Utility of the E/e’ index in ventilated patients and those with sepsisImran Sunderji 1, Alan G Fraser 2(Reply to the letter from Filippo Sanfilippo and colleagues, ECHO-2020-0930)1 Department of Cardiology, Castle Hill Hospital, Hull, U.K.2 Department of Cardiology, University Hospital of Wales, Cardiff, U.K.Address for correspondence :Professor Alan G. Fraser,University Hospital of Wales,Heath Park,Cardiff, CF14 4XW,Wales, U.K.firstname.lastname@example.orgTelephone: +44 (0)29 2074 5366Fax: +44 (0)29 2074 4473915 wordsWe thank Sanfilippo and his colleagues for their interest in our paper, and for the opportunity thus afforded to comment on the E/e’ index in critically ill patients and in those who have severe sepsis.We agree that the E/e’ index has some utility in predicting successful weaning from mechanical ventilation, as they have shown in their most recent meta-analysis,1 but published studies show high heterogeneity, there are often only small initial differences in mean E/e’ between patients who will remain off ventilation and those who will not, and average E/e’ values in both groups are sometimes within normal or intermediate ranges. Earlier systematic reviews also concluded that a higher E/e′ ratio is associated with weaning failure in ventilated patients2 and that E/e′ (as well as other markers of diastolic dysfunction) predicts mortality in critically ill patients.3 In a large study of 161 patients, however, neither E/e’ at the lateral mitral annulus nor any other echocardiographic index predicted success in weaning.4The heterogeneity of criteria for diastolic dysfunction in these studies is illustrated by cut-points for abnormal E/e’ varying between 8 and 12 at the lateral mitral annulus and 8 and 9.6 at the medial (septal) annulus.3In ventilated as in other patients, both E and e’ are preload-dependent.5 Positive end-expiratory pressure (PEEP) reduces both; for example PEEP of 12 cm H2O decreased lateral e’ by 19.7% and E by 13.7%, so E/e’ was unchanged.6 An increase in e’ when a patient is taken off a ventilator could indicate a response to changed loading rather than an improvement in intrinsic diastolic function. Before concluding that observed changes in E/e’ imply corresponding changes in left ventricular (LV) filling pressures, we should consider if E/e’ has been validated by correlation with pulmonary capilllary wedge pressure (PCW) measured with Swan Ganz catheters, specifically in ventilated and critically ill patients.In 39 patients there was no difference in E/e’ before a trial of spontaneous breathing, between those subjects in whom it was successful (defined as PCW remaining <18 mmHg after 60 minutes; mean baseline E/e’ 8.0) and those in whom it was not (PCW increasing to >18 mmHg; baseline E/e’ 7.6).7 The area under the receiver operating characteristic curve (AUC) for E/e’ as a guide to PCW at the end of the trial of spontaneous breathing was 0.8. In an earlier study of patients in intensive care who were also breathing spontaneously, E/e’ had a modest correlation with PCW (r=0.69); a patient with E/e’ of around 10 could have a PCW ranging from <10 to >20 mmHg.8 In other studies of ventilated patients, the correlation of lateral E/e’ with PCW was 0.849 and its AUC was 0.91.10Recently, Brault et al reported that the 2016 American Society of Echocardiography and European Association of Cardiovascular Imaging guidelines for diastolic dysfunction did not accurately assess PCW in 98 ventilated and critically ill patients, of whom 54% experienced septic shock. The diagnostic score was indeterminate in 49% of patients, sensitivity and specificity were both 74%, and agreement between echocardiography and PCW was moderate (Cohen’s Kappa, 0.48). The best echocardiographic predictor of a normal PCW was not the E/e’ ratio but a lateral e′ >8.11From experimental and clinical observations it is clear that severe sepsis can depress myocardial contractile function, probably through multiple mechanisms.12 In 40 patients with sepsis, however, there were no significant correlations between serum concentrations of inflammatory cytokines and measurements of e’ or calculated E/e’.13 In another study, mortality was predicted by the APACHE II score and mitral annular systolic excursion (MAPSE) with an AUC of 0.88, while the E/e’ index was not selected as a predictor in a logistic regression analysis.14Reproducibility of echocardiographic measurements in patients with septic shock is moderate to good15 but it is difficult to rely on single observations to guide clinical decisions.In patients with sepsis and severe diastolic dysfunction, failure to respond to volume replacement may be caused by impaired early diastolic relaxation and LV suction, which cannot be detected by the E/e’ index. In a randomised trial, an intravenous infusion of esmolol to slow the heart rate prolonged LV filling and increased stroke volume, with a subsequent reduction in mortality.16 In a prospective observational study, levosimendan increased the probability of successful weaning from ventilation, and averted any increase in E/e’;17 that could also be explained by improved early diastolic relaxation and filling, since levosimendan is positively lusitropic.18 Detailed echocardiographic assessment of ventilated patients after cardiac surgery showed that levosimendan increased early diastolic strain rate by 30%.19 Thus changes in E/e’ as a marker of mean PCW do not necessarily confirm a causal relationship with any particular aspect of LV diastolic function, while more comprehensive echocardiographic analysis of pathophysiological mechanisms may be more informative.These thoughts reinforce some of the conclusions that we drew in our review. Many studies are difficult to interpret because the E/e’ index is reported without information on changes in its individual components, and because dichotomising patients into normal or diastolic dysfunction (grades) loses information from multiple continuous variables that are inter-related but may change with differing patterns according to particular circumstances. It is unwise to use discrete cut-points especially if they are unadjusted for age and gender, and mistaken to conclude that LV diastolic function has changed when there are significant differences in the E/e’ index but its mean values remain within the normal range. The optimal assessment of diastolic dysfunction in septic and ventilated patients requires a multiparametric approach and we caution against over-reliance on E/e’.
