Basic and advanced echocardiographic evaluation of myocardial dysfunction in sepsis and septic shock

Mixed Cardiogenic-Vasodilatory Shock: Current Insights and Future Directions

This state-of-the-art review describes the potential etiologies, pathophysiology, and management of mixed shock in the context of a proposed novel classification system. Cardiogenic-vasodilatory shock occurs when cardiogenic shock is complicated by inappropriate vasodilation, impairing compensatory mechanisms, and contributing to worsening shock. Vasodilatory-cardiogenic shock occurs when vasodilatory shock is complicated by myocardial dysfunction, resulting in low cardiac output. Primary mixed shock occurs when a systemic insult triggers both myocardial dysfunction and vasoplegia. Regardless of the etiology of mixed shock, the hemodynamic profile can be similar, and outcomes tend to be poor. Identification and treatment of both the initial and complicating disease processes is essential along with invasive hemodynamic monitoring given the evolving nature of mixed shock states. Hemodynamic support typically involves a combination of inotropes and vasopressors, with few data available to guide the use of mechanical circulatory support. Consensus definitions and novel treatment strategies are needed for this dangerous condition.

Diagnostic and Predictive Value of LncRNA MCM3AP-AS1 in Sepsis and Its Regulatory Role in Sepsis-Induced Myocardial Dysfunction

The present study focused on exploring the clinical value and molecular mechanism of LncRNA MCM3AP antisense RNA 1 (MCM3AP-AS1) in sepsis and sepsis-induced myocardial dysfunction (SIMD). 122 sepsis patients and 90 healthy were included. Sepsis patients were categorized into SIMD and non-MD. The expression levels of MCM3AP-AS1 and miRNA were examined using RT-qPCR. Diagnostic value of MCM3AP-AS1 in sepsis assessed by ROC curves. Logistic regression to explore risk factors influencing the occurrence of SIMD. Cardiomyocytes were induced by LPS to construct cell models in vitro. CCK-8, flow cytometry, and ELISA to analyze cell viability, apoptosis, and inflammation levels. Serum MCM3AP-AS1 was upregulated in patients with sepsis. The sensitivity and specificity of MCM3AP-AS1 were 75.41% and 93.33%, for recognizing sepsis from healthy controls. Additionally, elevated MCM3AP-AS1 is a risk factor for SIMD and can predict SIMD development. Compared with the LPS-induced cardiomyocytes, inhibition of MCM3AP-AS1 significantly attenuated LPS-induced apoptosis and inflammation; however, this attenuation was partially reversed by lowered miR-28-5p, but this reversal was partially eliminated by CASP2. MCM3AP-AS1 may be a novel diagnostic biomarker for sepsis and can predict the development of SIMD. MCM3AP-AS1 probably participated in SIMD progression by regulating cardiomyocyte inflammation and apoptosis through the target miR-28-5p/CASP2 axis.

The Usefulness of Strain Echocardiography as Diagnostic and Prognostic Index of Cardiac Dysfunction in Septic Patients in Correlation with Cardiac Biomarkers

Background

Compared to standard echocardiography, speckle tracking echocardiography (STE) looks more accurate for the detection of subclinical dysfunction of the myocardium. The aim of our work was to assess the value of STE in the diagnosis of subclinical ventricular dysfunction and as a prognostic index in sepsis patients.

Patients and Methods

An observational prospective study involving critically ill patients aged ≥ 18 years diagnosed with sepsis or septic shock. All patients were subjected to full history-taking, clinical assessment, and scoring system, including Acute Physiology and Chronic Health (APACHE) II score and quick sequential organ failure assessment score. Investigations were done for all patients, including laboratory (complete blood count, C-reactive protein, N-terminal pro-brain natriuretic peptide [NT-proBNP], and troponin-I and serum lactate level), ECG, and echocardiographic examination (conventional and speckle tracking) for measurement of global left ventricular strain.

Results

This study involved 50 patients, nine patients with sepsis and 41 patients with septic shock. Regarding cardiac biomarkers, the mean value of troponin-I was 0.18 ± 0.05 ng/L and for NT-proBNP was 1228.2 ± 832.9 pmol/L. All patients in the study had elevated lactate levels. There was a significant correlation between global longitudinal strain (GLS) and troponin I, NT-proBNP, and lactate levels after 3 days of admission. GLS, lactate, NT-proBNP, troponin levels, and APACHE II Score were significant predictors of mortality with a sensitivity of 76.5%, 88.2%, 88.2%, 76.5%, and 88.2%, respectively.

Conclusion

GLS measured by speckle tracking echocardiography looks to be a sensitive diagnostic tool for early detection of subclinical left ventricular dysfunction in patients with sepsis in addition to be a sensitive predictor of in-hospital mortality.

Clinical usefulness of NT-proBNP as a prognostic factor for septic shock patients presenting to the emergency department

Plasma N-terminal prohormone of brain natriuretic peptide (NT-proBNP) level is primarily used as a biomarker for left ventricular (LV) dysfunction. It is influenced by various conditions, such as myocardial strain and situations affecting the clearance of NT-proBNP, including sepsis and shock. In this study, we investigated the appropriateness of NT-proBNP as a prognostic factor for septic shock. Patients with septic shock who visited the emergency department of the Ewha Womans' University Mokdong Hospital between January 1, 2018, and December 31, 2020, were classified into the survival group (those who survived in the hospital and were discharged) and the death group (those who died in the hospital). The effectiveness of NT-proBNP, lactate, and blood urea nitrogen as predictive factors of in-hospital mortality was evaluated using the area under the receiver operating characteristic (AUROC) curve. The AUROC curve was 0.678 and 0.648 for lactate and NT-proBNP, respectively, with lactate showing the highest value. However, there was no significant difference between lactate and NT-proBNP levels in the comparison of their AUROC curve (p = 0.6278). NT-proBNP could be a useful predictor of in-hospital mortality in patients with septic shock who present to the emergency department.

Meta-analysis of initial natriuretic peptides in the setting of sepsis-induced myocardial dysfunction

Aim: To investigate the association of initial brain natriuretic peptide (BNP) and N-terminal pro-BNP (NT-proBNP) with the detection of sepsis-induced myocardial dysfunction (SIMD) in the setting of Sepsis 3.0. Methods: Three databases were searched to analyze initial BNP and NT-proBNP levels between SIMD and non-SIMD groups. Results: Eighteen studies were included, most of which defined SIMD based on echocardiography. The SIMD group exhibited higher initial BNP and NT-proBNP levels in blood. NT-proBNP higher than a certain cutoff value (>3000 pg/ml) was an independent risk factor for SIMD and its accuracy for SIMD diagnosis was moderate (pooled area under the curve: 0.81). Conclusion: Initial blood BNP and NT-proBNP levels are useful to assist in the detection of SIMD and further studies are warranted to determine the SIMD definition.

Association between left ventricular systolic function parameters and myocardial injury, organ failure and mortality in patients with septic shock

BACKGROUND

Left ventricular ejection fraction (LVEF) is inconsistently associated with poor outcomes in patients with sepsis. Newer parameters such as LV longitudinal strain (LVLS), mitral annular plane systolic excursion (MAPSE) and LV longitudinal wall fractional shortening (LV-LWFS) may be more sensitive indicators of LV dysfunction, but are sparsely investigated. Our objective was to evaluate the association between five traditional and novel echocardiographic parameters of LV systolic function (LVEF, peak tissue Doppler velocity at the mitral valve (s´), LVLS, MAPSE and LV-LWFS) and outcomes in patients admitted to the Intensive Care Unit (ICU) with septic shock.

