INFERIOR VENA CAVA DILATATION PREDICTS GLOBAL CARDIAC DYSFUNCTION IN ARDS: A STRAIN ECHOCARDIOGRAPHIC STUDY

Abstract

SESSION TITLE: Cardiovascular Disease SESSION TYPE: Original Investigations PRESENTED ON: 10/09/2018 02:30 PM - 03:30 PM PURPOSE: The evaluation of the inferior vena cava (IVC) with ultrasound is frequently utilized to gauge intravascular volume in critically ill patients. The reliability of this technique has been questioned on mechanically ventilated patients, and specific data about its use in acute respiratory distress syndrome (ARDS) is practically nonexistent. We examined the utility of IVC diameter in the evaluation of cardiac and hemodynamic performances in patients with ARDS. METHODS: At a quaternary academic center, we did a retrospective cross-sectional analysis of Doppler Echocardiograms of ventilated patients with moderate-severe ARDS. Right ventricular(RV) fractional area change(RVFAC), tricuspid annular plane systolic excursion(TAPSE) and velocity(S'), and IVC diameter were estimated according to the American Society of Echocardiography guidelines. Using speckle tracking echocardiography, RV free wall(RVFWS), RV septal(RVSS) and RV Global longitudinal(RVGLS) strain were calculated. Left ventricular(LV) ejection fraction(LVEF) and LV diastolic function variables were also measured. Pertinent hemodynamic, ventilatory and laboratory data were collected. RESULTS: Fifty-one patients were included. A bimodal IVC classification method created two groups (IVC<2.1cm and IVC≥2.1cm). An IVC≥2.1cm was associated with lower systolic blood pressure (105±15 vs 124±8 mmHg, p:0.002), higher creatinine (1.4±0.6 vs 0.9±0.4 mg/dL, p:0.004), increased lactate (3.2±1.5 vs 1.8±1.2 mmol/L, p:0.002), higher incidence of shock (62% vs 30%, p:0.02), higher central venous pressure(CVP) (16±4 vs 10±4 mmHg, p:0.0001) and higher systolic pulmonary pressure. RVFAC, TAPSE, S', RVFWS and RVGLS (but not RVSS), were also depressed in this group. An IVC≥2.1cm was also associated with lower LVEF (55±12 vs 67±10%, p:0.01) and abnormal LV diastolic function. Positive correlations of RVFAC, TAPSE, S', RVFWS, RVSS and RVGLS with LVEF were observed. CVP and IVC negatively correlated with LVEF. Regression analysis demonstrated that the best predictor of IVC diameter was CVP (R2:0.35, p:0.001) and that the association RVSS+IVC diameter was a strong independent predictor of LVEF (R2:0.25, p:0.002). No significant differences in ventilatory parameters were observed. CONCLUSIONS: In patients with ARDS, an IVC≥2.1cm was independently associated with worse biventricular cardiac function and more abnormal hemodynamic performance. The biventricular interaction of a functionally impaired RV with the LV only partially explained our observations. The role of systemic negative inotropic factors (i.e., inflammatory response mediators) should be considered. CLINICAL IMPLICATIONS: The hemodynamic management of ARDS patients is extremely challenging. Our study suggests that in moderate-severe ARDS, an IVC≥2.1cm is strongly associated with poor global hemodynamic performance and should signal intensivists the potential necessity for a better hemodynamic optimization. DISCLOSURES: No relevant relationships by Romel Garcia-Montilla, source=Web Response No relevant relationships by Stephen Heitner, source=Web Response No relevant relationships by Faryal Imam, source=Web Response Study PI relationship with United Therapeutics Please note: $20001 - $100000 Added 11/29/2017 by Akram Khan, source=Web Response, value=Grant/Research Support study PI relationship with AstraZeneca Please note: $20001 - $100000 Added 11/29/2017 by Akram Khan, source=Web Response, value=Grant/Research Support Study PI relationship with Glaxo SmithKline Please note: $20001 - $100000 Added 11/29/2017 by Akram Khan, source=Web Response, value=Grant/Research Support Study PI relationship with Actelion pharmaceuticals Please note: $20001 - $100000 Added 11/29/2017 by Akram Khan, source=Web Response, value=Grant/Research Support Study PI relationship with National Institute of Health Please note: >$100000 Added 11/29/2017 by Akram Khan, source=Web Response, value=Grant/Research Support Removed 11/29/2017 by Akram Khan, source=Web Response Study PI relationship with Intermune Please note: $20001 - $100000 Added 11/29/2017 by Akram Khan, source=Web Response, value=Grant/Research Support Study PI relationship with Lung LLC Please note: $20001 - $100000 Added 11/29/2017 by Akram Khan, source=Web Response, value=Grant/Research Support Research Grant relationship with Actelion pharmaceuticals Please note: $20001 - $100000 Added 03/02/2018 by Akram Khan, source=Web Response, value=Grant/Research Support Research Grant relationship with AstraZeneca Please note: $20001 - $100000 Added 03/02/2018 by Akram Khan, source=Web Response, value=Grant/Research Support Research Grant relationship with Bristol-Myers Squibb Please note: $5001 - $20000 Added 03/02/2018 by Akram Khan, source=Web Response, value=Grant/Research Support Research Grant relationship with EMD Serono Please note: $5001 - $20000 Added 03/02/2018 by Akram Khan, source=Web Response, value=Grant/Research Support Research Grant relationship with Genentech Please note: $5001 - $20000 Added 03/02/2018 by Akram Khan, source=Web Response, value=Grant/Research Support Research Grant relationship with Glaxo SmithKline Please note: $20001 - $100000 Added 03/02/2018 by Akram Khan, source=Web Response, value=Grant/Research Support Research Grant relationship with Intermune Please note: $20001 - $100000 Added 03/02/2018 by Akram Khan, source=Web Response, value=Grant/Research Support Research Grant relationship with United Therapeutics Please note: >$100000 Added 03/02/2018 by Akram Khan, source=Web Response, value=Grant/Research Support No relevant relationships by Mi Miao, source=Web Response No relevant relationships by Srini Mukundan, source=Web Response No relevant relationships by Kathryn Stinson, source=Web Response