Medicina Intensiva 48 (2024) 220---230

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UPDATE IN INTENSIVE CARE MEDICINE: ULTRASOUND IN THE CRITICALLY ILL PATIENT. CLINICAL
APPLICATIONS

How to use echocardiography to manage patients with

shock?
Guillaume Théry a,e,∗ , Victor Gascon b , Virginia Fraile c , Ana Ochagavia d , Olfa Hamzaoui a,e

a
Service de Médecine Intensive --- Réanimation Polyvalente, Hôpital Robert Debré, Centre Hospitalo-Universitaire de Reims
b
Servicio de Medicina Intensiva, Hospital Universitario de la Ribera, Alcira (Valencia)
c
Servicio de Medicina Intensiva, Hospital Universitario Río Hortega, Valladolid
d
Servicio de Medicina Intensiva, Hospital Universitario de Bellvitge, L’Hospitalet de Llobregat, Barcelona
e
Unité HERVI ‘‘Hémostase et Remodelage Vasculaire Post-Ischémie’’ ---- EA 3801

Received 1 September 2023; accepted 23 October 2023

Available online 26 December 2023

KEYWORDS Abstract Echocardiography enables the intensivist to assess the patient with circulatory fail-
Echocardiography; ure. It allows the clinician to identify rapidly the type and the cause of shock in order to
Shock; develop an effective management strategy. Important characteristics in the setting of shock
Doppler parameters are that it is non-invasive and can be rapidly applied. Early and repeated echocardiography is
a valuable tool for the management of shock in the intensive care unit. Competency in basic
critical care echocardiography is now regarded as a mandatory part of critical care training with
clear guidelines available. The majority of pathologies found in shocked patients are readily
identified using basic level 2D and M-mode echocardiography.
The four core types of shock (cardiogenic, hypovolemic, obstructive, and septic) can readily
be identified by echocardiography. Echocardiography can differentiate the different pathologies
that may be the cause of each type of shock. More importantly, as a result of more complex
and elderly patients, the shock may be multifactorial, such as a combination of cardiogenic and
septic shock, which emphasises on the added value of transthoracic echocardiography (TTE) in
such population of patients.

Abbreviations: AMI, acute myocardial infarction; CS, cardiogenic shock; CO, cardiac output; EFG, effective filling gradient; IVC, inferior
vena cava; MAPSE, mitral annular plane systolic excursion; MCS, mechanical cardiac support; LA, left atrium; LV, left ventricle; LVEF,
left ventricular ejection fraction; LVOT, left ventricular outflow tract; PAdP, pulmonary artery diastolic pressures; PAmP, pulmonary artery
mean pressures; PAsP, pulmonary arterial systolic pressure; PE, pulmonary embolism; PWD, pulsed wave Doppler; RVOT, right ventricular
outflow tract; RV, right ventricle; RWMA, regional wall motion abnormalities; STE, speckle tracking echocardiography; SV, stroke volume; TR,
tricuspid regurgitation; TTE, transthoracic echocardiography; VA-ECMO, veno-arterial extracorporeal membrane oxygenation; VTI, velocity
time integral.
∗ Corresponding author.

E-mail address: [email protected] (G. Théry).

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2173-5727/© 2023 Published by Elsevier España, S.L.U.
 Medicina Intensiva 48 (2024) 220---230

In this review we aimed to provide to clinicians a bedside strategy of the use of TTE parameters
to manage patients with shock. In the first part of this overview, we detailed the different TTE
parameters and how to use them to identify the type of shock. And in the second part, we
focused on the use of these parameters to evaluate the effect of treatments, in different types
of shock.
© 2023 Published by Elsevier España, S.L.U.

PALABRAS CLAVE ¿Cuál es la utilidad de la ecocardiografía en el shock?

