Full and simplified assessment of left ventricular diastolic function in covid-19 patients admitted to ICU: Feasibility, incidence, and association with mortality.

PURPOSE: Left ventricular diastolic dysfunction (LVDD) is associated with poor outcomes in the intensive care unit (ICU). Nonetheless, precise reporting of LVDD in COVID-19 patients is currently lacking and assessment could be challenging. METHODS: We performed an echocardiography study in COVID-19 patients admitted to ICU with the aim to describe the feasibility of full or simplified LVDD assessment and its incidence. We also evaluated the association of LVDD or of single echocardiographic parameters with hospital mortality. RESULTS: Between 06.10.2020 and 18.02.2021, full diastolic assessment was feasible in 74% (n = 26/35) of patients receiving a full echocardiogram study. LVDD incidence was 46% (n = 12/26), while the simplified assessment produced different results (incidence 81%, n = 21/26). Nine patients with normal function on full assessment had LVDD with simplified criteria (grade I = 2; grade II = 3; grade III = 4). Nine patients were hospital-survivors (39%); the incidence of LVDD (full assessment) was not different between survivors (n = 2/9, 22%) and non-survivors (n = 10/17, 59%; p = .11). The E/e' ratio lateral was lower in survivors (7.4 [3.6] vs. non-survivors 10.5 [6.3], p = .03). We also found that s' wave was higher in survivors (average, p = .01). CONCLUSION: In a small single-center study, assessment of LVDD according to the latest guidelines was feasible in three quarters of COVID-19 patients. Non-survivors showed a trend toward greater LVDD incidence; moreover, they had significantly worse s' values (all) and higher E/e' ratio (lateral).

The PRICES statement: an ESICM expert consensus on methodology for conducting and reporting critical care echocardiography research studies.

PURPOSE: Echocardiography is a common tool for cardiac and hemodynamic assessments in critical care research. However, interpretation (and applications) of results and between-study comparisons are often difficult due to the lack of certain important details in the studies. PRICES (Preferred Reporting Items for Critical care Echocardiography Studies) is a project endorsed by the European Society of Intensive Care Medicine and conducted by the Echocardiography Working Group, aiming at producing recommendations for standardized reporting of critical care echocardiography (CCE) research studies. METHODS: The PRICE panel identified lists of clinical and echocardiographic parameters (the "items") deemed important in four main areas of CCE research: left ventricular systolic and diastolic functions, right ventricular function and fluid management. Each item was graded using a critical index (CI) that combined the relative importance of each item and the fraction of studies that did not report it, also taking experts' opinion into account. RESULTS: A list of items in each area that deemed essential for the proper interpretation and application of research results is recommended. Additional items which aid interpretation were also proposed. CONCLUSION: The PRICES recommendations reported in this document, as a checklist, represent an international consensus of experts as to which parameters and information should be included in the design of echocardiography research studies. PRICES recommendations provide guidance to scientists in the field of CCE with the objective of providing a recommended framework for reporting of CCE methodology and results.

Right ventricular failure in septic shock: characterization, incidence and impact on fluid responsiveness.

OBJECTIVE: Incidence of right ventricular (RV) failure in septic shock patients is not well known, and tricuspid annular plane systolic excursion (TAPSE) could be of limited value. We report the incidence of RV failure in patients with septic shock, its potential impact on the response to fluids, as well as TAPSE values. DESIGN: Ancillary study of the HEMOPRED prospective multicenter study includes patients under mechanical ventilation with circulatory failure. SETTING: This is a multicenter intensive care unit study PATIENTS: Two hundred and eighty-two patients with septic shock were analyzed. Patients were classified in three groups based on central venous pressure (CVP) and RV size (RV/LV end-diastolic area, EDA). In group 1, patients had no RV dilatation (RV/LVEDA < 0.6). In group 2, patients had RV dilatation (RV/LVEDA ≥ 0.6) with a CVP < 8 mmHg (no venous congestion). RV failure was defined in group 3 by RV dilatation and a CVP ≥ 8 mmHg. Pulse pressure variation (PPV) was systematically recorded. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: In total, 41% of patients were in group 1, 17% in group 2 and 42% in group 3. A correlation between RV size and CVP was only observed in group 3. Higher RV size was associated with a lower response to passive leg raising for a given PPV. A large overlap of TAPSE values was observed between the 3 groups. 63.5% of patients with RV failure had a normal TAPSE. CONCLUSIONS: RV failure, defined by critical care echocardiography (RV dilatation) and a surrogate of venous congestion (CVP ≥ 8 mmHg), was frequently observed in septic shock patients and negatively associated with response to a fluid challenge despite significant PPV. TAPSE was unable to discriminate patients with or without RV failure.