METHODS

A total of 152 patients admitted to the ICU with septic shock from two data repositories were included. Transthoracic echocardiograms were performed within 24 h of ICU admission. The primary outcome was myocardial injury, defined as high-sensitivity troponin T ≥ 45 ng/L on ICU admission. Secondary outcomes were organ support-free days (OSFD) and 30-day mortality. We also tested for the prognostic value of the systolic function parameters using multivariable analysis.

RESULTS

LVLS, MAPSE and LV-LWFS, but not LVEF and s´, differed between patients with and without myocardial injury. After adjustment for age, pre-existing cardiac disease, Simplified Acute Physiology (SAPS3) score, Sequential Organ Failure Assessment (SOFA) score, plasma creatinine and presence of right ventricular dysfunction, only MAPSE and LV-LWFS were independently associated with myocardial injury. None of the systolic function parameters were associated with OSFD or 30-day mortality.

CONCLUSIONS

MAPSE and LV-LWFS are independently associated with myocardial injury and outperform LVEF, s´ and LVLS. Whether these parameters are associated with clinical outcomes such as the need for organ support and short-term mortality is still unclear. Trial registration NCT01747187 and NCT04695119.

RIGHT VENTRICULAR DYSFUNCTION IN SEPSIS: AN UPDATED NARRATIVE REVIEW

ABSTRACT

Sepsis is a multisystem disease process, which constitutes a significant public health challenge and is associated with high morbidity and mortality. Among other systems, sepsis is known to affect the cardiovascular system, which may manifest as myocardial injury, arrhythmias, refractory shock, and/or septic cardiomyopathy. Septic cardiomyopathy is defined as the reversible systolic and/or diastolic dysfunction of one or both ventricles. Left ventricle dysfunction has been extensively studied in the past, and its prognostic role in patients with sepsis is well documented. However, there is relatively scarce literature on right ventricle (RV) dysfunction and its role. Given the importance of timely detection of septic cardiomyopathy and its bearing on prognosis of patients, the role of RV dysfunction has come into renewed focus. Hence, through this review, we sought to describe the pathophysiology of RV dysfunction in sepsis and what have we learnt so far about its multifactorial nature. We also elucidate the roles of different biomarkers for its detection and prognosis, along with appropriate management of such patient population.

ACETAMINOPHEN ATTENUATES PULMONARY VASCULAR RESISTANCE AND PULMONARY ARTERIAL PRESSURE AND INHIBITS CARDIOVASCULAR COLLAPSE IN A PORCINE MODEL OF ENDOTOXEMIA

ABSTRACT

Acetaminophen (paracetamol) is often used in critically ill patients with fever and pain; however, little is known about the effects of acetaminophen on cardiovascular function during systemic inflammation. Here, we investigated the effect of acetaminophen on changes in the systemic and pulmonary circulation induced by endotoxin (0.5 μg/kg per hour) in anesthetized pigs. Endotoxin infusion led to a rapid increase in pulmonary artery pressure and pulmonary vascular resistance index. Acetaminophen delayed and attenuated this increase. Furthermore, acetaminophen reduced tachycardia and decreased stroke volume, accompanied by systemic inflammation, without affecting inflammatory parameters such as white blood cell count and TNF-α in blood. As a proof of concept, we injected a high dose of endotoxin (100 μg), which induced rapid cardiovascular collapse in pigs. Pigs treated with acetaminophen survived with no obvious hemodynamic instability during the 50-min observation period. In conclusion, acetaminophen attenuates the effects of endotoxin on pulmonary circulation in anesthetized pigs. This may play a role in severe systemic inflammation.

Heart Failure with Preserved Ejection Fraction in Children

Diastolic dysfunction (DD) refers to abnormalities in the mechanical function of the left ventricle (LV) during diastole. Severe LVDD can cause symptoms and the signs of heart failure (HF) in the setting of normal or near normal LV systolic function and is referred to as diastolic HF or HF with preserved ejection fraction (HFpEF). Pediatric cardiologists have long speculated HFpEF in children with congenital heart disease and cardiomyopathy. However, understanding the risk factors, clinical course, and validated biomarkers predictive of the outcome of HFpEF in children is challenging due to heterogeneous etiologies and overlapping pathophysiological mechanisms. The natural history of HFpEF varies depending upon the patient's age, sex, race, geographic location, nutritional status, biochemical risk factors, underlying heart disease, and genetic-environmental interaction, among other factors. Pediatric onset HFpEF is often not the same disease as in adults. Advances in the noninvasive evaluation of the LV diastolic function by strain, and strain rate analysis with speckle-tracking echocardiography, tissue Doppler imaging, and cardiac magnetic resonance imaging have increased our understanding of the HFpEF in children. This review addresses HFpEF in children and identifies knowledge gaps in the underlying etiologies, pathogenesis, diagnosis, and management, especially compared to adults with HFpEF.

Is venoarterial extracorporeal membrane oxygenation an option for managing septic shock

PURPOSE OF REVIEW

To describe sepsis-induced cardiomyopathy. Discuss indications and current evidence of using venoarterial extracorporeal membrane oxygenation (VA-ECMO) in setting of sepsis-induced cardiomyopathy.

RECENT FINDINGS

Recent data suggests a survival benefit with the use of VA-ECMO in patients with septic shock complicated by septic-induced cardiomyopathy with severe left ventricular systolic dysfunction. VA-ECMO was associated with poor outcomes in adults with septic shock without severe systolic dysfunction. The evidence is generated from retrospective and meta-analysis of observational studies.

SUMMARY

Sepsis-induced cardiomyopathy is an increasingly recognized entity characterized by reversible ventricular dysfunction in the setting of sepsis. When hypotension persists despite standard management of septic shock (e.g. adequate fluid resuscitation, vasopressors, inotropes) and there is evidence of severe cardiac systolic dysfunction and end-organ hypoperfusion, VA-ECMO should be considered as a bridge therapy to recovery. VA-ECMO should not be used for isolated vasodilatory septic shock without significant myocardial dysfunction.

Therapeutic Approaches in Heart Failure with Preserved Ejection Fraction (HFpEF) in Children: Present and Future

For a long time, pediatric heart failure (HF) with preserved systolic function (HFpEF) has been noted in patients with cardiomyopathies and congenital heart disease. HFpEF is infrequently reported in children and instead of using the  HFpEF terminology the HF symptoms are attributed to diastolic dysfunction. Identifying HFpEF in children is challenging because of heterogeneous etiologies and unknown pathophysiological mechanisms. Advances in echocardiography and cardiac magnetic resonance imaging techniques have further increased our understanding of HFpEF in children. However, the literature does not describe the incidence, etiology, clinical features, and treatment of HFpEF in children. At present, treatment of HFpEF in children is extrapolated from clinical trials in adults. There are significant differences between pediatric and adult HF with reduced ejection fraction, supported by a lack of adequate response to adult HF therapies. Evidence-based clinical trials in children are still not available because of the difficulty of conducting trials with a limited number of pediatric patients with HF. The treatment of HFpEF in children is based upon the clinician's experience, and the majority of children receive off-level medications. There are significant differences between pediatric and adult HFpEF pharmacotherapies in many areas, including side-effect profiles, underlying pathophysiologies, the β-receptor physiology, and pharmacokinetics and pharmacodynamics. This review describes the present and future treatments for children with HFpEF compared with adults. This review also highlights the need to urgently test new therapies in children with HFpEF to demonstrate the safety and efficacy of drugs and devices with proven benefits in adults.

