Abstract 18302: Left Ventricular Structure by Echocardiography is Associated With Vasopressor Requirements and Severity of Organ Failure After Cardiac Arrest
Meshe ChondeJacob C. JentzerHussein Abu-DayaAsher ShaftonDidier ChalhoubAndrew D. AlthouseJon C. Rittenberger
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Introduction: Patients resuscitated from cardiac arrest (CA) often require vasopressors for hemodynamic support and frequently have cardiac dysfunction identified on transthoracic echocardiography (TTE). The association between TTE parameters and vasopressor requirements is not well-described. Hypothesis: Echocardiographic findings early after resuscitation from CA will predict vasopressor requirements. Methods: Prospective registry of patients resuscitated from CA underwent TTE within 24 hours after CA. We determined 2D measurements, LVEF, spectral Doppler of mitral inflow (E) and LV outflow and systolic and early diastolic (e’) tissue Doppler of the mitral annulus. Using Pearson correlation coefficients, we examined the association between TTE parameters and number of vasopressor drugs, cumulative vasopressor index (CVI) and Sequential Organ Failure Assessment (SOFA) score. Mean values of TTE parameters were compared in patients with high and low cardiovascular SOFA subscores using t-tests. Results: Among the 55 patients, LV end-diastolic diameter (LVEDD, r = -0.498 to -0.569, p = 0.0001 to 0.0003), LV end-systolic diameter (LVESD, r = -0.392 to -0.463, p = 0.0008 to 0.0053) and LV relative wall thickness (RWT, r = 0.452 to 0.503, p = 0.0002 to 0.0011) correlated significantly with admission and peak 24 hour number of vasopressor drugs and CVI. LVEDD (r = -0.324, p = 0.0229), LVESD (r = -0.290, p = 0.0431), RWT (0.429, p = 0.0021) and septal e’ velocity (r = -0.344, p = 0.037) correlated with admission SOFA score. Other TTE parameters including LVEF did not correlate with vasopressor requirements or SOFA score. Patients with cardiovascular SOFA subscore = 4 had lower LVEDD (4.16cm vs. 5.0cm, p = 0.0008), lower LVESD (3.07cm vs. 4.03cm, p = 0.0008), higher RWT (0.48 vs. 0.65, p = 0.0026) and lower E/e’ ratio (10.84 vs. 18.91, p = 0.0169) compared with patients with cardiovascular SOFA subscore < 4. Conclusions: A smaller, thicker LV cavity by echocardiography at 24 hours after CA is associated with higher vasopressor requirements and more severe organ failure. Patients who required more vasopressor support had smaller, thicker LV cavities and a lower E/e’ ratio. LV systolic dysfunction was not a significant predictor of vasopressor requirements.Keywords:
SOFA score
Diastolic heart failure
Doppler imaging
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Doppler imaging
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In order to estimate left ventricular diastolic function in systemic sarcoidosis, Doppler echocardiography was utilized in 10 normal female subjects (aged 45 +/- 13 years) and in 10 female patients (aged 48 +/- 14 years), with biopsy proven sarcoidosis and without any clinical evidence of other cardiac disease or hypertension. Left ventricular systolic function assessed by two-dimensional echocardiography was normal in both groups (ejection fraction greater than 60%). The following Doppler echocardiographic parameters were measured: peak early diastolic flow velocity (E), peak late atrial diastolic flow velocity (A), the ratio (E/A) and deceleration of the flow velocity in early diastole (E-F slope). The results showed that 5 patients had two or more abnormal Doppler diastolic indexes, indicating impaired left ventricular relaxation, while the remaining 5 patients had values within or just outside normal limits. The mean values for the patients as a whole showed increased A velocity (0.77 +/- 0.11 m/s versus 0.61 +/- 0.10 m/s; P + 0.05), decreased E/A ratio (1.05 +/- 0.32 versus 1.4 +/- 0.30; P + 0.01), normal E velocity and normal E-F slope, compared with the mean values of the normal group. We concluded that a large percentage (50%) of patients with systemic sarcoidosis, had reduced diastolic performance of the left ventricle, at a stage of the disease when systolic dysfunction is not yet evident.
Isovolumic relaxation time
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Diastolic heart failure
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To evaluate the feasibility and usefulness of transthoracic Doppler echocardiography (TTDE) as a non-invasive method in recording distal anterior descending (LAD) coronary flow velocity, we compared coronary flow reserve (CFR) measured by TTDE with measurements by intracoronary Doppler wire (ICDW). Twenty-one patients without LAD stenosis were studied. ICDW performed at baseline and after intracoronary injection of 18 microg adenosine. TTDE was performed at baseline and after intravenous adenosine (140 microg/kgmin for 2 min). Adequate Doppler recordings of coronary flow velocities during systole were obtained in 14 of 21 study patients (67%) and during diastole in 17 (81%) patients. Baseline and hyperemic peak diastolic flow velocities measured by TTDE were significantly smaller than those obtained by ICDW (p<0.05). However, diminishing trends of diastolic and systolic velocity ratio after hyperemia were similarly observed in both methods. CFR obtained by TTDE (3.0+/-0.5), was higher than the value calculated by ICDW (2.5+/-0.4). There were significant correlations between the values obtained by the two methods (r=0.72, p<0.01). It is concluded that TTDE is a feasible method in measuring coronary flow velocity and appears to be a promising non-invasive method in evaluating CFR.
