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Forner J, Weidner K, Rusnak J, Dudda J, Behnes M, Akin I, Schupp T. Prognostic Impact of Left Compared to Right Heart Function in Sepsis and Septic Shock. ASAIO J 2024; 70:502-509. [PMID: 38237636 DOI: 10.1097/mat.0000000000002131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2024] Open
Abstract
This study investigates the prognostic impact of left ventricular ejection fraction (LVEF) and tricuspid annular plane systolic excursion (TAPSE) in patients with sepsis and septic shock. Consecutive patients with sepsis and septic shock were included from 2019 to 2021. LVEF and TAPSE were assessed during the first 24 hours of intensive care unit (ICU) treatment. Patients were stratified by LVEF of less than 45% and greater than or equal to 45%. The primary endpoint was 30 day all-cause mortality. Two hundred ninety-two consecutive patients were included, of which 26% presented with LVEF of less than 45%. Within the entire study cohort (60% vs. 48%; hazard ratio [HR] = 1.414; 95% confidence interval [CI] = 0.999-2.001; p = 0.050) and specifically in patients with sepsis (58% vs. 36%; HR = 1.919; 95% CI = 1.148-3.208; p = 0.013), LVEF of less than 45% was associated with an increased risk of 30 day all-cause mortality, whereas TAPSE of less than 17 mm was not (56% vs. 52%; log rank p = 0.798). Even after multivariable adjustment, LVEF of less than 45% was accompanied by a worse prognosis in septic patients (HR = 1.944; 95% CI = 1.084-3.485; p = 0.026). Contrarily, LVEF < 45% was not accompanied with increased mortality in septic shock patients (63% vs. 67%; log rank p = 0.847; HR = 0.956; 95% CI 0.596-1.533; p = 0.853). In conclusion, impaired LVEF was associated with increased mortality in septic patients without shock, but not in patients with septic shock. In contrast, impaired right ventricular function was not associated with adverse prognosis in both conditions.
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Affiliation(s)
- Jan Forner
- From the Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
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2
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Hendrickson KW, Cirulis MM, Burk RE, Lanspa MJ, Peltan ID, Marshall H, Groat D, Jephson A, Beesley SJ, Brown SM. Identifying predictors and determining mortality rates of septic cardiomyopathy and sepsis-related cardiogenic shock: A retrospective, observational study. PLoS One 2024; 19:e0299876. [PMID: 38662672 PMCID: PMC11045062 DOI: 10.1371/journal.pone.0299876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 02/16/2024] [Indexed: 04/28/2024] Open
Abstract
INTRODUCTION Septic shock is a severe form of sepsis that has a high mortality rate, and a substantial proportion of these patients will develop cardiac dysfunction, often termed septic cardiomyopathy (SCM). Some SCM patients may develop frank cardiac failure, termed sepsis-related cardiogenic shock (SeRCS). Little is known of SeRCS. This study describes baseline characteristics of patients with SCM and SeRCS compared to patients with septic shock without cardiac dysfunction. We compare clinical outcomes among SCM, SeRCS, and septic shock, and identify risk factors for the development of SCM and SeRCS. METHODS Septic patients admitted to the ICU with an echocardiogram obtained within 72 hours were included. Left ventricular ejection fraction of ≤55% was used to define SCM, and cardiac index ≤2.1 L/min/m2 among patients with SCM defined SeRCS. Machine learning was used to identify risk factors for development of SCM and SeRCS. Logistic regression was used to compare mortality among groups. RESULTS Among 1229 patients, 977 patients had septic shock without cardiac dysfunction, 207 had SCM, and 45 had SeRCS. In patients with septic shock, the strongest predictor for developing SCM and SeRCs was a prior history of cardiac dysfunction. Mortality did not significantly differ among the three groups. CONCLUSIONS SCM and SeRCS affect a minority of patients with septic shock, disproportionately affecting individuals with a history of cardiac disease. We did not identify a mortality difference associated with SCM or SeRCS. Additional work is needed to define further subtypes and treatment options for this patient population.
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Affiliation(s)
- Kathryn W. Hendrickson
- The Oregon Clinic Department of Pulmonary, Critical Care, and Sleep Medicine East, Portland, OR, United States of America
| | - Meghan M. Cirulis
- Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Salt Lake City, UT, United States of America
- Division of Pulmonary and Critical Care Medicine, University of Utah, Salt Lake City, UT, United States of America
| | - Rebecca E. Burk
- Renown Medical Group Department of Pulmonary and Critical Care Medicine, Reno, NV, United States of America
| | - Michael J. Lanspa
- Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Salt Lake City, UT, United States of America
- Division of Pulmonary and Critical Care Medicine, University of Utah, Salt Lake City, UT, United States of America
| | - Ithan D. Peltan
- Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Salt Lake City, UT, United States of America
- Division of Pulmonary and Critical Care Medicine, University of Utah, Salt Lake City, UT, United States of America
| | - Hunter Marshall
- Division of Pulmonary and Critical Care Medicine, University of Utah, Salt Lake City, UT, United States of America
| | - Danielle Groat
- Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Salt Lake City, UT, United States of America
- Intermountain Healthcare, Information and Analytics, Salt Lake City, UT, United States of America
| | - Al Jephson
- Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Salt Lake City, UT, United States of America
- Intermountain Healthcare, Information and Analytics, Salt Lake City, UT, United States of America
| | - Sarah J. Beesley
- Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Salt Lake City, UT, United States of America
- Division of Pulmonary and Critical Care Medicine, University of Utah, Salt Lake City, UT, United States of America
| | - Samuel M. Brown
- Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Salt Lake City, UT, United States of America
- Division of Pulmonary and Critical Care Medicine, University of Utah, Salt Lake City, UT, United States of America
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3
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Pruszczyk A, Zawadka M, Andruszkiewicz P, LaVia L, Herpain A, Sato R, Dugar S, Chew MS, Sanfilippo F. Mortality in patients with septic cardiomyopathy identified by longitudinal strain by speckle tracking echocardiography: An updated systematic review and meta-analysis with trial sequential analysis. Anaesth Crit Care Pain Med 2024; 43:101339. [PMID: 38128732 DOI: 10.1016/j.accpm.2023.101339] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Revised: 11/27/2023] [Accepted: 12/04/2023] [Indexed: 12/23/2023]
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 a 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 a mean difference (MD) of -1.45%[-2.10, -0.80] (p < 0.0001;I2 = 42%). No subgroup differences were found stratifying studies according to number of views used to calculate LS (p = 0.31;I2 = 16%), severity of sepsis (p = 0.42;I2 = 0%), and sepsis criteria (p = 0.59;I2 = 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;I2 = 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. REGISTRATION PROSPERO number CRD42023432354.
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Affiliation(s)
- Andrzej Pruszczyk
- 2nd Department of Anesthesiology and Intensive Care, Medical University of Warsaw, Poland
| | - Mateusz Zawadka
- 2nd Department of Anesthesiology and Intensive Care, Medical University of Warsaw, Poland
| | - Pawel Andruszkiewicz
- 2nd Department of Anesthesiology and Intensive Care, Medical University of Warsaw, Poland
| | - Luigi LaVia
- Department of Anesthesia and Intensive Care, "Policlinico-San Marco" University Hospital, Catania, Italy
| | - Antoine Herpain
- Department of Intensive Care, St.-Pierre University Hospital, Université Libre de Bruxelles, 1050 Brussels, Belgium; Experimental Laboratory of Intensive Care, Université Libre de Bruxelles, 1050 Brussels, Belgium
| | - Ryota Sato
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Siddharth Dugar
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Michelle S Chew
- Department of Anaesthesia and Intensive Care, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Filippo Sanfilippo
- Department of Anesthesia and Intensive Care, "Policlinico-San Marco" University Hospital, Catania, Italy; Department of General Surgery and Medico-Surgical Specialties, School of Anaesthesia and Intensive Care, University of Catania, Catania, Italy.
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4
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Ramasco F, Aguilar G, Aldecoa C, Bakker J, Carmona P, Dominguez D, Galiana M, Hernández G, Kattan E, Olea C, Ospina-Tascón G, Pérez A, Ramos K, Ramos S, Tamayo G, Tuero G. Towards the personalization of septic shock resuscitation: the fundamentals of ANDROMEDA-SHOCK-2 trial. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2024; 71:112-124. [PMID: 38244774 DOI: 10.1016/j.redare.2024.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 07/04/2023] [Indexed: 01/22/2024]
Abstract
Septic shock is a highly lethal and prevalent disease. Progressive circulatory dysfunction leads to tissue hypoperfusion and hypoxia, eventually evolving to multiorgan dysfunction and death. Prompt resuscitation may revert these pathogenic mechanisms, restoring oxygen delivery and organ function. High heterogeneity exists among the determinants of circulatory dysfunction in septic shock, and current algorithms provide a stepwise and standardized approach to conduct resuscitation. This review provides the pathophysiological and clinical rationale behind ANDROMEDA-SHOCK-2, an ongoing multicenter randomized controlled trial that aims to compare a personalized resuscitation strategy based on clinical phenotyping and peripheral perfusion assessment, versus standard of care, in early septic shock resuscitation.
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Affiliation(s)
- F Ramasco
- Hospital Universitario de La Princesa, Madrid, Spain.
| | - G Aguilar
- Hospital Clínico Universitario de Valencia, Spain
| | - C Aldecoa
- Hospital Universitario Río Hortega, Valladolid, Spain
| | - J Bakker
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Región Metropolitana, Chile; The Latin American Intensive Care Network (LIVEN); Department of Intensive Care, Erasmus MC University Medical Center, Rotterdam, Netherlands; Division of Pulmonary Critical Care, and Sleep Medicine, New York University and Columbia University, New York, USA
| | - P Carmona
- Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - D Dominguez
- Hospital Universitario Ntra. Sra. de Candelaria, Santa Cruz de Tenerife, Spain
| | - M Galiana
- Hospital General Universitario Doctor Balmis, Alicante, Spain
| | - G Hernández
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Región Metropolitana, Chile; The Latin American Intensive Care Network (LIVEN)
| | - E Kattan
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Región Metropolitana, Chile; The Latin American Intensive Care Network (LIVEN)
| | - C Olea
- Hospital Universitario 12 de Octubre, Madrid. Spain
| | - G Ospina-Tascón
- The Latin American Intensive Care Network (LIVEN); Department of Intensive Care, Fundación Valle del Lili, Cali, Colombia; Translational Research Laboratory in Critical Care Medicine (TransLab-CCM), Universidad Icesi, Cali, Colombia
| | - A Pérez
- Hospital General Universitario de Elche, Spain
| | - K Ramos
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Región Metropolitana, Chile; The Latin American Intensive Care Network (LIVEN)
| | - S Ramos
- Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - G Tamayo
- Hospital Universitario de Cruces, Baracaldo, Vizcaya, Spain
| | - G Tuero
- Hospital Can Misses, Ibiza, Spain
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5
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Gonzalez FA, Santonocito C, Maybauer MO, Lopes LR, Almeida AG, Sanfilippo F. Diastology in the intensive care unit: Challenges for the assessment and future directions. Echocardiography 2024; 41:e15773. [PMID: 38380688 DOI: 10.1111/echo.15773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Revised: 01/19/2024] [Accepted: 01/20/2024] [Indexed: 02/22/2024] Open
Abstract
Myocardial dysfunction is common in patients admitted to the intensive care unit (ICU). Septic disease frequently results in cardiac dysfunction, and sepsis represents the most common cause of admission and death in the ICU. The association between left ventricular (LV) systolic dysfunction and mortality is not clear for critically ill patients. Conversely, LV diastolic dysfunction (DD) seems increasingly recognized as a factor associated with poor outcomes, not only in sepsis but also more generally in critically ill patients. Despite recent attempts to simplify the diagnosis and grading of DD, this remains relatively complex, with the need to use several echocardiographic parameters. Furthermore, the current guidelines have several intrinsic limitations when applied to the ICU setting. In this manuscript, we discuss the challenges in DD classification when applied to critically ill patients, the importance of left atrial pressure estimates for the management of patients in ICU, and whether the study of cardiac dysfunction spectrum during critical illness may benefit from the integration of left ventricular and left atrial strain data to improve diagnostic accuracy and implications for the treatment and prognosis.
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Affiliation(s)
- Filipe A Gonzalez
- Intensive Care Department of Hospital Garcia de Orta, Almada, Portugal
- Centro Cardiovascular da Universidade de Lisboa, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Cristina Santonocito
- Department of Anesthesia and Intensive Care, "Policlinico-San Marco" University Hospital, Catania, Italy
| | - Marc O Maybauer
- Department of Anesthesiology, Division of Critical Care Medicine, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Luís Rocha Lopes
- Inherited Cardiac Disease Unit, Bart's Heart Centre St Bartholomew's Hospital London, London, UK
- Institute of Cardiovascular Science, University College London, London, UK
| | - Ana G Almeida
- Centro Cardiovascular da Universidade de Lisboa, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Filippo Sanfilippo
- Department of Anesthesia and Intensive Care, "Policlinico-San Marco" University Hospital, Catania, Italy
- Department of Surgery and Medical-Surgical Specialties, University of Catania, Catania, Italy
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6
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Sanfilippo F, Messina A, Scolletta S, Bignami E, Morelli A, Cecconi M, Landoni G, Romagnoli S. The "CHEOPS" bundle for the management of Left Ventricular Diastolic Dysfunction in critically ill patients: an experts' opinion. Anaesth Crit Care Pain Med 2023; 42:101283. [PMID: 37516408 DOI: 10.1016/j.accpm.2023.101283] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Revised: 07/18/2023] [Accepted: 07/19/2023] [Indexed: 07/31/2023]
Abstract
The impact of left ventricular (LV) diastolic dysfunction (DD) on the outcome of patients with heart failure was established over three decades ago. Nevertheless, the relevance of LVDD for critically ill patients admitted to the intensive care unit has seen growing interest recently, and LVDD is associated with poor prognosis. Whilst an assessment of LV diastolic function is desirable in critically ill patients, treatment options for LVDD are very limited, and pharmacological possibilities to rapidly optimize diastolic function have not been found yet. Hence, a proactive approach might have a substantial role in improving the outcomes of these patients. Recalling historical Egyptian parallelism suggesting that Doppler echocardiography has been the "Rosetta stone" to decipher the study of LV diastolic function, we developed a potentially useful acronym for physicians at the bedside to optimize the management of critically ill patients with LVDD with the application of the bundle. We summarized the bundle under the acronym of the famous ancient Egyptian pharaoh CHEOPS: Chest Ultrasound, combining information from echocardiography and lung ultrasound; HEmodynamics assessment, with careful evaluation of heart rate and rhythm, as well as afterload and vasoactive drugs; OPtimization of mechanical ventilation and pulmonary circulation, considering the effects of positive end-expiratory pressure on both right and left heart function; Stabilization, with cautious fluid administration and prompt fluid removal whenever judged safe and valuable. Notably, the CHEOPS bundle represents experts' opinion and are not targeted at the initial resuscitation phase but rather for the optimization and subsequent period of critical illness.