Evaluation of efficacy and safety of esmolol in treating patients with septic shock: A protocol for systematic review and meta-analysis

BACKGROUND

In septic shock cases, tachycardia and a hyperdynamic hemodynamic profile are characteristics of the condition. It has been reported that using beta antagonist esmolol constitutes a form of treatment to reduce heart rate to improve diastolic filling time and elevate cardiac output, which reduces vasopressor support. Still, there are controversial results. Therefore, in this study, the primary objective is to perform a meta-analysis by systematically evaluating the efficiency and security of using esmolol to treat septic shocks.

METHODS

A systematic literature search for relevant randomized controlled trials that report evaluations on the efficiency and safety of using esmolol to treat septic shock patients from their inception to February 2022 will be conducted in three databases containing publications in Chinese language (WanFang, Chinese BioMedical Literature Database, and China National Knowledge Infrastructure) and four databases containing English language publications (Cochrane Library, PubMed, Web of Science, and EMBASE). The screening of the relevant studies will be performed by a pair of authors independently, and the screening involves examining the title, abstract and full-text stages, data extraction, and bias risk assessment. The results are summarized through the fixed-effects and random-effects models, the respective models will be utilized for data pooling according to the heterogeneity of studies that will be included. Moreover, publication bias is assessed if more than ten studies are considered.

RESULTS

The results are a high-quality synthesis of the most recent evidence for esmolol usage in septic shock treatment.

CONCLUSION

Up-to-date evidence will be provided through the results of this systematic review related to assessing the efficacy and safeness of esmolol usage in treating septic shock.

ETHICS AND DISSEMINATION

Ethical permissions are not required as prepublished data are used.

OSF REGISTRATION NUMBER

DOI 10.17605/OSF.IO/SKEZ7.

Myocardial contraction fraction by echocardiography and mortality in cardiac intensive care unit patients

BACKGROUND

The myocardial contraction fraction (MCF) is proposed as an improved measure of left ventricular (LV) systolic function that overcomes important limitations of the left ventricular ejection fraction (LVEF). We sought to determine whether a low MCF was associated with higher mortality in cardiac intensive care unit (CICU) patients.

METHODS

We retrospectively analyzed unique Mayo Clinic CICU patients from 2007 to 2018 with MCF calculated as the ratio of the stroke volume to the left ventricular myocardial volume from a transthoracic echocardiogram within 1 day of CICU admission. Multivariable logistic regression analyzed the association between MCF and hospital mortality, after adjustment for LVEF and clinical variables.

RESULTS

We included 4794 patients with a mean age of 68.0 ± 14.8 years (37.1% females). The mean MCF was 0.41 ± 0.16, and was lower in the 6.6% of patients who died in the hospital (0.32 ± 0.14 versus 0.42 ± 0.16, p < 0.001). On multivariable analysis, higher MCF remained associated with lower hospital mortality (adjusted OR 0.78 per 0.1 higher, 95% CI 0.69-0.89, p < 0.001), whereas LVEF was not significantly associated with hospital mortality (unadjusted OR 0.91 per 10% higher, OR 95% CI 0.82-1.02, p = 0.09). Patients with MCF <0.2 had the highest in-hospital mortality, and those with MCF ≥0.5 had the lowest in-hospital mortality, irrespective of admission diagnosis or LVEF.

CONCLUSIONS

MCF demonstrated a strong, inverse relationship with hospital mortality in CICU patients, even after adjusting for LVEF and clinical variables. MCF can be used to identify prognostically-relevant myocardial dysfunction at the bedside, even among patients with preserved LVEF.

Effect of Glucose-Insulin-Potassium Infusion on Hemodynamics in Patients with Septic Shock

BACKGROUND: Glucose-insulin-potassium (GIK) demonstrates a cardioprotective effect by providing metabolic support and anti-inflammatory action, and may be useful in septic myocardial depression. AIM: The aim of this study was to assess role of GIK infusion in improving hemodynamics in patients with septic shock in addition to its role in myocardial protection and preventing occurrence of sepsis-induced myocardial dysfunction and sepsis-induced arrhythmias. METHODS: This study was conducted on 75 patients admitted to the Critical Care Department in Cairo University Hospital with the diagnosis of septic shock during the period from January 2019 to December 2019. Patients were divided into two groups; first group was managed according to the last guidelines of surviving sepsis campaign and was subjected to the GIK infusion protocol while second group was managed following the last guidelines of surviving sepsis campaign only without adding GIK infusion. RESULTS: Patients in the GIK group showed better lactate clearance (50% vs. 46.7%) and less time needed for successful weaning of vasopressors than the control group (3.57±1.16 vs. 3.6±1.45 days) thought not reaching statistical significance. There was no statistically significant difference between both groups regarding development of septic-induced cardiomyopathy (16.7% in the control group vs. 13.3% in the GIK group); however, patients with hypodynamic septic shock showed better improvement in hemodynamic profile in the GIK group. Sepsis-induced arrhythmias occurred more in patients of the control group than in patients of the GIK group with no statistically significant difference between both groups (33.3% vs. 20%, p = 0.243). Few side effects were developed as a result of using GIK infusion protocol. CONCLUSIONS: GIK may help in improving hemodynamics and weaning of vasopressors in patients with refractory septic shock and those with septic induced cardiomyopathy. The use of GIK was well tolerated with minimal adverse reactions.

Speckle Tracking Algorithm-Based Ultrasonic Cardiogram in Evaluation of the Efficacy of Dexmedetomidine Combined with Bundle Strategy on Patients with Severe Sepsis

The research aimed to study the effect of dexmedetomidine combined with bundle strategy on the cardiac function of patients with severe sepsis through pyramid speckle tracking algorithm-based echocardiography, expected to provide reference for its clinical treatment. 98 patients with severe sepsis or septic shock admitted to the hospital were selected as the research subjects, and they were equally divided into experimental group (dexmedetomidine + bundle strategy) and control group (dexmedetomidine + routine nursing), with 49 in each. Ultrasonic cardiogram examination was performed on patients before and after treatment, and the pyramid-based speckle tracking (PST) algorithm was designed and used. The results showed that the running time of the PST algorithm (105.25 s) was less than that of the BM algorithm (336.41 s), and the difference was statistically significant (P < 0.05), and the systolic blood pressure, diastolic blood pressure, left ventricular wall, and heart rate of the experimental group before treatment were not significantly different from those of the control group (P > 0.05). The ultrasound index results found that the ejection fraction (EF) and fractional shortening (FS) of the two groups of patients showed a downward trend over time (1-7 days), while the E/A ratio showed an upward trend, and the E/A ratio of the experimental group was significantly greater than the control group (P < 0.05). The systolic blood pressure, diastolic blood pressure, left ventricular wall, and heart rate of the two groups of patients showed a downward trend over time (1-7 days), and the systolic blood pressure, diastolic blood pressure, left ventricular wall, and heart rate of the experimental group were significantly lower than those of the control group (P < 0.05). The 28-day mechanical ventilation time (6.97 ± 3.11 days), intensive care unit (ICU) stay time (9.18 ± 2.86 days), and the 28-day mortality rate (15.31%) of the experimental group were lower than those of the control group (6.97 ± 3.11 days; 13.08 ± 2.53 days; 31.95%) (P < 0.05). In conclusion, the PST algorithm can effectively improve the quality of echocardiography and assist physicians in clinical evaluation, and dexmedetomidine combined with bundle strategy can stabilize the heart rate and reduce myocardial oxygen consumption in severe sepsis, while effectively shortens the recovery time and improves the overall prognosis.

