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Echocardiographic Evaluation of Left Ventricular Function in Critically Ill Patients^*

Dynamic Loading Challenge Using Medical Antishock Trousers

^* From the Medical Intensive Care Unit (Drs. Loubieres, Vieillard-Baron, Fourme, Page, and Jardin), and the Department of Biostatistics (Dr. Beauchet), University Hospital Ambroise Paré, Assistance Publique Hôpitaux de Paris, Boulogne Cedex, France.

Correspondence to: François Jardin, MD, Hôpital Ambroise Paré, 9 avenue Charles de Gaulle, 92104, Boulogne Cedex, France; e-mail: francois.jardin{at}apr.ap-hop-paris.fr

Study objective: We hypothesized that a dynamic left ventricular (LV) evaluation during a loading challenge might enhance diagnostic capabilities of routine transesophageal echocardiography in critically ill patients and selection of therapeutic options against circulatory failure, particularly the choice between volume expansion and vasoactive agent infusion.

Design: Prospective clinical study in a group of 26 patients requiring hemodynamic support by vasoactive infusion because of low systemic arterial pressure (< 90 mm Hg by invasive monitoring) during mechanical ventilation.

Setting: University hospital ICU.

Patients: Patients required respiratory support for an episode of acute respiratory failure of various causes or for an episode of coma. They were studied by transesophageal echocardiography during mechanical ventilation in the controlled mode, before and during a loading challenge made using the legs compartment of medical antishock trousers inflated at 80 mm Hg.

Measurements: A short-axis view of the left ventricle was obtained by a transgastric approach, and end-diastolic and end-systolic areas were measured. LV stroke area (LVSA) and LV fractional area contraction (LVFAC) were calculated.

Results: Changes in LV echocardiographic measurements permitted separation of the patients into two groups. In nine patients (group 1), LVSA, used as an index of stroke output, was significantly increased during the challenge, together with a significant increase in LV end-diastolic area, suggesting preload improvement by the challenge. Conversely, in 17 patients (group 2), LVSA was significantly reduced by the challenge, together with a significant decrease in LVFAC, suggesting a negative effect of increased afterload by the challenge.

Conclusion: Study of the changes in LV dimensions during loading challenge in hemodynamically unstable patients was used to evaluate the balance between the adequacy of preload and the ability of the heart to pump against an increased load, and might thus guide hemodynamic support.

Key Words: circulatory failure • loading challenge • medical antishock trousers • transesophageal echocardiography