Detecting impaired myocardial relaxation in sepsis with a novel tissue Doppler parameter (septal e\u2032/s\u2032)

David J Clancy,Stephen Huang,Timothy Scully,Anthony S Mclean,Michel Slama,Sam R Orde

doi:10.1186/s13054-017-1727-9

Abstract

BackgroundLeft ventricular diastolic dysfunction is associated with mortality outcomes in severe sepsis and septic shock. There are ongoing issues with diagnosing diastolic dysfunction in this cohort, partly owing to the poor applicability of traditional parameters in the hyperdynamic circulation. In this feasibility study, we sought to assess the utility of a novel parameter (septal e′/s′) to identify diastolic dysfunction in patients with severe sepsis and septic shock who had normal systolic function against the 2016 American Society Echocardiography and European Association of Cardiovascular Imaging (ASE/EACI) guidelines on diastolic dysfunction.MethodsIn this prospective observational pilot study, patients identified as having severe sepsis and septic shock underwent transthoracic echocardiography on day 1 and day 3 of their intensive care unit admission. In patients with normal systolic function, septal e′/s′ was calculated using the peak modal velocity of the s′ compared with the e′ from the septal annulus tissue Doppler imaging and compared with their diastolic grade according to the 2016 ASE/EACI guidelines on diastolic dysfunction.ResultsOn day 1 of admission, 44 of 62 patients with severe sepsis and septic shock had normal systolic function. There was a strong association of those with diastolic dysfunction having a reduced septal e′/s′ compared with patients with normal diastolic function (AUC 0.91). A similar relationship was seen with patients who had indeterminate diastolic dysfunction. On day 3, 37 patients had normal systolic function. Again, there was a strong association of those with diastolic dysfunction and a reduced septal e′/s′ (AUC 0.95).ConclusionsA reduction in septal e′/s′ may indicate diastolic dysfunction in patients with severe sepsis and septic shock who have normal systolic function. As opposed to limited traditional measures of diastolic dysfunction, it is applicable in those with hyperdynamic systolic function.

Highlights

Left ventricular diastolic dysfunction is associated with mortality outcomes in severe sepsis and septic shock
Clancy et al Critical Care (2017) 21:175 made in defining diastolic dysfunction, caveats remain with regard to traditional parameters that can make the recognition of impaired relaxation difficult in the intensive care unit (ICU) population, in those with normal or hyperdynamic systolic function, where cut-off values are determined on the basis of non-stressed hearts
We investigated the feasibility of using a novel method to assess diastolic function in patients with severe sepsis and septic shock: the ratio of early myocardial relaxation versus systolic motion of the septal annulus with tissue Doppler imaging in those with normal systolic function

Summary

Introduction

Left ventricular diastolic dysfunction is associated with mortality outcomes in severe sepsis and septic shock. There are ongoing issues with diagnosing diastolic dysfunction in this cohort, partly owing to the poor applicability of traditional parameters in the hyperdynamic circulation In this feasibility study, we sought to assess the utility of a novel parameter (septal e′/s′) to identify diastolic dysfunction in patients with severe sepsis and septic shock who had normal systolic function against the 2016 American Society Echocardiography and European Association of Cardiovascular Imaging (ASE/EACI) guidelines on diastolic dysfunction. A more appropriate measure might possibly reference the myocardial relaxation relative to the systolic function, based on theories that there is a link between systolic and diastolic function such as that due to myocardial fibre orientation [9,10,11] In this pilot study, we investigated the feasibility of using a novel method to assess diastolic function in patients with severe sepsis and septic shock: the ratio of early myocardial relaxation versus systolic motion of the septal annulus with tissue Doppler imaging (the e′/s′ ratio) in those with normal systolic function. Fusion is classically associated with tachycardia and first-degree heart block, but it is not known to indicate diastolic dysfunction [12]

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Conclusion