Gastrodin alleviates inflammatory injury of cardiomyocytes in septic shock mice via inhibiting NLRP3 expression

Septic shock leads to myocardial dysfunction and induces inflammation. Nod-like receptor family pyrin domain-containing 3 (NLRP3) inflammasomes are involved in inflammation, and gastrodin can inhibit the activity of inflammasomes. Our study aimed to explore the effect of gastrodin against septic shock-induced injury through inhibiting NLRP3. Before establishing septic shock mice model, the mice were injected with gastrodin of various concentrations. The cardiac function of mice was detected by a PowerLab, and the histopathological changes of mouse myocardial tissues were detected by hematoxylin-eosin staining. Apoptosis of cardiomyocytes from mice was detected by TUNEL assay, and IL-1β concentration was detected by enzyme-linked immunosorbent assay. After culture in vitro and treatment with gastrodin, lipopolysaccharide (LPS), and NLRP3 vector, the cell viability and apoptosis of cardiomyocytes were detected by cell counting kit-8 and flow cytometry respectively. Besides, the expressions of NLRP3, Caspase-1, IL-1β, Bax, and Bcl-2 in mouse myocardial tissue or cultured cardiomyocytes were detected by Western blot. Gastrodin improved survival and promoted the recovery of cardiac function in septic shock mice, as it reversed the abnormality of left ventricular function indices in septic shock mice. Besides, gastrodin decreased IL-1β concentration and apoptosis in myocardial tissues of septic shock mice and decreased apoptosis and increased cell viability in LPS-induced cardiomyocytes. In addition, gastrodin downregulated NLRP3, Caspase-1, IL-1β, and Bax expressions and upregulated Bcl-2 expression in myocardial tissues of septic shock mice and LPS-induced cardiomyocytes. NLRP3 overexpression reversed the effect of gastrodin on LPS-induced cardiomyocytes. Gastrodin promoted cardiac function recovery and protected cardiomyocytes against septic shock-induced injury by regulating NLRP3.

Effect of focused cardiopulmonary ultrasonography on clinical outcome of septic shock: a randomized study

Objective

To investigate the effect of focused ultrasonography on clinical outcomes of septic shock.

Methods

Patients with septic shock were randomized into an integrated cardiopulmonary ultrasonography (ICUS) group and conventional (CON) group. Within 1 hour of admission, the ICUS group underwent ICUS examination for hemodynamic decision-making, while the CON group received standard treatment. The primary endpoint was 28-day mortality after admission. The secondary endpoints were cumulative fluid administration in the first 6, 24, and 72 hours; use of vasoactive drugs; lactate clearance; duration of ventilation; and ICU stay.

Results

Ninety-four qualified patients were enrolled (ICUS group, 49; CON group, 45). ICUS showed no significant effect on 28-day mortality. Within the initial 6 hours, the ICUS group tended to have a higher fluid balance and fluid intake than the CON group. The duration of vasopressor support was shorter in the ICUS group. There were no differences in the cumulative fluid infusion within 24 or 72 hours, lactate clearance, ICU stay, or duration of ventilation.

Conclusions

The initially focused ICUS did not affect the clinical outcomes of septic shock, but it tended to be associated with a higher fluid balance within the initial 6 hours and shorter duration of vasopressor support.

Loss of sarcomeric proteins via upregulation of JAK/STAT signaling underlies interferon-γ-induced contractile deficit in engineered human myocardium

The level of circulating interferon-γ (IFNγ) is elevated in various clinical conditions including autoimmune and inflammatory diseases, sepsis, acute coronary syndrome, and viral infections. As these conditions are associated with high risk of myocardial dysfunction, we investigated the effects of IFNγ on 3D fibrin-based engineered human cardiac tissues ("cardiobundles"). Cardiobundles were fabricated from human pluripotent stem cell-derived cardiomyocytes, exposed to 0-20 ng/ml of IFNγ on culture days 7-14, and assessed for changes in tissue structure, viability, contractile force and calcium transient generation, action potential propagation, cytokine secretion, and expression of select genes and proteins. We found that application of IFNγ induced a dose-dependent reduction in contractile force generation, deterioration of sarcomeric organization, and cardiomyocyte disarray, without significantly altering cell viability, action potential propagation, or calcium transient amplitude. At molecular level, the IFNγ-induced structural and functional deficits could be attributed to altered balance of pro- and anti-inflammatory cytokines, upregulation of JAK/STAT signaling pathway (JAK1, JAK2, and STAT1), and reduced expression of myosin heavy chain, myosin light chain-2v, and sarcomeric α-actinin. Application of clinically used JAK/STAT inhibitors, tofacitinib and baricitinib, fully prevented IFNγ-induced cardiomyopathy, confirming the critical roles of this signaling pathway in inflammatory cardiac disease. Taken together, our in vitro studies in engineered myocardial tissues reveal direct adverse effects of pro-inflammatory cytokine IFNγ on human cardiomyocytes and establish the foundation for a potential use of cardiobundle platform in modeling of inflammatory myocardial disease and therapy. STATEMENT OF SIGNIFICANCE: Various inflammatory and autoimmune diseases including rheumatoid arthritis, sepsis, lupus erythematosus, Chagas disease, and others, as well as viral infections including H1N1 influenza and COVID-19 show increased systemic levels of a pro-inflammatory cytokine interferon-γ (IFNγ) and are associated with high risk of heart disease. Here we explored for the first time if chronically elevated levels of IFNγ can negatively affect structure and function of engineered human heart tissues in vitro. Our studies revealed IFNγ-induced deterioration of myofibrillar organization and contractile force production in human cardiomyocytes, attributed to decreased expression of multiple sarcomeric proteins and upregulation of JAK/STAT signaling pathway. FDA-approved JAK inhibitors fully blocked the adverse effects of IFNγ, suggesting a potentially effective strategy against human inflammatory cardiomyopathy.

Diagnostic Value of High-Sensitivity Troponin T for Subclinical Left Ventricular Systolic Dysfunction in Patients with Sepsis

Background

Left ventricular systolic dysfunction (LVSD) is common in sepsis. Speckle-tracking echocardiography (STE) is a useful emerging tool for evaluating the intrinsic left ventricular systolic function. High-sensitivity cardiac troponin T (hs-cTnT) is the most sensitive biomarker of myocardial injury. However, there are limited data regarding the association between hs-cTnT level and left ventricular systolic dysfunction based on STE in septic patients. We performed this prospective study to evaluate the diagnostic value of hs-cTnT level for subclinical left ventricular systolic dysfunction measured by STE in septic patients according to the sepsis-3 definition.

Methods

Patients with sepsis based on sepsis-3 definition admitted to the intensive care unit were prospectively performed STE and hs-cTnT level within 24 hours after the onset of sepsis. Baseline clinical and echocardiographic variables were collected. Left ventricular systolic dysfunction was defined as a global longitudinal strain of ≥−15%.

