Prevalence and prognostic value of various types of right ventricular dysfunction in mechanically ventilated septic patients

Zhang, Hongmin; Huang, Wei; Zhang, Qing; Chen, Xiukai; Wang, Xiaoting

doi:10.1186/s13613-021-00902-9

Cited by 12 publications

(12 citation statements)

References 29 publications

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“…R/LVEDA is commonly used in detecting RV dysfunction 2,30 . Our previous study found that RV failure alone defined by an increase in R/LVEDA and CVP was not associated with 30 day mortality, but RV failure in combination with RVSD had the worst prognosis 9 . This study had a larger sample volume and found that although R/LVEDA was not as robust a predictor as RVSD and RV‐PA decoupling, it displayed an additive effect in the prediction of poor prognosis.…”

Section: Discussionmentioning

confidence: 96%

“… 3 There is a great variation in terms of RV function parameters in previous studies. 7 , 8 , 9 , 10 , 11 We hypothesized that an RV injury (RVI) score that incorporates RV contraction, RV dimension, and RV‐PA coupling might provide a comprehensive method of RV assessment. Thus, the aim of this study was to investigate the prognostic values of RVI score based on RVSD, RV dilation, and RV‐PA decoupling in septic patients and to explore whether RVI score is able to grade the severity of RV dysfunction in these patients.…”

Section: Introductionmentioning

confidence: 99%

“…However, a knowledge gap remains regarding accurate RV function evaluation 3 . There is a great variation in terms of RV function parameters in previous studies 7–11 . We hypothesized that an RV injury (RVI) score that incorporates RV contraction, RV dimension, and RV‐PA coupling might provide a comprehensive method of RV assessment.…”

Section: Introductionmentioning

confidence: 99%

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Prognostic implication of a novel right ventricular injury score in septic patients

Zhang

Wang

et al. 2023

ESC Heart Failure

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Aims We aim to investigate the prognostic value of a right ventricular (RV) injury score based on the concept of RV dilation, RV systolic dysfunction, and RV‐pulmonary arterial (PA) decoupling in septic patients and to explore whether the RV injury (RVI) score can be used to grade the severity of RV dysfunction in these patients. Methods and results Septic patients admitted to the ICU were prospectively included. We collected haemodynamic and echocardiographic parameters as well as prognostic information. RV dilation was defined as right and left ventricular end‐diastolic area ratio (R/LVEDA) > 2/3. RVSD was defined as tricuspid annular plane systolic excursion (TAPSE) < 17 mm, right ventricular fractional area change (FAC) < 35%, or peak velocity of tricuspid annulus via tissue Doppler (S′) < 10 cm/s. RV‐PA decoupling was represented by the TAPSE/pulmonary arterial systolic pressure (PASP) ratio. RVI score were determined by the presence of the following findings: RVSD, RV dilation, and RV‐PA decoupling, that is, one point for each finding. A total of 327 patients were enrolled in this study, among whom 276 survived and 51 died at 30 days after admission. Overall, 18.0% had RV dilation, 35.8% had RVSD, and 21.4% had RV‐PA decoupling, with an appreciable overlap present. A multivariate Cox regression analysis showed that RV dilation (HR: 2.19, 95% CI: 1.19–4.01, P = 0.011), RVSD (HR: 2.25, 95% CI: 1.23–4.13, P = 0.009) and RV‐PA decoupling (HR: 2.08, 95% CI: 1.19–3.65, P = 0.011) were independently associated with a 30 day mortality. Furthermore, RVI score was also an independent predictor, displayed additive effect with respect to 30 day mortality (RVI score 1 vs. RVI score 0, HR: 2.94, 95% CI: 1.20–7.20, P = 0.018; RVI score 2 vs. RVI score 0, HR: 3.20, 95% CI: 1.28–7.98, P = 0.013; RVI score 3 vs. RVI score 0, HR: 7.17, 95% CI: 2.65–19.38, P < 0.001), and had the best performance in model goodness of fit, discrimination and variance explained than the other RV indices. Conclusions The RVI score was independently related to 30 day mortality and had the potential to grade the severity of RV dysfunction in septic patients.

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Section: Discussionmentioning

confidence: 96%

Section: Introductionmentioning

confidence: 99%

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Prognostic implication of a novel right ventricular injury score in septic patients

Zhang

Wang

et al. 2023

ESC Heart Failure

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“…Current guideline definitions of RVD include RV dilation with evidence of systemic congestion ( 5 ) (most recently defined as central venous pressure greater than 8 [ 6 ]) or RV systolic impairment (defined as low indices of TAPSE, RV S’, and RVFAC [ 7 ]). This study proposes using RVD with systolic impairment, which has been independently associated with mortality in COVID-19 ARDS ( 2 ) and sepsis ( 8 ).…”

