Tóm tắt Luận án Research on the changes and predictive value of left ventricular longitudinal strain by speckle tracking echocardiography in septic shock patients

Nội dung tài liệu: Tóm tắt Luận án Research on the changes and predictive value of left ventricular longitudinal strain by speckle tracking echocardiography in septic shock patients

1. MINISTRY OF EDUCATION AND TRAINING MINISTRY OF DEFENCE 108 INSTITUTE OF CLINICAL MEDICAL AND PHARMACEUTICAL SCIENCES PHAM DANG HAI RESEARCH ON THE CHANGES AND PREDICTIVE VALUE OF LEFT VENTRICULAR LONGITUDINAL STRAIN BY SPECKLE TRACKING ECHOCARDIOGRAPHY IN SEPTIC SHOCK PATIENTS Speciality: Anesthesiology and critical care Code: 62720122 ABSTRACT OF MEDICAL PHD THESIS Hà Nội – Năm 2019
2. THE THESIS WAS DONE IN: 108 INSTITUTE OF CLINICAL MEDICAL AND PHARMACEUTICAL SCIENCES Supervisor: 1. Ass. Prof. PhD. Le Thi Viet Hoa 2. Ass. Prof. PhD. Phạm Nguyen Son Reviewer: 1. 2. 3. This thesis will be presented at Institute Council at: 108 Institute of Clinical Medical and Pharmaceutical Sciences Day Month Year The thesis can be found at: 1. National Library of Vietnam 2. Library of 108 Institute of Clinical Medical and Pharmaceutical Sciences
3. THE PUBLISHED ARTICLES RELATED TO THIS STUDY 1. Pham Dang Hai, Do Van Quyen, Le Thi Viet Hoa, Pham Nguyen Son (2019) “Left ventricular systolic function in septic shock by speckle-tracking echocardiography”, Journal of 108 clinical medicine and pharmacy, vol 1 (1), pp.34-38 2. Pham Dang Hai, Do Van Quyen, Le Thi Viet Hoa, Pham Nguyen Son (2019) “Prognostic value of global longitudinal strain in patients with septic shock” Journal of 108 clinical medicine and pharmacy, vol (1), pp.46-50.
4. 1 INTRODUCTON 1. The urgent and demand of the study Septic shock is the major cause of hospitalization and also the leading cause of death in ICU. Septic shock can lead to organs dysfunction including cardiovascular system. Prevalence of cardiac dysfunction in patients with septic shock is aproximately 60-70%. This disorder aggravates the condidtion of disease and increases the mortality rate. Echocardiography is nowadays one of the first line investigations in patients with septic shock because of its accessibility and noninvasive nature. In sepsis and septic shock, however, assessment of myocardial function by conventional echocardiographic parameters such as left ventricular ejection fraction (LVEF) is affected to a large degree by ongoing changes in preload and afterload conditions. Speckle tracking echocardiography (STE) is a novel technology of echocardiography. Compared to LVEF, STE is affected to a much lesser degree by changes in ventricular loading conditions, angle - independent and reproducible. This method based on a semi-automated algorithm that tracks the displacement of acoustic “speckles” in the myocardium, the change in length of myocardial segments are measured. Global longitudinal strain is a valuable index in assessing left ventricular function, in the prognosis of cardiovascular events and mortality prognosis. In worldwide, the application of STE in clinical practice is being studied, especially in investigating cardiac function in patients with septic shock. However, there have not been any studies about it in Vietnam. Therefore, this is a novel and scientific issue and maybe benefits to doctors in the management of septic shock.
5. 2 2. The new conclusions of this study - Speckle tracking echocardiography can detect significant left ventricular impairment in patients with septic shock, which was not otherwise detectable by conventional echocardiography. - GLS is valuable in prognosis of severity in patients with septic shock through correlation with severity score (APACHE II, SOFA, SAPS2), biomarker (NT-proBNP, hs-Troponin T, Lactat) and number of organ dysfuctions. - GLS has predictive mortality value in septic shock patients. 3. The aims of this study - To evaluate some characteristics of changes in left ventricular longitudinal strain by Speckle tracking echocardiography in patients with septic shock. - To determine the association of global longitudinal strain with some prognostic factors in patients with septic shock. 4. The structure of thesis The thesis includes 119 pages, with introduction and aims of study 2 pages. Chapter one: overview 34 pages, chapter two: subject and method 25 pages; chapter three: results 24 pages; chapter four: discussion 27 pages, conclusion and recommendation 3 pages. There are 27 tables of data, 15 charts, 9 pictures and figures. The reference section has 169 articles including 157 English and 12 Vietnamese articles. Two study– related articles were published.