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Affiliation(s)
- Filippo Sanfilippo
- Department of Anaesthesia and Intensive Care, A.O.U. Policlinico-San Marco, Catania, Italy; Department of General Surgery and Medico-Surgical Specialties, School of Anaesthesia and Intensive Care, University of Catania, Catania, Italy.
| | - Antonio Messina
- Department of Anesthesia and Intensive Care Medicine, Humanitas Clinical and Research Center IRCCS, 20089, Rozzano, Milan, Italy.
| | - Sabino Scolletta
- Anesthesia and Intensive Care Unit, University Hospital of Siena, University of Siena, Siena, Italy.
| | - Elena Bignami
- Anesthesiology, Critical Care and Pain Medicine Division, Department of Medicine and Surgery, University of Parma, Parma, Italy.
| | - Andrea Morelli
- Department Clinical Internal, Anesthesiological and Cardiovascular Sciences, University of Rome, "La Sapienza", Policlinico Umberto Primo, Roma, Italy.
| | - Maurizio Cecconi
- Department of Anesthesia and Intensive Care Medicine, Humanitas Clinical and Research Center IRCCS, 20089, Rozzano, Milan, Italy.
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Faculty of Medicine, Vita-Salute San Raffaele University, Milan, Italy.
| | - Stefano Romagnoli
- Department of Health Science, Section of Anaesthesia and Intensive Care, University of Florence, Department of Anetshesia and Critical Care, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy.
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7
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Pei XB, Liu B. Research Progress on the Mechanism and Management of Septic Cardiomyopathy: A Comprehensive Review. Emerg Med Int 2023; 2023:8107336. [PMID: 38029224 PMCID: PMC10681771 DOI: 10.1155/2023/8107336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 11/08/2023] [Accepted: 11/13/2023] [Indexed: 12/01/2023] Open
Abstract
Sepsis is defined as a kind of life-threatening organ dysfunction due to a dysregulated host immune response to infection and is a leading cause of mortality in the intensive care unit. Sepsis-induced myocardial dysfunction, also called septic cardiomyopathy, is a common and serious complication in patients with sepsis, which may indicate a bad prognosis. Although efforts have been made to uncover the pathophysiology of septic cardiomyopathy, a number of uncertainties remain. This article sought to review available literature to summarize the existing knowledge on current diagnostic tools and biomarkers, pathogenesis, and treatments for septic cardiomyopathy.
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Affiliation(s)
- Xue-Bin Pei
- Emergency Medicine Clinical Research Center, Beijing Chao-Yang Hospital, Capital Medical University, Beijing 100020, China
| | - Bo Liu
- Department of Emergency Medicine, Beijing YouAn Hospital, Capital Medical University, Beijing 100069, China
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8
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Fan Y, Guan B, Xu J, Zhang H, Yi L, Yang Z. Role of toll-like receptor-mediated pyroptosis in sepsis-induced cardiomyopathy. Biomed Pharmacother 2023; 167:115493. [PMID: 37734261 DOI: 10.1016/j.biopha.2023.115493] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 09/08/2023] [Accepted: 09/12/2023] [Indexed: 09/23/2023] Open
Abstract
Sepsis, a life-threatening dysregulated status of the host response to infection, can cause multiorgan dysfunction and mortality. Sepsis places a heavy burden on the cardiovascular system due to the pathological imbalance of hyperinflammation and immune suppression. Myocardial injury and cardiac dysfunction caused by the aberrant host responses to pathogens can lead to cardiomyopathy, one of the most critical complications of sepsis. However, many questions about the specific mechanisms and characteristics of this complication remain to be answered. The causes of sepsis-induced cardiac dysfunction include abnormal cardiac perfusion, myocardial inhibitory substances, autonomic dysfunction, mitochondrial dysfunction, and calcium homeostasis dysregulation. The fight between the host and pathogens acts as the trigger for sepsis-induced cardiomyopathy. Pyroptosis, a form of programmed cell death, plays a critical role in the progress of sepsis. Toll-like receptors (TLRs) act as pattern recognition receptors and participate in innate immune pathways that recognize damage-associated molecular patterns as well as pathogen-associated molecular patterns to mediate pyroptosis. Notably, pyroptosis is tightly associated with cardiac dysfunction in sepsis and septic shock. In line with these observations, induction of TLR-mediated pyroptosis may be a promising therapeutic approach to treat sepsis-induced cardiomyopathy. This review focuses on the potential roles of TLR-mediated pyroptosis in sepsis-induced cardiomyopathy, to shed light on this promising therapeutic approach, thus helping to prevent and control septic shock caused by cardiovascular disorders and improve the prognosis of sepsis patients.
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Affiliation(s)
- Yixuan Fan
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China; Intensive Care Unit, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Baoyi Guan
- Department of Internal Medicine-Cardiovascular, The First Affiliated Hospital of Guangzhou University of Chinese Medicine
| | - Jianxing Xu
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China; Intensive Care Unit, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - He Zhang
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China; National Clinical Research Center for Chinese Medicine Cardiology, Beijing, China
| | - Liang Yi
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China; Intensive Care Unit, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China.
| | - Zhixu Yang
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China; Intensive Care Unit, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China.
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9
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Jakobsson G, Papareddy P, Andersson H, Mulholland M, Bhongir R, Ljungcrantz I, Engelbertsen D, Björkbacka H, Nilsson J, Manea A, Herwald H, Ruiz-Meana M, Rodríguez-Sinovas A, Chew M, Schiopu A. Therapeutic S100A8/A9 blockade inhibits myocardial and systemic inflammation and mitigates sepsis-induced myocardial dysfunction. Crit Care 2023; 27:374. [PMID: 37773186 PMCID: PMC10540409 DOI: 10.1186/s13054-023-04652-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 09/19/2023] [Indexed: 10/01/2023] Open
Abstract
BACKGROUND AND AIMS The triggering factors of sepsis-induced myocardial dysfunction (SIMD) are poorly understood and are not addressed by current treatments. S100A8/A9 is a pro-inflammatory alarmin abundantly secreted by activated neutrophils during infection and inflammation. We investigated the efficacy of S100A8/A9 blockade as a potential new treatment in SIMD. METHODS The relationship between plasma S100A8/A9 and cardiac dysfunction was assessed in a cohort of 62 patients with severe sepsis admitted to the intensive care unit of Linköping University Hospital, Sweden. We used S100A8/A9 blockade with the small-molecule inhibitor ABR-238901 and S100A9-/- mice for therapeutic and mechanistic studies on endotoxemia-induced cardiac dysfunction in mice. RESULTS In sepsis patients, elevated plasma S100A8/A9 was associated with left-ventricular (LV) systolic dysfunction and increased SOFA score. In wild-type mice, 5 mg/kg of bacterial lipopolysaccharide (LPS) induced rapid plasma S100A8/A9 increase and acute LV dysfunction. Two ABR-238901 doses (30 mg/kg) administered intraperitoneally with a 6 h interval, starting directly after LPS or at a later time-point when LV dysfunction is fully established, efficiently prevented and reversed the phenotype, respectively. In contrast, dexamethasone did not improve cardiac function compared to PBS-treated endotoxemic controls. S100A8/A9 inhibition potently reduced systemic levels of inflammatory mediators, prevented upregulation of inflammatory genes and restored mitochondrial function in the myocardium. The S100A9-/- mice were protected against LPS-induced LV dysfunction to an extent comparable with pharmacologic S100A8/A9 blockade. The ABR-238901 treatment did not induce an additional improvement of LV function in the S100A9-/- mice, confirming target specificity. CONCLUSION Elevated S100A8/A9 is associated with the development of LV dysfunction in severe sepsis patients and in a mouse model of endotoxemia. Pharmacological blockade of S100A8/A9 with ABR-238901 has potent anti-inflammatory effects, mitigates myocardial dysfunction and might represent a novel therapeutic strategy for patients with severe sepsis.
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Affiliation(s)
- Gabriel Jakobsson
- Department of Translational Medicine, Lund University, Lund, Sweden
- Cardiac Inflammation Research Group, Clinical Research Center, 91:12, Jan Waldenströms Gata 35, 21 428, Malmö, Sweden
| | | | - Henrik Andersson
- Department of Anaesthesia and Intensive Care, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Megan Mulholland
- Department of Clinical Sciences Malmö, Lund University, Lund, Sweden
| | - Ravi Bhongir
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Irena Ljungcrantz
- Department of Clinical Sciences Malmö, Lund University, Lund, Sweden
| | | | - Harry Björkbacka
- Department of Clinical Sciences Malmö, Lund University, Lund, Sweden
| | - Jan Nilsson
- Department of Clinical Sciences Malmö, Lund University, Lund, Sweden
| | - Adrian Manea
- Nicolae Simionescu Institute of Cellular Biology and Pathology, Bucharest, Romania
| | - Heiko Herwald
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Marisol Ruiz-Meana
- Cardiovascular Diseases Research Group, Vall d'Hebron Institut de Recerca, Vall d'Hebron Hospital Universitari, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares, Instituto de Salud Carlos III, Madrid, Spain
| | - Antonio Rodríguez-Sinovas
- Cardiovascular Diseases Research Group, Vall d'Hebron Institut de Recerca, Vall d'Hebron Hospital Universitari, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares, Instituto de Salud Carlos III, Madrid, Spain
| | - Michelle Chew
- Department of Anaesthesia and Intensive Care, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Alexandru Schiopu
- Department of Translational Medicine, Lund University, Lund, Sweden.
- Nicolae Simionescu Institute of Cellular Biology and Pathology, Bucharest, Romania.
- Department of Internal Medicine, Skane University Hospital, Lund, Sweden.
- Cardiac Inflammation Research Group, Clinical Research Center, 91:12, Jan Waldenströms Gata 35, 21 428, Malmö, Sweden.
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10
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Brault C, Zerbib Y, Mercado P, Diouf M, Michaud A, Tribouilloy C, Maizel J, Slama M. Mitral annular plane systolic excursion for assessing left ventricular systolic dysfunction in patients with septic shock. BJA OPEN 2023; 7:100220. [PMID: 37638090 PMCID: PMC10457489 DOI: 10.1016/j.bjao.2023.100220] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 05/19/2023] [Accepted: 07/20/2023] [Indexed: 08/29/2023]
Abstract
Background Using easy-to-determine bedside measurements, we developed an echocardiographic algorithm for predicting left ventricular ejection fraction (LVEF) and longitudinal strain (LVLS) in patients with septic shock. Methods We measured septal and lateral mitral annular plane systolic excursion (MAPSE), septal and lateral mitral S-wave velocity, and the left ventricular longitudinal wall fractional shortening in patients with septic shock. We used a conditional inference tree method to build a stratification algorithm. The left ventricular systolic dysfunction was defined as an LVEF <50%, an LVLS greater than -17%, or both. Results We included 71 patients (males: 61%; mean [standard deviation] age: 61 [15] yr). Septal MAPSE (cut-off: 1.2 cm) was the best predictor of left ventricular systolic dysfunction. The level of agreement between the septal MAPSE and the left ventricular systolic dysfunction was 0.525 [0.299-0.751]. A septal MAPSE ≥1.2 cm predicted normal LVEF in 17/18 patients, or 94%. In contrast, a septal MAPSE <1.2 cm predicted left ventricular systolic dysfunction with impaired LVLS in 46/53 patients (87%), although 32/53 (60%) patients had a preserved LVEF. Conclusions Septal MAPSE is easily measured at the bedside and might help clinicians to detect left ventricular systolic dysfunction early-especially when myocardial strain measurements are not feasible.
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Affiliation(s)
- Clément Brault
- Intensive Care Department, Amiens-Picardie University Hospital, Amiens, France
| | - Yoann Zerbib
- Intensive Care Department, Amiens-Picardie University Hospital, Amiens, France
| | - Pablo Mercado
- Intensive Care Department, Amiens-Picardie University Hospital, Amiens, France
- Universidad del Desarrollo, Departamento de Paciente Crítico, Facultad de Medicina Clínica Alemana, Santiago, Chile
| | - Momar Diouf
- Clinical Research Department Amiens-Picardie University Hospital, Amiens, France
| | - Audrey Michaud
- Clinical Research Department Amiens-Picardie University Hospital, Amiens, France
| | | | - Julien Maizel
- Intensive Care Department, Amiens-Picardie University Hospital, Amiens, France
| | - Michel Slama
- Intensive Care Department, Amiens-Picardie University Hospital, Amiens, France
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11
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Hasegawa D, Ishisaka Y, Maeda T, Prasitlumkum N, Nishida K, Dugar S, Sato R. Prevalence and Prognosis of Sepsis-Induced Cardiomyopathy: A Systematic Review and Meta-Analysis. J Intensive Care Med 2023; 38:797-808. [PMID: 37272081 DOI: 10.1177/08850666231180526] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Purpose: The prevalence and its impact on mortality of sepsis-induced cardiomyopathy (SICM) remain controversial. In this systematic review and meta-analysis, we investigated the prevalence and prognosis of SICM. Materials and Methods: We searched MEDLINE, Cochrane Central Register of Controlled Trials, and Embase. Titles and abstracts were evaluated based on the following criteria: (1) published in English, (2) randomized controlled trials, cohort studies, or cross-sectional studies, (3) ≥ 18 years with sepsis, (4) reporting the prevalence and/or comparison of short-term mortality between those with and without SICM, defined as the new-onset reduction in left ventricular ejection fraction (LVEF) within 72 h on admission or from the diagnosis of sepsis. The random-effect model was used for all analyses. This meta-analysis was registered at PROSPERO (CDR42022332896). Results: Sixteen studies reported the prevalence of SICM and the pooled prevalence of SICM was 20% (95% confidence interval [CI], 16-25%; I2 = 89.9%, P < 0.01). Eleven studies reported short-term mortality and SICM was associated with significantly higher short-term mortality (The pooled odds ratio: 2.30, 95% CI, 1.43-3.69; I2 = 0%, P = 0.001). Conclusion: The prevalence of SICM was 20% in patients with sepsis, and the occurrence of SICM was associated with significantly higher short-term mortality.
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Affiliation(s)
- Daisuke Hasegawa
- Department of Internal Medicine, Mount Sinai Beth Israel, New York, NY, USA
| | - Yoshiko Ishisaka
- Department of Internal Medicine, Mount Sinai Beth Israel, New York, NY, USA
| | - Tetsuro Maeda
- Division of Pulmonary and Critical Care, Department of Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | - Narut Prasitlumkum
- Department of Cardiology, University of California Riverside School of Medicine, Riverside, CA, USA
| | - Kazuki Nishida
- Department of Biostatistics, Graduate School of Medicine, Nagoya University, Nagoya, Japan
| | - Siddharth Dugar
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA
| | - Ryota Sato
- Department of Critical Care Medicine, The Queen's Medical Center, Honolulu, HI, USA
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12
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Dugar S, Siuba MT, Sacha GL, Sato R, Moghekar A, Collier P, Grimm RA, Vachharajani V, Bauer SR. Echocardiographic profiles and hemodynamic response after vasopressin initiation in septic shock: A cross-sectional study. J Crit Care 2023; 76:154298. [PMID: 37030157 PMCID: PMC10239343 DOI: 10.1016/j.jcrc.2023.154298] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 03/27/2023] [Accepted: 03/28/2023] [Indexed: 04/10/2023]
Abstract
PURPOSE Vasopressin, used as a catecholamine adjunct, is a vasoconstrictor that may be detrimental in some hemodynamic profiles, particularly left ventricular (LV) systolic dysfunction. This study tested the hypothesis that echocardiographic parameters differ between patients with a hemodynamic response after vasopressin initiation and those without a response. METHODS This retrospective, single-center, cross-sectional study included adults with septic shock receiving catecholamines and vasopressin with an echocardiogram performed after shock onset but before vasopressin initiation. Patients were grouped by hemodynamic response, defined as decreased catecholamine dosage with mean arterial pressure ≥ 65 mmHg six hours after vasopressin initiation, with echocardiographic parameters compared. LV systolic dysfunction was defined as LV ejection fraction (LVEF) <45%. RESULTS Of 129 included patients, 72 (56%) were hemodynamic responders. Hemodynamic responders, versus non-responders, had higher LVEF (61% [55%,68%] vs. 55% [40%,65%]; p = 0.02) and less-frequent LV systolic dysfunction (absolute difference -16%; 95% CI -30%,-2%). Higher LVEF was associated with higher odds of hemodynamic response (for each LVEF 10%, response OR 1.32; 95% CI 1.04-1.68). Patients with LV systolic dysfunction, versus without LV systolic dysfunction, had higher mortality risk (HR(t) = e[0.81-0.1*t]; at t = 0, HR 2.24; 95% CI 1.08-4.64). CONCLUSIONS Pre-drug echocardiographic profiles differed in hemodynamic responders after vasopressin initiation versus non-responders.
