R E S U S C I T A T I O N 194 (2024) 110097

Available online at ScienceDirect

Resuscitation
journal homepage: www.elsevier.com/locate/resuscitation

Letter to the Editor

A visualization of ejection fraction change after
adjusting the area of maximal compression

To the Editor,

Cardiopulmonary resuscitation (CPR) is a critical intervention
employed to restore circulation and oxygenation in individuals expe-
riencing cardiac arrest. Survival and neurological outcomes in post-
CPR patients are heavily influenced by the effectiveness of CPR
and the underlying cardiac function.1 To enhance our understanding
of the hemodynamic consequences of CPR and its impact on cardiac
function, speckle tracking echocardiography (STE) has emerged as
a valuable imaging modality.
STE is an advanced echocardiographic technique that provides
quantitative assessments of myocardial strain and strain rate.2 By
tracking the movement of speckles within cardiac tissue, STE offers
a comprehensive analysis of myocardial mechanics, allowing for the
evaluation of both global and regional cardiac function.3 In the con-
text of CPR, STE has the potential to provide valuable insights into
the immediate changes in cardiac function during resuscitation
efforts.
Assessing cardiac function during and after CPR is challenging
due to the dynamic nature of the process.1 Traditional echocardio-
graphic methods may not capture the alterations in myocardial
mechanics that occur during chest compression.4 Transesophageal
echocardiography combined with STE, with its ability to detect
changes in strain and strain rate, can offer a more detailed assess-
ment of cardiac performance during resuscitation and its immediate
aftermath,5 allows quantitative evaluation of chest compressions in
real time during CPR, offering valuable insights into the effectiveness
of cardiac massage and chest compression quality. We demon-
strated a case in whom the area of maximal compression (AMC)
was adjusted with increased ejection fraction (EF) from 21% to
42.4%. The calculation can be done immediately after the trans-
esophageal probe is inserted within 2 minutes. The AMC and ejec-
tion fraction are evaluated by 2D-speckle tracking bull‘s eye
display of LV segmental and global longitudinal strain (GLS). Apical
and anterolateral dyskinesia is observed before adjusting AMC
location with depressed EF down to 21% (Fig. 1a) and synchronized
cardiac mechanical activity with chest compression is achieved after
adjusting CPR location with increased EF up to 42.4% (Fig. 1b).
Nevertheless, there are still several limitations. First, the STE
image takes time from 60 seconds to 5 minutes depending on the
machine. Second, AMC might change during manual chest compres-
sion. Therefore, the STE image should be used under mechanical
chest compressions.
In conclusion, transesophageal echocardiography is feasible dur-
ing chest compression without interruption of CPR. CPR quality can
be quantitatively assessed by EF and AMC location illustrated by
bull‘s eye display of LV segmental and GLS. Further validation of
its efficacy and impact on CPR performance is mandated.
Meeting presented
None.
Grant or financial support
None.
Source of funding
None.
CRediT authorship contribution statement
Chia-Ching Chen: Conceptualization, Resources, Writing – original
draft. Chia-Szu Huang: Data curation. Hung-Tsang Yen:
Supervision. Wan-Ching Lien: Writing – review & editing.
2 R E S U S C I T A T I O N 194 (2024) 110097

Fig. 1 – Speckle tracking echocardiography during resuscitation. (A) Before adjusting the location of compression,
the area of maximal compression (AMC) is outside of left ventricle and dyskinesia is illustrated by bull‘s eye display
of LV segmental and GLS (B) after adjusting CPR location, AMC location is found among segments 12, 16, and 17 of
the left ventricle on bull‘s eye display of LV segmental and GLS. EF: ejection fraction; SV: stroke volume; EDV: end-
diastolic volume; ESV: end-systolic volume.

Declaration of competing interest R E F E R E N C E S

The authors declare that they have no known competing financial

interests or personal relationships that could have appeared to influ- 1. Teran F, Owyang CG, Martin-Flores M, et al. Hemodynamic impact of
ence the work reported in this paper. chest compression location during cardiopulmonary resuscitation
guided by transesophageal echocardiography. Crit Care 2023;27:319.
 R E S U S C I T A T I O N 194 (2024) 110097 3

2. Tunnemann-Tarr A, Stobe S, Laufs U, Hagendorff A, Tayal B. Speckle Chia-Ching Chen

tracking echocardiography in a patient with viral myocarditis and acute Chia-Szu Huang
myocardial infarction. J Cardiol Cases 2020;22:184–91. Hung-Tsang Yen
3. Rakesh K, Rajesh GN, Vellani H. 3D speckle tracking
Department of Emergency Medicine, Chang Bing Show-Chwan Memorial
echocardiographic strain pattern in Hypertrophic Cardiomyopathy and
Hospital, Changhua County, Taiwan
its relation with Sudden Cardiac Death risk markers. Indian Heart J
2021;73:451–7. Wan-Ching Lien *
4. Liu RB, Bogucki S, Marcolini EG, et al. Guiding cardiopulmonary
resuscitation with focused echocardiography: a report of five cases. Department of Emergency Medicine, National Taiwan University
Hospital, Taipei, Taiwan
Prehosp Emerg Care 2020;24:297–302.
Department of Emergency Medicine, College of Medicine, National
5. Gao L, Lin Y, Ji M, et al. Clinical utility of three-dimensional speckle-
Taiwan University, Taipei, Taiwan
tracking echocardiography in heart failure. J Clin Med 2022;11.

* Corresponding author at: Department of Emergency Medicine, National

Taiwan University Hospital and National Taiwan University, No.7,
Chung-Shan South Road, Taipei 100, Taiwan

E-mail address: wanchinglien@ntu.edu.tw

Received 11 December 2023

Accepted 14 December 2023

https://doi.org/10.1016/j.resuscitation.2023.110097
Ó 2023 Elsevier B.V. All rights reserved.