Ecocardiografía;
Resumen La ecocardiografía permite al intensivista valorar al paciente con fallo circulatorio
Shock;
agudo. Esta técnica ayuda a identificar, rápidamente y de una manera no invasiva, el tipo
Parámetros Doppler
y la causa del shock para instaurar una estrategia terapéutica. La realización de exámenes
ecocardiográficos precoces y repetidos es una valiosa herramienta para el manejo del shock
en la unidad de cuidados intensivos. La mayoría de patologías responsables del shock pueden
ser identificadas con un nivel básico de ecocardiografía en 2D y modo M. En la actualidad,
las competencias en ecocardiografía básica se consideran mandatorias en la formación de los
profesionales de Medicina Intensiva.
Los cuatro tipos básicos de shock (cardiogénico, hipovolémico, obstructivo y séptico) pueden
ser adecuadamente identificados con la ecocardiografía. Además, la ecografía puede diferen-
ciar las diferentes patologías que pueden ser la causa de cada uno de los tipos de shock. Es
importante señalar que, dada la complejidad y la edad avanzada de muchos pacientes críti-
cos, el shock puede ser multifactorial (p.ej.: combinación de shock séptico y cardiogénico), lo
que enfatiza el valor añadido de la ecocardiografía transtorácica (ETT) en esta población de
pacientes.
En esta revisión, queremos proporcionar a los clínicos una estrategia, a pie de cama, del uso
de los parámetros obtenidos con la ETT para manejo de los pacientes en shock. En la primera
parte de este artículo, se detallan los diferentes parámetros ecocardiográficos y cómo pueden
utilizarse para identificar los tipos de shock. En la segunda parte, se expone el uso de estos
parámetros para evaluar el efecto de los tratamientos en los diferentes tipos de shock.
© 2023 Publicado por Elsevier España, S.L.U.

Introduction How to diagnose the mechanism of shock ?

Shock is best defined as a life-threatening, generalized Cardiogenic shock

form of acute circulatory failure associated with inadequate
oxygen utilization by the cells. It is a state in which the cir- Cardiogenic shock (CS) is a critical syndrome of life-
culation is unable to deliver sufficient oxygen to meet the threatening peripheral hypoperfusion and organ dysfunction
demands of the tissues, resulting in cellular dysfunction. due to primary cardiac dysfunction and inadequate cardiac
The result is cellular dysoxia, i.e. the loss of the physio- output (CO). Several etiologies may be responsible of the
logical independence between oxygen delivery and oxygen initial cardiac insult. Indeed, during several years, the main
consumption, associated with increased lactate levels.1 causes of CS were dominated by acute myocardial infarction
Transthoracic echocardiography (TTE) is a key exam in (AMI). Thanks to early treatments of AMI, the prevalence
the diagnosis of shock and therapy guidance. of ischemic cardiogenic shock is decreasing. And so, other
The main challenge during shock management is to aetiologies of CS are increasing, like myocarditis, Takotsubo
quickly restore hemodynamics and to identify rapidly the syndrome, post-partum cardiomyopathy, valvular patholo-
type and the cause of shock in order to optimize therapeutic gies or end-stage cardiomyopathies.3
interventions.
Echocardiography is now proposed as the first-line evalu-
Cardiac function
ation modality1,2 to allow rapid characterization of the type
of shock and to guide the management of patients in spe-
A common cause of shock is severe ventricular dysfunction.
cific clinical settings for whom the situation may evolve over
To rule it out, we can perform a basic echocardiography in
time. Furthermore, repeated echocardiography may be nec-
which, with a quick view of the heart, we determine its
essary to evaluate the response to therapeutics.
contractile capacity.