Epidemiology, pathophysiology and contemporary management of cardiogenic shock - a position statement from the Heart Failure Association of the European Society of Cardiology.

Cardiogenic shock (CS) is a complex multifactorial clinical syndrome with extremely high mortality, developing as a continuum, and progressing from the initial insult (underlying cause) to the subsequent occurrence of organ failure and death. There is a large spectrum of CS presentations resulting from the interaction between an acute cardiac insult and a patient's underlying cardiac and overall medical condition. Phenotyping patients with CS may have clinical impact on management because classification would support initiation of appropriate therapies. CS management should consider appropriate organization of the health care services, and therapies must be given to the appropriately selected patients, in a timely manner, whilst avoiding iatrogenic harm. Although several consensus-driven algorithms have been proposed, CS management remains challenging and substantial investments in research and development have not yielded proof of efficacy and safety for most of the therapies tested, and outcome in this condition remains poor. Future studies should consider the identification of the new pathophysiological targets, and high-quality translational research should facilitate incorporation of more targeted interventions in clinical research protocols, aimed to improve individual patient outcomes. Designing outcome clinical trials in CS remains particularly challenging in this critical and very costly scenario in cardiology, but information from these trials is imperiously needed to better inform the guidelines and clinical practice. The goal of this review is to summarize the current knowledge concerning the definition, epidemiology, underlying causes, pathophysiology and management of CS based on important lessons from clinical trials and registries, with a focus on improving in-hospital management.

Assessment of volume status and volume responsiveness in the ICU: Protocol for an observational, multicentre cohort study.

BACKGROUND: Expansion of the intravascular compartment is common to treat haemodynamic instability in ICU patients. The most useful and accurate variables to guide and evaluate a fluid challenge remain debated and incompletely investigated resulting in significant variability in practice. The analogue mean systemic pressure has been reported as a measure of the intravascular volume state. METHODS: This is a protocol and statistical analysis plan for a review of the application of an analogue of the mean systemic pressure and the use of derived variables to assess the volume state and volume responsiveness. A pulmonary artery catheter was used in 286 postoperative cardiac surgical patients to monitor cardiac output before and after a fluid bolus in addition to arterial and central venous pressures. With otherwise similar monitoring, echocardiography was used in 540 general ICU patients to determine cardiac outputs and indices related to intravascular filling. The responses to a fluid bolus or the passive leg raising manoeuvre will be investigated using continuous and dichotomous definitions of volume responsiveness. The results will be stratified according to the method of monitoring cardiac output. CONCLUSIONS: This study investigating 2 cohorts that encompass a wide variety of reasons for haemodynamic instability will illustrate the applicability of the analogue mean systemic pressure and derived variables to assess the volume state and responsiveness. The results may guide the rationale and design of interventional studies.

Assessment of Right Ventricular Function in the Research Setting: Knowledge Gaps and Pathways Forward. An Official American Thoracic Society Research Statement.

BACKGROUND: Right ventricular (RV) adaptation to acute and chronic pulmonary hypertensive syndromes is a significant determinant of short- and long-term outcomes. Although remarkable progress has been made in the understanding of RV function and failure since the meeting of the NIH Working Group on Cellular and Molecular Mechanisms of Right Heart Failure in 2005, significant gaps remain at many levels in the understanding of cellular and molecular mechanisms of RV responses to pressure and volume overload, in the validation of diagnostic modalities, and in the development of evidence-based therapies. METHODS: A multidisciplinary working group of 20 international experts from the American Thoracic Society Assemblies on Pulmonary Circulation and Critical Care, as well as external content experts, reviewed the literature, identified important knowledge gaps, and provided recommendations. RESULTS: This document reviews the knowledge in the field of RV failure, identifies and prioritizes the most pertinent research gaps, and provides a prioritized pathway for addressing these preclinical and clinical questions. The group identified knowledge gaps and research opportunities in three major topic areas: 1) optimizing the methodology to assess RV function in acute and chronic conditions in preclinical models, human studies, and clinical trials; 2) analyzing advanced RV hemodynamic parameters at rest and in response to exercise; and 3) deciphering the underlying molecular and pathogenic mechanisms of RV function and failure in diverse pulmonary hypertension syndromes. CONCLUSIONS: This statement provides a roadmap to further advance the state of knowledge, with the ultimate goal of developing RV-targeted therapies for patients with RV failure of any etiology.

Assessment of the effects of inspiratory load on right ventricular function.

