https://ir.ymlib.yonsei.ac.kr/bitstream/22282913/161167/1/T201704229.pdf

Estimating Left Ventricular Filling Pressure by Echocardiography

Objective
To determine the frequency and spectrum of myocardial dysfunction in patients with severe sepsis and septic shock using transthoracic echocardiography and to evaluate the impact of the myocardial dysfunction types on mortality.

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Clinical Spectrum, Frequency, and Significance of Myocardial Dysfunction in Severe Sepsis and Septic Shock

Sepsis is the life-threatening organ dysfunction caused by a dysregulated host response to infection and is the leading cause of death in intensive care units. Cardiac dysfunction caused by sepsis, usually termed sepsis-induced cardiomyopathy, is common and has long been a subject of interest. In this Review, we explore the definition, epidemiology, diagnosis and pathophysiology of septic cardiomyopathy, with an emphasis on how best to interpret this condition in the clinical context. Advances in diagnostic techniques have increased the sensitivity of detection of myocardial abnormalities but have posed challenges in linking those abnormalities to therapeutic strategies and relevant clinical outcomes. Sophisticated methodologies have elucidated various pathophysiological mechanisms but the extent to which these are adaptive responses is yet to be definitively answered. Although the indications for monitoring and treating septic cardiomyopathy are clinical and directed towards restoring tissue perfusion, a better understanding of the course and implications of septic cardiomyopathy can help to optimize interventions and improve clinical outcomes.

Pathophysiology of sepsis-induced cardiomyopathy.

Echocardiography is increasingly recommended for the diagnosis and assessment of patients with severe cardiac disease, including acute heart failure. Although previously considered to be within the realm of cardiologists, the development of ultrasonography technology has led to the adoption of echocardiography by acute care clinicians across a range of specialties. Data from echocardiography and lung ultrasonography can be used to improve diagnostic accuracy, guide and monitor the response to interventions, and communicate important prognostic information in patients with acute heart failure. However, without the appropriate skills and a good understanding of ultrasonography, its wider application to the most acutely unwell patients can have substantial pitfalls. This Consensus Statement, prepared by the Acute Heart Failure Study Group of the ESC Acute Cardiovascular Care Association, reviews the existing and potential roles of echocardiography and lung ultrasonography in the assessment and management of patients with acute heart failure, highlighting the differences from established practice where relevant.

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Expert consensus document: Echocardiography and lung ultrasonography for the assessment and management of acute heart failure

Tissue Doppler imaging (TDI) is a useful echocardiographic technique to evaluate global and regional myocardial systolic as well as diastolic function. It can also be used to quantify right ventricular and left atrial function. Recent studies have demonstrated its utility as a diagnostic as well as prognostic tool in different cardiac conditions including coronary artery disease, heart failure (both systolic and diastolic), valvular heart disease, cardiomyopathies as well as constrictive pericarditis. TDI measurements are also helpful to identify patients who will benefit from cardiac resynchronisation therapy. Even though it is reproducible and relatively easy to obtain, it is underutilised in routine clinical practice. TDI is readily available on most commercially available echocardiographic systems, and we recommend that TDI be used for routine clinical echocardiographic evaluation of patients.

Tissue Doppler Imaging in Echocardiography: Value and Limitations

A cardiac cycle consists of systolic (contraction) and diastolic (relaxation and filling) phases that are linked closely together for optimal function of the heart. Normal diastolic function allows adequate filling of the heart without an excessive increase in diastolic filling pressure both in the resting state and with stress or exertion.1 The diastolic phase is remarkably well designed to ensure that the ventricle is optimally filled for a given clinical condition.2 Basically, at the end of systole, left ventricular (LV) relaxation begins as an initial diastolic process, and LV pressure falls rapidly as the LV expands. This relaxation phase is accompanied by active movement of the mitral annulus away from the apex. The velocity of LV dilatation and mitral annular movement during early diastole correlates well with how fast the LV fills and relaxes, respectively.3,4 Myocardial relaxation continues during early diastole to reach the minimal LV diastolic pressure, which helps with “sucking” or “pulling” the blood actively into the LV (Figure 1, online-only Data Supplement Video 1A). The minimal LV diastolic pressure or completion of relaxation normally occurs by 3.5 times the value of tau—the time constant of relaxation (normal <45 ms)—after the mitral opening.5 LV pressure then rises to be equilibrated with left atrial (LA) pressure, at which time the early diastolic filling decelerates to close the mitral valve until the time of atrial contraction when LA pressure increases to initiate the late filling to complete diastole (Figure 1, online-only Data Supplement Video 1B).



Figure 1. 
Top, Schematic diagram of mitral inflow and mitral medial annulus velocities from normal to progressive stages of diastolic dysfunction. Mitral inflow E is sensitive to preload, becoming higher with shorter deceleration time (time from the peak to the baseline) as diastolic function becomes worse with increasing filling …

Sung Ji Park

Papers

Established and novel clinical applications of diastolic function assessment by echocardiography.