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Left ventricular ejection fraction (LVEF) (Fig. 1A) mated by temporal integration of velocities measured by
Depending on the origin of CS and initial state of the cardiac either pulsed tissue Doppler or colour Doppler in healthy
function, TTE can be used for tracking LVEF evolution. Visual subjects.11,12 Similar results were reported, showing a sig-
assessment by a simple eyeballing of LVEF is considered to nificant correlation between S′ . and MAPSE both at rest
be reliable in Cardiovascular Intensive Care Unit, when used and during exercise in heart failure patients with preserved
by trained practitioners2 (Videos 1, 2). LVEF13 S′ value >10 cm/s is correlated to preserved LVEF,
Additionally, LVEF can be measured by the Simpson’s 6---8 cm/s corresponds to altered LVEF between 30 and 45%,
Biplane Formula,4 requiring area tracing of left ventricle and S′ value <6 cm/s is associated with LVEF < 30%.14
(LV) cavity and contouring the endocardial border in both the
apical four-chamber and two-chamber views in end-diastole
Regional wall motion
and end-systole. LV is considered to have the shape of a
Even if systolic ventricular function estimated by LVEF is one
cone. Area tracings of the LV cavity divide it into a number
of the strongest predictors of total and cardiovascular mor-
of discs (usually 20) and the total of volume of these discs
tality, assessment of regional wall motion is part of visual
is equal to LV volume. The difference between diastolic and
echocardiographic examination. Wall motion is assessed in
systolic disc volumes divided by the diastolic volume gives
each 17 segments of the LV and LV segments can be akinetic,
LVEF value. In other words:
hypokinetic or dyskinetic, that may be due to a chronic or
LVEF(%) = (end-diastolicLVvolume acute coronary disease.
More precise methods have been developed during the
− end-systolicLVvolume)/end-diastolicLVvolume × 100. past decades for a better quantification of global and
regional myocardial function, as the Strain, Strain Rate
Other methods for LVEF measurement such as 3D echocar- and Speckle Tracking (Fig. 1B). These methods can track
diography is more accurate but not usable in routine. the motion and the deformation of the myocardium dur-
ing systole and diastole and point out regional wall motion
abnormalities (RWMA) that are not visible on visual echocar-
Other parameters of cardiac function
diography. LV Global Longitudinal Strain alteration precedes
• Mitral annular plane systolic excursion (MAPSE) (Fig. 2A
the LVEF one and was demonstrated to be strongly correlated
and B):
to mortality.4
It is measured by the use of M-mode echocardiography
from four sites of the atrioventricular plane corresponding Cardiac output (CO)
to the septal, lateral, anterior, and posterior walls using the Measurement of CO remains a corner- stone in the hemody-
apical four- and two-chamber views by M-mode echocardio- namic assessment of critically ill patients and in particular
graphy. The M-mode cursor should always be aligned parallel in CS patients as decreased CO is often observed in
to the LV walls. The systolic excursion of mitral annulus such population. Several methods for determining CO have
should be measured from the lowest point at end-diastole been described using both two-dimensional and Doppler
to aortic valve closure (end of the T-wave on the electrocar- echocardiography.15,16 Of these methods, the one using the
diogram). MAPSE represents the amount of displacement of left ventricular outflow tract (LVOT) and aortic valve as the
the mitral annular plane towards the apex and thus assesses conduit, is probably the most reliable and most commonly
the global change in size of the LV cavity (in the long-axis used as there is an excellent agreement with the reference
direction). The average normal value of MAPSE derived from CO measured by thermodilution in most situations 15 (Fig. 3B
previous studies for the four annular regions (septal, ante- and C). The measurement of stroke volume (SV) is usu-
rior, lateral, and posterior) ranged between 12 and 15 mm5,6 ally made at the LVOT. When using the TTE approach, the
and a value of 8 mm was associated with a depressed LVEF operator measures the LVOT diameter from the parasternal
(<50%) with a specificity of 82% and a sensitivity of 98%.5 In long-axis view immediately below the hinge point of the aor-
addition, a mean value for MAPSE of 7 mm could be used tic valve leaflets (Fig. 3A). The LVOT area (cm2 ) is calculated
to detect an EF < 30% with a sensitivity of 92% and a speci- from this diameter measurement using the formula:
ficity of 67% in dilated cardiomyopathy patients with severe
congestive heart failure.6 It is of note that the association LVOTarea(cm2 ) = (LVOTdiameter/2)2 × .
between MAPSE and EF is only valid in case of normal or
dilated left ventricles7,8 while the correlation is rather poor
in patients with LV hypertrophy.9 Next, the operator places the pulsed wave Doppler (PWD)
sample volume in the LVOT to measure the velocity time
• Tissue Doppler peak systolic wave at the mitral lateral integral (VTI) of blood flow in the LVOT, using the five-
annulus (S′ ) (Fig. 2C and D): chamber apical view. The SV is calculated as follows:

