Detection of Myocardial Dysfunction in Septic Shock

Abstract

In patients with septic shock, but not sepsis, myocardial strain imaging using speckle-tracking echocardiography identified myocardial dysfunction in the absence of changes in EF. These data suggest that strain imaging may play a role in cardiovascular assessment during septic shock.

Levosimendan in Sepsis

“…Nonetheless, pragmatic, multicenter, randomized, controlled trials represent the best available design to test treatments, 2 and all previous evidence on mortality reduction with levosimendan in patients with sepsis and those undergoing surgery was based on poor-quality single-center, randomized, controlled trials. Results of two large, multicenter, randomized, controlled trials on perioperative use of levosimendan 3,4 are awaited to see whether this drug is only an inotropic agent or can also improve survival. Alessandro Putzu, M.D.…”

“…Previous studies, [1][2][3][4] in which more severely ill patients were enrolled, focused on the effects of levosimendan on organ perfusion rather than function, and improved organ perfusion was observed with improved systemic hemodynamics when additional volume was administered. In our view, the patients in the LeoPARDS trial were not receiving sufficient volume loading during levosimendan infusion, which led to relative hypovolemia, causing tachycardia, supraventricular arrhythmia, and eventually decreased organ perfusion.…”

“…A strong supportive evidence base for echocardiography is lacking, and the risk of misinterpretation exists. 2 More objective assessments of ventricular dysfunction, such as total isovolemic time and strain-rate imaging using speckletracking echocardiography (which characterizes and measures myocardial deformation), 3 are certainly not within the scope of a clinician with basic echocardiographic training and thus are not suitable to use for inclusion in a large, multicenter clinical trial.…”

“…3,4 Therefore, the majority of patients with septic shock could still be expected to benefit from the inotropic effects of levosimendan, not to mention its antiinflammatory, antioxidative, antiapoptotic, and cardioprotective effects. 5 Such effects may offer additional systemic benefit, regardless of the presence of myocardial dysfunction.…”

“…The rationale for using levosimendan in sepsis is based on studies that have shown a mortality benefit among patients with septic cardiomyopathy who were treated with levosimendan. 2,3 Unfortunately, the number of patients with myocardial dysfunction who were included in the LeoPARDS trial was evidently rather low, according to the sparse hemodynamic information (only 30% of the patients underwent baseline cardiacoutput assessment), the liberal inclusion criteria, and the negligible use of dobutamine. In addition, neither routine echocardiography nor hemodynamic monitoring was required during the course of the trial.…”