Aortic atresia is uncommonly associated with atrioventricular and ventriculoarterial discordance.(1) Presence of severe regurgitation of Ebsteinoid malformation of the tricuspid valve in this subset results in reduced aortic blood flow in-utero. The hemodynamic explanation of this anomaly was reported by Celermajer and colleagues.(2) We report here a term neonate with this anomaly detect antenatally.
Purpose: Degenerative mitral stenosis (DMS) is an increasingly recognized cause of mitral stenosis. The goal of this study was to compare echocardiographic differences between DMS and rheumatic mitral stenosis (RMS), identify echocardiographic variables reflective of DMS severity, and propose a dimensionless mitral stenosis index (DMSI) for assessment of DMS severity. Methods: This is a single-center, retrospective cohort study. We included patients with at least mild MS and a mean transmitral pressure gradient (TMPG) ≥ 4 mmHg. Mitral valve area by the continuity equation (MVACEQ) was used as an independent reference. The DMSI was calculated as follows: DMSI = VTILVOT / VTIMV. All-cause mortality data were collected retrospectively. Results: A total of 64 patients with DMS and 24 patients with RMS were identified. MVACEQ was larger in patients with DMS (1.43 0.4 cm2) than RMS (0.9 0.3 cm2) by ~0.5 cm2 (p = <0.001) and mean TMPG was lower in the DMS group (6.0 2 vs. 7.93 mmHg, p=0.003). A DMSI of 0.50 and ≤ 0.351 were associated with MVACEQ ≤ 1.5 and MVACEQ ≤ 1.0 cm2 (p<0.001), respectively. With the progression of DMS from severe to very severe, there was a significant drop in DMSI. There was a non-significant trend towards worse survival in patients with MVACEQ ≤ 1.0 cm2 and DMSI ≤ 0.35, suggesting severe stenosis severity. Conclusion: Our results show that TMPG correlates poorly with MVA in patients with DMS. Proposed DMSI may serve as a simple echocardiographic indicator of hemodynamically significant DMS.
A patient with heart failure due to dilated ischemic cardiomyopathy presented in cardiogenic shock for institution of veno-arterial extracorporeal membrane oxygenation as a bridge to cardiac transplantation. To provide adequate venous drainage and simultaneous decompression of the left atrium (indirect left ventricular venting) a single venous cannula was placed across the interatrial septum so the distal orifice and side ports were located within the left atrium and the proximal set of side ports at the cavoatrial junction. Three-dimensional transesophageal echocardiography demonstrated utility in guiding cannula placement and appropriate positioning within the left atrium.
