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      Left ventricular systolic function evaluated by strain echocardiography and relationship with mortality in patients with severe sepsis or septic shock: a systematic review and meta-analysis

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          Abstract

          Background

          Sepsis-induced myocardial dysfunction is associated with poor outcomes, but traditional measurements of systolic function such as left ventricular ejection fraction (LVEF) do not directly correlate with prognosis. Global longitudinal strain (GLS) utilizing speckle-tracking echocardiography (STE) could be a better marker of intrinsic left ventricular (LV) function, reflecting myocardial deformation rather than displacement and volume changes. We sought to investigate the prognostic value of GLS in patients with sepsis and/or septic shock.

          Methods

          We conducted a systematic review (PubMed and Embase up to 26 October 2017) and meta-analysis to investigate the association between GLS and mortality at longest follow up in patients with severe sepsis and/or septic shock. In the primary analysis, we included studies reporting transthoracic echocardiography data on GLS according to mortality. A secondary analysis evaluated the association between LVEF and mortality including data from studies reporting GLS.

          Results

          We included eight studies in the primary analysis with a total of 794 patients (survival 68%, n = 540). We found a significant association between worse LV function and GLS values and mortality: standard mean difference (SMD) − 0.26; 95% confidence interval (CI) − 0.47, − 0.04; p = 0.02 (low heterogeneity, I 2 = 43%). No significant association was found between LVEF and mortality in the same population of patients (eight studies; SMD, 0.02; 95% CI − 0.14, 0.17; p = 0.83; no heterogeneity, I 2 = 3%).

          Conclusions

          Worse GLS (less negative) values are associated with higher mortality in patients with severe sepsis or septic shock, while such association is not valid for LVEF. More critical care research is warranted to confirm the better ability of STE in demonstrating underlying intrinsic myocardial disease compared to LVEF.

          Electronic supplementary material

          The online version of this article (10.1186/s13054-018-2113-y) contains supplementary material, which is available to authorized users.

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          Most cited references61

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          Two-dimensional strain-a novel software for real-time quantitative echocardiographic assessment of myocardial function.

          Marina Leitman, Peter Lysyansky, Stanislav Sidenko … (2004)
          We sought to assess the feasibility of 2-dimensional strain, a novel software for real-time quantitative echocardiographic assessment of myocardial function. Conventional and a novel non-Doppler-based echocardiography technique for advanced wall-motion analysis were performed in 20 patients with myocardial infarction and 10 healthy volunteers from the apical views. Two-dimensional strain is on the basis of the estimation that a discrete set of tissue velocities are present per each of many small elements on the ultrasound image. This software permits real-time assessment of myocardial velocities, strain, and strain rate. These parameters were also compared with Doppler tissue imaging measurements in 10 additional patients. In all, 80.3% of infarct and 97.8% of normal segments could be adequately tracked by the software. Peak systolic strain, strain rate, and peak systolic myocardial velocities, calculated from the software, were significantly higher in the normal than in the infarct segments. In the 10 additional patients, velocities, strain, and strain rate obtained with the novel software were not significantly different from those obtained with Doppler tissue imaging. Two-dimensional strain can accomplish real-time wall-motion analysis, and has the potential to become a standard for real-time automatic echocardiographic assessment of cardiac function.
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            Prediction of all-cause mortality and heart failure admissions from global left ventricular longitudinal strain in patients with acute myocardial infarction and preserved left ventricular ejection fraction.

            Mads Ersbøll, Nana Valeur, Ulrik Madvig Mogensen … (2013)
            This study sought to test the hypothesis that semiautomated calculation of left ventricular global longitudinal strain (GLS) can identify high-risk subjects among patients with myocardial infarctions (MIs) with left ventricular ejection fractions (LVEFs) >40%. LVEF is a key determinant in decision making after acute MI, yet it is relatively indiscriminant within the normal range. Novel echocardiographic deformation parameters may be of particular clinical relevance in patients with relatively preserved LVEFs. Patients with MIs and LVEFs >40% within 48 h of admission for coronary angiography were prospectively included. All patients underwent echocardiography with semiautomated measurement of GLS. The primary composite endpoint (all-cause mortality and hospitalization for heart failure) was analyzed using Cox regression analyses. The secondary endpoints were cardiac death and heart failure hospitalization. A total of 849 patients (mean age 61.9 ± 12.0 years, 73% men) were included, and 57 (6.7%) reached the primary endpoint (median follow-up 30 months). Significant prognostic value was found for GLS (hazard ratio [HR]: 1.20; 95% confidence interval [CI]: 1.10 to 1.32; p   -14% was associated with a 3-fold increase in risk for the combined endpoint (HR: 3.21; 95% CI: 1.82 to 5.67; p   -14% was significantly associated with cardiovascular death (HR: 12.7; 95% CI: 3.0 to 54.6; p  40% above and beyond traditional indexes of high-risk MI. Copyright © 2013 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.
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              Outcome prediction by quantitative right ventricular function assessment in 575 subjects evaluated for pulmonary hypertension.

