Global Longitudinal Strain by Speckle Tracking Echocardiography and Mortality in Septic Patients: an updated systematic review and meta-analysis with trial sequential analysis

Abstract Background : Septic cardiomyopathy is associated with poor outcomes but its definition remains unclear. In a previous meta-analysis, left ventricular (LV) longitudinal strain (LS) showed significant prognostic value in septic patients, but findings were not robust due to limited number of studies, differences in effect size and no adjustment for confounders. Methods : We conducted an updated systematic review (PubMed and Scopus up to 14.02.2023) and meta-analysis to investigate the association between LS and survival in septic patients. We included studies reporting global (from three apical views) or regional LS (one or two apical windows). A secondary analysis evaluated the association between LV ejection fraction (EF) and survival using data from the selected studies. Results: We included fourteen studies (1678 patients, survival 69.6%) and demonstrated an association between better performance (more negative LS) and survival with mean difference (MD):-1.45%;[-2.10,-0.80] (p<0.0001;I 2 =42%). No subgroup differences were found stratifying studies according to number of views used to calculate LS (p=0.31;I 2 =16%), severity of sepsis (p=0.42;I 2 =0%), and sepsis criteria (p=0.59;I 2 =0%). Trial sequential analysis and sensitivity analyses confirmed the primary findings. Grade of evidence was low. In the included studies, thirteen reported LVEF and we found an association between higher LVEF and survival (MD:2.44%;[0.44,4.45]; p=0.02;I 2 =42%). Conclusions : We confirmed that more negative LS values are associated with higher survival in septic patients. The clinical relevance of this difference and whether the use of LS may improve understanding of septic cardiomyopathy and prognostication deserve further investigation. The association found between LVEF and survival is of unlikely clinical meaning.