lower in survivors. TAPSE has the strongest association with increased 30-day mortality from date of TTE. Accordingly, TAPSE has a strong positive correlation with PaO 2 ∶ FiO 2 ratios, and Tei index has a strong negative correlation with PaO 2 ∶ FiO 2 ratios. Septal shift was associated with lower PaO 2 ∶ FiO 2 ratios. Decrease in TAPSE, increase in Tei index, and septal shift were seen in the severe ARDS group. In multivariate logistic regression models, TAPSE maintained a significant association with mortality independent of age, pH, PaO 2 ∶ FiO 2 ratios, positive end expiratory pressure, PCO 2 , serum bicarbonate, plateau pressures, driving pressures, APACHE II, SAPS II, and SOFA scores. In conclusion, TAPSE and other TTE parameters should be used as novel predictive indicators for RV dysfunction in ARDS. These parameters can be used as surrogate noninvasive RV hemodynamic measurements to be manipulated to improve mortality in patients with ARDS and contributory RV dysfunction.Keywords: pulmonary hypertension, tricuspid annular plane systolic excursion, transthoracic echocardiography. Acute respiratory distress syndrome (ARDS) is a life-threatening respiratory syndrome characterized by hypoxemia, noncardiogenic pulmonary edema, pulmonary inflammation, and decreased pulmonary compliance. Despite our best efforts, mortality rates associated with ARDS still remain between 30% and 40%.1,2 Current management of ARDS is mainly supportive with mechanical ventilation and hemodynamic support. 3 Pulmonary hypertension and right ventricular (RV) dysfunction are independent predictors of mortality associated with poorer outcomes in patients with ARDS. [4][5][6][7][8] The increased lung mass in ARDS due to accumulation of inflammatory exudate in the alveolar space compresses not only the dependent alveoli but also the pulmonary vessels, leading to increased pulmonary vascular resistance. 9 In addition to direct compression, pulmonary endothelial cell dysfunction and microvascular thrombosis from systemic inflammatory response lead to development of pulmonary hypertension in ARDS. 10...

Blood transfusions, blood storage, and correlation with elevated pulmonary arterial pressures

“…25 Likewise, the presence of PH has been associated with increased mortality in acute respiratory distress syndrome as well as chronic obstructive pulmonary disease. 26,27 In our study, we found that transfusion of RBCs is followed by a sustained increase in MPAP of 2 to 3 mm Hg relative to already-elevated pretransfusion values and to a comparator group of asanguinous fluid infusions in the same patient population. Colloid infusions elevated MPAP relative to crystalloid infusions, but not as greatly as RBCs.…”

“…In a retrospective analysis in a medical ICU, echocardiographically determined PH was found in over 40% of patients and was associated with increased mortality . Likewise, the presence of PH has been associated with increased mortality in acute respiratory distress syndrome as well as chronic obstructive pulmonary disease …”

Early detection of right ventricular dysfunction using transthoracic echocardiography in ARDS: a more objective approach

“…We have previously shown in the larger cohort of 38 patients that TAPSE, MPI, and septal shift correlated with ARDS severity and death, and of these indices, TAPSE was an independent predictor of mortality. 25 The data from this study expand on our pre- The following limitations are recognized in our study. As specific echocardiographic views adequate for measurement of TAPSE, MPI, and FAC were not routinely obtained at our institution before 2013 and only patients with two complete echocardiograms for comparison were included, our study size of fourteen patients was small.…”

“…We have previously shown in the larger cohort of 38 patients that TAPSE, MPI, and septal shift correlated with ARDS severity and death, and of these indices, TAPSE was an independent predictor of mortality . The data from this study expand on our previous results by showing that patients will show trends in TAPSE, MPI, and FAC toward RV dysfunction from a pre‐ARDS baseline to an acute ARDS state.…”

Ehokardiografija u ranoj detekciji poremećaja funkcije desne komore pri promjeni volumena krvi kod bolesnika na hemodijalizi

“…Dokazano je da je Tei indeks nepouzdan ukoliko je povišen pritisak u desnoj pretkomori (npr. infarkt desne komore), budući da u tim okolnostima dolazi do brzog izjednačavanja pritiska između desne komore i desne pretkomore, ali i ukoliko se vremenski intervali potrebni za njegovo izračunavanje mjere u okolnostima postojanja različitih R-R intervala, što se prije svega odnosi na pacijente sa atrijalnom fibrilacijom [23][24][25]. Do sada nisu objavljene studije u kojima je analiziran značaj Tei indeksa za procjenu funkcije desnog srca, te prognostički značaj ovog indeksa kod bolesnika na programu hronične HD, bez značajne sekundarne plućne hipertenzije.…”