6. 3 Chapter one OVERVIEW 1.1. Septic shock. 1.1.1. Definition of septic shock. In 2016, A task force with expertise of society of Critical Care Medicine and the European Society of Intensive Care Medicine gave new definition of sepsis and septic shock. - Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection. - Septic shock is defined as a subset of sepsis in which underlying circulatory and cellular metabolism abnormalities are profound enough to substantially increase mortality. Patients with septic shock can be clinically identified by a vasopressor requirement to maintain a mean arterial pressure of 65 mmHg or greater and serum lactate level greater than 2 mmol/L in the absence of hypovolemia. 1.1.2. Risk factors of sepsis and septic shock Some risk factors of sepsis and septic shock include: - Intensive care unit admission - Advanced age (≥ 65 years) - Immunosuppression - Diabetes and cancer - Previous hospitalization 1.1.3. Prognosis of sepsis and septic shock Prognostic factors include clinical characteristics that impact the severity of sepsis, the host's response to infection, the site and type of infection, and the timing and type of antimicrobial therapy. 1.2. Cardiac dysfunction in septic shock
7. 4 1.2.1. The clinical characteristics of sepsis induced myocardial dysfunction - Increased cardiac output and decreased systemic vascular resistence - Patients who survived had a depressed left ventricular EF and acute left ventricular dilatation. However, nonsurvivors of septic shock maintained normal left ventricular EF and volume. 1.2.2. Pathogenesis of sepsis induced myocardial dysfunction - Role of coronary blood flow. - Myocardium-depressing factors - Autonomic dysregulation - Dysfunction of intracellular Ca2+ transporters in cardiomyocytes - Energetic starvation of cardiomyocytes - Mitochondrial dysfunction and oxidative-nitrosative stress 1.3. Image methods evaluating cardiac function in septic shock - Transthoracic echocardiography - Cardiac magnetic resonance imaging - Myocardial perfusion imaging (MPI) 1.4. Speckle tracking echocardiography 1.4.1. Parameters of speckle tracking echocardiography - Strain - Strain rate 1.4.2. Clinical applications - Detection of subclinical myocardial dysfunction - Monitoring response to treatment - Role in acute coronary event - As a measure of myocardial ischemia and viability - Role in cardiac resynchronization therapy - Assessment of LV diastolic function
8. 5 - Assessment of RV function - LA function 1.4.3. Some studies regarding speckle tracking echocardiography in septic shock. The first study evaluating this in 2014 by Landesberg et al demonstrate the association between diastolic strain measured by longitudinal strain early diastolic filling wave and in-hospital mortality (Wald test = 6.6; p =0.02). A subsequent study by Orde et al (2014) on 60 adult patients with severe sepsis or septic shock, 33% of patients had left ventricle (LV) dysfunction based on ejection fraction compared to 69% assessed with STE. Lui et al (2015), the non-survivors exhibited GLSs that were less negative than those of the survivors (non-survivors vs. survivors: -11.8 ± 4.5% vs. -15.0±3.6%, p <0.001), which indicated worse LV systolic function. The patients with GLS ≥-13% exhibited higher ICU and in- hospital mortality rates (hazard ratio: 4.34, p <0.001 and hazard ratio: 4.21, p <0.001, respectively). Cox regression analyses revealed that higher Acute Physiology and Chronic Health Evaluation (APACHE) II scores and less negative GLS were independent predictors of ICU and in- hospital mortalities. In SPECKSS study (2016), Septic shock group had a greater degree of myocardial dysfunction measured by global longitudinal strain (GLS) than sepsis group (-14.5 % vs -18.3 %, p < 0.001), and the myocardial strain differed upon diagnosis and recovery (-14.5 % vs -16.0 %, P = 0.010). Conventional echocardiographic measurements such as LVEF (59 % in the study group vs 61 % in the control group, p = 0.169) did not differ between the two groups.
9. 6 Innocenti et al (2018), Analyses through ROC curves focusing on day-7 mortality show that less negative GLS (AUC 0.73, p = 0.001). In multivariate analyses, mortality by day-7 follow-up is more likely per higher GLS (i.e., indicative of worst systolic dysfunction, HR 1.22/%, p = 0.005) and the same analysis by 28-day follow-up, LV GLS is an independent prognostic value ((RR 1,14; KTC 95%: 1,03–1,26, p = 0,009). Some issues need further research - To determine the prognostic value of the severity through the correlation between GLS with scores such as SOFA, APACHE II and SAPS 2 as well as biomarkers (hs-Troponin T, NT-proBNP, Lactat). - To determine cut- off value of GLS in predictor of mortality. Chapter two SUBJECTS AND METHOD 2.1. Subjects From May 2017 to December 2018, we prospectively studied 127 patients admitted to the ICU of 108 Military Central Hospital, divided 2 groups: 90 patients with septic shock and 37 patients with sepsis. 2.1.1. Study group Include criteria. - Age 18 years or older, - Diagnosis of septic shock according to SCCM/ESICM (2016) Exclude criteria. Patients were excluded if they met one of the following criteria: - Active diagnoses directly relating to myocardial dysfunction, such as acute myocardial infarction, myocarditis and post-cardiopulmonary resuscitation status;
10. 7 - Significant underlying cardiac conditions, such as congenital heart disease, valvular heart disease, and cardiomyopathy. 2.1.2. Control group Inclusion criteria. - Age 18 years or older, - Diagnosis of sepsis according to SCCM/ESICM (2016) Exclusion criteria. Patients were excluded if they met one of the following criteria: - Active diagnoses directly relating to myocardial dysfunction, such as acute myocardial infarction, myocarditis and post-cardiopulmonary resuscitation status; - Significant underlying cardiac conditions, such as congenital heart disease, valvular heart disease, and cardiomyopathy. 2.1.3. Withdrawal criteria in study - Patients who are eligible for study but the patient's family demands to stop the management. - Poor quality echocardiography images do not qualify for analysis. 2.2. Methods 2.2.1. Study design Prospective study, cross-sectional description and comparison with the control group. 2.2.2. Sample size Convenience sampling 2.2.3. Research facilities - Hemodynamic and respiratory monitoring devices - Machines for continuous renal replacement therapy - Hematological and biochemical tests are performed on multi- parameter testing machines at 108 Military Central Hospital.