Noninvasive Echocardiographic Left Ventricular Stroke Work Index Predicts Mortality in Cardiac Intensive Care Unit Patients

Jentzer, Jacob C.; Anavekar, Nandan S.; Burstein, Barry; Borlaug, Barry A.; Oh, Jae K.

doi:10.1161/circimaging.120.011642

Cited by 26 publications

(51 citation statements)

References 34 publications

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“…The median LVEF was 35% (22,50) and 65.5% of patients had LVSD based on LVEF. Among patients with available data on RV function (71.4% of the population), 48.2% had RVSD.…”

Section: Echocardiographic Findingsmentioning

confidence: 99%

Echocardiographic Correlates of Mortality Among Cardiac Intensive Care Unit Patients With Cardiogenic Shock

Jentzer

Tabi

Wiley

et al. 2021

Shock

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Background: Prior studies have shown worse outcomes in patients with cardiogenic shock (CS) who have reduced left ventricular ejection fraction (LVEF), but the association between other transthoracic echocardiogram (TTE) findings and mortality in CS patients remains uncertain. We hypothesized that Doppler TTE measurements would outperform LVEF for risk stratification. Methods: Retrospective analysis of cardiac intensive care unit patients with an admission diagnosis of CS and a TTE within 1 day of admission. Hospital survivors and inpatient deaths were compared, and multivariable logistic regression was used to analyze the associations between TTE variables and hospital mortality. Results: We included 1,085 patients, with a median age of 69.5 (59.6, 77.5) years; 37% were females and 62% had an acute coronary syndrome. Most patients (66%) had moderate or severe left ventricular (LV) systolic dysfunction, and 48% had moderate or severe right ventricular (RV) systolic dysfunction. Hospital mortality occurred in 31%, and inpatient deaths had a lower median LVEF (29% vs. 35%, P < 0.001). Patients with mild or no LV or RV dysfunction were at lower risk of adjusted hospital mortality (P < 0.01). The LV outflow tract (LVOT) velocity-time integral (VTI) was the single best predictor of hospital mortality. After multivariable adjustment, both the LVEF and LVOT VTI remained strongly associated with hospital mortality (P < 0.001). Conclusions: Early comprehensive Doppler TTE can provide important prognostic insights in CS patients, highlighting its potential utility in clinical practice. The LVOT VTI, reflecting forward flow, is an important measurement to obtain on bedside TTE.

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“…The median LVEF was 35% (22,50) and 65.5% of patients had LVSD based on LVEF. Among patients with available data on RV function (71.4% of the population), 48.2% had RVSD.…”

Section: Echocardiographic Findingsmentioning

confidence: 99%

Echocardiographic Correlates of Mortality Among Cardiac Intensive Care Unit Patients With Cardiogenic Shock

Jentzer

Tabi

Wiley

et al. 2021

Shock

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“…An often-cited study by Shah et al showed that 5year mortality for hospitalized patients with HF does not differ significantly among the 3 groups (6). Among the most severe patients, LVEF is outperformed by other echocardiographic more physiologically robust indices (7). Kerkhof et al previously described the limitations of LVEF as a dimensionless index ratio when compared to the more informative indexed left ventricular end-systolic volume (ESVi) for the assessment of LV function (8,9).…”

Section: Dimensionless Ratiosmentioning

confidence: 99%

“…But simpler estimation for indexed LVSW (LVSWi) is feasible and clinically relevant. Jentzer et al recently showed on an impressive number of 4,536 patients admitted to a cardiac intensive care unit, that low LVSWI (calculated by echocardiography), predicts increased mortality risk and outperforms LVEF (7).…”

Section: Dimensionless Ratiosmentioning

confidence: 99%

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Overcoming the Limits of Ejection Fraction and Ventricular-Arterial Coupling in Heart Failure

Antohi

Chioncel²,

Mihǎileanu³

2022

Front. Cardiovasc. Med.