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Affiliation(s)
- Siddharth Dugar
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA; Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Matthew T Siuba
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA; Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | | | - Ryota Sato
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Ajit Moghekar
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA; Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Patrick Collier
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH, USA; Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, USA
| | - Richard A Grimm
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH, USA; Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, USA
| | - Vidula Vachharajani
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA; Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH, USA; Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, USA
| | - Seth R Bauer
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH, USA; Department of Pharmacy, Cleveland Clinic, USA.
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13
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Shvilkina T, Shapiro N. Sepsis-Induced myocardial dysfunction: heterogeneity of functional effects and clinical significance. Front Cardiovasc Med 2023; 10:1200441. [PMID: 37522079 PMCID: PMC10375025 DOI: 10.3389/fcvm.2023.1200441] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 06/05/2023] [Indexed: 08/01/2023] Open
Abstract
Sepsis is a life-threatening disease state characterized by organ dysfunction and a dysregulated response to infection. The heart is one of the many organs affected by sepsis, in an entity termed sepsis-induced cardiomyopathy. This was initially used to describe a reversible depression in ejection fraction with ventricular dilation but advances in echocardiography and introduction of new techniques such as speckle tracking have led to descriptions of other common abnormalities in cardiac function associated with sepsis. This includes not only depression of systolic function, but also supranormal ejection fraction, diastolic dysfunction, and right ventricular dysfunction. These reports have led to inconsistent definitions of sepsis-induced cardiomyopathy. Just as there is heterogeneity among patients with sepsis, there is heterogeneity in the cardiac response; thus resuscitating these patients with a single approach is likely suboptimal. Many factors affect the heart in sepsis including inflammatory mediators, catecholamine responsiveness, and pathogen related toxins. This review will discuss different functional effects characterized by echocardiographic changes in sepsis and their prognostic and management implications.
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14
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Dugar S, Sato R, Chawla S, You JY, Wang X, Grimm R, Collier P, Lanspa M, Duggal A. Is Left Ventricular Systolic Dysfunction Associated With Increased Mortality Among Patients With Sepsis and Septic Shock? Chest 2023; 163:1437-1447. [PMID: 36646415 DOI: 10.1016/j.chest.2023.01.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 12/13/2022] [Accepted: 01/05/2023] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND The impact of left ventricular (LV) systolic function on outcomes in patients with sepsis and septic shock remains uncertain. The association, if any, may be nonlinear. RESEARCH QUESTION Is LV systolic dysfunction associated with increased mortality among patients with sepsis and septic shock? STUDY DESIGN AND METHODS Retrospective cohort study comprising all adult patients admitted to the medical ICU from January 1, 2011, through December 31, 2020, with sepsis and septic shock as defined by the Third International Consensus Definitions for Sepsis and Septic Shock guidelines. All adult patients with sepsis or septic shock who underwent transthoracic echocardiography within 3 days from admission to the medical ICU were included. We divided patients into five groups based on LV ejection fraction (LVEF). In addition to univariate analysis, we also performed multivariate logistic regression analysis adjusting for patients' baseline characteristics and severity of illness. The primary outcome was the association between each classification of LVEF and in-hospital mortality. RESULTS A total of 3,151 patients were included in this study (LVEF < 25%, 133 patients; 25% ≤ LVEF < 40%, 305 patients; 40% ≤ LVEF < 55%, 568 patients; 55% ≤ LVEF < 70%, 1,792 patients; and LVEF ≥ 70%, 353 patients). In-hospital mortalities in each LVEF category were 51.1%, 34.8%, 26.6%, 26.2%, and 41.9%, respectively. In the multivariate logistic regression analysis, LVEF of < 25% (OR, 2.75; 95% CI, 1.82-4.17; P < .001) and LVEF of ≥ 70% (OR, 1.70; 95% CI, 1.09-1.88; P = .010) were associated independently with significantly higher in-hospital mortality compared with the reference LVEF category of 55% to 70%. INTERPRETATION The association of LVEF to in-hospital mortality in sepsis and septic shock was U-shaped. Both severe LV systolic dysfunction (LVEF < 25%) and hyperdynamic LVEF (LVEF ≥ 70%) were associated independently with significantly higher in-hospital mortality.
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Affiliation(s)
- Siddharth Dugar
- Respiratory Institute, Department of Critical Care Medicine, Cleveland Clinic, Cleveland, OH; Cleveland Clinic Lerner College of Medicine, Case Western University Reserve University, Cleveland, OH.
| | - Ryota Sato
- Respiratory Institute, Department of Critical Care Medicine, Cleveland Clinic, Cleveland, OH
| | - Sanchit Chawla
- Respiratory Institute, Department of Critical Care Medicine, Cleveland Clinic, Cleveland, OH
| | - Jee Young You
- Respiratory Institute, Department of Critical Care Medicine, Cleveland Clinic, Cleveland, OH
| | - Xiaofeng Wang
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH
| | - Richard Grimm
- Heart, Vascular, and Thoracic Institute, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH
| | - Patrick Collier
- Heart, Vascular, and Thoracic Institute, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH
| | - Michael Lanspa
- Critical Care Echocardiography Service, Intermountain Medical Center, Murray, Salt Lake City, UT; Division of Pulmonary and Critical Care Medicine, University of Utah, Salt Lake City, UT
| | - Abhijit Duggal
- Respiratory Institute, Department of Critical Care Medicine, Cleveland Clinic, Cleveland, OH; Cleveland Clinic Lerner College of Medicine, Case Western University Reserve University, Cleveland, OH
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15
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Bansal M, Mehta A, Machanahalli Balakrishna A, Kalyan Sundaram A, Kanwar A, Singh M, Vallabhajosyula S. RIGHT VENTRICULAR DYSFUNCTION IN SEPSIS: AN UPDATED NARRATIVE REVIEW. Shock 2023; 59:829-837. [PMID: 36943772 DOI: 10.1097/shk.0000000000002120] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
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.
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Affiliation(s)
- Mridul Bansal
- Section of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Aryan Mehta
- Section of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | | | - Arvind Kalyan Sundaram
- Section of Cardiovascular Medicine, Department of Medicine, UMass Chan-Baystate Medical Center, Springfield, Massachusetts
| | | | - Mandeep Singh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
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16
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Zhu MY, Tang XK, Gao Y, Xu JJ, Gong YQ. Impact of heart failure on outcomes in patients with sepsis: A systematic review and meta-analysis. World J Clin Cases 2023; 11:3511-3521. [PMID: 37383893 PMCID: PMC10294198 DOI: 10.12998/wjcc.v11.i15.3511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 03/06/2023] [Accepted: 04/06/2023] [Indexed: 05/25/2023] Open
Abstract
BACKGROUND Heart failure (HF) often affects the progress of sepsis patients, although its impact on outcomes is inconsistent and inconclusive.
AIM To conduct a systematic review and meta-analysis of the impact of HF on mortality in patients with sepsis.
METHODS PubMed, Embase, Web of Science, and the Cochrane Library databases were searched to compare the outcomes of sepsis patients with HF. A random effect model was used to summarize the mortality data, and the odds ratio (OR) and 95% confidence interval (CI) were calculated as effect indicators.
RESULTS Among 18001 records retrieved in the literature search, 35712 patients from 10 separate studies were included. The results showed that sepsis patients with HF were associated with increased total mortality (OR = 1.80, 95%CI: 1.34-2.43; I2 = 92.1%), with high heterogeneity between studies. Significant subgroup differences according to age, geographical location, and HF patient sample were observed. HF did not increase the 1-year mortality of patients (OR = 1.11, 95%CI: 0.75-1.62; I2 = 93.2%), and the mortality of patients with isolated right ventricular dysfunction (OR=2.32, 95%CI: 1.29-4.14; I2 = 91.5%) increased significantly.
CONCLUSION In patients with sepsis, HF is often associated with adverse outcomes and mortality. Our results call for more high-quality research and strategies to improve outcomes for sepsis patients with HF.
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Affiliation(s)
- Ming-Yu Zhu
- Department of the Intensive Care Unit, The Second Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi Province, China
| | - Xiao-Kai Tang
- Department of the Orthopaedic, The First Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi Province, China
| | - Yi Gao
- Department of the Intensive Care Unit, The Second Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi Province, China
| | - Jing-Jing Xu
- Department of the Intensive Care Unit, The Second Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi Province, China
| | - Yuan-Qi Gong
- Department of the Intensive Care Unit, The Second Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi Province, China
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17
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Lu NF, Shao J, Niu HX, Han WY, Chen YL, Liu AQ, Liu HN, Xi XM. Early Diastolic Peak Velocity of Mitral Valve Annulus and Right Ventricular Systolic Tricuspid Annular Velocity as Predictors in Assessing Prognosis of Patients with Sepsis. Risk Manag Healthc Policy 2023; 16:921-930. [PMID: 37223427 PMCID: PMC10200692 DOI: 10.2147/rmhp.s407929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 04/28/2023] [Indexed: 05/25/2023] Open
Abstract
Objective To analyze the epidemiological data of patients with septic cardiomyopathy and investigate the relationship between ultrasonic parameters and prognosis of patients with sepsis. Methods In this study, we enrolled patients with sepsis who were treated at the Department of Critical Care Medicine in the Beijing Electric Power Hospital (No.1 Taipingqiao Xili, Fengtai District, Beijing) from January 2020 to June 2022. All patients received standardized treatment. Their general medical status and 28-day prognosis were recorded. Transthoracic echocardiography was performed within 24 hours after admission. We compared the ultrasound indexes between the mortality group and the survival group at the end of 28 days. We included parameters with significant difference in the logistic regression model to identify the independent risk factors for prognosis and evaluated their predictive value using receiver operating characteristic (ROC) curve. Results We included 100 patients with sepsis in this study; the mortality rate was 33% and the prevalence rate of septic cardiomyopathy was 49%. The peak e' velocity and right ventricular systolic tricuspid annulus velocity (RV-Sm) of the survival group were significantly higher than those of the mortality group (P < 0.05). Results of logistic regression analysis showed that the peak e' velocity and RV-Sm were independent risk factors for prognosis. The area under curve of the peak e' velocity and the RV-Sm was 0.657 and 0.668, respectively (P < 0.05). Conclusion The prevalence rate of septic cardiomyopathy in septic patients is high. In this study, we found that the peak e' velocity and right ventricular systolic tricuspid annulus velocity were important predictors of short-term prognosis.
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Affiliation(s)
- Nian-Fang Lu
- Department of Critical Care Medicine, Capital Medical University Electric Teaching Hospital/Beijing Electric Power Hospital, Beijing, 100073, People’s Republic of China
| | - Jun Shao
- Department of Critical Care Medicine, Subei People’s Hospital of Jiangsu Province, Yangzhou, Jiangsu, 225001, People’s Republic of China
| | - Hong-Xia Niu
- Department of Emergency, Capital medical university electric teaching hospital/Beijing Electric Power Hospital, Beijing, 100073, People’s Republic of China
| | - Wen-Yong Han
- Department of Anesthesiology, Capital Medical University Electric Teaching Hospital/Beijing Electric Power Hospital, Beijing, 100073, People’s Republic of China
| | - Ya-Lei Chen
- Department of Critical Care Medicine, Capital Medical University Electric Teaching Hospital/Beijing Electric Power Hospital, Beijing, 100073, People’s Republic of China
| | - An-Qi Liu
- Department of Critical Care Medicine, Capital Medical University Electric Teaching Hospital/Beijing Electric Power Hospital, Beijing, 100073, People’s Republic of China
| | - Hu-Nan Liu
- Department of Critical Care Medicine, Capital Medical University Electric Teaching Hospital/Beijing Electric Power Hospital, Beijing, 100073, People’s Republic of China
| | - Xiu-Ming Xi
- Department of Critical Care Medicine, Capital Medical University Fuxing Hospital, Beijing, People’s Republic of China
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18
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Nasu M, Sato R, Takahashi K, Nakaizumi T, Maruyama A, Ueda S. The Chronological Demographics of Ventricular-Arterial Decoupling in Patients with Sepsis and Septic Shock: A Prospective Observational Study. J Intensive Care Med 2023; 38:340-348. [PMID: 35957601 DOI: 10.1177/08850666221120219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Ventricular-arterial coupling (V-A coupling) recently gathers attention from clinicians to evaluate the interaction between afterload and left ventricular systolic function. We aimed to describe the chronological demographics of V-A decoupling in patients with sepsis and septic shock through the clinical course. METHOD We conducted a single-center prospective observational study comprising adult patients with sepsis and septic shock admitted to the tertiary care hospital between 04/2017 and 03/2019. Patients' characteristics, lab data on admission, and echocardiographic parameters including Ea and Ees on the day- 1, 2, 3, 7, and 14-28 were collected. V-A decoupling was defined as Ea/Ees ≥ 1.36. RESULTS Seventy-one patients with sepsis or septic shock were enrolled. The prevalence of V-A decoupling was as follows; day-1: 25.4%, day-2: 23.8%, day-3: 13.3%, day-7: 18.5%, day-14-28: 30.3%, respectively. Ea was higher in patients with V-A decoupling than those without throughout the clinical course (day1; 2.8 vs. 1.8, p < 0.01, day2; 2.7 vs. 1.9, p < 0.01, day3; 2.8 vs. 2.1, p = 0.06, day7; 2.7 vs. 1.9, p = 0.02, day14-28; 2.4 vs. 1.8, p = 0.08). This increase in Ea was mainly induced by reduced stroke volume (SV) as well as high systolic blood pressure (SBP) in the earlier course of sepsis but only by increased SBP in the later course of sepsis. Ees was lower in patients with V-A decoupling than those without throughout the clinical course (day1; 1.3 vs. 2.1, p < 0.01, day2; 1.5 vs. 2.3, p < 0.01, day3; 1.6 vs. 2.3, p = 0.02, day7; 1.8 vs. 2.3, p = 0.01, day14-28; 1.2 vs. 1.9, p = 0.07). CONCLUSION We reported that V-A decoupling was commonly seen in patients with sepsis and septic shock. In patients with V-A decoupling, both Ea and Ees were significantly altered, but the causes of these alterations appeared to be changing over the clinical course of sepsis.
