Menoufia Medical Journal

ORIGINAL ARTICLE
Year
: 2016  |  Volume : 29  |  Issue : 2  |  Page : 406--411

The effect of hemodialysis-induced preload changes on the left ventricular function: a speckle-tracking echocardiographic study


Said S Ibrahim, Mahmoud A Koura, Ahmed A Emara, Mahmoud Kamel, Wagdy A.Abd El-Wahed 
 Department of Cardiology and Internal Medicine, Faculty of Medicine, Dialysis Unit, Menoufia University, Menoufia, Egypt

Correspondence Address:
Wagdy A.Abd El-Wahed
Talkha, Al-Dakahlia, 35511
Egypt

Abstract

Objective: This study aim to evaluate the effect of hemodialysis (HD)-induced preload changes on the left ventricular (LV) function in patients with chronic renal failure using LV imaging strain. Background: In dialysis patients, both cardiovascular and noncardiovascular mortality are significantly increased as compared with the general population. In particular, cardiovascular mortality contributes to 40% of all-cause mortality in patients on HD. Patients and methods: Twenty-six participants were enrolled in this study on maintenance HD three times per week for 3 h; they included 13 patients with hypertension, six with diabetes mellitus, and eight with ECG criteria of left ventricular hypertrophy. All participants underwent standard two-dimensional echocardiography and myocardial strain imaging. Results: There was a significant reduction of the stroke volume, the LV internal diameter in diastole, the LV internal diameter in systole, the LV posterior wall thickness in systole, the end-diastolic volume, the end-systolic volume, E wave, the E/A ratio, and finally the pulmonary artery systolic pressure after HD set (P < 0.05). In contrast, there were no significant changes in the interventricular septum in either diastole or systole, the LV posterior wall thickness in diastole, fractional shortening, A wave, the ejection fraction or left atrial dimensions (P > 0.05). Also, there was a significant reduction in the global longitudinal peak systolic strain in the long-axis view (GLPS_LAX) (−19.32 ± 4.30 to −16.58 ± 3.87), the global longitudinal peak systolic strain in the apical four-chamber view (GLPS_A4C) (−17.73 ± 4.76 to −15.98 ± 3.70), the global longitudinal peak systolic strain in the apical two-chamber view (GLPS_A2C) (−18.73 ± 4.22 to −16.79 ± 4.25), and the global longitudinal peak systolic strain average (GLPS_AVG) (−18.59 ± 3.96 to −16.45 ± 3.31) after HD set (P < 0.05). Conclusion: The preload reduction resulting from HD is associated with a reduction of the LV systolic function when assessed by the peak systolic longitudinal strain. This indicates preload dependence of the LV systolic function.



How to cite this article:
Ibrahim SS, Koura MA, Emara AA, Kamel M, El-Wahed WA. The effect of hemodialysis-induced preload changes on the left ventricular function: a speckle-tracking echocardiographic study.Menoufia Med J 2016;29:406-411


How to cite this URL:
Ibrahim SS, Koura MA, Emara AA, Kamel M, El-Wahed WA. The effect of hemodialysis-induced preload changes on the left ventricular function: a speckle-tracking echocardiographic study. Menoufia Med J [serial online] 2016 [cited 2019 Dec 9 ];29:406-411
Available from: http://www.mmj.eg.net/text.asp?2016/29/2/406/192409


Full Text



 Introduction



In dialysis patients, both cardiovascular and noncardiovascular mortality are significantly increased as compared with the general population [1]; cardiovascular mortality, in particular, contributes to 40% of all-cause mortality in these patients, mainly due to sudden cardiac death [2].

Several parameters, such as left ventricular hypertrophy (LVH) and left ventricular (LV) systolic dysfunction, have been identified as independent predictors of the cardiovascular outcome in dialysis patients [3].

Significant diastolic heart failure as assessed by tissue Doppler imaging (TDI) has also demonstrated a significant incremental prognostic value for all causes of mortality and cardiovascular death [4]. Diastolic heart failure in dialysis patients often exists in the absence of significant systolic heart failure [5],[6].

Two-dimensional echocardiography underestimates end-diastolic and end-systolic volume, whereas it overestimates the ejection fraction (EF) [7].

