Authors: Emre Özlüer, Asst. Prof.
Editor: Betül Gülalp, Prof.
Date: 1 July 2018
DOI: 10.1016/j.resuscitation.2015.08.008

Appreciate To Dear Authors For Their Contribution In This Issue With Their Manuscript


In this research, the authors investigated the relationship between right ventricular dysfunction (RVD) and survival along with neurological outcome in postresuscitative period of cardiac arrest patients. The study was designed as a retrospective cohort study in third level hospitals which are registered to Penn Alliance for Therapeutic Hypotermia (PATH) Registry. Cases registered between 2000 and 2012 were investigated.

Two hundred and ninety-one patients whom achieved return of spontaneous circulation (ROSC) were enrolled. In initial echocardiogram following ROSC, left ventricular dysfunction (LVD) was described as ejection fraction (EF) of  <50%. Right ventricle dimensions were subjectively categorized as normal, mild, moderate and severe dilation by a Level-III Board Certified echocardiography operator. Each category was assigned to a value: normal (0 point), mild dilation (1 point), moderate dilation (2 points), severe dilation (3 points). The level of right ventricular systolic function was also categorized by the same operator as normal, mild depression, moderate depression and severe depression while assigned to a value of 0,1,2,3 points respectively. All these values obtained were combined and a composite right ventricular dysfunction score (RVDS) was acquired between 0 to 6. By this means, patients were divided into three seperate groups (Table 1).

Group I

Normal right ventricular functions


Group II

Mild or moderate right ventricular dysfunction


Group III

Severe right ventricular dysfunction


Table 1: Categorization of patients according to composite RVDS


Similarly, neurologic outcome was assessed with cerebral performance score (CPC) calculated at disposition. Accordingly, a score of 1 to 2 of CPC was associated with poor and a score of 3 to 5 was associated with good neurologic outcome.

Statistical analysis provided the investigation of the relationship between causes of cardiac arrest and RVD along with the relationship between predictive variables and both neurologic and cardiac outcome. Left ventricular dysfunction, targeted temperature management, doses of epinephrine, duration of cardiac arrest and initial cardiac rhythm were described as determining variables.

Out of 291 patients, 179 (63%) had LVD, 173 (59%) had RVD and 124 (44%) had biventricular dysfunction. There was no significant difference regarding survival between LVD patients who were disposed and patients with normal LV functions (51% to 52%, p=0,91). This was similar in terms of good neurologic outcome (CPC 1-2) (43% to  42%, p=0,88). Multivariant logistic regression analysis revealed that RVD represent a predictive value for poor neurologic outcome (Group II/RVDS 1-4: OR 0,33, CI0,17-0,65, p=0,001; Group III/RVDS 5-6: OR 0,11, CI 0,02-0,50, p=0,005) and survival (Group II/RVDS 1-4: OR 0,51, CI 0,26-0,99, p<0,05; Group III/RVDS 5-6: OR 0,19, CI 0,06-0,65, p=0,008) independent of LV function. Furthermore, it has been postulated that there is a constant relationship between RVD and poor neurologic outcome and mortality.

The median time from cardiac arrest to index echocardiogram with LV dysfunction was 600 min. Besides, there was not any  significant difference in median time in any groups (p = 0.438).

However, there are numerous limitations in the study. Utilization of semi-quantitative modalities such as RVD rather than quantitative measurements like tricuspid annular plane systolic tissue excursion (TAPSE), RV fractional area change (FAC), tricuspid annular plane systolic tissue velocities, RV myocardial performance index, RV free wall tension and 3-D volumetric measurements leads to a decrese in accuracy. Also, it is not stated how many of these patients were in-hospital cardiac arrest victims.

In my opinion, despite the fact that there were no significant difference regarding median index echocardiography time between in patient groups, this period of 600 minutes can not be ignored. Also, it is not clear whether patients had inotrope agent infusions.

Another limitation is the lack of intra- and inter-rater reliabilities because it is also not clear how many operators conducted echocardiograms. These limitations jeopardize the reliability and the efficacy of study results, but I think this study might lead to better designed studies in the future. 


Emre Özlüer, Asst. Prof.

Betül Gülalp, Prof.

EMATUS web coordinator. Anyone...Behind the passion and heart...


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