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Affiliation(s)
- Michitaka Nasu
- Department of Emergency and Critical Care Medicine, Urasoe General Hospital, Okinawa, Japan
| | - Ryota Sato
- Division of Critical Care Medicine, Department of Medicine, The Queen's Medical Center, HI, USA
| | - Kuniko Takahashi
- Department of Emergency and Critical Care Medicine, Urasoe General Hospital, Okinawa, Japan
| | - Takayuki Nakaizumi
- Department of Emergency and Critical Care Medicine, Urasoe General Hospital, Okinawa, Japan
| | - Akiyoshi Maruyama
- Department of Emergency and Critical Care Medicine, Urasoe General Hospital, Okinawa, Japan
| | - Shinichiro Ueda
- Department of Clinical Pharmacology and Therapeutics, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
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19
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Lima MR, Silva D. Septic cardiomyopathy: A narrative review. Rev Port Cardiol 2023; 42:471-481. [PMID: 36893835 DOI: 10.1016/j.repc.2021.05.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Revised: 03/03/2021] [Accepted: 05/01/2021] [Indexed: 03/09/2023] Open
Abstract
Sepsis is a systemic inflammatory response syndrome of suspected or documented infectious origin, whose outcome is multiorgan failure. Sepsis-induced myocardial dysfunction (SIMD), present in more than 50% of septic patients, is characterized by (i) left ventricular (LV) dilatation with normal or low filling pressure, (ii) right and/or LV (systolic and/or diastolic) dysfunction and (iii) reversibility. Since the first definition proposed by Parker et al. in 1984, attempts have been made to define SIMD. Many parameters are used to assess cardiac function in septic patients, sometimes making it more difficult to measure due to the intrinsic hemodynamical changes in this condition. Nevertheless, with advanced echocardiographic techniques, such as speckle tracking analysis, it is possible to diagnose and assess systolic and diastolic dysfunction, even in the earliest stages of sepsis. Cardiac magnetic resonance imaging brings new insights into the reversibility of this condition. Many uncertainties still remain regarding the mechanisms, characteristics, treatment and even prognosis of this condition. There are also inconsistent conclusions from studies, therefore this review attempts to summarize our current knowledge of SIMD.
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Affiliation(s)
- Maria Rita Lima
- Internal Medicine Department, Egas Moniz Hospital, Lisbon Ocidental Hospital Center, Lisbon, Portugal.
| | - Doroteia Silva
- Intensive Care Department, Santa Maria University Hospital, Lisbon North Hospital Center, Lisbon, Portugal; CCUL, Lisbon Academic Medical Center, Faculty of Medicine of Lisbon, Lisbon, Portugal
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20
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Liu MX, Yang J, Qin Y, Li ZD, Jin J, Zhang YB, Yang XJ. ESMOLOL PROTECTS AGAINST LPS-INDUCED CARDIAC INJURY VIA THE AMPK/mTOR/ULK1 PATHWAY IN RAT. Shock 2023; 59:469-476. [PMID: 36579896 DOI: 10.1097/shk.0000000000002071] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
ABSTRACT Aim: The purpose of this study was to investigate the effect of esmolol (ES) on LPS-induced cardiac injury and the possible mechanism. Methods: Sepsis was induced by i.p. injection of LPS (10 mg/kg) in male Sprague-Dawley rats pretreated with ES, 3-methyladenine or rapamycin. The severity of myocardial damage was analyzed by hematoxylin-eosin staining, and myocardial damage scores were calculated. The concentration of cardiac troponin was measured by enzyme-linked immunosorbent assay. The expression of autophagy-related proteins (beclin-1, LC3-II, p-AMPK, p-ULK1, p-mTOR) in myocardial tissue was detected by Western blotting. Autophagosome formation and the ultrastructural damage of mitochondria were assessed using transmission electron microscopy. Results: LPS induced an increase in myocardial damage score in a time-dependent manner, accompanied with an increase in autophagy at 3 h and decrease in autophagy at 6, 12, and 24 h. Pretreatment of LPS-treated rats with ES or rapamycin reduced myocardial injury (release of cardiac troponin, myocardial damage score) and increased autophagy (LC3-II, beclin-1, p-AMPK, and p-ULK1 levels and autophagosome numbers) at 12 and 24 h. In contrast, 3-methyladenine showed no effect. Conclusion: Esmolol alleviates LPS-induced myocardial damage through activating the AMPK/mTOR/ULK1 signal pathway-regulated autophagy.
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Affiliation(s)
- Mao-Xia Liu
- Department of Intensive Care Unit, the First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Jia Yang
- Shanxi Academy of Advanced Research and Innovation, Taiyuan, Shanxi China
| | - Yan Qin
- Department of Emergency Medicine, the First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Zheng-da Li
- Department of Intensive Care Unit, the First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Jun Jin
- Department of Intensive Care Unit, the First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Yan-Bing Zhang
- Department of Anesthesiology, the First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Xin-Jing Yang
- Department of Intensive Care Unit, the First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
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21
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La Via L, Merola F, Schembari G, Liotta C, Sanfilippo F. The interplay between left ventricular diastolic and right ventricular dysfunction: challenges in the interpretation of critical care echocardiography studies. Egypt Heart J 2023; 75:7. [PMID: 36692697 PMCID: PMC9872744 DOI: 10.1186/s43044-023-00333-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 01/17/2023] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Sepsis is a leading cause of death and it is characterized not only by profound vasoplegia but also by myocardial dysfunction. Critical care echocardiography is the preferred modality for the initial assessment of the cause of shock. Moreover, it can be extremely helpful in the identification of progressing myocardial dysfunction during the course of sepsis, also known as septic cardiomyopathy. MAIN BODY One of the issues in the identification of septic cardiomyopathy is that it can be manifest with different clinical phenotypes, from overt biventricular dysfunction to isolated left ventricular (LV) systolic and/or diastolic dysfunction, from right ventricular (RV) systolic dysfunction to RV failure and dilatation. However, the commonly used echocardiography parameters for the assessment of LV and/or RV function are not always entirely reliable. Indeed, these are influenced by variable preload and afterload conditions imposed by critical illness such as fluid shifts, sedation level and mechanical ventilation with positive pressure. CONCLUSIONS Strain echocardiography is a promising tool for the early identification of myocardial dysfunction in the context of sepsis. Studies reporting data on strain echocardiography should be particularly detailed in order to increase the reproducibility of results and to favor comparison with future studies.
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Affiliation(s)
- Luigi La Via
- grid.412844.f0000 0004 1766 6239Department of Anesthesia and Intensive Care, “Policlinico-San Marco” University Hospital, Catania, Italy ,grid.8158.40000 0004 1757 1969School of Anesthesia and Intensive Care, University of Catania, Catania, Italy
| | - Federica Merola
- grid.8158.40000 0004 1757 1969School of Anesthesia and Intensive Care, University of Catania, Catania, Italy
| | - Giovanni Schembari
- grid.411489.10000 0001 2168 2547School of Anesthesia and Intensive Care, University “Magna Graecia”, Catanzaro, Italy
| | - Calogero Liotta
- grid.411489.10000 0001 2168 2547School of Anesthesia and Intensive Care, University “Magna Graecia”, Catanzaro, Italy
| | - Filippo Sanfilippo
- grid.412844.f0000 0004 1766 6239Department of Anesthesia and Intensive Care, “Policlinico-San Marco” University Hospital, Catania, Italy ,grid.8158.40000 0004 1757 1969Department of Surgery and Medical-Surgical Specialties, University of Catania, Catania, Italy
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22
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Ehrman RR, Bredell BX, Harrison NE, Favot MJ, Haber BD, Welch RD, Levy PD, Sherwin RL. Increasing illness severity is associated with global myocardial dysfunction in the first 24 hours of sepsis admission. Ultrasound J 2022; 14:32. [PMID: 35900610 PMCID: PMC9334514 DOI: 10.1186/s13089-022-00282-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Accepted: 07/19/2022] [Indexed: 11/11/2022] Open
Abstract
Background Septic cardiomyopathy was recognized more than 30 years ago, but the early phase remains uncharacterized as no existing studies captured patients at the time of Emergency Department (ED) presentation, prior to resuscitation. Therapeutic interventions alter cardiac function, thereby distorting the relationship with disease severity and outcomes. The goal of this study was to assess the impact of illness severity on cardiac function during the first 24 h of sepsis admission. Methods This was a pre-planned secondary analysis of a prospective observational study of adults presenting to the ED with suspected sepsis (treatment for infection plus either lactate > 2 mmol/liter or systolic blood pressure < 90 mm/Hg) who received < 1L IV fluid before enrollment. Patients had 3 echocardiograms performed (presentation, 3, and 24 h). The primary outcome was the effect of increasing sepsis illness severity, defined by ED Sequential Organ Failure Assessment (SOFA) score, on parameters of cardiac function, assessed using linear mixed-effects models. The secondary goal was to determine whether cardiac function differed between survivors and non-survivors, also using mixed-effects models. Results We enrolled 73 patients with a mean age of 60 (SD 16.1) years and in-hospital mortality of 23%. For the primary analysis, we found that increasing ED SOFA score was associated with worse cardiac function over the first 24 h across all assessed parameters of left-ventricular systolic and diastolic function as well as right-ventricular systolic function. While baseline strain and E/e' were better in survivors, in the mixed models analysis, the trajectory of Global Longitudinal Strain and septal E/e′ over the first 24 h of illness differed between survivors and non-survivors, with improved function at 24 h in non-survivors. Conclusions In the first study to capture patients prior to the initiation of resuscitation, we found a direct relationship between sepsis severity and global myocardial dysfunction. Future studies are needed to confirm these results, to identify myocardial depressants, and to investigate the link with adverse outcomes so that therapeutic interventions can be developed. Supplementary Information The online version contains supplementary material available at 10.1186/s13089-022-00282-6.
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23
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La Via L, Dezio V, Santonocito C, Astuto M, Morelli A, Huang S, Vieillard‐Baron A, Sanfilippo F. Full and simplified assessment of left ventricular diastolic function in covid-19 patients admitted to ICU: Feasibility, incidence, and association with mortality. Echocardiography 2022; 39:1391-1400. [PMID: 36200491 PMCID: PMC9827986 DOI: 10.1111/echo.15462] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 09/06/2022] [Accepted: 09/09/2022] [Indexed: 01/12/2023] Open
Abstract
PURPOSE Left ventricular diastolic dysfunction (LVDD) is associated with poor outcomes in the intensive care unit (ICU). Nonetheless, precise reporting of LVDD in COVID-19 patients is currently lacking and assessment could be challenging. METHODS We performed an echocardiography study in COVID-19 patients admitted to ICU with the aim to describe the feasibility of full or simplified LVDD assessment and its incidence. We also evaluated the association of LVDD or of single echocardiographic parameters with hospital mortality. RESULTS Between 06.10.2020 and 18.02.2021, full diastolic assessment was feasible in 74% (n = 26/35) of patients receiving a full echocardiogram study. LVDD incidence was 46% (n = 12/26), while the simplified assessment produced different results (incidence 81%, n = 21/26). Nine patients with normal function on full assessment had LVDD with simplified criteria (grade I = 2; grade II = 3; grade III = 4). Nine patients were hospital-survivors (39%); the incidence of LVDD (full assessment) was not different between survivors (n = 2/9, 22%) and non-survivors (n = 10/17, 59%; p = .11). The E/e' ratio lateral was lower in survivors (7.4 [3.6] vs. non-survivors 10.5 [6.3], p = .03). We also found that s' wave was higher in survivors (average, p = .01). CONCLUSION In a small single-center study, assessment of LVDD according to the latest guidelines was feasible in three quarters of COVID-19 patients. Non-survivors showed a trend toward greater LVDD incidence; moreover, they had significantly worse s' values (all) and higher E/e' ratio (lateral).
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Affiliation(s)
- Luigi La Via
- Department of Anaesthesia and Intensive Care“Policlinico‐San Marco” University HospitalCataniaItaly
| | - Veronica Dezio
- Department of Anaesthesia and Intensive Care“Policlinico‐San Marco” University HospitalCataniaItaly
| | - Cristina Santonocito
- Department of Anaesthesia and Intensive Care“Policlinico‐San Marco” University HospitalCataniaItaly
| | - Marinella Astuto
- Department of Anaesthesia and Intensive Care“Policlinico‐San Marco” University HospitalCataniaItaly
| | - Andrea Morelli
- Department Clinical Internal, Anesthesiological and Cardiovascular Sciences, University of Rome“La Sapienza”, Policlinico Umberto PrimoRomaItaly
| | - Stephen Huang
- Intensive Care Medicine, Nepean HospitalThe University of SydneySydneyAustralia
| | - Antoine Vieillard‐Baron
- Service de Médecine Intensive Réanimation, Assistance Publique‐Hôpitaux de ParisUniversity Hospital Ambroise ParéBoulogne‐BillancourtFrance
| | - Filippo Sanfilippo
- Department of Anaesthesia and Intensive Care“Policlinico‐San Marco” University HospitalCataniaItaly
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24
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The Role of Left Ventricular Ejection Fraction and Left Ventricular Outflow Tract Velocity-Time Integral in Assessing Cardiovascular Impairment in Septic Shock. J Pers Med 2022; 12:jpm12111786. [PMID: 36579502 PMCID: PMC9696803 DOI: 10.3390/jpm12111786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Revised: 10/22/2022] [Accepted: 10/25/2022] [Indexed: 02/01/2023] Open
Abstract
Background: the role of echocardiography in septic shock remains controversial, since depressed cardiac afterload may overestimate left ventricular (LV) systolic performance and mask septic cardiomyopathy (SC). We hypothesized that afterload-adjusted LV ejection fraction (LVEF) and LV outflow tract velocity-time integral (VTI) values for given systemic vascular resistances (SVR) could provide novel insights into recognizing and stratifying the severity of SC. Methods: in this observational, monocentric study, we prospectively included 14 mechanically-ventilated patients under septic-shock who all had a Pulse index Continuous Cardiac Output (PiCCO) system in place for hemodynamic monitoring. Echocardiographic and PiCCO longitudinal examinations (71 measurements overall) were performed simultaneously at the onset of septic shock and every 12 h for 60 h overall. Results: VTI-derived stroke volume (SV) and cardiac output (CO) were significantly correlated with PiCCO measurements (r ≥ 0.993, both p < 0.001). LVEF and VTI showed linear and exponential inverse correlation to SVR (R2 = 0.183 vs. 0.507 and p < 0.001 vs. p < 0.001, respectively). The equations LVEF = 86.168 − 0.011 × SVR and VTI = 41.23 × e(−0.0005×SVR) were found to provide “predicted” values for given SVR. Measured to predicted LVEF ratios (for given SVR), the afterload-adjusted LVEF defined the severity of SC (mild ≥ 90%, 80% ≤ moderate < 90% and severe < 80%). Mild SC demonstrated normal/supra-normal LVEF, normal VTI and SVR. Moderate SC showed lower LVEF and SVR, yet increased LV end-diastolic volume (LVEDV), VTI, SV and CO compared with mild SC (all p < 0.05). Severe SC was distinguished from moderate SC by markedly reduced LVEF, LVEDV, VTI, SV, CO and significantly increased SVR (all p < 0.05). LVEF and VTI decreased over time in mild SC, LVEF decreased in moderate SC, and LVEF and VTI increased over time in severe SC (p ≤ 0.038). LVEF and VTI demonstrated significant performance in identifying severe SC [cut-off < 61.5%, area under the curve (AUC) = 1 ± 0.0, sensitivity/specificity = 100/100, p < 0.001 vs. cut-off < 17.9 cm, AUC = 0.882 ± 0.042, sensitivity/specificity = 80/77, p < 0.001, respectively]. VTI but not LVEF demonstrated significant diagnostic performance in identifying both SVR < 800 dynes·s·cm−5 and SVR > 1500 dynes·s·cm−5 (cut-off > 24.46 cm, AUC = 0.889 ± 0.049, sensitivity/specificity = 75/100, p < 0.001; cut-off < 16.8, AUC = 0.0.857 ± 0.082, sensitivity/specificity = 83/86, p = 0.002, respectively).Conclusions: our study suggests that ICU bedside echocardiographic assessment of LVEF, VTI and their adjusted to corresponding SVR values provides valuable insights for the comprehension of SC phenotypes, underlying vasoplegia and cardiac output fluctuations in septic shock.
