This study evaluated the feasibility of transthoracic echocardiography (TTE) for assessing cardiac function in 76 patients with septic shock. TTE was able to determine left ventricular systolic function in 90% of patients, right ventricular function in 99%, and left ventricular diastolic function in 73%. Diastolic dysfunction was present in 50% of patients. Factors like obesity, mechanical ventilation, age, and illness severity did not impact the ability of TTE to evaluate cardiac function. TTE is therefore a reliable tool for comprehensive cardiac assessment, including diastolic function, in critically ill septic shock patients.

1. Feasibility of Transthoracic Echocardiography in Septic Shock J. HAMMES 1 , A.S. BERAUD 2 , M.C. VAZQUEZ GUILAMET 3 , L. MENG 4 , J. HSU 3 1 Stanford University, CA, USA; 2 Division of Cardiovascular Medicine, Department of Medicine, Stanford University Medical School, CA, USA; 3 Division of Pulmonary Critical Care Medicine, Department of Medicine, Stanford University Medical School, CA, USA; 4 Department of Pharmacy, Stanford Hospital and Clinics, CA, USA. The feasibility of TTE was very high in patients with septic shock: 90% for the determination of left ventricular systolic function, 99% for right ventricular function, and 73% for left ventricular diastolic function. The prevalence of diastolic dysfunction was 50%. Obesity, mechanical ventilation, age, or severity of illness did not alter feasibility in logistic regression analyses. Whether diastolic dysfunction is a direct consequence of sepsis, or of its management (volume expansion, inotropes and vasopressors use) is still to be determined, as well as its role in management and prognosis. References Jardin F, Fourme T, Page B, et al. Persistent preload defect in severe sepsis despite fluid loading: a longitudinal echocardiographic study in patients with septic shock. Chest 1999; 116:1354–1359. Vieillard-Baron A, Caille V, Charron C, et al. Actual incidence of global left ventricular hypokinesia in adult septic shock. Critical Care Medicine 2008; 36:1701– 1706. Sturgess DJ, Marwick TH, Joyce CJ et al: Prediction of hospital outcome in septic shock: a prospective comparison of tissue Doppler and cardiac biomarkers. Critical Care Medicine. 2010;14(2):R44. Landesberg G, Gilon D, Meroz Y et al: Diastolic dysfunction and mortality in severe sepsis and septic shock. Eur Heart J . 2011 Sep 11. [Epub ahead of print] Bouhemad B, Nicolas-Robin A, Arbelot C et al: Isolated and reversible impairment of ventricular relaxation in patients with septic shock. Critical Care Medicine . 2008 Mar;36(3):766-74. Recommendations for chamber quantification: a report from the American Society of Echocardiography's Guidelines and Standards Committee and the Chamber Quantification Writing Group, developed in conjunction with the European Association of Echocardiography, a branch of the European Society of Cardiology. Journal of the American Society of Echocardiography [0894-7317] Lang yr:2005 vol:18 iss:12 pg:1440 -1463 Recommendations for the evaluation of left ventricular diastolic function by echocardiography. Nagueh SF, Appleton CP, Gillebert TC, Marino PN, Oh JK, Smiseth OA, Waggoner AD, Flachskampf FA, Pellikka PA, Evangelista A. J Am Soc Echocardiogr. 2009 Feb;22(2):107-33. Review. Fig. 2 , Assessment of systolic and diastolic function Diastolic parameters were collected in 65% of patients (49/76). In 73% of these patients (36/49), diastolic function could be determined; it was abnormal in 53% (19/36). Contact Information J. Hsu: Division of Pu l monary and Critical Care Medicine, Stanford University Medical Center, 300 Pasteur Dr., Stanford, CA 94305-XXXX, United States. Tel.: +1 650 725 7061; fax: +1 650 498 6288. #221 Septic cardiomyopathy is estimated to occur in up to 80% of patients with septic shock. Mortality is XX% Transthoracic echocardiography (TTE) is a reliable non-invasive tool to comprehensively assess cardiac function, specifically diastolic function. However its feasibility for the diagnosis of diastolic function is still perceived as poor in critically ill patients. Our objective was to address the feasibility of TTE for the characterization of diastolic function in patients with septic shock. INTRODUCTION Demographic characteristics Inclusion criteria were met in 76 patients. Mean age was 70 years, 59% patients were female, 69% patients were Caucasian, with the highest minority being Asian (15%). The mean APACHE II score on admission was 28 (+/- 8). Overall 28-day mortality for the sample group was 39.5%. 