Hyperdynamic heart function in ICU patients does not mirror longitudinal strain measures

A hyperdynamic left ventricle in intensive care patients does not necessarily show the same exaggerated behaviour in the longitudinal measures that echocardiographers use to gauge systolic function, according to a formal reply by Oscar Cavefors and Jonatan Oras published in Critical Care. The reply responds to a commentary that had proposed hyperdynamic left ventricular function as a promising new area for echocardiographic exploration in critical illness.

The authors agreed with the commentators on a key premise: a preserved or increased left ventricular ejection fraction does not automatically indicate normal myocardial physiology. A hyperdynamic phenotype, they wrote, may represent an important area for further investigation. To move the discussion from hypothesis to data, they carried out exploratory post hoc analyses in their mixed intensive care unit cohort, comparing patients whose ejection fraction exceeded 70 percent with patients whose ejection fraction sat in the conventional 50 to 70 percent range.

The hyperdynamic group was a minority of the cohort. Forty-eight patients, or 17 percent of those with an available ejection fraction measurement, fell above the 70 percent threshold, while 177 patients, or 61 percent, were in the 50 to 70 percent band. Ninety-day mortality was 27 percent among the hyperdynamic patients, with 13 of 48 dying within that window, and 23 percent in the comparison group, with 41 of 177 deaths. The difference was not statistically significant: the adjusted odds ratio for 90-day mortality was 1.36, with a 95 percent confidence interval of 0.55 to 3.37 and a p value of 0.501. The authors stressed that these analyses are exploratory and rest on a limited number of patients with the hyperdynamic phenotype, so they should be interpreted cautiously.

The more technically revealing part of the reply concerns how the hyperdynamic ejection fraction relates to longitudinal systolic parameters. Global longitudinal strain, expressed as a negative value, was higher in absolute magnitude in the hyperdynamic group: a median of 21.0 percent with an interquartile range of 17.5 to 24.7, against a median of 18.2 percent with an interquartile range of 15.4 to 20.3 in the 50 to 70 percent group, a difference with a p value below 0.001. Mitral annular plane systolic excursion, a measure of how far the mitral valve ring moves during contraction, was also slightly higher in the hyperdynamic group, at a median of 14.0 millimetres with an interquartile range of 12.0 to 15.5, compared with 13.0 millimetres with an interquartile range of 11.0 to 15.0, with a p value of 0.048.

Tissue Doppler imaging told a different story. S-prime, the mean peak systolic velocity of the septal and lateral left ventricular wall, did not differ significantly between the groups. The hyperdynamic group had a median of 9.5 centimetres per second with an interquartile range of 8.0 to 11.0, while the comparison group had a median of 9.0 centimetres per second with an interquartile range of 7.5 to 11.0, yielding a p value of 0.348. The authors also looked for a cut-off value of mitral annular plane systolic excursion, global longitudinal strain or S-prime that would correspond to a hyperdynamic ejection fraction profile, and none could be identified.

The team then inverted the question, asking whether patients with the highest longitudinal values show the same prognostic pattern as the hyperdynamic ejection fraction group. Because patients with an ejection fraction above 70 percent made up roughly the upper 20 percent of the study population, the researchers defined matching cut-offs at the upper 20 percent of each longitudinal marker’s distribution: global longitudinal strain more negative than minus 21 percent, mitral annular plane systolic excursion above 15 millimetres, and S-prime above 11 centimetres per second. These high-value patients were compared with those whose measurements fell within the corresponding normal ranges, defined as strain between minus 21 and minus 16 percent, excursion between 10 and 15 millimetres, and velocity between 7.5 and 11 centimetres per second.

None of the three high-value longitudinal groups was associated with 90-day mortality, either in unadjusted or in adjusted analyses. The direction of the point estimates, however, caught the authors’ attention. Hyperdynamic ejection fraction showed point estimates above unity, with an unadjusted odds ratio of 1.23 and a 95 percent confidence interval of 0.60 to 2.55, and an adjusted odds ratio of 1.36 with a confidence interval of 0.55 to 3.37. All three longitudinal markers moved the opposite way, with adjusted odds ratios below unity: 0.68 for global longitudinal strain, 0.54 for mitral annular plane systolic excursion and 0.58 for S-prime. Although none of these analyses reached statistical significance, the authors argued that the opposite direction of the estimates suggests that a hyperdynamic ejection fraction and longitudinal systolic markers may not reflect identical physiological processes.

In summary, the authors concluded that their exploratory analyses suggest hyperdynamic ejection fraction does not necessarily correspond to an equivalent hyperdynamic longitudinal systolic profile. They framed the observations as hypothesis-generating rather than definitive, cautioning that the small number of hyperdynamic patients limits the precision of every estimate reported. Even so, they argued that the hyperdynamic left ventricular phenotype is an important and underexplored area in critical care echocardiography, and that the findings support a more detailed analysis of the phenotype, including its relationship with longitudinal myocardial function, haemodynamic characteristics and clinical outcome. For clinicians and researchers following the debate, the practical message is that ejection fraction and longitudinal deformation measures, which are often assumed to move together, can diverge in critically ill patients, and that the authors present the work as an invitation for larger, dedicated studies rather than as evidence for any change in practice.

Subject of Research: The relationship between hyperdynamic left ventricular ejection fraction and longitudinal systolic function markers in critically ill patients

Article Title: Answer to: “Left ventricular longitudinal function and hyperkinetic profile: a new echo world to explore?”

Article References: Cavefors, O., & Oras, J. (2026). Answer to: “Left ventricular longitudinal function and hyperkinetic profile: a new echo world to explore?”. Critical Care, 30(1), Article 543. https://doi.org/10.1186/s13054-026-06403-0

Image Credits: AI Generated

DOI: 10.1186/s13054-026-06403-0

Keywords: echocardiography, left ventricular ejection fraction, global longitudinal strain, mitral annular plane systolic excursion, tissue Doppler imaging, critical care, intensive care unit, hyperdynamic phenotype, 90-day mortality, systolic function, Answer, Left