Tissue Doppler imaging enables measurements of atri- SV(cm3 ormL) = LVOTarea(cm2 ) × VTI(cm)
oventricular annular and regional myocardial velocities, and
may be more sensitive than conventional echocardiogra-
phy in detecting abnormalities of LV systolic and diastolic
function.10 Two previous studies showed that there was Obstructive shock
a close correlation between systolic annular displacement
directly measured by M-mode and that indirectly esti- There are two main causes of obstructive shock:

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Figure 1 Left ventricle function assessment: left ventricular ejection fraction calculated using Biplan Simpson method (A), and
global longitudinal strain based on apical 4-, 2-,and 3-chamber view.

Figure 2 Left ventricular ejection fraction surrogates: mitral annulus plane systolic excursion (MAPSE) (A, B), and Tissue Doppler
peak systolic wave at the mitral lateral annulus (S′ ) (C, D).

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 G. Théry, V. Gascon, V. Fraile et al.

Figure 3 Measurement of the left ventricular outflow tract in parasternal long axis view (A), and velocity time integral (VTO) in
left ventricle outflow tract in 5-chamber apical view using pulsed wave Doppler (B, C).

Pericardial tamponade Pulmonary embolism

Leads to right ventricle collapse and decrease of RV out- TTE can help to establish a prompt diagnosis of acute pul-
put and by consequence LV output. From a subcostal view, monary embolism (PE) and to identify patients with high-risk
we can assess the presence of pericardial effusion, which features. Additionally, when the patient is hemodynamically
compromises the functionality of the heart. In a basic anal- unstable, TTE may be the only immediately available and
ysis of shock, the existence of severe effusion (>2 cm), appropriate imaging investigation. 19
collapse of the cavities in their respective diastoles, dila- Using a basic approach, the cause of the shock towards
tion of the Inferior Vena Cava with absence of respiratory PE when we observe the evidence of hyperechogenic images
variations and in some situations, visualisation on the in the right cavities, in this context, has a high specificity
two-dimensional TTE of ‘‘Swinging heart’’ which is associ- of PE. Additionally, signs of the consequences of acutely
ated to a large pericardial effusion testifies often cardiac increased pulmonary artery/right heart pressures can be
tamponade.17 observed including dilatation of right heart chambers and
Doppler assessment provides unique information regard- more precisely the evolution of an initial abnormal ratio of
ing haemodynamic of pericardial tamponade. the following RV diameter or area to LV diameter or area (Fig. 4, Video 3).
Doppler features are observed during inspiration: in the left Tricuspid regurgitation is frequent in patients with
heart, there will be a reduction in effective filling gradi- intermediate-to-high-risk pulmonary embolism. It allows the
ent (EFG) of the LV (pressure difference between pulmonary estimation of RV systolic pressure and thus of pulmonary
capillaries and left ventricle) due to a reduction in pul- arterial systolic pressure (PAsP) in the absence of pulmonary
monary capillary pressure while left atrium (LA) and LV valve stenosis. PAsP can be estimated from the peak veloc-
diastolic pressures are relatively maintained due to reduced ity of the tricuspid regurgitation (TR) jet (V) according to
transmission of intrathoracic pressure into the heart. There- the simplified Bernoulli equation but may underestimate it
fore, LV filling will be reduced18 and consequently, the when tricuspid regurgitation is very severe (Fig. 4D).
transmittal Doppler early diastolic (E)-wave and in turn LV In the absence of perceptible TR or inadequate alignment
outflow will be reduced. In the right heart, the opposite is of PWD, Pulmonary Regurgitation (PR) from the paraster-
observed; RV filling is increased with increased RV volume nal short-axis view is usable to estimate pulmonary artery
as the septum moves to the left (ventricular interdepen- diastolic and mean pressures (PAdP and PAmP). The mea-
dence), increased tricuspid E-wave and increased RV outflow surement of RVOT VTI can estimate RV output which is
velocity. associated with increased pulmonary embolism-related mor-
In critically ill patients, however, mechanical ventilation, tality when it is low.19 Moreover, a decreased Pulmonary
bronchospasm, significant pleural effusion, respiratory dis-
tress, and arrhythmias make the Doppler findings difficult to
interpret.