91% patients were in sinus rhythm with mean heart rate 95 ± 24 /minute (range 71-119). Troponin was elevated (>0.3 units?? ) in 52% (25/49). Echocardiographic characteristics Mean EF was 55±16.7% and was abnormal in 35% of these patients (24/68). 19% of patients with systolic dysfunction were on inotropic support on the day of TTE. XX patients could be evaluated from a change from a baseline echocardiogram (Figure 2). Right ventricular function was assessed in 99% of patients (75/76) and was impaired in 31% of patients (23/75). In 47% of patients with diastolic dysfunction the LA was dilated (9/19). Significant mitral regurgitation or aortic stenosis were the most frequent impediments for the assessment of diastolic function (10/13s). 72% (26/35) showed some type of cardiac dysfunction: left or right ventricular systolic dysfunction or diastolic dysfunction. RESULTS METHODS Study design: 2-year retrospective study of patients with septic shock in whom a TTE was performed within 72 hours of admission to the intensive care unit (ICU). DESCRIBE ALGORITHM FOR OBTAINING INITIAL LIST. Septic shock was defined as per the CORTICUS study [Ref]. Detailed patient information including: demographics, clinical course, vitals, laboratory values, and pharmacologic data from the day of the TTE were also collected through an extensive chart review. Severity of illness was based on a patient’s Acute Physiology and Chronic Health Evaluation (APACHE) II score on admission. Hypothesis: We hypothesized that TTE would have high diagnostic capabilities in the absence of certain factors thought to be associated with poor image acquisition: mechanical ventilation status, body mass index (BMI), age, heart rate and severity of illness. Echocardiograms analysis: TTEs were obtained by experienced sonographers and reviewed by a single cardiologist (ASB), blinded to clinical outcome. Left ventricular (LV) systolic dysfunction was defined as an ejection fraction (EF) < 50% using the Simpson method [Ref]. Right ventricular (RV) dysfunction was qualitatively assessed. Diastolic dysfunction was determined using ASE recommendations for the assessment of left ventricular diastolic function [ ref] . Left atrial (LA) dilatation (area > 20 cm 2 ) was used to assess chronicity of diastolic dysfunction. CONCLUSIONS Figure 3 , Feasibility of TTE to determine systolic and diastolic function. Percentages of patients with readable ECHO images. 1 (Number patients with feasible ECHOs/Total number of patients in subgroup) Figure 1, TTE showing normal left ventricular function before the onset of sepsis, moderate dysfunction during sepsis (day 1) Diastole Systole Before Sepsis Onset After Sepsis Onset Acknowledgements This work was made possible by the efforts of Gomathi Krishnan AND THE RESOURCES OF THE STANFORD IRT, who helped to obtain the initial list of patients involved in this study. Feasibility of ECHO to Determine Systolic and Diastolic Functionality BMI ≥ 25 Mechanically APACHE II ≥ 22 HR ≥ 90bpm (17/41) 1 Ventilated (20/41) (28/36) (30/62) TTE + Septic Cardiomyopathy 76 Patients Feasibility of Systolic Function 99% Feasibility of Diastolic Function 73% 36 Patients with Interpretable Data Systolic dysfunction 24 Diastolic dysfunction 19 Normal diastolic function 17 Parameters collected in 68 Patients Normal systolic function 44 Parameters collected in 49 Patients ASB : IMAGE NEEDS TO BE MORE QUANTITATIVE INCLUDING VOLUME CALCULATION LINES [TRACING THE VENTRICLE WILL HELP THE VIEWER TO SEE DIFFERENCES… DOPPLER IMAGES WOULD ALSO BE USEFUL MAYBE ANOTHER FIGURE ASB : CAN YOU PROVIDE AN EXAMPLE OF THE DIASTOLIC MEASUREMENT [THIS IS ALSO AN EDUCATIONAL CONFERENCE]. BIGGER. I AGREE WITH ASB WE NEED TO SORT OUT ANOTHER FIGURE. THE DATA DOESN’T LOOK SO HOT CRISTINA. CAN YOU REPEAT THIS ANALYSIS? LET’S DEFINE APACHE II BY >25 [REF] JH: Make this your “table” less detail focus on echo characteristics. Sentences need to be shortened As for my own hypothesis, I thought that BMI, HR, etc would affect the ECHO feasibility. Is it ok that I was wrong? (JLH)