Coronary flow reserve
Coronary circulation
Systole
Fractional Flow Reserve
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The examination of diastolic filling velocities by Doppler echocardiography has provided increasing insights into the understanding of left ventricular diastolic performance in health and disease. However, several recent studies have emphasized the importance of a wide variety of physiologic variables, including heart rate, respiration, age, and loading conditions that need to be considered as potential confounding factors in the interpretation of these filling patterns. Despite this, Doppler echocardiographic assessment has been useful in the evaluation and prognostication of a variety of restrictive cardiomyopathies. Furthermore, the study of Doppler diastolic filling velocities has improved our understanding of common cardiac diseases, including hypertensive and ischemic myocardial disease. Further enhancement of our understanding of left ventricular diastolic filling in health and disease will depend on more precise elucidation of the mechanisms responsible for diastolic function.
Ventricular Function
Tissue Doppler echocardiography
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Doppler echocardiography has been proposed to detect left ventricular (LV) diastolic dysfunction in the elderly. However, the validity of this technique in differentiating the effects of pathology from those of normal aging has not been defined.Doppler indices of LV diastolic function were obtained in 85 patients (34 hypertensive, 29 with coronary artery disease, 22 with both conditions) and in 56 healthy volunteers.A linear correlation with age was found for all parameters in controls, and for many parameters in patients. Also, in the presence of heart diseases, age exerted a powerful, independent effect on Doppler parameters. None of these differed between patients and controls in advanced age.Due to the prevailing age-related variations in Doppler indices of diastolic performance occurring beyond the age of 65, Doppler echocardiography cannot be employed to diagnose LV diastolic dysfunction in the elderly.
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A study of left ventricular diastolic function in early hypertension was performed by the new method of acoustic quantification and Doppler echocardiography. A total of 23 untreated patients, five males and 18 females (mean age 53.52 +/- 9.10 years) with mild or moderate hypertension (160 +/- 13/98 +/- 10 mmHg) and 12 normal, age- and heart-rate-matched, control subjects were studied. All subjects showed normal left ventricular systolic function and wall thickness on two-dimensional echocardiography. The following indices were obtained. (1) Acoustic quantification (AQ): the time rate of area change in early diastole (dA/dt)E, in late diastole (dA/dt)A and their ratio (dA/dt)E/(dA/dt)A. (2) Doppler echocardiography: the early peak E, the late peak A flow velocities, their ratio E/A and deceleration E-F slope in early diastole. Measurements of left ventricular diastolic function by acoustic quantification showed, in the patient group, that the time rate of area change in early diastole (dA/dt)E was significantly lower (64.7 +/- 11.0 cm2/second versus 74.3 +/- 5.9 cm2/second; P < 0.01), the rate of area change in late diastole (dA/dt)A was not significantly higher (43.3 +/- 9.2 cm2/second versus 38.4 +/- 6.0 cm2/second; P > 0.05), and the ratio between the above indices (dA/dt)E/(dA/dt)A was significantly lower (1.55 +/- 0.42 versus 1.95 +/- 0.20; P < 0.01), compared with normal values. Doppler diastolic indices were all significantly abnormal in patients, in comparison with the values of the control group. Reduced left ventricular diastolic function was found in nine of 23 patients (39.1%) by the AQ method and eleven of 23 patients (47.8%) by Doppler echocardiography. Acoustic quantification was in agreement with Doppler echocardiography in identifying left ventricular diastolic dsyfunction in nine of 11 hypertensive patients with reduced Doppler diastolic values (82% sensitivity, 100% specificity). The correlation between the two methods showed that the time rate of area change in early diastole (dA/dt)E correlated well with the early peak E flow velocity (r = 0.59), the ratio between the time rates in early and late diastole (dA/dt)E/(dA/dt)A also correlated well with the Doppler E/A ratio (r = 0.89), while a poor correlation was found between the time rate of area change in late diastole (dA/dt)A and peak A flow velocity (r = 0.26). Thus abnormal diastolic filling of the left ventricle can be seen in the early stages of hypertension, even in the presence of normal systolic function and wall thickness, while acoustic quantification could be considered as a useful noninvasive modality for the early identification of left ventricular diastolic abnormalities.
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Doppler echocardiography is the gold standard for assessment of diastolic dysfunction, which is increasingly recognised as a cause of heart failure, especially in the elderly. Using a combination of Doppler echocardiography techniques, it is possible to identify grades of diastolic dysfunction, estimate left ventricular filling pressures and establish the chronicity of diastolic dysfunction. These physiologically-derived measures have been widely validated against invasive measurements of left heart pressures and have been shown to be prognostically valuable in a wide range of clinical settings. This review explores the mechanisms, and approaches to the assessment of diastolic dysfunction in the elderly. The challenge for clinicians is to identify pathophysiological changes from those associated with normal ageing. When used in combination, and taking age into account, Doppler echocardiographic parameters are helpful in the assessment of dyspnoea in older patients and provide prognostic insights.
Gold standard (test)
Diastolic heart failure
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