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25
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Bowcock EM, Gerhardy B, Huang S, Orde S. Right ventricular outflow tract Doppler flow analysis and pulmonary arterial coupling by transthoracic echocardiography in sepsis: a retrospective exploratory study. Crit Care 2022; 26:303. [PMID: 36192793 PMCID: PMC9527734 DOI: 10.1186/s13054-022-04160-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Accepted: 09/07/2022] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Right ventricular (RV) and pulmonary vascular dysfunction appear to be common in sepsis. RV performance is frequently assessed in isolation, yet its close relationship to afterload means combined analysis with right ventricular outflow tract (RVOT) Doppler and RV-pulmonary arterial (RV-PA) coupling may be more informative than standard assessment techniques. Data on feasibility and utility of these parameters in sepsis are lacking and were explored in this study. METHODS This is a retrospective study over a 3-year period of one-hundred and thirty-one patients admitted to ICU with sepsis who underwent transthoracic echocardiography (TTE) with RVOT pulsed wave Doppler. RVOT Doppler flow and RV-PA coupling was evaluated alongside standard measurements of RV systolic function and pulmonary pressures. RVOT Doppler analysis included assessment of pulmonary artery acceleration time (PAAT), velocity time integral and presence of notching. RV-PA coupling was assessed using tricuspid annular planar systolic excursion/pulmonary artery systolic pressure (TAPSE/PASP) ratio. RESULTS PAAT was measurable in 106 (81%) patients, and TAPSE/PASP was measurable in 77 (73%). Seventy-three (69%) patients had a PAAT of ≤ 100 ms suggesting raised pulmonary vascular resistance (PVR) is common. RVOT flow notching occurred in 15 (14%) of patients. TRV was unable to be assessed in 24 (23%) patients where measurement of PAAT was possible. RV dysfunction (RVD) was present in 28 (26%), 26 (25%) and 36 (34%) patients if subjective assessment, TAPSE < 17 mm and RV dilatation definitions were used, respectively. There was a trend towards shorter PAAT with increasing severity of RVD. RV-PA uncoupling defined as a TAPSE/PASP < 0.31 mm/mmHg was present in 15 (19%) patients. As RV dilatation increased the RV-PA coupling ratio decreased independent of LV systolic function, whereas TAPSE appeared to be more susceptible to changes in LV systolic function. CONCLUSION Raised PVR and RV-PA uncoupling is seen in a significant proportion of patients with sepsis. Non-invasive assessment with TTE is feasible. The role of these parameters in assisting improved definitions of RVD, as well as their therapeutic and prognostic utility against standard parameters, deserves further investigation.
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Affiliation(s)
- Emma Maria Bowcock
- grid.1013.30000 0004 1936 834XIntensive Care Medicine and Respiratory Medicine, Intensive Care Unit, Nepean Hospital, The University of Sydney, Derby Street, Penrith, Sydney, 2747 Australia
| | - Benjamin Gerhardy
- grid.1013.30000 0004 1936 834XIntensive Care Medicine and Respiratory Medicine, Intensive Care Unit, Nepean Hospital, The University of Sydney, Derby Street, Penrith, Sydney, 2747 Australia
| | - Stephen Huang
- grid.1013.30000 0004 1936 834XIntensive Care Medicine and Respiratory Medicine, Intensive Care Unit, Nepean Hospital, The University of Sydney, Derby Street, Penrith, Sydney, 2747 Australia
| | - Sam Orde
- grid.1013.30000 0004 1936 834XIntensive Care Medicine and Respiratory Medicine, Intensive Care Unit, Nepean Hospital, The University of Sydney, Derby Street, Penrith, Sydney, 2747 Australia
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26
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Carbone F, Liberale L, Preda A, Schindler TH, Montecucco F. Septic Cardiomyopathy: From Pathophysiology to the Clinical Setting. Cells 2022; 11:cells11182833. [PMID: 36139408 PMCID: PMC9496713 DOI: 10.3390/cells11182833] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 09/05/2022] [Accepted: 09/07/2022] [Indexed: 11/21/2022] Open
Abstract
The onset of cardiomyopathy is a common feature in sepsis, with relevant effects on its pathophysiology and clinical care. Septic cardiomyopathy is characterized by reduced left ventricular (LV) contractility eventually associated with LV dilatation with or without right ventricle failure. Unfortunately, such a wide range of ultrasonographic findings does not reflect a deep comprehension of sepsis-induced cardiomyopathy, but rather a lack of consensus about its definition. Several echocardiographic parameters intrinsically depend on loading conditions (both preload and afterload) so that it may be challenging to discriminate which is primitive and which is induced by hemodynamic perturbances. Here, we explore the state of the art in sepsis-related cardiomyopathy. We focus on the shortcomings in its definition and point out how cardiac performance dynamically changes in response to different hemodynamic clusters. A special attention is also given to update the knowledge about molecular mechanisms leading to myocardial dysfunction and that recall those of myocardial hibernation. Ultimately, the aim of this review is to highlight the unsolved issue in the field of sepsis-induced cardiomyopathy as their implementation would lead to improve risk stratification and clinical care.
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Affiliation(s)
- Federico Carbone
- First Clinic of Internal Medicine, Department of Internal Medicine, University of Genoa, 16132 Genoa, Italy
- IRCCS Ospedale Policlinico San Martino, Genoa-Italian Cardiovascular Network, 16132 Genoa, Italy
| | - Luca Liberale
- First Clinic of Internal Medicine, Department of Internal Medicine, University of Genoa, 16132 Genoa, Italy
- IRCCS Ospedale Policlinico San Martino, Genoa-Italian Cardiovascular Network, 16132 Genoa, Italy
| | - Alberto Preda
- Vita-Salute San Raffaele University, 20132 Milan, Italy
| | - Thomas Hellmut Schindler
- Mallinckrodt Institute of Radiology, Division of Nuclear Medicine, School of Medicine, Washington University, Saint Louis, MO 63110, USA
| | - Fabrizio Montecucco
- First Clinic of Internal Medicine, Department of Internal Medicine, University of Genoa, 16132 Genoa, Italy
- IRCCS Ospedale Policlinico San Martino, Genoa-Italian Cardiovascular Network, 16132 Genoa, Italy
- Correspondence: or ; Tel.: +39-010-353-8996; Fax: +39-010-353-8686
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27
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Ehrman RR, Favot MJ, Harrison NE, Khait L, Ottenhoff JE, Welch RD, Levy PD, Sherwin RL. Early echocardiographic assessment of cardiac function may be prognostically informative in unresuscitated patients with sepsis: A prospective observational study. PLoS One 2022; 17:e0269814. [PMID: 35802886 PMCID: PMC9270056 DOI: 10.1371/journal.pone.0269814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Accepted: 05/29/2022] [Indexed: 11/19/2022] Open
Abstract
Purpose The goal of this study was to explore the association cardiac function at Emergency Department (ED) presentation prior to the initiation of resuscitation, and its change at 3-hours, with adverse outcomes in patients with sepsis. Methods This was a prospective observational study of patients presenting to an urban ED with suspected sepsis. Patients had a point-of-care echocardiogram performed prior to initiation of resuscitation and again 3 hours later. Left-ventricular (LV) parameters recorded included e’, and E/e’, and ejection fraction (EF); right-ventricular (RV) function was evaluated using tricuspid annular plane systolic excursion (TAPSE). Logistic and generalized linear regression were used to assess the association of echocardiographic parameters and ≥ 2-point increase in SOFA score at 24 hours (primary outcome) and 24-hours SOFA score and in-hospital mortality (secondary outcomes). Results For ΔSOFA ≥ 2 and 24-hour SOFA score, declining LVEF was associated with better outcomes in patients with greater baseline SOFA scores, but worse outcomes in patients with lower baseline scores. A similar relationship was found for ΔTAPSE at 3 hours. Reduced LVEF at presentation was associated with increased mortality after adjusting for ED SOFA score (odds-ratio (OR) 0.76 (CI 0.60–0.96). No relationship between diastolic parameters and outcomes was found. IVF administration was similar across ΔLVEF/TAPSE sub-groups. Conclusions Our results suggest that early change in LV and RV systolic function are independently prognostic of sepsis illness severity at 24-hours. Further study is needed to determine if this information can be used to guide treatment and improve outcomes.
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Affiliation(s)
- Robert R. Ehrman
- Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, Michigan, United States of America
- * E-mail:
| | - Mark J. Favot
- Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, Michigan, United States of America
| | - Nicholas E. Harrison
- Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, Michigan, United States of America
| | - Lyudmila Khait
- Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, Michigan, United States of America
| | - Jakob E. Ottenhoff
- Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, Michigan, United States of America
| | - Robert D. Welch
- Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, Michigan, United States of America
| | - Phillip D. Levy
- Department of Emergency Medicine, Integrative Biosciences Center, Wayne State University School of Medicine, Detroit, Michigan, United States of America
| | - Robert L. Sherwin
- Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, Michigan, United States of America
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28
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Meta-Analysis Comparing Right Ventricular Function as a Predictor of Mortality in Patients With Sepsis. Am J Cardiol 2022; 173:152-154. [PMID: 35461696 DOI: 10.1016/j.amjcard.2022.03.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 03/29/2022] [Indexed: 11/22/2022]
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29
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Takagi K, Akiyama E, Paternot A, Miró Ò, Charron C, Gayat E, Deye N, Cariou A, Monnet X, Jaber S, Guidet B, Damoisel C, Barthélémy R, Azoulay E, Kimmoun A, Fournier MC, Cholley B, Edwards C, Davison BA, Cotter G, Vieillard-Baron A, Mebazaa A. Early echocardiography by treating physicians and outcome in the critically ill: An ancillary study from the prospective multicenter trial FROG-ICU. J Crit Care 2022; 69:154013. [PMID: 35278876 DOI: 10.1016/j.jcrc.2022.154013] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 01/28/2022] [Accepted: 02/15/2022] [Indexed: 12/15/2022]
Abstract
PURPOSE This study aimed to investigate the association between the use of early echocardiography performed by the treating physician certified in critical care ultrasound and mortality in ICU patients. MATERIALS AND METHODS FROG-ICU was a multi-center cohort designed to investigate the outcome of critically ill patients. Of the 1359 patients admitted to centers where echocardiography was available, 372 patients underwent echocardiography during the initial 3 days. RESULTS Of the ICU patients admitted for cardiac disease, 47.4% underwent echocardiography, and those patients had the lowest left ventricular ejection fraction 40 [31-58] % and the lowest cardiac output 4.2 [3.2-5.7] L/min compared to patients admitted for other causes (p < 0.001 for both). One-year mortality was 36.8% and 39.9% in patients with and without echocardiography, respectively [HR 0.92 (95% CI 0.75-1.11)]. This result was confirmed after multivariable Cox regression analysis [HR 0.88 (95% CI 0.71-1.08)]. Subgroup analyses suggest that among patients admitted to ICU for cardiac disease, those managed with echocardiography had a lower risk of one-year mortality [HR 0.65 (95% CI 0.43-0.98)]. CONCLUSIONS Early echocardiography by treating physicians was not associated with short- or long-term survival in ICU patients. In subgroups, early echocardiography improved survival in ICU patients admitted for cardiac disease. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01367093.
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Affiliation(s)
- Koji Takagi
- Inserm UMR-S 942, Cardiovascular Markers in Stress Conditions (MASCOT), Université de Paris, Paris, France; Momentum Research, Inc., Chapel Hill, NC, USA
| | - Eiichi Akiyama
- Inserm UMR-S 942, Cardiovascular Markers in Stress Conditions (MASCOT), Université de Paris, Paris, France; Division of Cardiology, Yokohama City University Medical Center, Yokohama, Japan
| | - Alexis Paternot
- Intensive Care Unit, University hospital Ambroise Paré, AP-HP, Boulogne-Billancourt, France
| | - Òscar Miró
- Emergency Department, Hospital Clínic, Barcelona, Spain; IDIBAPS (Institut d'Investigacions Biomèdiques August Pi i Sunyer), Barcelona, Spain; Medical School, University of Barcelona, Barcelona, Spain
| | - Cyril Charron
- Intensive Care Unit, University hospital Ambroise Paré, AP-HP, Boulogne-Billancourt, France
| | - Etienne Gayat
- Inserm UMR-S 942, Cardiovascular Markers in Stress Conditions (MASCOT), Université de Paris, Paris, France; Department of Anesthesia and Critical Care, University Hospitals Saint-Louis-Lariboisière, DMU Parabol, FHU Promice, APHP.Nord, INI-CRCT, Paris, France
| | - Nicolas Deye
- Medical and Toxicology Intensive Care Unit, Hôpitaux Universitaires Saint Louis-Lariboisière, AP-HP, Université Paris Diderot-Paris 7, Inserm U942, Paris, France
| | - Alain Cariou
- Medical Intensive Care Unit, Cochin University Hospital, AP-HP, Université de Paris, Paris, France
| | - Xavier Monnet
- Medical Intensive Care Unit, Bicêtre Hospital, Paris-Saclay University Hospitals, Inserm UMR_S999, Paris-Suclay University, Le Kremlin-Bicetre, France
| | - Samir Jaber
- Intensive Care Unit, Anaesthesia and Critical Care Department, Saint Eloi Teaching Hospital, Centre Hospitalier, Montpellier, France
| | - Bertrand Guidet
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP, Hôpital Saint-Antoine, Service de réanimation, F75012 Paris, France
| | - Charles Damoisel
- Department of Anesthesia and Critical Care, University Hospitals Saint-Louis-Lariboisière, DMU Parabol, FHU Promice, APHP.Nord, INI-CRCT, Paris, France
| | - Romain Barthélémy
- Department of Anesthesia and Critical Care, University Hospitals Saint-Louis-Lariboisière, DMU Parabol, FHU Promice, APHP.Nord, INI-CRCT, Paris, France
| | - Elie Azoulay
- Médecine Intensive et Réanimation, Hôpital Saint-Louis, AP-HP et Université de Paris, Paris, France
| | - Antoine Kimmoun
- Inserm UMR-S 942, Cardiovascular Markers in Stress Conditions (MASCOT), Université de Paris, Paris, France; Intensive Care Medicine Brabois, CHRU de Nancy, INSERM U1116, Université de Lorraine, 54511 Vandoeuvre-les-Nancy, France
| | - Marie-Céline Fournier
- Inserm UMR-S 942, Cardiovascular Markers in Stress Conditions (MASCOT), Université de Paris, Paris, France; Department of Anesthesia and Critical Care, University Hospitals Saint-Louis-Lariboisière, DMU Parabol, FHU Promice, APHP.Nord, INI-CRCT, Paris, France
| | - Bernard Cholley
- Department of Anesthesiology and Critical Care Medicine, Hôpital Européen Georges Pompidou, AP-HP, Université de Paris, Paris, France; Inserm UMR_S 1140, Innovations Thérapeutiques en Hémostase, Paris, France
| | | | - Beth A Davison
- Inserm UMR-S 942, Cardiovascular Markers in Stress Conditions (MASCOT), Université de Paris, Paris, France; Momentum Research, Inc., Chapel Hill, NC, USA
| | - Gad Cotter
- Inserm UMR-S 942, Cardiovascular Markers in Stress Conditions (MASCOT), Université de Paris, Paris, France; Momentum Research, Inc., Chapel Hill, NC, USA
| | | | - Alexandre Mebazaa
- Inserm UMR-S 942, Cardiovascular Markers in Stress Conditions (MASCOT), Université de Paris, Paris, France; Department of Anesthesia and Critical Care, University Hospitals Saint-Louis-Lariboisière, DMU Parabol, FHU Promice, APHP.Nord, INI-CRCT, Paris, France.
