Advertisement
Mayo Clinic Proceedings Home

Clinical Spectrum, Frequency, and Significance of Myocardial Dysfunction in Severe Sepsis and Septic Shock

      Abstract

      Objective

      To determine the frequency and spectrum of myocardial dysfunction in patients with severe sepsis and septic shock using transthoracic echocardiography and to evaluate the impact of the myocardial dysfunction types on mortality.

      Patients and Methods

      A prospective study of 106 patients with severe sepsis or septic shock was conducted from August 1, 2007, to January 31, 2009. All patients underwent transthoracic echocardiography within 24 hours of admission to the intensive care unit. Myocardial dysfunction was classified as left ventricular (LV) diastolic, LV systolic, and right ventricular (RV) dysfunction. Frequency of myocardial dysfunction was calculated, and demographic, hemodynamic, and physiologic variables and mortality were compared between the myocardial dysfunction types and patients without cardiac dysfunction.

      Results

      The frequency of myocardial dysfunction in patients with severe sepsis or septic shock was 64% (n=68). Left ventricular diastolic dysfunction was present in 39 patients (37%), LV systolic dysfunction in 29 (27%), and RV dysfunction in 33 (31%). There was significant overlap. The 30-day and 1-year mortality rates were 36% and 57%, respectively. There was no difference in mortality between patients with normal myocardial function and those with left, right, or any ventricular dysfunction.

      Conclusion

      Myocardial dysfunction is frequent in patients with severe sepsis or septic shock and has a wide spectrum including LV diastolic, LV systolic, and RV dysfunction types. Although evaluation for the presence and type of myocardial dysfunction is important for tailoring specific therapy, its presence in patients with severe sepsis and septic shock was not associated with increased 30-day or 1-year mortality.

      Abbreviations and Acronyms:

      APACHE (Acute Physiology and Chronic Health Evaluation), Fio2 (fraction of inspired oxygen), LV (left ventricular), LVEF (left ventricular ejection fraction), Pao2 (partial pressure of arterial oxygen), RV (right ventricular), SOFA (Sequential Organ Failure Assessment)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Mayo Clinic Proceedings
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Flierl M.A.
        • Rittirsch D.
        • Huber-Lang M.S.
        • Sarma J.V.
        • Ward P.A.
        Molecular events in the cardiomyopathy of sepsis.
        Mol Med. 2008; 14: 327-336
        • Hochstadt A.
        • Meroz Y.
        • Landesberg G.
        Myocardial dysfunction in severe sepsis and septic shock: more questions than answers?.
        J Cardiothorac Vasc Anesth. 2011; 25: 526-535
        • Parker M.M.
        • Shelhamer J.H.
        • Bacharach S.L.
        • et al.
        Profound but reversible myocardial depression in patients with septic shock.
        Ann Intern Med. 1984; 100: 483-490
        • Vieillard-Baron A.
        • Caille V.
        • Charron C.
        • Belliard G.
        • Page B.
        • Jardin F.
        Actual incidence of global left ventricular hypokinesia in adult septic shock.
        Crit Care Med. 2008; 36: 1701-1706
        • Bouhemad B.
        • Nicolas-Robin A.
        • Arbelot C.
        • Arthaud M.
        • Feger F.
        • Rouby J.J.
        Isolated and reversible impairment of ventricular relaxation in patients with septic shock.
        Crit Care Med. 2008; 36: 766-774
        • Munt B.
        • Jue J.
        • Gin K.
        • Fenwick J.
        • Tweeddale M.
        Diastolic filling in human severe sepsis: an echocardiographic study.
        Crit Care Med. 1998; 26: 1829-1833
        • Poelaert J.
        • Declerck C.
        • Vogelaers D.
        • Colardyn F.
        • Visser C.A.
        Left ventricular systolic and diastolic function in septic shock.
        Intensive Care Med. 1997; 23: 553-560
        • Jafri S.M.
        • Lavine S.
        • Field B.E.
        • Bahorozian M.T.
        • Carlson R.W.
        Left ventricular diastolic function in sepsis.
        Crit Care Med. 1990; 18: 709-714
        • Sturgess D.J.
        • Marwick T.H.
        • Joyce C.
        • et al.
        Prediction of hospital outcome in septic shock: a prospective comparison of tissue Doppler and cardiac biomarkers.
        Crit Care. 2010; 14: R44
        • Parker M.M.
        • McCarthy K.E.
        • Ognibene F.P.
        • Parrillo J.E.
        Right ventricular dysfunction and dilatation, similar to left ventricular changes, characterize the cardiac depression of septic shock in humans.
        Chest. 1990; 97: 126-131
        • Liu D.
        • Du B.
        • Long Y.
        • Zhao C.
        • Hou B.
        Right ventricular function of patients with septic shock: clinical significance.
        Zhonghua Wai Ke Za Zhi. 2000; 38: 488-492
        • Chan C.M.
        • Klinger J.R.
        The right ventricle in sepsis.
        Clin Chest Med. 2008; 29 (ix): 661-676
        • Burns J.R.
        • Menapace F.J.
        Acute reversible cardiomyopathy complicating toxic shock syndrome.
        Arch Intern Med. 1982; 142: 1032-1034
        • Oh J.K.
        • Park S.J.
        • Nagueh S.F.
        Established and novel clinical applications of diastolic function assessment by echocardiography.
        Circ Cardiovasc Imaging. 2011; 4: 444-455
        • Nagueh S.F.
        • Appleton C.P.
        • Gillebert T.C.
        • et al.
        Recommendations for the evaluation of left ventricular diastolic function by echocardiography.
        Eur J Echocardiogr. 2009; 10: 165-193
        • Troughton R.W.
        • Prior D.L.
        • Frampton C.M.
        • et al.
        Usefulness of tissue Doppler and color M-mode indexes of left ventricular diastolic function in predicting outcomes in systolic left ventricular heart failure (from the ADEPT study).
        Am J Cardiol. 2005; 96: 257-262
        • Wang M.
        • Yip G.W.
        • Wang A.Y.
        • et al.
        Peak early diastolic mitral annulus velocity by tissue Doppler imaging adds independent and incremental prognostic value.
        J Am Coll Cardiol. 2003; 41: 820-826
        • Hillis G.S.
        • Moller J.E.
        • Pellikka P.A.
        • et al.
        Noninvasive estimation of left ventricular filling pressure by E/e' is a powerful predictor of survival after acute myocardial infarction.
        J Am Coll Cardiol. 2004; 43: 360-367
        • Parrillo J.E.
        Pathogenetic mechanisms of septic shock.
        N Engl J Med. 1993; 328: 1471-1477
      1. Furian T, Aguiar C, Prado K, et al. Ventricular dysfunction and dilation in severe sepsis and septic shock: relation to endothelial function and mortality [published online ahead of print August 18, 2011]. J Crit Care. PMID: 21855287