PURPOSE OF REVIEW: The right ventricle (RV) plays a pivotal role during respiratory failure because of its high sensitivity to small loading changes during inspiration. Both RVs, preload and afterload, are altered during inspiration, either in spontaneous breathing or during mechanical ventilation. Some clinical situations especially affect RV load during inspiration, for example acute asthma and acute respiratory distress syndrome. The aim of this review is to explain and to summarize the different mechanisms leading to RV failure in these situations. RECENT FINDINGS: Research has recently reemphasized the importance to well known physiology of the venous return which is a contributor of RV preload. Authors recently focused on the mean systemic filling pressure which is one of the determinants of venous return. Venous return may change in opposite direction according to the type of ventilation (spontaneous or assisted). Recent works have also demonstrated the crucial impact of lung inflation and driving pressure on RV afterload, and have confirmed the deleterious effect of severe RV failure, described as acute cor pulmonale. In most situations of RV overload induced by inspiration, significant pulse pressure variations are observed, either called 'pulsus paradoxus' in spontaneously breathing patients or 'reverse pulsus paradoxus' in mechanically ventilated patients. SUMMARY: RV is very sensitive to abnormal inspiration, which is always responsible for an increase in its afterload. Pulse pressure variations, central venous pressure and especially echocardiography may monitor RV function in abnormal clinical situations. The pulmonary artery catheter was also proposed although now less used.

The use of computerized echocardiographic simulation improves the learning curve for transesophageal hemodynamic assessment in critically ill patients.

BACKGROUND: Our aim was to evaluate the impact of a computerized echocardiographic simulator on the learning curve for transesophageal echocardiography (TEE) hemodynamic assessment of ventilated patients in the ICU. METHODS: We performed a prospective study in two university hospital medical ICUs. Using our previously validated skill assessment scoring system (/40 points), we compared learning curves obtained with (interventional group, n = 25 trainees) and without (control group, n = 31 trainees) use of a simulator in the training. Three evaluations were performed after 1 (M1), 3 (M3) and 6 months (M6) while performing two TEE examinations graded by an expert. Competency was defined as a score >35/40. RESULTS: Competency was achieved after an average of 32.5 ± 10 supervised studies in the control group compared with only 13.6 ± 8.5 in the interventional group (p < 0.0001). At M6, a significant between-group difference in number of supervised TEE was observed (17 [14-28] in the control group vs. 30.5 [21.5-39.5] in the interventional group, p = 0.001). The score was significantly higher in the interventional group at M1 (32.5 [29.25-35.5] vs. 24.75 [20-30.25]; p = 0.0001), M3 (37 [33.5-38.5] vs. 32 [30.37-34.5]; p = 0.0004), but not at M6 (37.5 [33-39] vs. 36 [33.5-37.5] p = 0.24). CONCLUSION: Inclusion of echocardiographic simulator sessions in a standardized curriculum may improve the learning curve for hemodynamic evaluation of ventilated ICU patients.

Initial resuscitation guided by the Surviving Sepsis Campaign recommendations and early echocardiographic assessment of hemodynamics in intensive care unit septic patients: a pilot study.

OBJECTIVE: To compare therapeutic interventions during initial resuscitation derived from echocardiographic assessment of hemodynamics and from the Surviving Sepsis Campaign guidelines in intensive care unit septic patients. DESIGN AND SETTING: Prospective, descriptive study in two intensive care units of teaching hospitals. METHODS: The number of ventilated patients with septic shock who were studied was 46. Transesophageal echocardiography was first performed (T1<3 hrs after intensive care unit admission) to adapt therapy according to the following predefined hemodynamic profiles: fluid loading (index of collapsibility of the superior vena cava≥36%), inotropic support (left ventricular fractional area change<45% without relevant index of collapsibility of the superior vena cava), or increased vasopressor support (right ventricular systolic dysfunction, unremarkable transesophageal echocardiography study consistent with sustained vasoplegia). Agreement for treatment decision between transesophageal echocardiography and Surviving Sepsis Campaign guidelines was evaluated. A second transesophageal echocardiography assessment (T2) was performed to validate therapeutic interventions. RESULTS: Although transesophageal echocardiography and Surviving Sepsis Campaign approaches were concordant to manage fluid loading in 32 of 46 patients (70%), echocardiography led to the absence of blood volume expansion in the remaining 14 patients who all had a central venous pressure<12 mm Hg. Accordingly, the agreement was weak between transesophageal echocardiography and Surviving Sepsis Campaign for the decision of fluid loading (κ: 0.37 [0.16;0.59]). With a cut-off value<8 mm Hg for central venous pressure, κ was 0.33 [-0.03;0.69]. Inotropes were prescribed based on transesophageal echocardiography assessment in 14 patients but would have been decided in only four patients according to Surviving Sepsis Campaign guidelines. As a result, the agreement between the two approaches for the decision of inotropic support was weak (κ: 0.23 [-0.04;0.50]). No right ventricular dysfunction was observed. No patient had anemia and only three patients with transesophageal echocardiography documented left ventricular systolic dysfunction had a central venous oxygen saturation<70%. CONCLUSIONS: A weak agreement was found in the prescription of fluid loading and inotropic support derived from early transesophageal echocardiography assessment of hemodynamics and Surviving Sepsis Campaign guidelines in patients presenting with septic shock.