Speckle-tracking echocardiography is a new noninvasive ultrasound imaging technique that allows an objective and quantitative evaluation of global and regional myocardial function independent of the angle of insonation and of cardiac translational movements [8]; the semiautomated nature of speckle-tracking echocardiography also guarantees good intraobserver and interobserver reproducibility [9].

In addition, speckle-tracking echocardiography enables the evaluation of LV rotational and torsional dynamics, aspects of LV function that were analyzed exclusively by MRI before the introduction of this technique [8].

 Patients and Methods



The study was conducted on 26 patients with chronic renal failure on maintenance regular hemodialysis (MHD) three times per week in the Dialysis Unit of Menoufia University Hospital. Patients were enrolled in the study after their informed consent and approval of the Ethics Committee of Menoufia University Hospital were obtained.

There was 12 (46.2%) male and 14 (53.8%) female patients, with a mean age of 45.46 ± 16.65 years; there were 13 patients with hypertension and six with diabetes mellitus (DM); their weight was 71.27 ± 14.03 kg with systolic blood pressure of 142.69 ± 17.10 mmHg and diastolic blood pressure of 90.38 ± 13.11 mmHg. There were eight patients with ECG criteria of LVH.

Patients with a history of coronary artery disease, congestive heart failure (CHF), cardiomyopathies, pericardial disease, significant arrhythmias (other than sinus rhythm), significant valvular heart disease, and poor image quality on echocardiography were excluded from the study.

Methods

All patients were subjected to full history taking, focusing on a clinical history of hypertension, DM, dyslipidemia, and smoking, thorough physical examination, measurement of the blood pressure immediately before and immediately after the dialysis, 12-lead resting ECG, measurement of the body weight immediately before and immediately after the dialysis, estimation of the amount of volume loss per se t, standard transthoracic echocardiogram immediately before and immediately after the dialysis, and finally LV longitudinal strain immediately before and immediately after the dialysis.

Conventional echocardiography

Echocardiographic examinations were performed in the left lateral decubitus to obtain parasternal long-axis and short-axis, apical two-chamber and four-chamber views. GE Vivid 9 Norton Norway equipped with a multifrequency 1.7–4-MHz MS5 transducer was utilized. LV end-diastolic and end-systolic diameters, septum and posterior wall thicknesses, the EF%, and the LA diameter and volume were measured in accordance with the recommendations of the American Society of Echocardiography [0]. Color flow mapping and continuous-wave Doppler were used to estimate pulmonary artery pressure from the tricuspid regurge velocity using the Bernoulli equation. Peak early (E) and late (A) transmitral velocities were measured.

Speckle-tracking echocardiography

The software then generated a region of interest (ROI) including the entire myocardial thickness. The ROI was manually adjusted to achieve a satisfactory image. Myocardial speckles were tracked frame by frame and moving images displaying the tracking were generated.

Careful visual inspection of the moving image was performed to determine the adequacy of the tracking. If the tracking was not accurate, readjustment of the ROI or selection of a new ROI was performed.

The software divided the LV myocardium into six segments to generate segmental and global longitudinal strain. As the myocardium usually shortens in the longitudinal direction during systole, the longitudinal strain was displayed below the baseline ([Figure 1]).{Figure 1}

The apical long-axis image (i.e. three-chamber view) was the first image to be analyzed. In this view, the movement of aortic valve leaflets helps in timing the aortic valve closure, which is essential for the software to be able to perform the deformation analysis. The same process was then repeated with the apical four-chamber and two-chamber views. The strain values for all the segments were recorded and averaged to obtain the global longitudinal strain. The ultrasound system also provided a bull's eye display of the regional and global longitudinal strain ([Figure 2]).{Figure 2}

Statistical analysis

Using statistical package for the social sciences (SPSS, version 16; SPSS Inc., Chicago, Illinois, USA) software, data from patients and controls were collected and subjected to statistical analysis. Comparison between categorical values was performed using the Student t-test. The level of significance was 95%. Hence, P value less than 0.05 was considered as a significant result, and values less than 0.001 were considered as a highly significant result [1].

