Hyperdynamic Left Ventricular Ejection Fraction in ICU Patients With Sepsis

Chotalia, Minesh; Ali, Muzzammil; Hebballi, Ravi; Singh, Harjot; Parekh, Dhruv; Bangash, Mansoor N.; Patel, Jaimin

doi:10.1097/ccm.0000000000005315

Cited by 32 publications

(43 citation statements)

References 27 publications

Supporting

Mentioning

Contrasting

Unclassified

Order By: Relevance

“…Several studies have confirmed the high mortality rate in patients with sepsis, ranging from 34 to 56% (5) and 33.5% (6) in foreign and domestic countries, respectively, and even higher in patients with combined hyperdynamic left ventricular function or myocardial depression (3,7). Standardizing the staging of myocardial depression in sepsis and realizing the early identification of patients with sepsis are of great significance for clarifying the cardiac changes in sepsis at various stages, adjusting and guiding treatment in a timely manner, and optimizing hemodynamics.…”

Section: Discussionmentioning

confidence: 94%

A multicenter prospective cohort study of cardiac ultrasound phenotypes in patients with sepsis: Study protocol for a multicenter prospective cohort trial

et al. 2022

View full text Add to dashboard Cite

BackgroundSepsis-induced cardiomyopathy significantly increased the mortality of patients with sepsis. The diagnostic criteria for septic cardiomyopathy has not been unified, which brings serious difficulties to clinical treatment. This study aimed to provide evidence for the early identification and intervention in patients with sepsis by clarifying the relationship between the ultrasound phenotype of septic cardiomyopathy and the prognosis of patients with sepsis.MethodsThis was a multicenter, prospective cohort study. The study population will consist of all eligible consecutive patients with sepsis or septic shock who meet the Sepsis 3.0 diagnostic criteria and were aged ≥18 years. Clinical data and echocardiographic measurements will be recorded within 2 h, at the 24th hour, at the 72nd hour, and on the 7th day after admission. The prevalence of each phenotype will be described as well, and their association with prognosis will be analyzed statistically.DiscussionTo achieve early recognition, prevent reinjury, achieve precise treatment, and reduce mortality in patients with sepsis, it is important to identify septic cardiac alterations and classify the phenotypes at all stages of sepsis. First, there is a lack of studies on the prevalence of each phenotype in Chinese populations. Second, each phenotype and its corresponding prognosis are not clear. In addition, the prognosis of patients with normal cardiac ultrasound phenotypes vs. those with suppressed or hyperdynamic cardiac phenotypes is unclear. Finally, this study was designed to collect data at four specific timing, then the timing of occurrence, duration, changes over time, impact to outcomes of each phenotype will probably be found. This study is expected to establish a standard and objective method to assess the ultrasound phenotype of septic cardiomyopathy due to its advantages of visualization, non-invasiveness and reproducibility, and to provide more precise information for the hemodynamic management of septic patients. In addition, this research will promote the clinical application of critical care ultrasound, which will play an important role in medical education and make ultrasound the best method to assess cardiac changes in sepsis.Trial registrationhttps://clinicaltrials.gov/ct2/show/NCT05161104, identifier NCT05161104.

show abstract

Section: Discussionmentioning

confidence: 94%

A multicenter prospective cohort study of cardiac ultrasound phenotypes in patients with sepsis: Study protocol for a multicenter prospective cohort trial

et al. 2022

View full text Add to dashboard Cite

show abstract

“…Our murine model was calibrated to ensure systemic inflammation and lack of hypovolaemia without mortality. Hyperdynamic physiology appears to be an independent predictor of mortality independent of preload as a likely contributory factor [ 5 ]. Although impaired left ventricular relaxation may also reduce preload, diastolic dysfunction appears to be common when myocardial contractility is depressed in sepsis [ 5 ].…”

Section: Discussionmentioning

confidence: 99%

“…Hyperdynamic physiology appears to be an independent predictor of mortality independent of preload as a likely contributory factor [ 5 ]. Although impaired left ventricular relaxation may also reduce preload, diastolic dysfunction appears to be common when myocardial contractility is depressed in sepsis [ 5 ]. By using a model where surgery (such as caecal ligation and puncture) requiring anaesthesia could be avoided, further confounding factors that may have blurred sex-specific differences in previous studies were minimised.…”

Section: Discussionmentioning

confidence: 99%

“…Preservation of normal cardiac function and/or absence of myocardial injury (as evidenced by elevated levels of circulating troponin) are independently associated with reduced mortality in early sepsis and appears to correlate with the lower number of females requiring critical care and/or dying [ 3 , 4 ]. By contrast, hyperdynamic left ventricular ejection fraction is associated with higher mortality [ 5 – 7 ]. Although selection bias may account for this apparent sex-related discrepancy in critical care utilisation [ 1 ], several biologic reasons seem more likely to underpin such sex-specific epidemiologic outcomes in sepsis [ 2 ].…”

Section: Introductionmentioning

confidence: 99%

See 1 more Smart Citation

Sex-specific differences in cardiac function, inflammation and injury during early polymicrobial sepsis