Results

During a 19-month period, 116 patients were enrolled in the study. The elevated hs-cTnT level was seen in 86.2% of septic patients, and 43.1% of patients had LVSD on STE. The median hs-cTnT level and the proportion of elevated hs-cTnT level (>14 ng/L) were significantly higher in patients with LVSD than in patients without LVSD. The area under the ROC curves of hs-cTnT to detect LVSD was 0.73 (P < 0.001). In the multivariate analysis, hs-cTnT (HR, 1.002; 95% CI, 1.000 to 1.004; P = 0.025) and septic shock (HR, 7.6; 95% CI, 2.25 to 25.76; P = 0.001) were independent predictors of LVSD.

Conclusion

Our study indicated that the serum hs-cTnT level might be a useful biomarker for detecting LVSD in septic patients.

Risk factors for postoperative sepsis-induced cardiomyopathy in patients undergoing general thoracic surgery: a single center experience

Background

The current study aimed to investigate the incidence of sepsis-induced cardiomyopathy (SICM) in patients who received general thoracic surgery, along with the risk factors and management strategies for this complication.

Methods

The clinical records of 163 patients with postoperative sepsis were retrospectively reviewed. After propensity score matching, 144 patients were divided into 2 groups by stroke volume: the SICM group (n=72) and the non-SICM group (n=72).

Results

The overall incidence of postoperative SICM was 53.99%. Multiple logistic regression analysis showed that stroke volume and C-reactive protein were independent predictors of mortality in patients with postoperative sepsis. Statistical analysis by t-test and χ² test indicated that mortality (P=0.000), B-type natriuretic peptide (P=0.001), left ventricular ejection fraction (P=0.000), the mitral peak velocity of early filling/early diastolic mitral annular velocity (E/e’) (P=0.049), C-reactive protein (P=0.016), procalcitonin (P=0.013), serum creatinine (P=0.016), platelets (P=0.028), and lactic acid (P=0.002) were significantly associated with the occurrence of postoperative SICM. Among these parameters, B-type natriuretic peptide was identified as the best biomarker for predicting SICM by receiver operating characteristic (ROC) curve analysis.

Conclusions

It is vital to improve the diagnosis and standard management of SICM. A combined strategy comprising early detection of suspected infection, adequate use of antibiotics, close monitoring, effective drainage, and supportive care may improve the outcomes of patients with postoperative SICM.

Regulatory role of the TLR4/JNK signaling pathway in sepsis‑induced myocardial dysfunction

Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection, and is a leading cause of mortality worldwide. Myocardial dysfunction is associated with poor prognosis in patients with sepsis and contributes to a high risk of mortality. However, the pathophysiological mechanisms underlying sepsis-induced myocardial dysfunction are not completely understood. The aim of the present study was to investigate the role of toll-like receptor 4 (TLR4)/c-Jun N-terminal kinase (JNK) signaling in pro-inflammatory cytokine expression and cardiac dysfunction during lipopolysaccharide (LPS)-induced sepsis in mice. C57BL/6 mice were pretreated with TAK-242 or saline for 1 h and then subjected to LPS (12 mg/kg, intraperitoneal) treatment. Cardiac function was assessed using an echocardiogram. The morphological changes of the myocardium were examined by hematoxylin and eosin staining and transmission electron microscopy. The serum protein levels of cardiac troponin I (cTnI) and tumor necrosis factor-α (TNF-α) were determined by an enzyme-linked immunosorbent assay (ELISA). The TLR4 and JNK mRNA levels were analyzed via reverse transcription-quantitative PCR. TLR4, JNK and phosphorylated-JNK protein levels were measured by western blotting. In response to LPS, the activation of TLR4 and JNK in the myocardium was upregulated. There were significant increases in the serum levels of TNF-α and cTnI, as well as histopathological changes in the myocardium and suppressed cardiac function, following LPS stimulation. Inhibition of TLR4 activation using TAK-242 led to a decrease in the activation of JNK and reduced the protein expression of TNF-α in plasma, and alleviated histological myocardial injury and improved cardiac function during sepsis in mice. The present data suggested that the TLR4/JNK signaling pathway played a critical role in regulating the production of pro-inflammatory cytokines and myocardial dysfunction induced by LPS.

How to diagnose heart failure with preserved ejection fraction: the HFA-PEFF diagnostic algorithm: a consensus recommendation from the Heart Failure Association (HFA) of the European Society of Cardiology (ESC)

Making a firm diagnosis of chronic heart failure with preserved ejection fraction (HFpEF) remains a challenge. We recommend a new stepwise diagnostic process, the 'HFA-PEFF diagnostic algorithm'. Step 1 (P=Pre-test assessment) is typically performed in the ambulatory setting and includes assessment for HF symptoms and signs, typical clinical demographics (obesity, hypertension, diabetes mellitus, elderly, atrial fibrillation), and diagnostic laboratory tests, electrocardiogram, and echocardiography. In the absence of overt non-cardiac causes of breathlessness, HFpEF can be suspected if there is a normal left ventricular ejection fraction, no significant heart valve disease or cardiac ischaemia, and at least one typical risk factor. Elevated natriuretic peptides support, but normal levels do not exclude a diagnosis of HFpEF. The second step (E: Echocardiography and Natriuretic Peptide Score) requires comprehensive echocardiography and is typically performed by a cardiologist. Measures include mitral annular early diastolic velocity (e'), left ventricular (LV) filling pressure estimated using E/e', left atrial volume index, LV mass index, LV relative wall thickness, tricuspid regurgitation velocity, LV global longitudinal systolic strain, and serum natriuretic peptide levels. Major (2 points) and Minor (1 point) criteria were defined from these measures. A score ≥5 points implies definite HFpEF; ≤1 point makes HFpEF unlikely. An intermediate score (2-4 points) implies diagnostic uncertainty, in which case Step 3 (F1: Functional testing) is recommended with echocardiographic or invasive haemodynamic exercise stress tests. Step 4 (F2: Final aetiology) is recommended to establish a possible specific cause of HFpEF or alternative explanations. Further research is needed for a better classification of HFpEF.

Noninvasive Echocardiographic Left Ventricular Stroke Work Index Predicts Mortality in Cardiac Intensive Care Unit Patients

BACKGROUND

Reduced left ventricular stroke work index (LVSWI) has been associated with adverse outcomes in several populations of patients with chronic heart disease, but no prior studies have examined this metric in cardiac intensive care unit (CICU) patients. We sought to determine whether a low LVSWI, as measured noninvasively using transthoracic echocardiography, is associated with higher mortality in CICU patients.

METHODS

Using a database of unique Mayo Clinic CICU admissions from 2007 to 2018, we identified patients with LVSWI measured by transthoracic echocardiography within 1 day of CICU admission. Hospital mortality was analyzed using multivariable logistic regression, and 1-year mortality was analyzed using multivariable Cox proportional-hazards analysis, adjusted for left ventricular ejection fraction and known predictors of hospital mortality.

RESULTS

We included 4536 patients with a mean age of 68±14 years (36% women). Admission diagnoses (not mutually exclusive) included acute coronary syndrome in 62%, heart failure in 46%, and cardiogenic shock in 11%. The mean LVSWI was 38±14 g×min/m², and in-hospital mortality occurred in 6% of patients. LVSWI had better discrimination for hospital mortality than left ventricular ejection fraction (P<0.001 by De Long test). Higher LVSWI was associated with lower in-hospital mortality (adjusted odds ratio, 0.72 per 10 g×min/m² higher [95% CI, 0.61-0.84]; P<0.001) and lower 1-year mortality (adjusted hazard ratio, 0.812 per 1 g×min/m² higher [95% CI, 0.759-0.868]; P<0.001). Stepwise decreases in hospital and 1-year mortality were observed with higher LVSWI.