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 Medicina Intensiva 48 (2024) 220---230

Figure 4 Indices of right ventricle dilation and/or pulmonary hypertension: parasternal short-axis view at the mid-ventricular
level illustrating measurements of left ventricular diameters for calculation of the eccentricity index (A), and assessment of septal
motion (C), right and left ventricle basal diameter ratio in apical 4-chamber view (B), peak velocity of tricuspid regurgitation (TR
Vmax) obtained in apical 4-chamber view with continuous wave Doppler through tricuspid valve (D).

artery acceleration time and the presence of a ‘‘notch’’ For example, in shock a hyperdynamic, after optimal
on the RVOT VTI are valid signs of pulmonary hyperten- fluid resuscitation, usually a clue to the presence of marked
sion (60/60 sign: right ventricular ejection acceleration time peripheral vasodilatation.
<60 ms with peak systolic gradient of tricuspid regurgitation Furthermore, the absence of elevation in LV filling pres-
<60 mmHg; a mid-systolic notch).20,21 sure has been reported as a specific characteristic of this
hemodynamic profile, not only when evaluated by the E/e’
but also when measured in the past using a pulmonary artery
catheter.23,24 It was suggested to be related to an increase
Septic shock in LV compliance due to sepsis.25

Sepsis is defined as a life-threatening organ dysfunction

caused by a dysregulated host response to infection.22 The Hypovolemia
recognition of sepsis can be challenging. It requires an accu- It is constant during sepsis and no need for a diag-
rate history taking, physical examination and interpretation nostic tool at the early phase. Nevertheless, after the
of laboratory data. Three pathophysiological mechanisms initial phase, optimization of fluid therapy using dynamic
can be involved in septic shock: hypovolemia, vasoplegia, parameters is mandatory as suggested by the most recent
and cardiac dysfunction. recommendations.22 This will be detailed below.

Sepsis-related cardiomyopathy
Vasoplegia Severe sepsis is frequently associated with cardiopulmonary
A major pathological contribution to shock in sepsis is dysfunction driven by a cascade of cellular and molecular
peripheral vasoplegia and although this is not measurable processes.26 Myocardial dysfunction occurs frequently, early
with echo, the cardiac findings can be taken into account and involves both ventricles.26,27 Parker et al. were the first
when estimating it. to describe LV hypokinesis in septic shock.23

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 G. Théry, V. Gascon, V. Fraile et al.