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30
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Sanfilippo F, La Via L, Merola F, Messina S, Dezio V, Astuto M. Systolic dysfunction and mortality in critically ill patients: more data are needed to believe in this association! ESC Heart Fail 2022; 9:2051-2052. [PMID: 35261193 PMCID: PMC9065813 DOI: 10.1002/ehf2.13866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 02/17/2022] [Indexed: 11/10/2022] Open
Affiliation(s)
- Filippo Sanfilippo
- Department of Anesthesiology and Intensive CareAOU ‘Policlinico – San Marco’CataniaItaly
| | - Luigi La Via
- Department of Anesthesiology and Intensive CareAOU ‘Policlinico – San Marco’CataniaItaly
| | - Federica Merola
- School of Specialization in Anesthesiology and Intensive CareUniversity of CataniaCataniaItaly
| | - Simone Messina
- School of Specialization in Anesthesiology and Intensive CareUniversity ‘Magna Graecia’CatanzaroItaly
| | - Veronica Dezio
- Department of Anesthesiology and Intensive CareAOU ‘Policlinico – San Marco’CataniaItaly
| | - Marinella Astuto
- Department of Anesthesiology and Intensive CareAOU ‘Policlinico – San Marco’CataniaItaly
- School of Specialization in Anesthesiology and Intensive CareUniversity of CataniaCataniaItaly
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Chotalia M, Ali M, Hebballi R, Singh H, Parekh D, Bangash MN, Patel JM. Hyperdynamic Left Ventricular Ejection Fraction in ICU Patients With Sepsis. Crit Care Med 2022; 50:770-779. [PMID: 34605779 DOI: 10.1097/ccm.0000000000005315] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To evaluate the cause and prognosis of hyperdynamic left ventricular ejection fraction in critically ill patients with sepsis. DESIGN Retrospective, single-center cohort study. SETTING University Hospital ICU, Birmingham, United Kingdom. PATIENTS ICU patients who received a transthoracic echocardiogram within 7 days of sepsis between April 2016 and December 2019. INTERVENTION None. MEASUREMENTS AND MAIN RESULTS The 90-day mortality rates of normal (55-70%), depressed (< 55%), and hyperdynamic left ventricular ejection fraction (> 70%) were compared. Multivariate logistic regression analysis was performed to determine the association of left ventricular ejection fraction phenotypes with mortality and the association of clinical variables with left ventricular ejection fraction phenotypes. One thousand fourteen patients met inclusion criteria and were 62 years old (interquartile range, 47-72), with mostly respiratory infections (n = 557; 54.9%). Ninety-day mortality was 32.1% (n = 325). Patients with hyperdynamic left ventricular ejection fraction had a higher mortality than depressed and normal left ventricular ejection fraction cohorts (58.9% [n = 103] vs 34.0% [n = 55] vs 24.7% [n = 167]; p < 0.0001, respectively). After multivariate logistic regression, hyperdynamic left ventricular ejection fraction was independently associated with mortality (odds ratio, 3.90 [2.09-7.40]), whereas depressed left ventricular ejection fraction did not (odds ratio, 0.62 [0.28-1.37]). Systemic vascular resistance was inversely associated with hyperdynamic left ventricular ejection fraction (odds ratio, 0.79 [0.58-0.95]), and age, frailty, and ischemic heart disease were associated with depressed left ventricular ejection fraction. CONCLUSIONS Hyperdynamic left ventricular ejection fraction was associated with mortality in septic ICU patients and may reflect unmitigated vasoplegia from sepsis. Depressed left ventricular ejection fraction was not associated with mortality but was associated with cardiovascular disease.
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Affiliation(s)
- Minesh Chotalia
- Birmingham Acute Care Research Group, University of Birmingham, Birmingham, United Kingdom
- Department of Anaesthetics and Critical Care, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Muzzammil Ali
- Birmingham Acute Care Research Group, University of Birmingham, Birmingham, United Kingdom
| | - Ravi Hebballi
- Birmingham Acute Care Research Group, University of Birmingham, Birmingham, United Kingdom
| | - Harjot Singh
- Birmingham Acute Care Research Group, University of Birmingham, Birmingham, United Kingdom
| | - Dhruv Parekh
- Birmingham Acute Care Research Group, University of Birmingham, Birmingham, United Kingdom
- Department of Anaesthetics and Critical Care, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Mansoor N Bangash
- Birmingham Acute Care Research Group, University of Birmingham, Birmingham, United Kingdom
- Department of Anaesthetics and Critical Care, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Jaimin M Patel
- Birmingham Acute Care Research Group, University of Birmingham, Birmingham, United Kingdom
- Department of Anaesthetics and Critical Care, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
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Boissier F, Aissaoui N. Septic cardiomyopathy: Diagnosis and management. JOURNAL OF INTENSIVE MEDICINE 2021; 2:8-16. [PMID: 36789232 PMCID: PMC9923980 DOI: 10.1016/j.jointm.2021.11.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 11/14/2021] [Accepted: 11/25/2021] [Indexed: 12/12/2022]
Abstract
There is an extensive body of literature focused on sepsis-induced myocardial dysfunction, but results are conflicting and no objective definition of septic cardiomyopathy (SCM) has been established. SCM may be defined as a sepsis-associated acute syndrome of non-ischemic cardiac dysfunction with systolic and/or diastolic left ventricular (LV) dysfunction and/or right ventricular dysfunction. Physicians should consider this diagnosis in patients with sepsis-associated organ dysfunction, and particularly in cases of septic shock that require vasopressors. Echocardiography is currently the gold standard for diagnosis of SCM. Left ventricular ejection fraction is the most common parameter used to describe LV function in the literature, but its dependence on loading conditions, particularly afterload, limits its use as a measure of intrinsic myocardial contractility. Therefore, repeated echocardiography evaluation is mandatory. Evaluation of global longitudinal strain (GLS) may be more sensitive and specific for SCM than LV ejection fraction (LVEF). Standard management includes etiological treatment, adapted fluid resuscitation, use of vasopressors, and monitoring. Use of inotropes remains uncertain, and heart rate control could be an option in some patients.
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Affiliation(s)
- Florence Boissier
- Service de Médecine Intensive Réanimation, CHU de Poitiers, Poitiers 86021, France,Université de Poitiers, Poitiers INSERM CIC 1402 (ALIVE group), France
| | - Nadia Aissaoui
- Service de Médecine Intensive Réanimation, Hôpital Cochin, APHP, Paris 75014, France,Université de Paris, Paris Cardiovascular Research Center, INSERM U970, Paris 75015, France,Corresponding author: Nadia Aissaoui, Service de Médecine Intensive–Réanimation, Hôpital Cochin Assistance Publique–Hôpitaux de Paris, 27 Rue du Faubourg Saint-Jacques, 75014 Paris, France.
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33
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Kawaguchi S, Okada M. Cardiac Metabolism in Sepsis. Metabolites 2021; 11:metabo11120846. [PMID: 34940604 PMCID: PMC8707959 DOI: 10.3390/metabo11120846] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Revised: 12/02/2021] [Accepted: 12/02/2021] [Indexed: 12/11/2022] Open
Abstract
The mechanism of sepsis-induced cardiac dysfunction is believed to be different from that of myocardial ischemia. In sepsis, chemical mediators, such as endotoxins, cytokines, and nitric oxide, cause metabolic abnormalities, mitochondrial dysfunction, and downregulation of β-adrenergic receptors. These factors inhibit the production of ATP, essential for myocardial energy metabolism, resulting in cardiac dysfunction. This review focuses on the metabolic changes in sepsis, particularly in the heart. In addition to managing inflammation, interventions focusing on metabolism may be a new therapeutic strategy for cardiac dysfunction due to sepsis.
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Affiliation(s)
- Satoshi Kawaguchi
- Department of Anatomy, Cell Biology and Physiology, Indiana University School of Medicine, Bloomington, IN 46202, USA;
| | - Motoi Okada
- Department of Emergency Medicine, Asahikawa Medical University, Asahikawa 078-8510, Japan
- Correspondence: ; Tel.: +81-166-68-2852
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34
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Liang YW, Zhu YF, Zhang R, Zhang M, Ye XL, Wei JR. Incidence, prognosis, and risk factors of sepsis-induced cardiomyopathy. World J Clin Cases 2021; 9:9452-9468. [PMID: 34877280 PMCID: PMC8610866 DOI: 10.12998/wjcc.v9.i31.9452] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 05/20/2021] [Accepted: 09/02/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND At present, large-scale studies on the clinical characteristics of sepsis-induced cardiomyopathy (SIC) are lacking.
AIM To investigate the clinical characteristics of SIC.
METHODS Based on the analysis of the MIMIC-III public database, we performed a large-scale retrospective study involving sepsis patients who were admitted to the intensive care unit (ICU) and had no concomitant cardiac disease. We used propensity score matching analysis and multivariate logistic regression to ensure the robustness of the results. The primary outcome was hospital mortality, and the secondary outcomes included the number of patients who received mechanical ventilation or renal replacement therapy during their hospital stay, the number of patients administered with vasopressors, the length of ICU stay, and the length of hospital stay.
RESULTS In the present study, after screening 38605 patients, 3530 patients with sepsis were included. A total of 997 patients met the SIC diagnostic criteria, and the incidence of SIC was 28.20% (95% confidence interval [CI]: 26.80%-29.70%). Compared to patients in the non-SIC group, patients in the SIC group were of older age and had a higher Simplified Acute Physiology Score (SAPS)-I score, SAPS-II score, and Elixhauser comorbidity index (ECI). A total of 367 (36.8%) of 997 patients in the SIC group and 818 (32.3%) of 2533 patients in the non-SIC group died in the hospital, which resulted in a significant between-group difference (odds ratios = 1.22, 95%CI: 1.05-1.42; P = 0.011). For the secondary outcomes, more patients in the SIC group received mechanical ventilation and vasopressors. Multivariate logistic regression analysis showed that age, male sex, ECI, hemoglobin level, diabetes, and mechanical ventilation use on the first day of ICU admission were risk factors for SIC.
CONCLUSION Compared with non-SIC patients, hospital mortality is higher in SIC patients.
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Affiliation(s)
- Yan-Wen Liang
- Department of Intensive Care Unit, Guangzhou Red Cross Hospital, Guangzhou 510220, Guangdong Province, China
| | - You-Feng Zhu
- Department of Intensive Care Unit, Guangzhou Red Cross Hospital, Guangzhou 510220, Guangdong Province, China
| | - Rui Zhang
- Department of Intensive Care Unit, Guangzhou Red Cross Hospital, Guangzhou 510220, Guangdong Province, China
| | - Min Zhang
- Department of Geriatrics, The Affiliated Hospital of Qingdao University, Qingdao 270000, Shandong Province, China
| | - Xiao-Ling Ye
- Department of Intensive Care Unit, Guangzhou Red Cross Hospital, Guangzhou 510220, Guangdong Province, China
| | - Jian-Rui Wei
- Guangzhou Women and Children’s Medical Center, Guangzhou 510000, Guangdong Province, China
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35
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Clinical impact of visually assessed right ventricular dysfunction in patients with septic shock. Sci Rep 2021; 11:18823. [PMID: 34552188 PMCID: PMC8458318 DOI: 10.1038/s41598-021-98397-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 09/06/2021] [Indexed: 12/18/2022] Open
Abstract
We retrospectively analyzed data from the Medical Information Mart for Intensive Care-III critical care database to determine whether visually-assessed right ventricular (RV) dysfunction was associated with clinical outcomes in septic shock patients. Associations between visually-assessed RV dysfunction by echocardiography and in-hospital mortality, lethal arrhythmia, and hemodynamic indicators to determine the prognostic value of RV dysfunction in patients with septic shock were analyzed. Propensity score analysis showed RV dysfunction was associated with increased risk of in-hospital death in patients with septic shock (adjusted odds ratio [OR] 2.15; 95% confidence interval [CI] 1.99–2.32; P < 0.001). In multivariate logistic regression analysis, RV dysfunction was associated with in-hospital death (OR 2.19; 95% CI 1.91–2.53; P < 0.001), lethal arrhythmia (OR 2.19; 95% CI 1.34–3.57; P < 0.001), and tendency for increased blood lactate levels (OR 1.31; 95% CI 1.14–1.50; P < 0.001) independent of left ventricular (LV) dysfunction. RV dysfunction was associated with lower cardiac output, pulmonary artery pressure index, and RV stroke work index. In patients with septic shock, visually-assessed RV dysfunction was associated with in-hospital mortality, lethal arrhythmia, and circulatory insufficiency independent of LV dysfunction. Visual assessment of RV dysfunction using echocardiography might help to identify the short-term prognosis of patients with septic shock by reflecting hemodynamic status.