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confidence: 99%

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Chotalia

Ali

Alderman

et al. 2022

Critical Care Medicine

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We would like to thank Jha and Jha (1) for their many insightful comments about our article (2). First, although a dissociation between tricuspid annular plane systolic excursion (TAPSE) and right ventricular (RV) fractional area change (RVFAC) appears surprising, this has been reported by multiple studies assessing RV systolic function in COVID-19 acute respiratory distress syndrome (ARDS), including our own. TAPSE, lateral tricusipid annulus peak systolic velocity (RV S'), and RV free-wall longitudinal strain were all relatively preserved despite low RVFAC and were considered to be poorly sensitive of RV systolic impairment in COVID-19 ARDS (3). The authors proposed an RV phenotype in COVID-19 ARDS characterized by radial impairment with sparing of longitudinal function, a pattern of myocardial remodeling that resembles the response to pulmonary hypertension (3), and our results support these findings.We also disagree with the suggestion that all RV phenotypes were associated with normal left ventricular (LV) function. Thirty-seven percent of our cohort had hyperdynamic LV ejection fraction (HDLVEF), and this should not be considered "normal. " The prevalence of HDLVEF was higher in nonsurvivors than that in survivors (46% vs 32%). Although HDLVEF is associated with poor prognosis in critically ill patients with sepsis (4), likely due to unmitigated vasoplegia precipitating a high cardiac output state, in ARDS, its development may be due to low LV preload, caused by RV systolic impairment and/or obstruction of LV filling from RV dilation (RVD). HDLVEF may, therefore, reflect a low cardiac output state that precipitates multiple organ dysfunction and death. We were unable to estimate cardiac output via transthoracic echocardiography in these patients to corroborate this hypothesis.Jha and Jha (1) highlight the relatively low prevalence of RV volume and pressure overload as measured through the LV eccentricity index and septal dyskinesia, a surprising finding. This may be because we were only able to measure this parameter in 72% of patients due to poor views. However, we disagree with their suggestion that these findings are out of keeping with the measured maximum tricuspid regurgitation (TR) velocity (TRVmax), which at 2.7 (interquartile range, 2.3-3.1) is also relatively low: only 29% of patients had intermediate high risk of pulmonary hypertension. These findings are also limited as we were only able to measure TRVmax in 42% of patients, due to incomplete or absent TR Doppler signal in 58% of patients.Finally, we agree with the notion that the definition of RV dysfunction in ARDS should include multiple parameters that holistically assess RV size, function, and coupling to the pulmonary circulation but also include downstream consequences on organ congestion/LV function and cardiac output. However, these parameters should be chosen carefully: septal dyskinesia was previously included in definitions of RV dysfunction in ARDS but has recently been disregarded (5), perhaps due to its subjective nature. Current ...

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“…With so many unknowns, defining and treating RVD in critically ill patients is an important area for further research. We hope to aid these efforts by providing a common and prognostically enriched RV phenotype (RV dilation with systolic impairment) that, if validated in other populations ( 6 ), may be used as a target in randomized trials of interventions.…”

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confidence: 99%

The authors reply

Chotalia

Ali

Alderman

et al. 2022

Critical Care Medicine

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W e thank Prof. Dandel (1) for his many insightful comments with regard to our article (2). We agree that the prevalence and severity of tricuspid regurgitation (TR) are integral to interpreting right ventricular dysfunction (RVD) in acute respiratory distress syndrome (ARDS). This is included in Supplementary Table 2 in (2): approximately one-third of patients had none, 60% had mild, and 6% had moderate TR. There were no patients with severe TR. There was a trend toward an increased prevalence of moderate TR in nonsurvivors compared with survivors (10% vs 4%), although this was not statistically significant. We acknowledge that the presence of TR can lead to an overestimation of RV fractional area change and create false negatives in diagnosing RV systolic impairment. We were unable to provide evidence of this in the current study.We also agree that it is important to interpret RV systolic function relative to pulmonary artery systolic pressure. The severity of pulmonary arterial hypertension (PASP) can vary between patients due to varying degrees of hypoxic pulmonary vasoconstriction, hypercarbia, acidosis, microangiopathy, pulmonary emboli, and ventilator settings. With the Anrep and Frank Starling effect, an acute increase in PASP is coupled to an increase in RV contractility. When this process is uncoupled, RV forward flow is reduced. A marker of RV:PA uncoupling was independently associated with mortality in patients with COVID-19 ARDS (3), and this warrants prospective evaluation in larger critically ill cohorts. Given that PASP varies among patients, measuring RV systolic function relative to PASP is likely to provide additional useful information relating to RV forward flow and prognostication. Unfortunately, we were unable to measure PASP reliably in all patients and, therefore, unable to measure the degree of RV:PA coupling.We wholeheartedly agree that assessment of RV function is important in critically ill patients including those with COVID-19 ARDS. However, it is not possible to elucidate whether RVD directly contributes to mortality or is merely associated with death due to its correlation with disease severity/comorbid illness (4). As such, it is unknown whether efforts to improve RVD will translate to patient benefit. It is also unknown which therapies should be investigated to improve RVD: should these focus on reducing RV afterload with the use of pulmonary vasodilators, optimizing RV preload and reducing systemic congestion with the use of diuretics, and improving RV contractility with the use of inotropic agents, heart rate optimization, or mechanical circulatory support/ devices (5). The use of prone positioning and RV protective ventilator settings on improving RV function also warrants investigation. Although these therapies have physiologic equipoise, we are unaware of any randomized trials demonstrating benefit of these treatments in patients with RVD in ARDS. With so many unknowns, defining and treating RVD in critically ill patients is an important area for further research. We hope t...

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Prevalence and prognostic value of various types of right ventricular dysfunction in mechanically ventilated septic patients

Cited by 12 publications

References 29 publications

Prognostic implication of a novel right ventricular injury score in septic patients

Prognostic implication of a novel right ventricular injury score in septic patients

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