They reported that survivors manifested severely ties (RWMA) evolution after coronary revascularization. The
depressed LVEF but that adequate LV stroke output was quantification of global and regional myocardial function, as
maintained as a result of acute LV dilation.28 LVEF might not the Strain, Strain Rate and Speckle Tracking can be used also
be a reliable index of LV systolic function in patients with to follow the RWMA after revascularization.
early septic shock, as this is a state characterized by low sys-
temic vascular resistance that unloads the LV.24 Therefore,
normal or supra normal EF in early sepsis might lead clini-
cians to make the wrong inference about cardiac reserve. Cardiac output (CO)
Speckle tracking echocardiography (STE) is a relatively Assessment of CO is important not only to identify the
novel and sensitive method for assessing ventricular function type of shock in particular cardiogenic shock together with
and may unmask myocardial dysfunction not appreciated other parameters, but also to evaluate the response to
with conventional echocardiography.29 STE may unmask medical and surgical interventions, such as administra-
systolic dysfunction not seen with conventional echocardio- tion of inotropic agents for the treatment of right and
graphy. RV dysfunction unmasked by STE, especially when left heart failure. Indeed, CO is SV multiplied by heart
severe, was associated with high mortality in patients with rate. The measurement of SV is usually made at the
severe sepsis or septic shock. LVOT.
The VTI, SV or CO can be serially measured noninvasively
Hypovolemic shock before and after medical therapies in order to evaluate their
effects, all the three variables are interchangeable each can
Using a basic ultrasound, we can suspect the presence of be used as a sole parameter.
severe hypovolemia. In addition, it is to be noticed that Veno-Arterial Extra-
Some of the parameters assessed during basic echocar- corporeal Membrane Oxygenation (VA-ECMO) is now taking
diography although not very sensitive, together with the part in cardiogenic shock resuscitation and treatment, its
medical history and clinical examination may raise suspi- management may be guided by TTE.32
cion of hypovolemia as a main cause of shock. The most First, adequate venous canula position in right atrium
frequently assessed by intensivists are: kissing walls of the can be assessed by TTE. Secondly, CO is often diminished
LV which is a collapse of the walls of the LV during systole after VA-ECMO implantation because of competitive car-
and the reduced left ventricular end-diastolic area (Video diac and assistance flows this may be easily detected at
4). the bedside by TTE. Furthermore, a direct visualisation by
Although the administration of fluid is the first treatment two dimensional TTE of the aortic valve may show that it
this therapeutic option needs to be optimized later during remains closed indicating an urgent LV unloading. The indi-
the course of shock as it may pose two essential problems: cation of the maintenance of VA-ECMO, the need of further
the increase in cardiac output induced by a bolus of fluid concomitant mechanical circulatory support devices or the
after the initial phase is inconstant,30 and the deleterious detection of complications such as pericardial effusion or
effects of fluid overload are now clearly demonstrated.31 intracavitary/valves thrombosis need to be daily reassessed
This is why many tests and indices have been developed by repeating TTE.
to detect preload dependence and predict fluid responsive- Finally, TTE is now a corner stone of the VA-ECMO weaning
ness. This part will be developed later in the management protocol, by assessing LVEF, LVOT VTI, S′ and RV function
part. under VA-ECMO and during weaning protocol.33
The main limitations of echocardiographic measurements
of SV, CO, and VTI in the LVOT are that all of them, require
How to manage shock patients? accurate alignment with the LVOT, and consistent sampling
that should occur just beneath the aortic valve. The use
Cardiogenic shock of an LVOT diameter adds a second potentially more sig-
nificant error measurement. It is now recommended to use
By directly visualizing cardiac cavities and structures, TTE is the stroke distance (i.e., LVOT and RVOT VTI) alone for
an easy and reliable tool for the evaluation and the follow up serial measurements after therapeutic interventions, with
of cardiac function, adjusting fluid balance, optimizing vaso- the assumption that LVOT and RVOT diameters remain cons-
pressors and indicating monitoring or weaning of mechanical tant.
cardiac support (MCS) therapeutics. In clinical practice, only LVOT VTI is measured, consid-
ering LVOT to be constant and heart rate to be in stable
Cardiac function range. The increase in LVOT VTI reflects CO improvement
LVEF improvement after revascularization for acute myocar- and myocardial contractile reserve.
dial infarction or inotropic support introduction for In the absence of intracardiac shunt, LV output is equal
cardiogenic shock for instance should be followed up. How- to RV output. The latter can be estimated by measur-
ever, this need to be interpreted within other hemodynamic ing RVOT diameter from the parasternal short-axis view
parameters in case of shock for an overall assessment of and RVOT VTI. Like LVOT VTI, RVOT VTI is obtained by
tissue perfusion. Other parameters can be also reassessed placing PWD with a correct alignment in the RVOT. Inad-
after revascularisation as the MAPSE and the S′ , in order to equacy between LV output and RV output can be the sign
evaluate the efficacy of the revascularisation. of an atrial septal defect or a ventricular septal defect.
Additionally, and in the case of acute coronary disease, In these cases, and without major pulmonary hypertension,
it is important to follow up regional wall motion abnormali- left to right shunts lead to an increased RV output and a

