Optimal right heart filling pressure in acute respiratory distress syndrome determined by strain echocardiography

Right ventricular ( RV ) systolic dysfunction is common in acute respiratory distress syndrome ( ARDS ). While preload optimization is crucial in its management, dynamic fluid responsiveness indices lack reliability, and there is no consensus on target central venous pressure ( CVP ). We analyzed the utility of RV free wall longitudinal strain ( RVFWS ) in the estimation of optimal RV filling pressure in ARDS . Methods A retrospective cross‐sectional analysis of clinical data and echocardiograms of patients with ARDS was performed. Tricuspid annular plane systolic excursion ( TAPSE ), tricuspid peak systolic velocity (Sʹ), RV fractional area change ( RVFAC ), RVFWS , CVP , systolic pulmonary artery pressure ( SPAP ), and left ventricular ejection fraction ( LVEF ) were measured. Results Fifty‐one patients with moderate‐severe ARDS were included. There were inverse correlations between CVP and TAPSE , Sʹ, RVFAC , RVFWS , and LVEF . The most significant was with RVFWS ( r :.74, R 2 :.55, P :.00001). Direct correlations with creatinine and lactate were noted. Receiver operating characteristic analysis showed that RVFWS −21% (normal reference value) was associated with CVP : 13 mm Hg ( AUC : 0.92, 95% CI : 0.83–1.00). Regression model analysis of CVP , and RVFWS interactions established an RVFWS range from −18% to −24%. RVFWS −24% corresponded to CVP : 11 mm Hg and RVFWS −18% to CVP : 15 mm Hg. Beyond a CVP of 15 mm Hg, biventricular systolic dysfunction rapidly ensues. Conclusions Our data are the first to show that an RV filling pressure of 13±2 mm Hg—as by CVP —correlates with optimal RV mechanics as evaluated by strain echocardiography in patients with moderate‐severe ARDS .