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Hollenberg SM, Safi L, Parrillo JE, Fata M, Klinkhammer B, Gayed N, Glotzer T, Go RC, Gourna-Paleoudis E, Landers D, Jamal S, Shah N, Shah R, Tancredi J, Turi ZG. Hemodynamic Profiles of Shock in Patients With COVID-19. Am J Cardiol 2021; 153:135-139. [PMID: 34167784 PMCID: PMC8149198 DOI: 10.1016/j.amjcard.2021.05.029] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 05/10/2021] [Accepted: 05/14/2021] [Indexed: 01/08/2023]
Abstract
Patients with serious COVID infections develop shock frequently. To characterize the hemodynamic profile of this cohort, 156 patients with COVID pneumonia and shock requiring vasopressors had interpretable echocardiography with measurement of ejection fraction (EF) by Simpson's rule and stroke volume (SV) by Doppler. RV systolic pressure (RVSP) was estimated from the tricuspid regurgitation peak velocity. Patients were divided into groups with low or preserved EF (EFL or EFP, cutoff ≤45%), and low or normal cardiac index (CIL or CIN, cutoff ≤2.2 L/min/m2). Mean age was 67 ± 12.0, EF 59.5 ± 12.9, and CI 2.40 ± 0.86. A minority of patients had depressed EF (EFLCIL, n = 15, EFLCIN, n = 8); of those with preserved EF, less than half had low CI (EFPCIL, n = 55, EFPCIN, n = 73). Overall hospital mortality was 73%. Mortality was highest in the EFLCIL group (87%), but the difference between groups was not significant (p = 0.68 by ANOVA). High PEEP correlated with low CI in the EFPCIL group (r = 0.44, p = 0.04). In conclusion, this study reports the prevalence of shock characterized by EF and CI in patients with COVID-19. COVID-induced shock had a cardiogenic profile (EFLCIL) in 9.6% of patients, reflecting the impact of COVID-19 on myocardial function. Low CI despite preservation of EF and the correlation with PEEP suggests underfilling of the LV in this subset; these patients might benefit from additional volume. Hemodynamic assessment of COVID patients with shock with definition of subgroups may allow therapy to be tailored to the underlying causes of the hemodynamic abnormalities.
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37
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Use of Organ Dysfunction as a Primary Outcome Variable Following Cecal Ligation and Puncture: Recommendations for Future Studies. Shock 2021; 54:168-182. [PMID: 31764625 DOI: 10.1097/shk.0000000000001485] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Outcomes variables for research on sepsis have centered on mortality and changes in the host immune response. However, a recent task force (Sepsis-3) revised the definition of sepsis to "life-threatening organ dysfunction caused by a dysregulated host response to infection." This new definition suggests that human studies should focus on organ dysfunction. The appropriate criteria for organ dysfunction in either human sepsis or animal models are, however, poorly delineated, limiting the potential for translation. Further, in many systems, the difference between "dysfunction" and "injury" may not be clear. In this review, we identify criteria for organ dysfunction and/or injury in human sepsis and in rodents subjected to cecal ligation and puncture (CLP), the most commonly used animal model of sepsis. We further examine instances where overlap between human sepsis and CLP is sufficient to identify translational endpoints. Additional verification may demonstrate that these endpoints are applicable to other animals and to other sepsis models, for example, pneumonia. We believe that the use of these proposed measures of organ dysfunction will facilitate mechanistic studies on the pathobiology of sepsis and enhance our ability to develop animal model platforms to evaluate therapeutic approaches to human sepsis.
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Abstract
Sepsis is the life-threatening organ dysfunction caused by a dysregulated host response to infection and is the leading cause of death in intensive care units. Cardiac dysfunction caused by sepsis, usually termed sepsis-induced cardiomyopathy, is common and has long been a subject of interest. In this Review, we explore the definition, epidemiology, diagnosis and pathophysiology of septic cardiomyopathy, with an emphasis on how best to interpret this condition in the clinical context. Advances in diagnostic techniques have increased the sensitivity of detection of myocardial abnormalities but have posed challenges in linking those abnormalities to therapeutic strategies and relevant clinical outcomes. Sophisticated methodologies have elucidated various pathophysiological mechanisms but the extent to which these are adaptive responses is yet to be definitively answered. Although the indications for monitoring and treating septic cardiomyopathy are clinical and directed towards restoring tissue perfusion, a better understanding of the course and implications of septic cardiomyopathy can help to optimize interventions and improve clinical outcomes.
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Daulasim A, Vieillard-Baron A, Geri G. Hemodynamic clinical phenotyping in septic shock. Curr Opin Crit Care 2021; 27:290-297. [PMID: 33899819 DOI: 10.1097/mcc.0000000000000834] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
PURPOSE OF REVIEW Recent studies have failed to show significant benefit from a uniform strategy, suggesting that hemodynamic management must be individually adapted in septic shock depending on different phenotypes. Different approaches that may be used to this end will be discussed. RECENT FINDINGS Fluid management is a cornerstone of resuscitation, as the positive fluid balance has been associated with higher mortality and right ventricular failure. Myocardial evaluation is mandatory, as sepsis patients may present with a hyperkinetic state, left ventricular (systolic and diastolic) and/or right ventricular dysfunction, the latter being associated with higher mortality. Statistical approaches with the identification of hemodynamic clusters based on echocardiographic and clinical parameters might be integrated into daily practice to develop precision medicine. Such approaches may also predict the progression of septic shock. SUMMARY Different hemodynamic phenotypes can occur at any stage of sepsis and be associated with one another. The clinician must regularly assess dynamic changes in phenotypes in septic shock patients. Statistical approaches based on machine learning need to be validated by prospective studies.
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Affiliation(s)
- Anousone Daulasim
- Medical Intensive Care Unit, Ambroise Paré Hospital, AP-HP, Boulogne-Billancourt, INSERM UMR 1018, Clinical Epidemiology Team, CESP, Paris-Saclay University, Villejuif, France
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Abstract
BACKGROUND Cardiac dysfunction, a common complication from severe sepsis, is associated with increased morbidity and mortality. However, the molecular mechanisms of septic cardiac dysfunction are poorly understood. SIRT1, a member of the sirtuin family of NAD+-dependent protein deacetylases, is an important immunometabolic regulator of sepsis, and sustained SIRT1 elevation is associated with worse outcomes and organ dysfunction in severe sepsis. Herein, we explore the role of SIRT1 in septic cardiac dysfunction using a murine model of sepsis. METHODS An in vitro model of inflammation in isolated H9c2 cardiomyocytes was used to confirm SIRT1 response to stimulation with lipopolysaccharide (LPS), followed by a murine model of cecal ligation and puncture (CLP) to investigate the molecular and echocardiographic response to sepsis. A selective SIRT1 inhibitor, EX-527, was employed to test for SIRT1 participation in septic cardiac dysfunction. RESULTS SIRT1 mRNA and protein levels in cultured H9c2 cardiomyocytes were significantly elevated at later time points after stimulation with LPS. Similarly, cardiac tissue harvested from C57BL/6 mice 36 h after CLP demonstrated increased expression of SIRT1 mRNA and protein compared with sham controls. Administration of EX-527 18 h after CLP reduced SIRT1 protein expression in cardiac tissue at 36 h. Moreover, treatment with EX-527 improved cardiac performance with increased global longitudinal strain and longitudinal strain rate. CONCLUSIONS Our findings reveal that SIRT1 expression increases in isolated cardiomyocytes and cardiac tissue after sepsis inflammation. Moreover, rebalancing SIRT1 excess in late sepsis improves cardiac performance, suggesting that SIRT1 may serve as a therapeutic target for septic cardiomyopathy.
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Abstract
Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection. The heart is one of the most important oxygen delivery organs, and dysfunction significantly increases the mortality of the body. Hence, the heart has been studied in sepsis for over half a century. However, the definition of sepsis-induced cardiomyopathy is not unified yet, and the conventional conception seems outdated: left ventricular systolic dysfunction (LVSD) along with enlargement of the left ventricle, recovering in 7 to 10 days. With the application of echocardiography in intensive care units, not only LVSD but also left ventricular diastolic dysfunction, right ventricular dysfunction, and even diffuse ventricular dysfunction have been seen. The recognition of sepsis-induced cardiomyopathy is gradually becoming complete, although our understanding of it is not deep, which has made the diagnosis and treatment stagnate. In this review, we summarize the research on sepsis-induced cardiomyopathy. Women and young people with septic cardiomyopathy are more likely to have LVSD, which may have the same mechanism as stress cardiomyopathy. Elderly people with ischemic cardiomyopathy and hypertension tend to have left ventricular diastolic dysfunction. Patients with mechanical ventilation, acute respiratory distress syndrome or other complications of increased right ventricular afterload mostly have right ventricular dysfunction. Diffuse cardiac dysfunction has also been shown in some studies; patients with mixed or co-existing cardiac dysfunction are more common, theoretically. Thus, understanding the pathophysiology of sepsis-induced cardiomyopathy from the perspective of critical care echocardiography is essential.
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Diagnostic Value of High-Sensitivity Troponin T for Subclinical Left Ventricular Systolic Dysfunction in Patients with Sepsis. Cardiol Res Pract 2021; 2021:8897738. [PMID: 33981455 PMCID: PMC8088348 DOI: 10.1155/2021/8897738] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 04/06/2021] [Accepted: 04/10/2021] [Indexed: 12/31/2022] Open
Abstract
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.
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Chen WY, Zhang ZH, Tao LL, Xu Q, Wei X, Chen MS. Afterload-related cardiac performance identifies cardiac impairment and associates with outcome in patients with septic shock: a retrospective cohort study. J Intensive Care 2021; 9:33. [PMID: 33849653 PMCID: PMC8042871 DOI: 10.1186/s40560-021-00549-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Accepted: 03/29/2021] [Indexed: 11/25/2022] Open
Abstract
Background Septic patients with cardiac impairment are with high mortality. Afterload-related cardiac performance (ACP), as a new tool for diagnosing septic cardiomyopathy (SCM), still needs to be evaluated for its impact on the prognosis for patients with septic shock. Methods In this retrospective study, 100 patients with septic shock undertaken PiCCO monitoring were included. The ability of ACP, cardiac index (CI), and cardiac power index (CPI) to discriminate between survivors and non-survivors was tested by comparing the area under the receiver operating characteristic curve (AUROC) analysis. Cox proportional hazards regression analyses were performed to assess the associations of ACP with day-28 mortality. Curve estimation was used to describe the relationship between the hazard ratio (HR) of death and ACP. Results ACP had a strong linear correlation with CI and CPI (P < 0.001). ACP demonstrated significantly greater discrimination for day-28 mortality than CI before adjusted [AUROC 0.723 (95% CI 0.625 to 0.822) vs. 0.580 (95% CI 0.468 to 0.692), P = 0.007] and CPI after adjusted [AUROC 0.693 (95% CI 0.590 to 0.797) vs. 0.448 (0.332 to 0.565), P < 0.001]. Compared with ACP > 68.78%, HR for ACP ≤ 68.78% was 3.55 (1.93 to 6.54) (P < 0.001). When adjusted with age, APACHE-II score, Vasoactive Inotropic Score, Lactate, CRRT, day-1 volume, fibrinogen and total bilirubin as possible confounders, and decrease ACP are still associated with increasing day-28 mortality (P < 0.05). An exponential relationship was observed between ACP12h and HR of day-28 death. Conclusions Our results suggested thatACP could improve mortality predictions when compared to CI and CPI. Decreased ACP was still an independent risk factor for increased day-28 mortality. Supplementary Information The online version contains supplementary material available at 10.1186/s40560-021-00549-5.
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Affiliation(s)
- Wei-Yan Chen
- Department of Cardiology, Heart Center, Zhujiang Hospital, Southern Medical University, Guangzhou, China.,Intensive Care Unit, the Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Zhen-Hui Zhang
- Intensive Care Unit, the Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Li-Li Tao
- Intensive Care Unit, the Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Qi Xu
- Intensive Care Unit, the Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Xing Wei
- Intensive Care Unit, the Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Min-Sheng Chen
- Department of Cardiology, Heart Center, Zhujiang Hospital, Southern Medical University, Guangzhou, China. .,Guangdong Provincial Biomedical Engineering Technology Research Center for Cardiovascular Disease, Guangzhou, China. .,Sino-Japanese Cooperation Platform for Translational Research in Heart Failure, Guangzhou, China. .,Laboratory of Heart Center, Zhujiang Hospital, Southern Medical University, Guangzhou, China.
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Pecchiari M, Pontikis K, Alevrakis E, Vasileiadis I, Kompoti M, Koutsoukou A. Cardiovascular Responses During Sepsis. Compr Physiol 2021; 11:1605-1652. [PMID: 33792902 DOI: 10.1002/cphy.c190044] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Sepsis is the life-threatening organ dysfunction arising from a dysregulated host response to infection. Although the specific mechanisms leading to organ dysfunction are still debated, impaired tissue oxygenation appears to play a major role, and concomitant hemodynamic alterations are invariably present. The hemodynamic phenotype of affected individuals is highly variable for reasons that have been partially elucidated. Indeed, each patient's circulatory condition is shaped by the complex interplay between the medical history, the volemic status, the interval from disease onset, the pathogen, the site of infection, and the attempted resuscitation. Moreover, the same hemodynamic pattern can be generated by different combinations of various pathophysiological processes, so the presence of a given hemodynamic pattern cannot be directly related to a unique cluster of alterations. Research based on endotoxin administration to healthy volunteers and animal models compensate, to an extent, for the scarcity of clinical studies on the evolution of sepsis hemodynamics. Their results, however, cannot be directly extrapolated to the clinical setting, due to fundamental differences between the septic patient, the healthy volunteer, and the experimental model. Numerous microcirculatory derangements might exist in the septic host, even in the presence of a preserved macrocirculation. This dissociation between the macro- and the microcirculation might account for the limited success of therapeutic interventions targeting typical hemodynamic parameters, such as arterial and cardiac filling pressures, and cardiac output. Finally, physiological studies point to an early contribution of cardiac dysfunction to the septic phenotype, however, our defective diagnostic tools preclude its clinical recognition. © 2021 American Physiological Society. Compr Physiol 11:1605-1652, 2021.
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Affiliation(s)
- Matteo Pecchiari
- Dipartimento di Fisiopatologia Medico Chirurgica e dei Trapianti, Università degli Studi di Milano, Milan, Italy
| | - Konstantinos Pontikis
- Intensive Care Unit, 1st Department of Pulmonary Medicine, National & Kapodistrian University of Athens, General Hospital for Diseases of the Chest 'I Sotiria', Athens, Greece
| | - Emmanouil Alevrakis
- 4th Department of Pulmonary Medicine, General Hospital for Diseases of the Chest 'I Sotiria', Athens, Greece
| | - Ioannis Vasileiadis
- Intensive Care Unit, 1st Department of Pulmonary Medicine, National & Kapodistrian University of Athens, General Hospital for Diseases of the Chest 'I Sotiria', Athens, Greece
| | - Maria Kompoti
- Intensive Care Unit, Thriassio General Hospital of Eleusis, Magoula, Greece
| | - Antonia Koutsoukou
- Intensive Care Unit, 1st Department of Pulmonary Medicine, National & Kapodistrian University of Athens, General Hospital for Diseases of the Chest 'I Sotiria', Athens, Greece
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45
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Johansson Blixt P, Chew MS, Åhman R, de Geer L, Blomqwist L, Åström Aneq M, Engvall J, Andersson H. Left ventricular longitudinal wall fractional shortening accurately predicts longitudinal strain in critically ill patients with septic shock. Ann Intensive Care 2021; 11:52. [PMID: 33782770 PMCID: PMC8007689 DOI: 10.1186/s13613-021-00840-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 03/11/2021] [Indexed: 11/16/2022] Open
Abstract
Background Left ventricular longitudinal strain (LVLS) may be a sensitive indicator of left ventricular (LV) systolic function in patients with sepsis, but is dependent on high image quality and analysis software. Mitral annular plane systolic excursion (MAPSE) and the novel left ventricular longitudinal wall fractional shortening (LV-LWFS) are bedside echocardiographic indicators of LV systolic function that are less dependent on image quality. Both are sparsely investigated in the critically ill population, and may potentially be used as surrogates for LVLS. We assessed if LVLS may be predicted by LV-LWFS and MAPSE in patients with septic shock. We also assessed the repeatability and inter-rater agreement of LVLS, LV-LWFS and MAPSE measurements. Results 122 TTE studies from 3 echocardiographic data repositories of patients admitted to ICU with septic shock were retrospectively assessed, of which 73 were suitable for LVLS analysis using speckle tracking. The correlations between LVLS vs. LV-LWFS and LVLS vs. MAPSE were 0.89 (p < 0.001) and 0.81 (p < 0.001) with mean squared errors of 5.8% and 9.1%, respectively. Using the generated regression equation, LV-LWFS predicted LVLS with a high degree of accuracy and precision, with bias and limits of agreement of -0.044 ± 4.7% and mean squared prediction error of 5.8%. Interobserver repeatability was good, with high intraclass correlation coefficients (0.96–0.97), small bias and tight limits of agreement (≤ 4.1% for all analyses) between observers for all measurements. Conclusions LV-LWFS may be used to estimate LVLS in patients with septic shock. MAPSE also performed well, but was slightly inferior compared to LV-LWFS in estimating LVLS. Feasibility of MAPSE and LV-LWFS was excellent, as was interobserver repeatability.