Background This meta-analysis aims to evaluate the utility of speckle tracking echocardiography (STE) as a tool to evaluate for cardiac sarcoidosis (CS) early in its course. Electrocardiography and echocardiography have limited sensitivity in this role, while advanced imaging modalities such as cardiac magnetic resonance (CMR) and 18F-Fluorodeoxyglucose–Positron Emission Tomography (FDG-PET) are limited by cost and availability. Methods We compiled English language articles that reported left ventricular global longitudinal strain (LVGLS) or global circumferential strain (GCS) in patients with confirmed extra-cardiac sarcoidosis versus healthy controls. Studies that exclusively included patients with probable or definite CS were excluded. Continuous data were pooled as a standard mean difference (SMD) between the sarcoidosis group and controls. A random effect model was adopted in all analyses. Heterogeneity was assessed using Q and I2 statistics. Results Nine studies with 967 patients were included in our analysis. LVGLS was significantly lower in the extra-cardiac sarcoidosis group as compared to controls, SMD -3.98, 95% confidence interval (CI): -5.32, -2.64, p< 0.001, also was significantly lower in patients who suffered Major Cardiac Events(MCE), -3.89, 95% CI -6.14, -1.64, p< 0.001 . GCS was significantly lower in the extra-cardiac sarcoidosis group as compared to controls, SMD: -3.33, 95% CI -4.71, -1.95, p< 0.001 Conclusion LVGLS and GCS were significantly lower in extra-cardiac sarcoidosis patients despite not exhibiting any cardiac symptoms. LVGLS correlates with MCEs in CS. Further studies are required to investigate the role of STE in the early screening of CS.
Bioprosthetic valve thrombosis (BPVT) is more common than previously thought and likely underreported. BPVT can be accurately diagnosed with cardiac imaging and treated successfully with anticoagulation, thus preventing re-operation. We hereby report a case of recurrent BPVT in the mitral position successfully treated with anticoagulation along with review of literature.
Pulmonary artery sling (PAS) and tracheal agenesis (TA) are both very rare diseases. Most of PAS are associated with tracheal bronchial malformations. However, PAS associated with TA have not yet been reported so far. Here, we report one case of PSA associated with TA diagnosed prenatally in our hospital. Due to the extremely low incidence of two diseases, physicians do not have sufficient understanding of these disease, prenatal ultrasound examination found that these kinds of diseases are very challenging and confusable. Prenatal ultrasound and MRI examination of pulmonary artery branches, trachea and esophagus will provide useful information. Improving the accuracy of prenatal fetal diagnosis is helpful for perinatal management and counseling.
Background: Stress echocardiography (SE) is an established technique for assessment of coronary artery disease (CAD) which is difficult to perform and interpret. Left ventricular stroke volume (SV) is readily estimated with Doppler echocardiography. It can be affected by myocardial ischemia, with possible adjunctive value during SE. Methods: Patients underwent Bruce protocol SE with SV estimated before and after maximal treadmill exertion post routine regional wall analysis. Incremental change in SV (ΔSV) with exercise was measured. Results: A derivation cohort (n=273) was established to test the hypothesis. An optimal cut-off for detection on inducible ischemia was ΔSV ≤ +10ml. The validation cohort of consecutive patients (n = 1093, 376 [34%] female; age 59±12 years) were followed clinically after SE for 20,460 patient-months. There were 1000 patients with non-ischemic SE, and 93 patients with studies suggestive of myocardial ischemia. Secondary analysis yielded 831 patients with a normal exercise response (ΔSV > +10ml) and 192 with an abnormal ΔSV ≤ +10ml. Time to first combined adverse cardiac event (composite of angina, acute coronary syndrome, cardiac revascularization, worsening New York Heart Association (NYHA) class, a reduction in EF, and cardiovascular death) was analysed and adjusted using Cox proportional hazards regression. The hazard ratio for an adverse event with an abnormal ΔSV response (≤10ml) was 10.3 (95% confidence intervals 5.6-19.1, p<0.0001). Conclusions: SV assessment during SE is feasible and readily performed. It is simple, practical and has incremental diagnostic and prognostic value when added to exercise regional wall motion analysis.
Hypertrophic cardiomyopathy is a common heritable cardiomyopathy with various clinical phenotypes. A rare spiral variant has been recently reported that has been associated with adverse outcomes and has traditionally been diagnosed using cardiac magnetic resonance. We report a case of the rare variant spiral hypertrophic cardiomyopathy where we used transthoracic echocardiography with an ultrasound enhancing agent to demonstrate the geometry of spiral hypertrophic cardiomyopathy and compared to simultaneous cardiac MRI images. The use of echocardiography with ultrasound enhancing agents may prove to be a valuable tool in identifying the geometry of hypertrophic cardiomyopathy variants in selected patients.