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decreased LV output and by consequence haemodynamic Septic shock

instability.
It has to be noticed that RV output can be measured Three pathophysiological mechanisms can be involved in
through the modified subcostal window, enhancing monitor- septic shock: vasoplegia, hypovolemia, and cardiac dysfunc-
ing, especially in mechanically ventilated patients.34 tion. Obviously, optimal management of septic shock needs
to be readjusted in function of the predominant dysfunction,
this may be guided by echocardiography and fluid respon-
LV filling pressures
siveness indicators.
Although invasive methods are considered as the ‘‘gold
standard’’ for measuring intracardiac filling pressures,
echocardiography is routinely used as a non-invasive Preload responsiveness
alternative.35 This has been achieved using an algorithm Although during septic shock, patients frequently present
based on LVEF status (altered or preserved), Doppler-derived with hypovolemia, beyond the very initial phase, an increase
parameters from mitral inflow velocities (E- and A-peak in CO after fluid administration is observed in only 50% of the
wave velocities, E/A ratio, E velocity DT) and tissue Doppler- patients.40 Moreover, fluid overload is now widely admitted
derived mitral annular (e’-peak wave and E/e’ ratio). to be an independent predictor of mortality.41 In this regard,
It has to be underlined that LV filling pressures should recent guidelines recommend the use of dynamic parame-
not be considered a part of the clinical context, ventilation ters for the assessment of fluid responsiveness rather than
mode and other echocardiographic data such as LVEF. static parameters.22 Preload responsiveness can be assessed
Frequently, during cardiogenic shock, filling pressures are by measuring the response of VTI LVOT through dynamic tests
high, the improvement of cardiac function is often associ- as passive leg raising or to a combination of end-expiratory
ated to their decrease. and end-inspiratory occlusions in patients under mechanical
ventilation.42
Adequate TTE haemodynamic evaluation should be made
Obstructive shock
regarding ventilation status (spontaneous breathing or
mechanical ventilation) and cardiac rhythm (sinusal or not).
There are two main causes of obstructive shock:
Increase in LVOT VTI of >12.5% during passive leg raising
predicted the increases in SV in response to intravenous flu-
Pericardial tamponade ids with spontaneously breathing activity.43 In mechanically
Leads to right ventricle collapse and decrease of RV output ventilated patients, recruitment manoeuvres can change
and by consequence LV output. Acute cardiac tamponade cardiac loading conditions and decrease cardiac preload. For
with hemodynamic compromise requires urgent pericardio- instance, the decrease in stroke volume during a recruit-
centesis or surgical removal of pericardial fluid.36 ment manoeuvre predicted fluid bolus responsiveness in
As pericardial tamponade treatment is mostly procedural surgical patients during anaesthesia.44,45 Consecutive end-
rather than medical, echocardiography identifies the opti- inspiratory occlusion and end-expiratory occlusion change
mal site for pericardiocentesis by visualizing the location VTI ≥ 13% in total predicted fluid responsiveness more accu-
and distribution of pericardial effusion. The para-apical site rately with less inter-observer variability.42
is the most common entry site for pericardiocentesis and Among various indices, the assessment of respiratory
procedural rate is around 95%.17 Some may also recommend variation of the diameter of the inferior vena cava (IVC
injecting agitated saline solution through the pericardiocen- min and IVC max) has received growing interest since it
tesis needle in the pericardial effusion to avoid the puncture can be easily using two dimensional echocardiography in
of the ventricular cavity.37,38 most critically-ill patients.46 However, there are some main
concerns for the use of this parameter to predict preload
responsiveness in critically ill patients.
Pulmonary embolism Firstly, it has been demonstrated that neither the
TTE can help to establish a prompt diagnosis of acute pul- IVC diameter nor IVC variability accurately predict fluid
monary embolism and to identify patients with high-risk responsiveness in spontaneously breathing in critically
features. Additionally, when the patient is hemodynamically ill patients.47 Secondly, even in mechanically ventilated
unstable, TTE may be the only immediately available and patients (one of the largest published series of ventilated
appropriate imaging investigation.19,39 patients) assessed using advanced critical care echocardiog-
Indeed, echocardiography plays a determinant role in raphy for any type of acute circulatory failure. IVC variability
making therapeutic decisions in shock patients as it may had a low diagnostic accuracy to predict preload responsive-
help to rule out the diagnosis of severe pulmonary embolism ness with AUC of 0.608.48
in the absence of acute core pumonale. The main find-
ings in acute pulmonary embolism are the consequences of
acutely increased pulmonary artery/right heart pressures, Septic cardiomyopathy
these parameters simply assessed are used also to evaluate Initial assessment of MAPSE, speckle tracking and global lon-
the efficacy of the treatment in particular thrombolysis. gitudinal strain of LV and LVEF in 2D-mode may play a role
Rapid decrease in PAsP reflects adequate dissolution of in septic cardiomyopathy prognostication.29 Feng and al.
the thrombus. Finally, the improvement of the RV output reported in their analysis of MIMIC-III database that early
and the RV function can be helpful to monitor the evolution use of TTE in septic shock had a significant benefit in terms
of the thrombus. of 28-day mortality, with more fluids, administered during