        • Afessa B.
        • Keegan M.T.
        • Hubmayr R.D.
        • et al.
        Evaluating the performance of an institution using an intensive care unit benchmark.
        Mayo Clin Proc. 2005; 80: 174-180
      2. American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference: definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis.
        Crit Care Med. 1992; 20: 864-874
        • Vincent J.L.
        • de Mendonca A.
        • Cantraine F.
        • et al.
        Use of the SOFA score to assess the incidence of organ dysfunction/failure in intensive care units: results of a multicenter, prospective study: working group on ”sepsis-related problems” of the European Society of Intensive Care Medicine.
        Crit Care Med. 1998; 26: 1793-1800
        • Herasevich V.
        • Pieper M.S.
        • Pulido J.
        • Gajic O.
        Enrollment into a time sensitive clinical study in the critical care setting: results from computerized septic shock sniffer implementation.
        J Am Med Inform Assoc. 2011; 18: 639-644
        • Schiller N.B.
        • Shah P.M.
        • Crawford M.
        • et al.
        Recommendations for quantitation of the left ventricle by two-dimensional echocardiography: American Society of Echocardiography Committee on Standards, Subcommittee on Quantitation of Two-Dimensional Echocardiograms.
        J Am Soc Echocardiogr. 1989; 2: 358-367
        • Ommen S.R.
        • Nishimura R.A.
        • Appleton C.P.
        • et al.
        Clinical utility of Doppler echocardiography and tissue Doppler imaging in the estimation of left ventricular filling pressures: a comparative simultaneous Doppler-catheterization study.
        Circulation. 2000; 102: 1788-1794
        • Wahl A.
        • Praz F.
        • Schwerzmann M.
        • et al.
        Assessment of right ventricular systolic function: comparison between cardiac magnetic resonance derived ejection fraction and pulsed-wave tissue Doppler imaging of the tricuspid annulus.
        Int J Cardiol. 2011; 151: 58-62
        • Zanotti Cavazzoni S.L.
        • Guglielmi M.
        • Parrillo J.E.
        • Walker T.
        • Dellinger R.P.
        • Hollenberg S.M.
        Ventricular dilation is associated with improved cardiovascular performance and survival in sepsis.
        Chest. 2010; 138: 848-855
        • Bouhemad B.
        • Nicolas-Robin A.
        • Arbelot C.
        • Arthaud M.
        • Feger F.
        • Rouby J.J.
        Acute left ventricular dilatation and shock-induced myocardial dysfunction.
        Crit Care Med. 2009; 37: 441-447
        • Schramm G.E.
        • Kashyap R.
        • Mullon J.J.
        • Gajic O.
        • Afessa B.
        Septic shock: a multidisciplinary response team and weekly feedback to clinicians improve the process of care and mortality.
        Crit Care Med. 2011; 39: 252-258