Assessment of right ventricular function.

PURPOSE OF REVIEW: To emphasize the importance and clinical implications of right ventricular function assessment in many situations encountered by intensivists and to explain in practical terms how to perform such an assessment at the bedside. RECENT FINDINGS: Assessment of right ventricular function requires a full understanding of the physiology of the right ventricle. The right ventricle, unlike the left ventricle, is sensitive to acute increases in its afterload. The right ventricle is usually dilated when its failure is the cause of shock. Three possible causes of right ventricular failure must be evaluated: decrease in contractility, pressure overload and volume overload. Many devices are available to assess right ventricular performance, but they are not equal in terms of accuracy and invasiveness. Although noncontinuous, echocardiography is probably the best device and this technique can also be employed by nonexpert intensivists. Two main signs must be sought: right ventricular dilatation and paradoxical septal motion. SUMMARY: Assessment of right ventricular function in the ICU is crucial in many situations because right ventricular failure may be responsible for, or participate in, shock in pulmonary embolism, acute respiratory distress syndrome and septic shock. The best method is echocardiography, which is noninvasive and accurate.

Noninvasive assessment of cardiac index in healthy volunteers: a comparison between thoracic impedance cardiography and Doppler echocardiography.

BACKGROUND: Thoracic bioimpedance cardiography (ICG) has been proposed as a noninvasive, continuous, operator-independent, and cost-effective method for cardiac output monitoring. In the present study, we compared cardiac index (CI) measurements with ICG (Niccomo device) and transthoracic Doppler echocardiography in resting healthy volunteers undergoing hemodynamic load challenge. METHODS: Twenty-five healthy volunteers (7 men and 18 women, mean age 36 +/- 6 yr, body surface area 1.75 +/- 0.17 m(2)) were investigated during three experimental conditions: baseline, positive end-expiratory pressure + 10 cm H(2)O and lower body positive pressure by means of medical antishock trousers inflated to 30 cm H(2)O in the abdominal compartment. RESULTS: ICG signal quality was >89% over all sets of measurements. A weak but significant relationship was observed between CI(TTE) and CI(ICG) (r = 0.36; P = 0.002). Agreement between both techniques was 0.94 L x min(-1) x m(-2) (95% CI: 0.77-1.11), limits of agreement were -0.47 to 2.35 L x min(-1) x m(-2), and percentage error was 53%. No statistically significant relationships were found between percent changes in CI(TTE) and CI(ICG) after applications of positive end-expiratory pressure + 10 cm H(2)O (r = 0.21; P = 0.31) and medical antishock trousers (r = 0.22; P = 0.30). CONCLUSIONS: Poor correlation and lack of agreement between absolute values of CI measured by ICG and transthoracic Doppler echocardiography were found in resting healthy volunteers. The Niccomo device was also unreliable for monitoring changes in CI during hemodynamic load challenge.

Validation of a skills assessment scoring system for transesophageal echocardiographic monitoring of hemodynamics.

OBJECTIVE: Transesophageal echocardiography (TEE) is increasingly used in hemodynamic monitoring in the intensive care unit. This paper describes and validates a scoring system for assessing competence in TEE performed by intensivists for this indication. DESIGN: Prospective study over an 18-month period. SETTINGS: Two medical intensive care units. METHODS: The scoring system is used to assess four aspects of TEE: quality of the views (score out of 14); semiquantitative evaluation of respiratory variations in the superior vena cava, valve regurgitation, size of the right ventricle (score out of 10); accuracy of measurement of velocity-time integrals for pulmonary and aortic flow, peak velocity of the E and A waves of mitral flow, left ventricular fractional area change (score out of 8); summary and proposed treatment (score out of 8). The scoring system was validated by using it to assess intensivists after 1 month (M1), 3 months (M3) and 6 months (M6) of training. TEE was done on a mechanically ventilated, hypotensive patient and scored by comparing the intensivist's examination with that of the expert examiner. The intensivists were divided into two groups of theoretical expertise at the start of training. RESULTS: Nineteen intensivists were evaluated. The scores at M1 for level 0 (no experience in echocardiography) and level 1 (previous experience) were, respectively, 18.5 +/- 4 and 24.7 +/- 5. The scores at M1, M3, and M6 were, respectively, 20.4 +/- 5, 30.4 +/- 5 and 35.7 +/- 3. At M6, the intensivists had performed TEE 29 +/- 10 times. CONCLUSION: The scoring system was discriminatory and sensitive to change, and could be used as a tool to assess an intensivist's mastery of TEE.