Right ventricular outflow tract Doppler flow analysis and pulmonary arterial coupling by transthoracic echocardiography in sepsis: a retrospective exploratory study

Abstract

Introduction Right ventricular (RV) and pulmonary vascular dysfunction appear to be common in sepsis. RV performance is frequently assessed in isolation, yet its close relationship to afterload means combined analysis with right ventricular outflow tract (RVOT) Doppler and RV–pulmonary arterial (RV–PA) coupling may be more informative than standard assessment techniques. Data on feasibility and utility of these parameters in sepsis are lacking and were explored in this study. Methods This is a retrospective study over a 3-year period of one-hundred and thirty-one patients admitted to ICU with sepsis who underwent transthoracic echocardiography (TTE) with RVOT pulsed wave Doppler. RVOT Doppler flow and RV–PA coupling was evaluated alongside standard measurements of RV systolic function and pulmonary pressures. RVOT Doppler analysis included assessment of pulmonary artery acceleration time (PAAT), velocity time integral and presence of notching. RV–PA coupling was assessed using tricuspid annular planar systolic excursion/pulmonary artery systolic pressure (TAPSE/PASP) ratio. Results PAAT was measurable in 106 (81%) patients, and TAPSE/PASP was measurable in 77 (73%). Seventy-three (69%) patients had a PAAT of ≤ 100 ms suggesting raised pulmonary vascular resistance (PVR) is common. RVOT flow notching occurred in 15 (14%) of patients. TRV was unable to be assessed in 24 (23%) patients where measurement of PAAT was possible. RV dysfunction (RVD) was present in 28 (26%), 26 (25%) and 36 (34%) patients if subjective assessment, TAPSE < 17 mm and RV dilatation definitions were used, respectively. There was a trend towards shorter PAAT with increasing severity of RVD. RV–PA uncoupling defined as a TAPSE/PASP < 0.31 mm/mmHg was present in 15 (19%) patients. As RV dilatation increased the RV–PA coupling ratio decreased independent of LV systolic function, whereas TAPSE appeared to be more susceptible to changes in LV systolic function. Conclusion Raised PVR and RV–PA uncoupling is seen in a significant proportion of patients with sepsis. Non-invasive assessment with TTE is feasible. The role of these parameters in assisting improved definitions of RVD, as well as their therapeutic and prognostic utility against standard parameters, deserves further investigation.

Retrospectively gated ultrashort‐echo‐time MRI T1 mapping reveals compromised pulmonary microvascular NO‐dependent function in a murine model of acute lung injury

“…Similar to clinical reports of pulmonary trunk Doppler estimates in patients with sepsis, 72 a marked decrease in peak pulmonary artery blood flow velocity and stroke distance (abbreviated as velocity time integral in a clinical setting) was observed during endotoxemia development, starting as early as t = 2 h after LPS injection. Such an early decrease in pulmonary blood flow could indicate an important role of the declined vascular response in the development of proceeding pulmonary damage 55,56,73 .…”

A Study on Assessment of Right Ventricular Function by Right Ventricular Outflow Tract Systolic Excursion in Adult Population Attending a Tertiary Care Hospital in Eastern India

“…In the current study, RVOT SE was significantly lower in patients than in healthy controls (3.47±1.4 mm vs. 5.82±2.43 mm with p<0.001). Similar findings were also recorded in a study by Allam et al [14] This was somewhat different from that reported by Asmer et al [4] They reported that RVOT SE was significantly lower in patients with impaired RV systolic function than in individuals with normal RV function (1.7±1.1 mm vs. 9.6±1.5 mm with p<0.001). RVOT SE in their study was different within each group from that found in our study as reported above.…”

Right Ventricular Dysfunction in Sepsis: An Updated Narrative Review

“…In case of suspected deterioration of RV function, echocardiography and central venous pressure should be measured and used to evaluate further course of therapy. Along with this, pulmonary artery catheter placement might be necessary to assess cardiac output accurately, specifically in cases wherein there may be concern for right ventricular-pulmonary artery decoupling (88,89). Warning signs of excessive resuscitation might range from increased RV diameter causing inadequate LV filling to presence of new RV ischemic changes on electrocardiogram.…”