CONCLUSIONS

Low LVSWI, reflecting poor left ventricular systolic and diastolic performance, is associated with increased short-term and long-term mortality among CICU patients. This emphasizes the importance of Doppler transthoracic echocardiography as a predictor of outcomes among critically ill patients. Further study is required to determine whether early interventions to optimize LVSWI can improve outcomes in the CICU setting.

Prognostic Role of Left Ventricular Systolic Function Measured by Speckle Tracking Echocardiography in Septic Shock

Background

Left ventricular (LV) systolic dysfunction is common in septic shock. Global longitudinal strain (GLS) measured by speckle tracking echocardiography (STE) is a useful marker of intrinsic left ventricular systolic function. However, the association between left ventricular GLS and outcome in septic patients is not well understood. We performed this prospective study to investigate the prognostic value of LV systolic function utilizing speckle tracking echocardiography in patients with septic shock.

Methods

All the patients with septic shock based on sepsis-3 definition admitted to the intensive care unit were prospectively studied with STE within 24 hours after the onset of septic shock. Baseline clinical and echocardiographic variables were collected. The primary outcome was in-hospital mortality.

Results

During a 19-month period, 90 consecutive patients were enrolled in the study. The in-hospital mortality rate was 43.3%. Compared with survivors, nonsurvivors exhibited significantly less negative GLS (−13.1 ± 3.3% versus −15.8 ± 2.9%; p < 0.001), which reflected worse LV systolic function. The area under the ROC curves of GLS for the prediction of mortality was 0.76 (95% CI 0.67 to 0.87). Patients with GLS > −14.1% showed a significantly higher mortality rate (67.7% versus 15.6%; p < 0.0001; log‐rank = 23.3; p < 0.0001). In the multivariate analysis, GLS (HR, 1.27; 95% CI 1.07 to 1.50, p = 0.005) and SOFA scores (HR, 1.27; 95% CI 1.08 to 1.50, p = 0.004) were independent predictors of in-hospital mortality.

Conclusions

Our study indicated that LV systolic function measured by STE might be associated with mortality in patients with septic shock.

Mortality risk stratification using artificial intelligence-augmented electrocardiogram in cardiac intensive care unit patients

AIMS

An artificial intelligence-augmented electrocardiogram (AI-ECG) algorithm can identify left ventricular systolic dysfunction (LVSD). We sought to determine whether this AI-ECG algorithm could stratify mortality risk in cardiac intensive care unit (CICU) patients, independent of the presence of LVSD by transthoracic echocardiography (TTE).

METHODS AND RESULTS

We included 11 266 unique Mayo Clinic CICU patients admitted from 2007 to 2018 who underwent AI-ECG after CICU admission. Left ventricular ejection fraction (LVEF) data were extracted for patients with a TTE during hospitalization. Hospital mortality was analysed using multivariable logistic regression. Mean age was 68 ± 15 years, including 37% females. Higher AI-ECG probability of LVSD remained associated with higher hospital mortality [adjusted odds ratio (OR) 1.05 per 0.1 higher, 95% confidence interval (CI) 1.02-1.08, P = 0.003] after adjustment for LVEF, which itself was inversely related with the risk of hospital mortality (adjusted OR 0.96 per 5% higher, 95% CI 0.93-0.99, P = 0.02). Patients with available LVEF data (n = 8242) were divided based on the presence of predicted (by AI-ECG) vs. observed (by TTE) LVSD (defined as LVEF ≤ 35%), using TTE as the gold standard. A stepwise increase in hospital mortality was observed for patients with a true negative, false positive, false negative, and true positive AI-ECG.

CONCLUSION

The AI-ECG prediction of LVSD is associated with hospital mortality in CICU patients, affording risk stratification in addition to that provided by echocardiographic LVEF. Our results emphasize the prognostic value of electrocardiographic patterns reflecting underlying myocardial disease that are recognized by the AI-ECG.

Subclinical Left Ventricular Systolic Dysfunction in Patients with Septic Shock Based on Sepsis-3 Definition: A Speckle-Tracking Echocardiography Study

Introduction

Left ventricular dysfunction is quite common in septic shock. Speckle-tracking echocardiography (STE) is a novel, highly sensitive method for assessing left ventricular function, capable of detecting subclinical myocardial dysfunction, which is not identified with conventional echocardiography. We sought to evaluate subclinical left ventricular systolic function in patients with septic shock using speckle-tracking echocardiography.

Methods

From May 2017 to December 2018, patients aged ≥18 years admitted to the intensive care unit with the diagnosis of sepsis and septic shock based on the sepsis-3 definition were included. Patients with other causes of cardiac dysfunction were excluded. Transthoracic echocardiography was performed for all the patients within 24 hours of diagnosis. Left ventricular systolic function was assessed using conventional echocardiography and speckle-tracking echocardiography.

Results

Patients with septic shock (n = 90) (study group) and 37 matched patients with sepsis but no septic shock (control group) were included. Left ventricular ejection fraction (LVEF) by conventional echocardiography showed no significant difference between two groups (58.2 ± 9.9 vs. 58.6 ± 8.3, p=0.804). The global longitudinal strain (GLS) by STE was significantly reduced in patients with septic shock compared with that in the control (−14.6 ± 3.3 vs. −17.1 ± 3.3, p < 0.001). Based on the cutoff value of GLS ≥ −15% for the definition of subclinical left ventricular systolic dysfunction, this dysfunction was detected in 50 patients with septic shock (55.6%) and in 6 patients in the control group (16.2%) (p < 0.05).

Conclusions

Speckle-tracking echocardiography can detect early subclinical left ventricular systolic dysfunction via the left ventricular global longitudinal strain compared with conventional echocardiographic parameters in patients with septic shock.

Reporting of sex as a variable in cardiovascular studies using cultured cells: A systematic review

Reporting the sex of biological material is critical for transparency and reproducibility in science. This study examined the reporting of the sex of cells used in cardiovascular studies. Articles from 16 cardiovascular journals that publish peer-reviewed studies in cardiovascular physiology and pharmacology in the year 2018 were systematically reviewed using terms "cultured" and "cells." Data were collected on the sex of cells, the species from which the cells were isolated, and the type of cells, and summarized as a systematic review. Sex was reported in 88 (38.6%) of the 228 studies meeting inclusion criteria. Reporting rates varied with Circulation, Cardiovascular Research and American Journal of Physiology: Heart and Circulatory Physiology having the highest rates of sex reporting (>50%). A majority of the studies used cells from male (54.5%) or both male and female animals (32.9%). Humans (31.8%), rats (20.4%), and mice (43.8%) were the most common sources for cells. Cardiac myocytes were the most commonly used cell type (37.0%). Overall reporting of sex of experimental material remains below 50% and is inconsistent among journals. Sex chromosomes in cells have the potential to affect protein expression and molecular signaling pathways and should be consistently reported.

