Left ventricular strain is associated with acute postoperative refractory hypotension in patients with constrictive pericarditis and preserved ejection fraction

Abstract

Background: Pericardiectomy is an effective treatment for constrictive pericarditis (CP). Early postoperative complications such as refractory hypotension and congestive heart failure occur in these patients and are associated with increased morbidity and mortality. We hypothesized that left ventricular (LV) myocardial strain measured by two-dimensional speckle tracking echocardiography (2DSTE) could identify early cardiac dysfunction and relate to acute postoperative adverse events in CP patients.

Methods: Forty-four CP patients with preserved left ventricular ejection fraction (LVpEF, 64%±8%) and 44 age- and sex-matched controls were enrolled. Conventional 2DSTE was performed before pericardiectomy. Global and segmental peak systolic strain values were measured. The primary endpoint was a composite of postoperative refractory hypotension, congestive heart failure and cardiogenic death. Refractory hypotension was defined as hypotension requiring prolonged usage of intravenous inotropic medication (IVIM) (≥2 days).

Results: Postoperative refractory hypotension occurred in 26 cases, and no patients experienced congestive heart failure or cardiogenic death. Compared to controls, CP patients had decreased absolute global and segmental circumferential strain (CS), radial strain (RS), and longitudinal strain (LS) except septal LS. Patients with refractory hypotension exhibited lower epicardial CS (P=0.04). Epicardial CS was an independent risk factor correlated with postoperative adverse outcome [P=0.014, OR =1.236 (1.044-1.464)] while LVEF was not. Lower absolute value of epicardial CS was related to higher (P=0.02) and longer usage of intravenous furosemide (P=0.04) to keep negative fluid balance perioperatively.

Conclusions: LV strain value is markedly reduced in patients with CP and LVpEF. Lower preoperative epicardial CS value is associated with greater risk of early refractory hypotension and more aggressive fluid management.

Keywords: Strain; constrictive pericarditis (CP); outcome; pericardiectomy.

Figure 1

Pictures of myocardia in short-axis (left) and long-axis (right) views were shown. Dark red regions indicate septal segments, and light red regions indicate epicardia of left ventricle. Septal and epicardial LS were calculated separately by averaging septal segments and epicardial segments in long-axis views (including apical two-, three-, and four-chamber views). Regional CS and RS were calculated similarly in short-axis views (including mitral valve, papillary muscle and apex levels). RV, right ventricle; MV, mitral valve; LV, left ventricle; CS, circumferential strain; RS, radial strain; LS, longitudinal strain.

Figure 2

Comparison of baseline circumferential strain between patients with or without refractory hypotension. Patients with constrictive pericarditis who suffered from postoperative refractory hypotension had lower absolute value of global and epicardial circumferential strain than who didn’t. CS, circumferential strain.

Figure 3

Receiver operating characteristic curves of circumferential strain (CS) to distinguish constrictive pericarditis patients with acute postoperative refractory hypotension from those without. The results showed the area under the curve (AUC) of free wall epicardial CS was 0.70 (P=0.02). Additionally in tuberculous patients, the AUC of epicardial CS was 0.80 (P=0.01), and GCS was 0.77 (P=0.03). CS, circumferential strain; TB, tuberculosis.