Early signs of right ventricular systolic and diastolic dysfunction in acute severe respiratory failure: the importance of diastolic restrictive pattern.

Guido Tavazzi,Joana Alcada,Susanna Price,Niels Bergsland

doi:10.1177/2048872619883399

Abstract

Background:The incidence and pathophysiology of right ventricular failure in patients with severe respiratory insufficiency has been largely investigated. However, there is a lack of early signs suggesting right ventricular systolic and diastolic dysfunction prior to acute cor pulmonale development.Methods:We conducted a retrospective analytical cohort study of patients for acute respiratory distress syndrome undertaking an echocardiography during admission in the cardiothoracic intensive care unit. Patients were divided according to treatment: conventional protective ventilation (38 patients, 38%); interventional lung assist (23 patients, 23%); veno-venous extracorporeal membrane oxygenation (37 patients, 37%). Systolic and diastolic function was studied assessing, respectively: right ventricular systolic longitudinal function (tricuspid annular plane systolic excursion) and systolic contraction duration (tricuspid annular plane systolic excursion length); right ventricular diastolic filling time and right ventricular diastolic restrictive pattern (presence of pulmonary valve presystolic ejection wave). Correlation between the respiratory mechanics and systo-diastolic parameters were analysed.Results:In 98 patients studied, systolic dysfunction (tricuspid annular plane systolic excursion <16 mm) was present in 33.6% while diastolic restrictive pattern was present in 64%. A negative correlation was found between tricuspid annular plane systolic excursion and tricuspid annular plane systolic excursion length (P<0.0001; r −0.42). Tricuspid annular plane systolic excursion and tricuspid annular plane systolic excursion length correlated with right ventricular diastolic filling time (P<0.001; r −0.39). Pulmonary valve presystolic ejection wave was associated with tricuspid annular plane systolic excursion (P<0.0001), tricuspid annular plane systolic excursion length (P<0.0001), right ventricular diastolic filling time (P<0.0001), positive end-expiratory pressure (P<0.0001) and peak inspiratory pressure (P<0.0001).Conclusion:Diastolic restrictive pattern is present in a remarkable percentage of patients with respiratory distress syndrome. Bedside echocardiography allows a mechanistic evaluation of systolic and diastolic interaction of the right ventricle.

Highlights

Acute respiratory distress syndrome (ARDS) is associated with alveolar epithelial and microvascular endothelial injury, resulting in severe hypoxemia, decreased pulmonary compliance and increased pulmonary vascular resistance.[1,2] The resulting increase in right ventricular (RV) afterload and different ventilatory strategies may induce RV dysfunction and, in extreme cases, acute cor pulmonale (ACP),[3] with variable reported effects on mortality.[4]
Data regarding incidence and outcome vary among the studies[4] and, more importantly, the published data focused mainly on ACP, which represents the last stage of RV dysfunction.[8,9]
An inverse correlation resulted between tricuspid annular plane systolic excursion (TAPSE) and an increase in intrathoracic pressure (PEEP and peak inspiratory pressure (PIP) P

Summary

Introduction

Acute respiratory distress syndrome (ARDS) is associated with alveolar epithelial and microvascular endothelial injury, resulting in severe hypoxemia, decreased pulmonary compliance and increased pulmonary vascular resistance.[1,2] The resulting increase in right ventricular (RV) afterload and different ventilatory strategies may induce RV dysfunction and, in extreme cases, acute cor pulmonale (ACP),[3] with variable reported effects on mortality.[4]. Systolic and diastolic function was studied assessing, respectively: right ventricular systolic longitudinal function (tricuspid annular plane systolic excursion) and systolic contraction duration (tricuspid annular plane systolic excursion length); right ventricular diastolic filling time and right ventricular diastolic restrictive pattern (presence of pulmonary valve presystolic ejection wave). A negative correlation was found between tricuspid annular plane systolic excursion and tricuspid annular plane systolic excursion length (P

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