 Results



Twenty-six patients, who were on MHD three times per week for 3 h per se ssion, were enrolled in this study; their mean age was 45.46 ± 16.65 years; 13 patients had hypertension, six had DM, and eight had ECG criteria of LVH ([Table 1] and [Table 2]).{Table 1}{Table 2}

[Table 3] shows that there was a significant reduction of the stroke volume, the LV internal diameter in diastole, the LV internal diameter in systole, the LV posterior wall thickness in systole, the end-diastolic volume, the end-systolic volume, E wave, the E/A ratio, and finally the pulmonary artery systolic pressure after hemodialysis (HD) set (P < 0.05). In contrast, there were no significant changes in the interventricular septum thickness in both diastole and systole, the LV posterior wall thickness in diastole, fractional shortening, A wave, the EF, or left atrial dimensions (P > 0.05). [Table 4] shows that there was a significant reduction of the global longitudinal peak systolic strain in the long-axis view (GLPS_LAX), the global longitudinal peak systolic strain in the apical four-chamber view (GLPS_A4C), the global longitudinal peak systolic strain in the apical two-chamber view (GLPS_A2C), and the global longitudinal peak systolic strain average (GLPS_AVG) after HD set (P < 0.05).{Table 3}{Table 4}

 Discussion



Cardiovascular disease (CVD) is the most common complication and a chief cause of death in patients with end-stage renal disease (ESRD) accounting for 45–50% of the causes of death in ESRD patients.

In ESRD patients, mortality due to CVD is 10–30 times higher than in the general population. Eighty percent of the patients on MHD had cardiovascular complications. In Chinese patients, the prevalence of CVD in young MHD patients is as high as 63.8%. This is likely due to ventricular hypertrophy and nontraditional risk factors, such as chronic volume overload, anemia, inflammation, oxidant stress, homocysteine, and other aspects of the uremic milieu [2].

The incidence of CHF in the Medicare population with normal kidney function is 5.6% per patient-year; in patients with chronic kidney disease stages 3–5, it is 17.6% per patient-year. The median overall survival of dialysis patients with CHF is 36 months compared with 62 months in those without CHF [3].

In our study, we assessed LV systolic function in 26 patients with chronic renal failure on MHD three times per week before and immediately after the HD set by conventional echocardiography and LV two-dimensional longitudinal strain imaging.

Regarding weight and blood pressure, there was a significant reduction in the weight, and systolic and diastolic blood pressure of the patients after the HD set.

These results are concordant with results of Tansel et al. [4], who evaluated acute effects of HD on left and right ventricular function in 30 patients on chronic HD program (mean age 45.15 years).

In the present study, there was a significant decrease in left ventricular diastolic and systolic internal dimensions (LVIDs and LVIDd) and left ventricular diastolic and systolic volumes (EDV and ESV) after the HD set. These results are similar to that of Bruzgielewicz et al. [5], who studied systolic and diastolic LV function in 25 patients with ESRD on MHD using M-mode, two-dimensional, and Doppler echocardiography performed before and after HD, and reported that LVIDd, LVIDs, EDV, and ESV were reduced after the HD set, which was explained by the acute reduction of the preload volume occurring during HD.

Again, we found that the diastolic function of the LV is significantly altered after the HD set, which was reflected in a significant reduction of the peak E wave and the E/A ratio. These results are similar to that of Abdenasser et al. [6], who studied 17 chronically uremic patients (age 31 ± 10 years) without overt heart disease and who underwent conventional two-dimensional and Doppler echocardiography before and after the HD set and concluded preload dependence of the peak E and the E/A ratio. In this study, there were five patients with evidence of LV impaired relaxation at baseline (before HD set), with an E/A ratio of less than 1. Three separate additional patients had an E/A ratio of less than 1 after HD. All patients with E/A less than 1 before HD had the same pattern after HD. Pre-HD intravascular volume expansion leads to a high preload, which may mask impairment of early diastolic filling. HD reduces the preload acutely, resulting in decreased peak early filling velocities that may unmask delayed relaxation not apparent before HD. In this study, HD unmasked delayed relaxation in three patients whose mitral inflow pattern was pseudonormal.

