Use of speckle-tracking strain in preload-dependent patients, need for cautious interpretation!

Abstract

Background: In critical patients, left ventricular ejection fraction and fractional shortening are used to reflect left ventricular systolic function. An emerging technique, two-dimensional-strain echocardiography, allows assessment of the left ventricle systolic longitudinal deformation (global longitudinal strain) and the speed at which this deformation occurs (systolic strain rate). This technique is of increasing use in critical patients in intensive care units and in the peri-operative period where preload constantly varies. Our objective, in this prospective single-center observational study, was to evaluate the effect of fluid resuscitation on two-dimensional-strain echocardiography measurements in preload-dependent critically ill patients. We included 49 patients with preload dependence attested by an increase of at least 10% in the left ventricular outflow track velocity-time integral measured by echocardiography during a passive leg raising maneuver. Echocardiography was performed before fluid resuscitation (echocardiography 1) and after preload independency achievement (echocardiography 2).

Results: Two-dimensional-strain echocardiography was feasible in 40 (82%) among the 49 patients. With preload dependence correction, the absolute value of global longitudinal strain and systolic strain rate was significantly increased from, respectively, - 13.3 ± 3.5 to - 18.4% ± 4.5 (p < 0.01) and - 1.11 s^-1 ± 0.29 to - 1.55 s^-1 ± 0.55 (p < 0.001). The fluid resuscitation affects GLS and SSR in preload-dependent patients, with a shift, for GLS, from pathological to normal values.

Conclusion: In critically ill patients, the assessment of the systolic function by two-dimensional-strain echocardiography needs prior evaluation of preload dependency, in order to adequately interpret this variable. Future studies should assess the ability of global longitudinal strain to guide fluid management in the critically ill patients.

Keywords: 2D-strain echocardiography; Fluid responsiveness; Passive leg raising; Preload dependence; Speckle tracking.

Fig. 1

Flow chart protocol. PLR, passive leg raising; PLR Δ LVOT VTI, passive leg raising variation of left ventricular outflow track velocity–time integral; ↗ LVOT VTI, increase of left ventricular outflow track velocity–time integral after fluid resuscitation

Fig. 2

Significant increase of cardiac index before and after fluid challenge 2.4 ± 0.9–3.1 ± 1.2 L/min/m² (p < 0.01)

Fig. 3

Significant increase of absolute value in GLS: − 13.3 ± 3.5 versus − 18.4 ± 4.5% (p < 0.01)

Fig. 4

Correlation of global longitudinal strain and strain 4 chamber r = 0.81 (p < 0.01)