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the first day, greater use of dobutamine and a trend to be statement from the 2020 Critical Care Clinical Trial-
more quickly weaned from vasopressors.49 ists Workshop. Lancet Respir Med. 2021;9:1192---202,
Furthermore, and as mentioned above during cardiogenic http://dx.doi.org/10.1016/S2213-2600(21)00172-7 (10
shock: LVOT VTI and LVEF may be used to evaluate the effec- (October)).
4. Voigt J-U, Pedrizzetti G, Lysyansky P, Marwick TH, Houle H,
tiveness of inotropes in case of cardiac dysfunction.
Baumann R, et al. Definitions for a common standard for
2D speckle tracking echocardiography: consensus document of
Hypovolemic shock the EACVI/ASE/Industry Task Force to standardize deformation
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treatments.
9. Wandt B, Bojö L, Tolagen K, Wranne B. Echocar-
It is a non-invasive tool, easy to initiate and it can be diographic assessment of ejection fraction in left
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initial basic study can lead to the initiation of treatment, http://dx.doi.org/10.1136/hrt.82.2.192.
with a more advanced study subsequently providing incre- 10. Bolognesi R, Tsialtas D, Barilli AL, Manca C, Zeppellini
mental and vital additional information. R, Javernaro A, et al. Detection of early abnormalities
of left ventricular function by hemodynamic, echo-tissue
Doppler imaging, and mitral Doppler flow techniques in
Funding patients with coronary artery disease and normal ejec-
tion fraction. J Am Soc Echocardiogr. 2001;14(8):764---72,
None. http://dx.doi.org/10.1067/mje.2001.113234. August.
11. Ballo P, Bocelli A, Motto A, Mondillo S. Concordance between
M-mode, pulsed Tissue Doppler, and colour Tissue Doppler in
Conflict of interest the assessment of mitral annulus systolic excursion in normal
subjects. Eur J Echocardiogr. 2008;9(6 (November)):748---53,
None. http://dx.doi.org/10.1093/ejechocard/jen130.
12. Mondillo S, Galderisi M, Ballo P, Marino PN, Study Group
of Echocardiography of the Italian Society of Cardiology.
Appendix A. Supplementary data Left ventricular systolic longitudinal function: compari-
son among simple M-mode, pulsed, and M-mode color
Supplementary data associated with this article can be tissue Doppler of mitral annulus in healthy individuals.
found, in the online version, at https://doi.org/10.1016/j. J Am Soc Echocardiogr. 2006;19(9 (September)):1085---91,
medine.2023.10.017. http://dx.doi.org/10.1016/j.echo.2006.04.005.
13. Wenzelburger FWG, Tan YT, Choudhary FJ, Lee ESP,
Leyva F, Sanderson JE. Mitral annular plane sys-
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