In contrast Galetta et al. [7] evaluated the effect of a single HD session on LV systolic and diastolic function in 20 uremic patients on MHD, free from clinically overt cardiac dysfunction who underwent echocardiography with conventional and pulsed TDI 30 min before and 30 min after a HD session. They concluded that a single HD session is associated with acute deterioration of diastolic function as shown by standard sonography examination. These reversible changes could be considered as a cardiac stunning that seems to be related to the ultrafiltration rate and then to the interdialysis weight gain. These findings suggest that a low ultrafiltration volume and/or limited interdialytic weight gain are cardioprotective measures in HD patients.

Again, we found that there was no significant change in the left ventricular ejection fraction before and after the HD set. These results are similar to those of Hayashi et al. [8], who studied 13 clinically stable HD patients by conventional echocardiography, and TDI images were recorded before and after a single HD session.

It has been reported that the influence of altered conditions of loading on the measurements obtained is an important limitation for the assessment of LV systolic and diastolic function through routine indices from conventional echocardiography such as the cardiac output, fractional shortening, the EF%, and Doppler filling parameters; an increase in blood pressure may cause a reduction of EF% despite relatively normal contractility, which could be interpreted as a worsening of the myocardial function. Conversely, an augmented preload may increase the EF, which could be considered as an improvement in the myocardial contractility [9].

In addition, the nonreliability of EF as a good index of myocardial function in patients with LVH, the subjective visual interpretation, the semiquantitative evaluation of regional systolic LV contraction, and the high interobserver variability [0] complicate the evaluation of cardiac function by conventional echocardiography in ESRD patients.

A study by Alicja et al. [1] included 56 patients who underwent conventional and tissue Doppler echocardiography before and after 4-h HD. Pre-HD echocardiography indices revealed LV systolic dysfunction in 12.5% of their patients, and after the HD session, LV systolic dysfunction was shown in 10.7% patients. This was explained by the fact that HD treatment was associated with fluid removal and, as a consequence, a decrease in the LV filling pressure or the preload, which, at least theoretically, could result in an improvement of the ventricular function, if the heart is operating at or close to the maximum of the Frank–Starling curve, as in the presence of a failing heart [2]; other contributing factors include a reduction of the after load, resolving of interstitial myocardial edema, pH adjustment, and removal of cardiac inhibitory toxins.

In our study, there were significant reductions in GLPS_LAX, GLPS_A4C, GLPS_A2C, and GLPS_AVG after the HD set. Our results are consistent with Jin-Oh et al. [3], who studied 21 patients with EF% 62 ± 9 on a regular schedule of HD 3–4 sessions/week. Echocardiography was performed immediately before and after the HD set with global and segmental peak systolic longitudinal strain: they obtained two-dimensional gray-scale harmonic images using a 3.5-MHz transducer in the apical long-axis, the four-chamber, and the two-chamber views; their results showed that a significant reduction of GLPS_LAX and GLPS_A2C after the HD set, whereas the EF% did not change significantly. These results were explained by the fact that a heart with preserved systolic function obeys the Frank–Starling law [4] – that is, a reduction in the end-diastolic volume results in decreased inotropism.

Ligia et al. [5] studied 20 clinically stable patients with ESRD on HD for more than 4 months. All had a transthoracic echocardiogram immediately before and after HD, and pulsed TDI was used to record septal and lateral mitral annular velocities. Longitudinal systolic (Sm), early diastolic (Em), and late diastolic (Am) myocardial velocities and strain were determined by color TDI and also by speckle-tracking imaging (STI), using apical views. The ratio between the rapid filling wave E and the mitral annulus early diastolic filling velocity (E/Em) and the Am/Em ratio were calculated using spectral Doppler, pulsed TDI, color TDI, and STI. Their results showed that differences in the preload did not influence the systolic performance regardless of the evaluation method (all patients had an EF of over 44% before HD). Peak systolic myocardial longitudinal velocities obtained by pulsed TDI, color TDI, and STI did not change after HD, except the lateral Sm by pulsed TDI. The mean longitudinal and global strain remained unchanged after HD. This was explained by a reduction in inotropism secondary to a lower end-diastolic volume, which may have been canceled out by the increased inotropism arising from the removal of cardiotoxic metabolites [5].

 Conclusion



Preload reduction resulting from HD is associated with a reduction of the LV systolic function when assessed by the peak systolic longitudinal strain. This indicates preload dependence of the LV systolic function.

Conflicts of interest

There are no conflicts of interest.

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