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Left ventricular ejection fraction (LVEF) and ventricular-arterial coupling (VAC) [VAC = Ea/Ees; Ea: effective arterial elastance; Ees: left ventricle (LV) elastance] are both dimensionless ratios with important limitations, especially in heart failure setting. The LVEF to VAC relationship is a divergent non-linear function, having a point of intersection at the specific value of 0.62, where V0 = 0 ml (V0: the theoretical extrapolated value of the volume-axis intercept at end-systolic pressure 0 mmHg). For the dilated LV, both LVEF and VAC are highly dependent on V0 which is inconclusive when derived from single-beat Ees formulas. VAC simplification should be avoided. Revisiting the relationship between systolic time intervals (STI), pressure, and volumes could provide simple-to-use guiding formulas, affordable for daily clinical practice. We have analyzed by echocardiography the hemodynamics of 21 patients with severe symptomatic heart failure with reduced ejection (HFrEF) compared to 12 asymptomatic patients (at risk of heart failure with mild structural disease). The groups were unequivocally separated by ‘classic’ measures (LVEF, LV end-systolic volume (ESV), LV mass, STI). Chen's Ees formula was weakly correlated with LVEF and indexed ESV (ESVi) but better correlated to the pre-ejection period (PEP); PEP/total ejection time (PEP/TET); systolic blood pressure/PEP (SBP/PEP) (P < 0.001). Combining the predictability of the LVEF to the determinant role of SBP/PEP on the Ees variations, we obtained: (SBP*LVEF)/PEP mm Hg/ms, with an improved R2 value (R2 = 0.848; P < 0.001). The strongest correlations to VAC were for LVEF (R = −0.849; R2 = 0.722) and PEP/TET (R = 0.925; R2 = 0.857). By multiple regression, the VAC was strongly predicted (N = 33): (R = 0.975; R2 = 0.95): VAC = 0.553–0.009*LVEF + 3.463*PEP/TET, and natural logarithm: Ln (VAC) = 0.147–1.4563*DBP/SBP*0.9–0.010*LVEF + 4.207*PEP/TET (R = 0.987; R2 = 0.975; P = 0) demonstrating its exclusive determinants: LVEF, PEP/TET, and DBP/SBP. Considering Ea as a known value, the VAC-derived Ees formula: Ees_d ≈ Ea/(0.553–0.009*LVEF+3.463*PEP/TET) was strongly correlated to Chen's Ees formula (R = 0.973; R2 = 0.947) being based on SBP, ESV, LVEF, and PEP/TET and no exponential power. Thus, the new index supports our hypothesis, in the limited sample of patients with HFrEF. Indices like SBP/PEP, (SBP*LVEF)/PEP, PEP/TET, and DBP/SBP deserve further experiments, underlining the major role of the forgotten STI.

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“…The left ventricular stroke work index (LVSWI) is a beat-by-beat assessment of myocardial systolic and diastolic function that integrates systemic hemodynamics to produce a comprehensive measure of cardiac performance [ 17 , 23 ]. The LVSWI can be calculated using Doppler echocardiography (ECHO-LVSWI) based on the stroke volume index (SVI) and ratio of mitral valve E velocity to medial mitral annulus e’ velocity (E/e’ ratio, used to estimate left ventricular filling pressures), and has been found to be strongly associated with mortality in CICU patients [ 17 , 23 ]. In a prior analysis, we demonstrated that patients with a low SVI or high E/e’ ratio had higher in-hospital mortality across the SCAI shock stages, making it likely that ECHO-LVSWI would be associated with mortality as well [ 10 ].…”

Section: Introductionmentioning

confidence: 99%

Echocardiographic left ventricular stroke work index: An integrated noninvasive measure of shock severity

2022

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Background Echocardiographic findings vary with shock severity, as defined by the Society for Cardiovascular Angiography and Intervention (SCAI) shock stage. Left ventricular stroke work index (LVSWI) measured by transthoracic echocardiography (TTE) can predict mortality in the cardiac intensive care unit (CICU). We sought to determine whether LVSWI could refine mortality risk stratification by the SCAI shock classification in the CICU. Methods We included consecutive CICU patients from 2007 to 2015 with TTE data available to calculate the LVSWI, specifically the mean arterial pressure, stroke volume index and medial mitral E/e’ ratio. In-hospital mortality as a function of LVSWI was evaluated across the SCAI shock stages using logistic regression, before and after multivariable adjustment. Results We included 3635 unique CICU patients, with a mean age of 68.1 ± 14.5 years (36.5% females); 61.1% of patients had an acute coronary syndrome. The LVSWI progressively decreased with increasing shock severity, as defined by increasing SCAI shock stage. A total of 203 (5.6%) patients died during hospitalization, with higher in-hospital mortality among patients with lower LVSWI (adjusted OR 0.66 per 10 J/m2 higher) or higher SCAI shock stage (adjusted OR 1.24 per each higher stage). A LVSWI <33 J/m2 was associated with higher adjusted in-hospital mortality, particularly among patients with shock (SCAI stages C, D and E). Conclusions The LVSWI by TTE noninvasively characterizes the severity of shock, including both systolic and diastolic parameters, and can identify low-risk and high-risk patients at each level of clinical shock severity.

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Noninvasive Echocardiographic Left Ventricular Stroke Work Index Predicts Mortality in Cardiac Intensive Care Unit Patients

Cited by 26 publications

References 34 publications

Echocardiographic Correlates of Mortality Among Cardiac Intensive Care Unit Patients With Cardiogenic Shock

Echocardiographic Correlates of Mortality Among Cardiac Intensive Care Unit Patients With Cardiogenic Shock

Overcoming the Limits of Ejection Fraction and Ventricular-Arterial Coupling in Heart Failure

Echocardiographic left ventricular stroke work index: An integrated noninvasive measure of shock severity

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