Purpose: The aim of this study was to evaluate right ventricle (RV) dyssynchrony and its relation with mortality using speckle tracking echocardiography (STE) in patients with acute inferior myocardial infarction (IMI). Methods: One hundred and fifty-eight consecutive patients with acute IMI treated with primary percutaneous coronary intervention and 44 healthy subjects were included. RV myocardial involvement (RVMI) was defined as an elevation greater than 1 mm in V1 or V4R and/or the presence of a culprit lesion at the proximal portion of the first RV marginal branch after reviewing coronary angiography. Patients were followed for three years to determine the cardiovascular mortality. Results: Overall, 70 patients with IMI had RVMI. IMI patients had significantly higher RV peak systolic longitudinal strain dyssynchrony (PLSSD) index, lower peak longitudinal systolic strain (PLSS), longer time to PLSS and time to PLSS differences compared to healthy controls while the patients with RVMI had significantly worse values compared to patients without RVMI and healthy controls. Twenty-seven patients (17.1%) died within two years. RVMI was more prevalent in mortality group and they had significantly higher RV PSSD index, whereas they had lower RV free wall PLSS and longer time to PLSS differences. ROC analysis revealed that a RV PLSSD index > 65 ms predicted mortality with a sensitivity of 88.9% and specificity of 71.8,% in IMI patients. Conclusions:Intra- and interventricular dyssynhcrony may develop in patients with acute IMI, especially in those with RV involvement, which might have a negative effect on the prognosis of these patients.
Despite advancement in therapy and management, left ventricular thrombus (LVT) after anterior myocardial infarction (MI) is sporadically encountered and remains associated with a very high risk of major cardiovascular events and mortality. Cardiac magnetic resonance (CMR) is considered the gold standard technique for LVT detection, but it is a time consuming and expensive test not available in all centers, especially when repeated exams are necessary. Transthoracic echocardiography represents a useful tool to screen for LVT and to identify predictors of high risk of developing LVT. The advances in ultrasound technology and the use of contrast agents may potentially help clinicians to identify LVT and the use of sequential echocardiography for each patient with acute MI complicated by LVT may provide an opportunity to quantify regression and its correlation with outcomes to tailor the management of these patients. Hence, this narrative review focuses on the added value of echocardiographic-guided LVT management in patients with recent anterior MI to reduce mortality and morbidity excess related to LVT based on current evidence.
Background: Although diastolic dysfunction is common among patients treated with cancer therapy, no clear evidence has been shown that it predicts systolic dysfunction. This study evaluated the correlation of longitudinal diastolic strain time (Dst) with the routine echocardiography diastolic parameters and to estimated its role in the early detection of cardiotoxicity among patients with active breast cancer. Methods: Data were collected as part of the Israel Cardio-Oncology Registry (ICOR), a prospective registry enrolling all adult patients referred to the cardio-oncology clinic. All patients with breast cancer, planned for Doxorubicin therapy were included. Echocardiography, including Global longitudinal systolic strain (GLS) and Dst, was assessed at baseline before chemotherapy (T1), during Doxorubicin therapy (T2) and after the completion of Doxorubicin therapy (T3). Cardiotoxicity were determined by GLS relative reduction of ≥15%. Dst was assessed as the time measured (ms) of the myocardium lengthening during diastole. =diastolic time (ms) measured. Results: Among 69 patients, 67 (97.1%) were females with a mean age 52±13years. Diastolic strain timeDst measurement was significantly associated with the standard routine diastolic parameters. Significant GLS reduction was observed in 10 (20%) patients at T3 . Both in a univariate and a multivariate analyses the change in Ds basal time from T1 to T2 emerged to be significantly associated with GLS reduction at T3 (p<0.04). Conclusions: Among breast cancer patients, Dst time showed high correlation to standard the routine diastolic echocardiography parameters. Relative reductionChange in Ds basal time emerged associated with clinically significant systolic dysfunction as measured by GLS reduction.
Background: Right ventricular failure (RVF) following Left Ventricular Assist Device (LVAD) implantation is associated with worse outcomes. Prediction and early identification of RVF with speckle-tracking echocardiography (STE) has been proposed. Methods: We queried multiple databases for articles reporting on pre-operative/intraoperative global longitudinal strain (GLS) and free-wall strain (FWS) in LVAD recipients. We performed a systematic review and meta-analysis of published literature. The standard mean difference (SMD) in GLS and FWS in patients with and without RVF postoperatively was pooled using random effects model. Results: Fifteen studies, with a total of 967 LVAD recipients were included. There was statistically significant difference in GLS among patients who did and did not develop RVF; SMD= -3.09 (95% CI: -4.62 to -1.57; p-value <0.0001). There was significant difference in FWS between two groups; SMD: -2.75 (95% CI: -3.72 to -1.79; p-value <0.0001). Upon subgroup analysis of imaging modality, transthoracic echocardiography (TTE)-derived GLS and FWS remained predictive for RVF with SMD of -3.97 (95% CI: -5.40 to -2.54; p-value <0.001) and -3.05 (95% CI: -4.11 to -1.99; p-value <0.001), respectively. However, there was no significant difference between RVF and non-RVF groups upon using transesophageal echocardiography (TEE) to assess GLS and FWS. Conclusion: GLS and FWS assessment of the RV by STE is a useful tool to predict postoperative RVF in LVAD recipients. While the predictive role of TTE was robust, the TEE-derived measures seemed to be less predictive. Future studies need to specify the strain cut-off value that can predict the adverse outcome of RVF
Our case was initially admitted with presumptive diagnosis of Non-ST elevated myocardial infarction in congestive heart failure and was later found to have large left atrial (LA) mass. Apart from complete echocardiography study, we took help of multimodality imaging to better characterise this LA mass.However we did not have a confirmed diagnosis. Cardiac surgery was performed and surprisingly revealed large LA mass with pockets of fresh blood inside LA. Pathological specimen confirmed the presence of hematoma ruling out other atrial neoplasms. Though contrast echocardiography and cardiac magnetic resonance imaging were closest to intra-operative diagnoses, In the absence of any pre-disposing factors, final diagnosis was made at surgery and histopathological diagnosis.