How to diagnose heart failure with preserved ejection fraction: the HFA-PEFF diagnostic algorithm: a consensus recommendation from the Heart Failure Association (HFA) of the European Society of Cardiology (ESC)

Making a firm diagnosis of chronic heart failure with preserved ejection fraction (HFpEF) remains a challenge. We recommend a new stepwise diagnostic process, the 'HFA-PEFF diagnostic algorithm'. Step 1 (P=Pre-test assessment) is typically performed in the ambulatory setting and includes assessment for heart failure symptoms and signs, typical clinical demographics (obesity, hypertension, diabetes mellitus, elderly, atrial fibrillation), and diagnostic laboratory tests, electrocardiogram, and echocardiography. In the absence of overt non-cardiac causes of breathlessness, HFpEF can be suspected if there is a normal left ventricular (LV) ejection fraction, no significant heart valve disease or cardiac ischaemia, and at least one typical risk factor. Elevated natriuretic peptides support, but normal levels do not exclude a diagnosis of HFpEF. The second step (E: Echocardiography and Natriuretic Peptide Score) requires comprehensive echocardiography and is typically performed by a cardiologist. Measures include mitral annular early diastolic velocity (e'), LV filling pressure estimated using E/e', left atrial volume index, LV mass index, LV relative wall thickness, tricuspid regurgitation velocity, LV global longitudinal systolic strain, and serum natriuretic peptide levels. Major (2 points) and Minor (1 point) criteria were defined from these measures. A score ≥5 points implies definite HFpEF; ≤1 point makes HFpEF unlikely. An intermediate score (2-4 points) implies diagnostic uncertainty, in which case Step 3 (F₁ : Functional testing) is recommended with echocardiographic or invasive haemodynamic exercise stress tests. Step 4 (F₂ : Final aetiology) is recommended to establish a possible specific cause of HFpEF or alternative explanations. Further research is needed for a better classification of HFpEF.

Natriuretic Peptides to Predict Short-Term Mortality in Patients With Sepsis: A Systematic Review and Meta-analysis

Data are conflicting regarding the optimal cutoffs of B-type natriuretic peptide (BNP) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) to predict short-term mortality in patients with sepsis. We conducted a comprehensive search of several databases (MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Scopus) for English-language reports of studies evaluating adult patients with sepsis, severe sepsis, and septic shock with BNP/NT-proBNP levels and short-term mortality (intensive care unit, in-hospital, 28-day, or 30-day) published from January 1, 2000, to September 5, 2017. The average values in survivors and nonsurvivors were used to estimate the receiver operating characteristic curve (ROC) using a parametric regression model. Thirty-five observational studies (3508 patients) were included (median age, 51-75 years; 12%-74% males; cumulative mortality, 34.2%). A BNP of 622 pg/mL had the greatest discrimination for mortality (sensitivity, 0.695 [95% CI, 0.659-0.729]; specificity, 0.907 [95% CI, 0.810-1.003]; area under the ROC, 0.766 [95% CI, 0.734-0.797]). An NT-proBNP of 4000 pg/mL had the greatest discrimination for mortality (sensitivity, 0.728 [95% CI, 0.703-0.753]; specificity, 0.789 [95% CI, 0.710-0.867]; area under the ROC, 0.787 [95% CI, 0.766-0.809]). In prespecified subgroup analyses, identified BNP/NT-proBNP cutoffs had higher discrimination if specimens were obtained 24 hours or less after admission, in patients with severe sepsis/septic shock, in patients enrolled after 2010, and in studies performed in the United States and Europe. There was inconsistent adjustment for renal function. In this hypothesis-generating analysis, BNP and NT-proBNP cutoffs of 622 pg/mL and 4000 pg/mL optimally predicted short-term mortality in patients with sepsis. The applicability of these results is limited by the heterogeneity of included patient populations.

Complications of Temporary Percutaneous Mechanical Circulatory Support for Cardiogenic Shock: An Appraisal of Contemporary Literature

Cardiogenic shock (CS) is associated with hemodynamic compromise and end-organ hypoperfusion due to a primary cardiac etiology. In addition to vasoactive medications, percutaneous mechanical circulatory support (MCS) devices offer the ability to support the hemodynamics and prevent acute organ failure. Despite the wide array of available MCS devices for CS, there are limited data on the complications from these devices. In this review, we seek to summarize the complications of MCS devices in the contemporary era. Using a systems-based approach, this review covers domains of hematological, neurological, vascular, infectious, mechanical, and miscellaneous complications. These data are intended to provide a balanced narrative and aid in risk-benefit decision-making in this acutely ill population.

Prognosis of β-adrenergic blockade therapy on septic shock and sepsis: A systematic review and meta-analysis of randomized controlled studies

PURPOSE

β-adrenoceptor antagonist (β-blocker) may have potential in the treatment of septic shock and sepsis. However, the relevant research findings are still controversial.

METHODS

We conducted a systematic review and meta-analysis to explore the efficacy of β-blocker in patients with septic shock and sepsis. The primary sources of the reviewed studies through August 2018, with restriction on the language of English, were Pubmed and Embase. Randomized controlled trials (RCT) were included to evaluate the efficacy of β-blocker in the treatment of septic shock and sepsis. Meta analysis was performed using a random effect model. Two researchers independently searched articles, extracted data, and assessed the quality of the included studies.

RESULTS

A total of 6 studies related to 5 original RCTs were qualified for inclusion in this systematic review and meta-analysis with a total of 363 patients with sepsis and/or septic shock. β-blocker was associated with a significantly decreased 28-day mortality compared to usual treatment group as the control (RR = 0.59, 95%CI: 0.48, 0.74; P < 0.00001). Heart rate in β-blocker was significantly lower than that in the standard care group (SMD = -2.01, 95%CI: -3.03, -0.98; P = 0001).

CONCLUSION

β-blocker of esmolol is safe and effective in improving 28-day mortality and controlling ventricular rate in patients with sepsis after fluid resuscitation, and has no significant adverse effect on tissue perfusion.

The role of natriuretic peptides in the management, outcomes and prognosis of sepsis and septic shock

Sepsis continues to be a leading public health burden in the United States and worldwide. With the increasing use of advanced laboratory technology, there is a renewed interest in the use of biomarkers in sepsis to aid in more precise and targeted decision-making. Natriuretic peptides have been increasingly recognized to play a role outside of heart failure. They are commonly elevated among critically ill patients in the setting of cardiopulmonary dysfunction and may play a role in identifying patients with sepsis and septic shock. There are limited data on the role of these biomarkers in the diagnosis, management, outcomes and prognosis of septic patients. This review seeks to describe the role of natriuretic peptides in fluid resuscitation, diagnosis of ventricular dysfunction and outcomes and the prognosis of patients with sepsis. B-type natriuretic peptide (BNP) and N-terminal pro-BNP (NT-proBNP) have been noted to be associated with left ventricular systolic and diastolic and right ventricular dysfunction in patients with septic cardiomyopathy. BNP/NT-proBNP may predict fluid responsiveness, and trends of these peptides may play a role in fluid resuscitation. Despite suggestions of a correlation with mortality, the role of BNP in mortality outcomes and prognosis during sepsis needs further evaluation.

Myocardial caspase-3 and NF-κB activation promotes calpain-induced septic apoptosis: The role of Akt/eNOS/NO pathway

AIMS

To explore the potential mechanism that the role of the Akt/eNOS/NO pathway in calpain-induced caspase-3 and NF-κB activation during septic apoptosis.