              N Fine, G. Kane, LIBO CHEN … (2013)
              Although right ventricular (RV) dysfunction is a major determinant of outcome in patients with pulmonary hypertension (PH), the optimal measure of RV function is poorly defined. We hypothesized that RV strain measured by speckle-tracking echocardiography predicts outcome in PH over a broad range of pulmonary pressures. Prospective peak RV longitudinal systolic strain measurement was performed on 575 patients (mean age, 56 ± 18 years; 63% women) referred for echocardiography for known or suspected PH. Survival status was assessed over a median of 16.5 (interquartile range, 7.6-20.0) months. There were 406 patients with PH (71%) (74% group 1, 14% group 3, and 12% group 4) and 169 patients without evidence of PH (29%). Among patients with PH, 46% were World Health Organization functional class III-IV. The mean RV strain was -21.2 ± 6.7% for all patients. RV strain declined with worse functional class, shorter 6-minute walk distances, higher N-terminal pro-B-type natriuretic peptide levels, and the presence of right heart failure. RV strain predicted outcome across pulmonary pressures and groups of PH. Eighteen-month survival was 92%, 88%, 85%, and 71% according to RV strain quartile (P<0.001), with a 1.46 higher risk of death (95% confidence interval, 1.05-2.12) per 6.7% decline in RV strain. RV strain predicted survival when adjusted for pulmonary pressure, pulmonary vascular resistance, and right atrial pressure and provided incremental prognostic value over conventional clinical and echocardiographic variables. Quantitative assessment of RV free-wall systolic strain is feasible and is a powerful predictor of the clinical outcome of patients with known or suspected PH.
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                Author and article information

                Contributors
                F. Sanfilippo:
                ORCID: http://orcid.org/0000-0001-5144-0776
                00393289178766 , filipposanfi@yahoo.it
                C. Corredor: carloscorredor@doctors.org.uk
                N. Fletcher: snick@doctors.org.uk
                L. Tritapepe: luigi.tritapepe@uniroma1.it
                F. L. Lorini: llorini@asst-pg23.it
                A. Arcadipane: aarcadipane@ismett.edu
                A. Vieillard-Baron: antoine.vieillard-baron@aphp.fr
                M. Cecconi: m.cecconi@nhs.net
                Journal
                Journal ID (nlm-ta): Crit Care
                Title: Critical Care
                Publisher: BioMed Central (London )
                ISSN (Print): 1364-8535
                ISSN (Electronic): 1466-609X
                Publication date (Electronic): 4 August 2018
                Publication date PMC-release: 4 August 2018
                Publication date Collection: 2018
                Volume: 22
                Electronic Location Identifier: 183
                Affiliations
                [1 ]ISNI 0000 0001 2110 1693, GRID grid.419663.f, Department of Anaesthesia and Intensive Care, , IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), ; Via Tricomi 5, 90127 Palermo, Italy
                [2 ]ISNI 0000 0000 9244 0345, GRID grid.416353.6, Department of Perioperative Medicine, , Bart’s Heart Centre St. Bartholomew’s Hospital, ; W. Smithfield, London, UK
                [3 ]GRID grid.264200.2, Department of Anaesthesia and Critical Care, , St Georges University Hospitals NHS Trust, ; Blackshaw Road, London, SW170QT UK
                [4 ]GRID grid.7841.a, Department of Cardiovascular, Respiratory, Nephrological, Anaesthetic and Geriatric Sciences, , Sapienza University of Rome, ; Rome, Italy
                [5 ]ISNI 0000 0004 1757 8431, GRID grid.460094.f, Department of Anaesthesia and Intensive Care, , Papa Giovanni XXIII Hospital, ; Bergamo, Italy
                [6 ]ISNI 0000 0001 2175 4109, GRID grid.50550.35, Assistance Publique-Hopitaux de Paris, University Hospital Ambroise Paré, Intensive Care Unit, Section Thorax-Vascular Disease-Abdomen-Metabolism, ; 92100 Boulogne-Billancourt, France
                [7 ]ISNI 0000 0001 2323 0229, GRID grid.12832.3a, INSERM U-1018, CESP, Team 5 (EpReC, Renal and Cardiovascular Epidemiology), , Universite’ Versailles Saint Quentin en Yvelines, ; 94807 Villejuif, France
                [8 ]ISNI 0000 0004 1756 8807, GRID grid.417728.f, Humanitas Clinical and Research Center, ; Via A. Manzoni 56, 20089 Rozzano – Milan, Italy
                [9 ]GRID grid.452490.e, Humanitas University, Department of Biomedical Sciences, ; Via Rita Levi Montalcini 4, 20090 Pieve Emanuele – Milan, Italy
                Author information
                http://orcid.org/0000-0001-5144-0776
                Article
                Publisher ID: 2113
                DOI: 10.1186/s13054-018-2113-y
                PMC ID: 6091069
                PubMed ID: 30075792
                SO-VID: 3586a98c-1c73-4bd5-84b4-67ea350a41a7
                Copyright © © The Author(s). 2018
                License:

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                History
                Date received : 31 January 2018
                Date accepted : 3 July 2018
                Categories
                Subject: Research
                Custom metadata
                issue-copyright-statement © The Author(s) 2018

                ScienceOpen disciplines: Emergency medicine & Trauma
                Keywords: global longitudinal strain,intensive care,left ventricular ejection fraction,speckle tracking,systolic dysfunction
                Data availability:
                ScienceOpen disciplines: Emergency medicine & Trauma
                Keywords: global longitudinal strain, intensive care, left ventricular ejection fraction, speckle tracking, systolic dysfunction

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