Diagnosis of anomalous origin of the right subclavian artery (AORSA) from the right pulmonary artery (RPA) is usually made using CT or invasive angiography. We report a patient diagnosed using transthoracic echocardiography (TTE). A newborn girl prenatally known to have d-TGA presented with cyanosis sparing the right hemithorax and arm. Oxygen saturations on the right hand were persistently higher than on the right ear and other extremities. Repeat TTE using a modified echocardiographic imaging plane allowed for full visualization of the entire subclavian artery course, revealing AORSA from RPA. We discuss further the approach to echocardiographic diagnosis and surgical implications.
Objective: To evaluate the role of peak atrial longitudinal strain (PALS) through speckle tracking 2D echocardiography for the assessment of structural and functional left atrial (LA) remodelling in a type 2 diabetes mellitus (T2DM) population. Methodology: We conducted a cross-sectional study during a 9-month period. Were included T2DM adults aged 18 and above. The variables assessed during the study include age and gender of participants, diabetes characteristics, cardiovascular risk factors, clinical anthropometric and haemodynamic parameters, standard echocardiographic parameters, volume-derived LA functions and 2D PALS. Results: We included a total of 102 patients. The mean age was 58±11.7 years and the M/F sex ratio was 1:1.5. Coexistent arterial hypertension (HTN) was observed in more than half (59.8%) of the population sample. Mean 2D PALS was 29.2±8.9% with 58.8% (95% CI:50.0–68.6) of subjects having a reduced LA strain (i.e.<32%). Reservoir and pump functions were the most altered LA volumetric phasic functions. Mean indexed LA maximal volume was 22.2±6.8 ml/m². There was a significant association between abnormal PALS and age, Body mass index (BMI), indexed LA volume, E/E’ ratio, LA active ejection fraction (pump function) and LA expansion index (reservoir function). Conclusion: LA remodelling is a recurrent condition in adult T2DM Cameroonians. The Reservoir and pump LA functions were the most affected. Assessment of LA global strain allows early detection of LA remodelling with comparison to LA size standard analyses. Age, BMI, indexed LA volume, E/E’ ratio, reservoir and pump LA functions were associated to 2D LA global strain impairment.
Introduction: The right ventricle (RV) strain measured by speckle tracking (RVS) is a novel method of assessing RV function. We compared RVS to RV fractional area change (FAC%), tricuspid annular peak systolic excursion (TAPSE) and Doppler tissue imaging-derived peak systolic velocity (S’) in the assessment of right ventricular (RV) systolic function measured using cardiac magnetic resonance imaging (MRI). Methods: We enrolled consecutive patients who underwent cardiac MRI between Jan 2012- Dec 2017 and a transthoracic echocardiogram (TTE) within 1 month of the MRI with no interval event. Baseline clinical characteristics and MRI parameters were extracted from chart review. Echocardiographic parameters were measured prospectively. TTE parameters including RVS, TAPSE, S’ and FAC% were tested for accuracy to identify impaired RV EF (EF <45% & <30%) using receiver operator curves. Results: The study cohort included 500 patients with mean age 55 yr ± 18 and right ventricular systolic pressure 33.7 ± 13.6 mmHg. The area under ROC for RVS was 0.69 (95% CI 0.63 – 0.75) and 0.78 (95% CI 0.70 – 0.88) to predict RVEF <45% & RVEF <30% respectively. The RV FAC % had second highest accuracy of predicting RVEF among all the TTE parameters tested in study. Conclusion: Right ventricular strain is the most accurate echocardiographic method to detect impaired right ventricular systolic function when using MRI as the gold standard.