MAIN METHODS

Septic rats were stimulated by LPS (8 mg/kg, i.p.). Myocardial calpain, caspase-3, NO, TNF-α and IL-1β levels were detected by ELISA. The levels of Akt/p-Akt, eNOS/p-eNOS, iNOS proteins and number of apoptotic cells were evaluated by immunohistochemistry, western blot and TUNEL method.

KEY FINDINGS

Compared with sham, LPS treatment resulted in 4.1-fold and 1.8-fold increases in myocardial calpain activity and caspase-3 activation, respectively, and a significant increase (6.8-fold) in apoptotic cardiomyocytes was observed. The administration of calpain inhibitors (calpain inhibitor-IV, PD150606 and PD151746) showed that p-Akt and p-eNOS protein levels were correlated with the levels of LPS-induced myocardial calpain and caspase-3 activity. In addition, the quantity of p-Akt protein and NO content were markedly attenuated by wortmannin, a phosphoinositide 3-kinase (PI3K) inhibitor. Pretreatment with L-NAME, an NOS inhibitor, induced a decrease in p-eNOS proteins and apoptosis in myocardial tissues, while iNOS proteins were strongly increased in septic rats.

SIGNIFICANCE

This study suggests that the Akt/eNOS/NO pathway might lead to a novel pharmacological therapy for cardiomyocytes apoptosis in sepsis.

Inflammasomes: Pandora's box for sepsis

Sepsis was known to ancient Greeks since the time of great physician Hippocrates (460-377 BC) without exact information regarding its pathogenesis. With time and medical advances, it is now considered as a condition associated with organ dysfunction occurring in the presence of systemic infection as a result of dysregulation of the immune response. Still with this advancement, we are struggling for the development of target-based therapeutic approach for the management of sepsis. The advancement in understanding the immune system and its working has led to novel discoveries in the last 50 years, including different pattern recognition receptors. Inflammasomes are also part of these novel discoveries in the field of immunology which are <20 years old in terms of their first identification. They serve as important cytosolic pattern recognition receptors required for recognizing cytosolic pathogens, and their pathogen-associated molecular patterns play an important role in the pathogenesis of sepsis. The activation of both canonical and non-canonical inflammasome signaling pathways is involved in mounting a proinflammatory immune response via regulating the generation of IL-1β, IL-18, IL-33 cytokines and pyroptosis. In addition to pathogens and their pathogen-associated molecular patterns, death/damage-associated molecular patterns and other proinflammatory molecules involved in the pathogenesis of sepsis affect inflammasomes and vice versa. Thus, the present review is mainly focused on the inflammasomes, their role in the regulation of immune response associated with sepsis, and their targeting as a novel therapeutic approach.

Doppler-defined pulmonary hypertension in sepsis and septic shock

BACKGROUND

The association of pulmonary hypertension (PH) in patients with sepsis is lesser understood.

METHODS

This was a retrospective study of adult patients admitted to the intensive care unit during 2007-2014 for sepsis and septic shock, with echocardiography performed <72 h. PH was defined as tricuspid regurgitation peak velocity (TRV) > 3 m/s on Doppler echocardiography. Patients with prior PH, pulmonary stenosis, or without measurable TRV were excluded. Outcomes included 28-day mortality, one-year survival and length of stay.

RESULTS

Eighty-three, of 241 (34.4%) patients included, had PH. Patients with PH were older and had greater cardiovascular comorbidity but similar illness severity, including acute respiratory distress syndrome and mechanical ventilation use. PH was an independent predictor of 28-day mortality (odds ratio 3.6 [95% confidence interval 1.1-12.5] p = .04). In a proportional hazards model, PH was an independent predictor of one-year survival (hazard ratio 1.7 [95% confidence interval 1.1-2.7]; p = .03). Severity of PH was associated with worse one-year survival but not 28-day mortality.

CONCLUSIONS

In patients with sepsis and septic shock, PH is common and is noted to be associated with higher short and long-term mortality. Further studies are needed to understand the mechanisms by which PH is associated with outcomes.

Acute pancreatitis-induced takotsubo cardiomyopathy and cardiogenic shock treated with a percutaneous left ventricular assist device

A 63-year-old man was admitted for severe acute pancreatitis. On day 3 of hospitalisation, he developed shortness of breath and acute pulmonary oedema. Echocardiogram revealed global hypokinesis with a left ventricular ejection fraction of 20%, and he was diagnosed with takotsubo cardiomyopathy. He developed cardiogenic shock which was treated successfully with a percutaneous left ventricular assist device. His left ventricular ejection fraction improved by hospital follow-up 3 weeks later.

Effect of Xuefu Zhuyu Decoction Pretreatment on Myocardium in Sepsis Rats

Xuefu Zhuyu Decoction (XFZYD), the classical recipe for promoting blood circulation by removing blood stasis, has been used in China for a long history clinically. XFZYD has been found to improve cardiac function through reducing inflammation. However, the effect of XFZYD on myocardial apoptosis remains unclear. Herein, we investigated the mechanism of XFZYD preconditioning on myocardial injury in sepsis rats. The rats were treated with XFZYD one week, followed with intraperitoneal injection of lipopolysaccharide (LPS: 10 mg/kg) to induce sepsis. Pretreatment with XFZYD could reverse the effects of LPS-induced decreased mean arterial pressure (MAP) and increased heart rate (HR). XFZYD decreased the levels of malondialdehyde (MDA), superoxide dismutase (SOD), tumor necrosis factor-α (TNF-α), interleukin-1β (IL-1β), and interleukin-6 (IL-6) in serum or in heart. TUNEL staining revealed that the apoptotic index of XFZYD was significantly lower compared with the LPS group (P<0.05). Western blot results showed that the high doses of pretreatment XFZYD group can reduce the Bax expression of myocardial tissue in rats (P<0.05, P<0.01). The expression of Bcl-2 in XFZYD group was significantly higher than that in the LPS group (P<0.01), while the expression of caspase-3 in treatment group was significantly lower than that in the LPS group only after 12 h modeling (P<0.01). In addition, caspase-3 activity in rat cardiomyocytes of XFZYD-treated animals was significantly decreased. These findings suggest that pretreatment with XFZYD exerts a protective effect in the myocardium of septic rats by inhibiting myocardial cell apoptosis and antioxidation.

Global Longitudinal Strain Using Speckle-Tracking Echocardiography as a Mortality Predictor in Sepsis: A Systematic Review

The data on speckle-tracking echocardiography (STE) in patients with sepsis are limited. This systematic review from 1975 to 2016 included studies in adults and children evaluating cardiovascular dysfunction in sepsis, severe sepsis, and septic shock utilizing STE for systolic global longitudinal strain (GLS). The primary outcome was short- or long-term mortality. Given the significant methodological and statistical differences between published studies, combining the data using meta-analysis methods was not appropriate. A total of 120 studies were identified, with 5 studies (561 patients) included in the final analysis. All studies were prospective observational studies using the 2001 criteria for defining sepsis. Three studies demonstrated worse systolic GLS to be associated with higher mortality, whereas 2 did not show a statistically significant association. Various cutoffs between -10% and -17% were used to define abnormal GLS across studies. This systematic review revealed that STE may predict mortality in patients with sepsis; however, the strength of evidence is low due to heterogeneity in study populations, GLS technologies, cutoffs, and timing of STE. Further dedicated studies are needed to understand the optimal application of STE in patients with sepsis.