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Affiliation(s)
- Patrik Johansson Blixt
- Department of Anaesthesiology and Intensive Care, Biomedical and Clinical Sciences, Linköping University, S-58185, Linköping, Sweden.
| | - Michelle S Chew
- Department of Anaesthesiology and Intensive Care, Biomedical and Clinical Sciences, Linköping University, S-58185, Linköping, Sweden
| | - Rasmus Åhman
- Department of Anaesthesiology and Intensive Care, Biomedical and Clinical Sciences, Linköping University, S-58185, Linköping, Sweden
| | - Lina de Geer
- Department of Anaesthesiology and Intensive Care, Biomedical and Clinical Sciences, Linköping University, S-58185, Linköping, Sweden
| | - Lill Blomqwist
- Department of Anaesthesiology and Intensive Care, Skane University Hospital, Malmö, Sweden
| | - Meriam Åström Aneq
- Department of Clinical Physiology and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Jan Engvall
- Department of Clinical Physiology and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden.,Center of Medical Image Science and Visualization, Linköping University, Linköping, Sweden
| | - Henrik Andersson
- Department of Anaesthesiology and Intensive Care, Biomedical and Clinical Sciences, Linköping University, S-58185, Linköping, Sweden
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46
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Kingston HWF, Ghose A, Rungpradubvong V, Satitthummanid S, Herdman MT, Plewes K, Leopold SJ, Ishioka H, Mohanty S, Maude RJ, Schultz MJ, Lagrand WK, Hossain MA, Day NPJ, White NJ, Anstey NM, Dondorp AM. Reduced Cardiac Index Reserve and Hypovolemia in Severe Falciparum Malaria. J Infect Dis 2021; 221:1518-1527. [PMID: 31693130 PMCID: PMC7137886 DOI: 10.1093/infdis/jiz568] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2019] [Accepted: 11/05/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Impaired microvascular perfusion is central to the development of coma and lactic acidosis in severe falciparum malaria. Refractory hypotension is rare on admission but develops frequently in fatal cases. We assessed cardiac function and volume status in severe falciparum malaria and its prognostic significance. METHODS Patients with severe (N = 101) or acute uncomplicated falciparum malaria (N = 83) were recruited from 2 hospitals in India and Bangladesh, and healthy participants (N = 44) underwent echocardiography. RESULTS Patients with severe malaria had 38% shorter left ventricular (LV) filling times and 25% shorter LV ejection times than healthy participants because of tachycardia; however, stroke volume, LV internal diameter in diastole (LVIDd), and LV internal diameter in systole (LVIDs) indices were similar. A low endocardial fraction shortening (eFS) was present in 17% (9 of 52) of severe malaria patients. Adjusting for preload and afterload, eFS was similar in health and severe malaria. Fatal cases had smaller baseline LVIDd and LVIDs indices, more collapsible inferior vena cavae (IVC), and higher heart rates than survivors. The LVIDs and IVC collapsibility were independent predictors for mortality, together with base excess and Glasgow Coma Scale. CONCLUSIONS Patients with severe malaria have rapid ejection of a normal stroke volume. Fatal cases had features of relative hypovolemia and reduced cardiac index reserve.
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Affiliation(s)
- Hugh W F Kingston
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Australia.,Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, Churchill Hospital, Oxford, United Kingdom
| | | | - Voravut Rungpradubvong
- Division of Cardiology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Cardiac Center, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Sudarat Satitthummanid
- Division of Cardiology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Cardiac Center, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - M Trent Herdman
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Katherine Plewes
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, Churchill Hospital, Oxford, United Kingdom
| | - Stije J Leopold
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, Churchill Hospital, Oxford, United Kingdom
| | - Haruhiko Ishioka
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | | | - Richard J Maude
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, Churchill Hospital, Oxford, United Kingdom
| | - Marcus J Schultz
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Department of Intensive Care Medicine, Academic Medical Center, University of Amsterdam, The Netherlands
| | - Wim K Lagrand
- Department of Intensive Care Medicine, Academic Medical Center, University of Amsterdam, The Netherlands
| | | | - Nicholas P J Day
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, Churchill Hospital, Oxford, United Kingdom
| | - Nicholas J White
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, Churchill Hospital, Oxford, United Kingdom
| | - Nicholas M Anstey
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Australia
| | - Arjen M Dondorp
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, Churchill Hospital, Oxford, United Kingdom
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47
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Sanfilippo F, Huang S, Messina A, Franchi F, Oliveri F, Vieillard-Baron A, Cecconi M, Astuto M. Systolic dysfunction as evaluated by tissue Doppler imaging echocardiography and mortality in septic patients: A systematic review and meta-analysis. J Crit Care 2020; 62:256-264. [PMID: 33461118 DOI: 10.1016/j.jcrc.2020.12.026] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 11/06/2020] [Accepted: 12/23/2020] [Indexed: 12/16/2022]
Abstract
PURPOSE Septic induced cardiomyopathy has a wide spectrum of presentation, being associated with systolic and/or diastolic dysfunction. There is currently no evidence of association between left ventricular (LV) systolic dysfunction and mortality in septic patients. METHODS We conducted a systematic review and meta-analysis to investigate the association between systolic wave (s') obtained with Tissue Doppler Imaging (TDI) and mortality in septic patients. Secondary outcome was the association of LV ejection fraction with mortality. RESULTS In the primary analysis we included a total of 13 studies (1197 patients, mortality 39.9%); overall s' wave was not significantly different between survivors and non-survivors (Standardized Mean Difference 0.20, 95%Confidence-Interval - 0.18, 0.59). This result was confirmed also in sub-groups analyses according to regional criteria of TDI sampling. A post-hoc analysis including only septic shock patients confirmed that s' wave was not associated with mortality. Several sensitivity analyses confirmed these results. We found no evidence of publication bias. The secondary analysis (11 studies, 1081 patients, mortality 36.7%) showed that LV ejection fraction was not associated with mortality (Mean Difference 0.98, 95% Confidence-Interval - 1.79,3.75). CONCLUSIONS There is no association between mortality and LV systolic function as evaluated by TDI s' wave in septic patients.
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Affiliation(s)
- Filippo Sanfilippo
- Department of Anesthesia and Intensive Care, Policlinico - San Marco University Hospital, Catania, Italy.
| | - Stephen Huang
- Intensive Care Unit, Nepean Clinical School, University of Sydney, Kingswood, NSW, Australia
| | - Antonio Messina
- Department of Anesthesia and Intensive Care, Humanitas Clinical and Research Center - IRCCS, Rozzano, Italy
| | - Federico Franchi
- Department of Medicine, Surgery and Neuroscience, Anesthesia and Intensive Care Unit, University of Siena, Via Bracci 1, 53100 Siena, Italy
| | - Francesco Oliveri
- Department of Anesthesia and Intensive Care, Policlinico - San Marco University Hospital, Catania, Italy
| | - Antoine Vieillard-Baron
- Intensive Care Medicine Unit, Assistance Publique-Hôpitaux de Paris, University Hospital Ambroise, Boulogne-Billancourt, INSERM UMR-1018, CESP, Team Kidney and Heart, University of Versailles Saint-Quentin en Yvelines, Villejuif, France
| | - Maurizio Cecconi
- Department of Anesthesia and Intensive Care, Humanitas Clinical and Research Center - IRCCS, Rozzano, Italy
| | - Marinella Astuto
- Department of Anesthesia and Intensive Care, Policlinico - San Marco University Hospital, Catania, Italy; Department of General Surgery and Medical-Surgical Specialties, Section of Anesthesia and Intensive Care, University of Catania, Catania, Italy
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48
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Ravikumar N, Sayed MA, Poonsuph CJ, Sehgal R, Shirke MM, Harky A. Septic Cardiomyopathy: From Basics to Management Choices. Curr Probl Cardiol 2020; 46:100767. [PMID: 33388489 DOI: 10.1016/j.cpcardiol.2020.100767] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 11/24/2020] [Indexed: 10/22/2022]
Abstract
Septic cardiomyopathy (SCM) is increasingly recognized as a potential complication of septic shock; it is understood to be a reversible left ventricular systolic dysfunction. The presence of SCM in septic shock, in previous studies, infer a poorer prognosis as it significantly increases the mortality rate of patients to 70%-90% and its incidence varies from 18% to 40% of septic shock patients. The pathogenesis is unclear, but believed to be a combination of bacterial toxins, cytokines, nitric oxide, and cardiac mitochondrial dysfunction, that depresses intrinsic cardiac contractility. The presence of SCM can be diagnosed in patients using a bedside transthoracic echocardiogram which typically shows left ventricular ejection fraction <45% and right ventricular dilatation. For management, levosimendan provides a good hemodynamic response without increasing cardiac oxygen demand when compared to dobutamine, while more invasive techniques such as extracorporeal membrane oxygenation, and intra-aortic balloon pulsation are being explored as well as potential rescue strategies for patients with severe SCM.
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Affiliation(s)
| | | | | | | | | | - Amer Harky
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK; Department of Congenital Cardiac Surgery, Alder Hey Children Hospital, Liverpool, UK; Liverpool Centre for Cardiovascular Science, University of Liverpool and Livepool Heart and Chest Hospital, Liverpool, UK; School of Medicine, Faculty of Health and life Science, University of Liverpool, Liverpool, UK.
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49
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Denning NL, Aziz M, Diao L, Prince JM, Wang P. Targeting the eCIRP/TREM-1 interaction with a small molecule inhibitor improves cardiac dysfunction in neonatal sepsis. Mol Med 2020; 26:121. [PMID: 33276725 PMCID: PMC7716442 DOI: 10.1186/s10020-020-00243-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 11/12/2020] [Indexed: 02/06/2023] Open
Abstract
Background Neonatal sepsis and the associated myocardial dysfunction remain a leading cause of infant mortality. Extracellular cold-inducible RNA-binding protein (eCIRP) acts as a ligand of triggering receptor expressed on myeloid cells-1 (TREM-1). M3 is a small CIRP-derived peptide that inhibits the eCIRP/TREM-1 interaction. We hypothesize that the eCIRP/TREM-1 interaction in cardiomyocytes contributes to sepsis-induced cardiac dysfunction in neonatal sepsis, while M3 is cardioprotective. Methods Serum was collected from neonates in the Neonatal Intensive Care Unit (NICU). 5–7-day old C57BL/6 mouse pups were used in this study. Primary murine neonatal cardiomyocytes were stimulated with recombinant murine (rm) CIRP with M3. TREM-1 mRNA and supernatant cytokine levels were assayed. Mitochondrial oxidative stress, ROS, and membrane potential were assayed. Neonatal mice were injected with rmCIRP and speckle-tracking echocardiography was conducted to measure cardiac strain. Sepsis was induced by i.p. cecal slurry. Mouse pups were treated with M3 or vehicle. After 16 h, echocardiography was performed followed by euthanasia for tissue analysis. A 7-day survival study was conducted. Results Serum eCIRP levels were elevated in septic human neonates. rmCIRP stimulation of cardiomyocytes increased TREM-1 gene expression. Stimulation of cardiomyocytes with rmCIRP upregulated TNF-α and IL-6 in the supernatants, while this upregulation was inhibited by M3. Stimulation of cardiomyocytes with rmCIRP resulted in a reduction in mitochondrial membrane potential (MMP) while M3 treatment returned MMP to near baseline. rmCIRP caused mitochondrial calcium overload; this was inhibited by M3. rmCIRP injection impaired longitudinal and radial cardiac strain. Sepsis resulted in cardiac dysfunction with a reduction in cardiac output and left ventricular end diastolic diameter. Both were improved by M3 treatment. Treatment with M3 attenuated serum, cardiac, and pulmonary levels of pro-inflammatory cytokines compared to vehicle-treated septic neonates. M3 dramatically increased sepsis survival. Conclusions Inhibition of eCIRP/TREM-1 interaction with M3 is cardioprotective, decreases inflammation, and improves survival in neonatal sepsis. Trial registration Retrospectively registered.
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Affiliation(s)
- Naomi-Liza Denning
- Center for Immunology and Inflammation, The Feinstein Institutes for Medical Research, 350 Community Dr, Manhasset, NY, 11030, USA.,Elmezzi Graduate School of Molecular Medicine, Manhasset, NY, USA.,Department of Surgery, Donald and Barbara Zucker School of Medicine At Hofstra/Northwell, Hempstead, NY, USA
| | - Monowar Aziz
- Center for Immunology and Inflammation, The Feinstein Institutes for Medical Research, 350 Community Dr, Manhasset, NY, 11030, USA.,Elmezzi Graduate School of Molecular Medicine, Manhasset, NY, USA
| | - Li Diao
- Center for Immunology and Inflammation, The Feinstein Institutes for Medical Research, 350 Community Dr, Manhasset, NY, 11030, USA
| | - Jose M Prince
- Center for Immunology and Inflammation, The Feinstein Institutes for Medical Research, 350 Community Dr, Manhasset, NY, 11030, USA.,Elmezzi Graduate School of Molecular Medicine, Manhasset, NY, USA.,Department of Surgery, Donald and Barbara Zucker School of Medicine At Hofstra/Northwell, Hempstead, NY, USA.,Division of Pediatric Surgery, Cohen Children's Medical Center At Hofstra/Northwell, New Hyde Park, NY, USA
| | - Ping Wang
- Center for Immunology and Inflammation, The Feinstein Institutes for Medical Research, 350 Community Dr, Manhasset, NY, 11030, USA. .,Elmezzi Graduate School of Molecular Medicine, Manhasset, NY, USA. .,Department of Surgery, Donald and Barbara Zucker School of Medicine At Hofstra/Northwell, Hempstead, NY, USA.
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50
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Prognostic Role of Left Ventricular Systolic Function Measured by Speckle Tracking Echocardiography in Septic Shock. BIOMED RESEARCH INTERNATIONAL 2020; 2020:7927353. [PMID: 33150180 PMCID: PMC7603548 DOI: 10.1155/2020/7927353] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Revised: 10/06/2020] [Accepted: 10/07/2020] [Indexed: 01/08/2023]
Abstract
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.
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