Walker

Muthoo

Sanchez

et al. 2022

ICMx

View full text Add to dashboard Cite

Background Sex differences in sepsis are underexplored and incompletely understood. Cardiac function in early sepsis is pivotal in determining survival; hyperdynamic left ventricular ejection fraction is associated with higher mortality. Female sex may be cardioprotective, but variable experimental findings have not controlled for hypovolaemia. Sex-specific local cardiac versus peripheral inflammation in causing cardiovascular dysfunction also remain unclear. We therefore examined whether there are sex-specific differences in cardiac function in early sepsis, controlling for volaemic status and sex-specific differences in the peripheral inflammatory response initiated by tumour necrosis factor (TNFα). Methods We used an experimental polymicrobial sepsis (faecal slurry) model titrated to minimise hypovolaemia as a confounding factor. We quantified cardiac function (transthoracic cardiac echocardiography) 1 week before, and 18 h after, sepsis. Cardiac injury (troponin I), inflammation and immune cell infiltration (flow cytometry) were quantified in naïve and septic female and male mice 18 h after sepsis. To evaluate the sex-specific influence of TNFα derived from peripheral leukocytes, we repeated the experiments in iRHOM2−/− mice that are unable to shed TNFα exclusively from circulating leucocytes. Results Serum troponin I increased to 1.39 ± 0.38 ng mL−1 (from undetectable levels in controls) 18 h after onset of normovolaemic sepsis to a similar extent in both sexes. Stroke volume in male mice increased by 8 µL [(3–13); p = 0.004], compared to individualised pre-sepsis values. By contrast, stroke volume remained at baseline levels in females [mean difference: 4 µL (− 1 to 9)]. Messenger RNA levels of markers for cardiac injury/inflammation after sepsis (real-time polymerase-chain reaction) were elevated in male wild-type mice compared to female wild types (n = 10/sex), with higher cardiac mRNA levels of atrial natriuretic peptide, inflammation (TNFα) and oxidative stress (superoxide dismutase-1), although serum troponin I values were similarly elevated. Flow cytometry analysis of cardiac tissue showed doubling of CD4 + leukocyte infiltration in male mice. Sex-specific cardiac physiologic differences were similar in iRHOM2−/− mice that are unable to shed TNFα exclusively from leucocytes. Conclusions In early normovolaemic polymicrobial sepsis, a relative hyperdynamic response develops in male mice. Myocardial stress/injury after early sepsis is limited in females, with less cardiac infiltration of CD4 + leukocytes but independent of shedding of TNFα from peripheral circulating leukocytes.

show abstract

“…Thirty-seven percent of our cohort had hyperdynamic LV ejection fraction (HDLVEF), and this should not be considered “normal.” The prevalence of HDLVEF was higher in nonsurvivors than that in survivors (46% vs 32%). Although HDLVEF is associated with poor prognosis in critically ill patients with sepsis ( 4 ), likely due to unmitigated vasoplegia precipitating a high cardiac output state, in ARDS, its development may be due to low LV preload, caused by RV systolic impairment and/or obstruction of LV filling from RV dilation (RVD). HDLVEF may, therefore, reflect a low cardiac output state that precipitates multiple organ dysfunction and death.…”

mentioning

confidence: 99%

The authors reply

Chotalia

Ali

Alderman

et al. 2022

Critical Care Medicine

Self Cite

View full text Add to dashboard Cite

We would like to thank Jha and Jha (1) for their many insightful comments about our article (2). First, although a dissociation between tricuspid annular plane systolic excursion (TAPSE) and right ventricular (RV) fractional area change (RVFAC) appears surprising, this has been reported by multiple studies assessing RV systolic function in COVID-19 acute respiratory distress syndrome (ARDS), including our own. TAPSE, lateral tricusipid annulus peak systolic velocity (RV S'), and RV free-wall longitudinal strain were all relatively preserved despite low RVFAC and were considered to be poorly sensitive of RV systolic impairment in COVID-19 ARDS (3). The authors proposed an RV phenotype in COVID-19 ARDS characterized by radial impairment with sparing of longitudinal function, a pattern of myocardial remodeling that resembles the response to pulmonary hypertension (3), and our results support these findings.We also disagree with the suggestion that all RV phenotypes were associated with normal left ventricular (LV) function. Thirty-seven percent of our cohort had hyperdynamic LV ejection fraction (HDLVEF), and this should not be considered "normal. " The prevalence of HDLVEF was higher in nonsurvivors than that in survivors (46% vs 32%). Although HDLVEF is associated with poor prognosis in critically ill patients with sepsis (4), likely due to unmitigated vasoplegia precipitating a high cardiac output state, in ARDS, its development may be due to low LV preload, caused by RV systolic impairment and/or obstruction of LV filling from RV dilation (RVD). HDLVEF may, therefore, reflect a low cardiac output state that precipitates multiple organ dysfunction and death. We were unable to estimate cardiac output via transthoracic echocardiography in these patients to corroborate this hypothesis.Jha and Jha (1) highlight the relatively low prevalence of RV volume and pressure overload as measured through the LV eccentricity index and septal dyskinesia, a surprising finding. This may be because we were only able to measure this parameter in 72% of patients due to poor views. However, we disagree with their suggestion that these findings are out of keeping with the measured maximum tricuspid regurgitation (TR) velocity (TRVmax), which at 2.7 (interquartile range, 2.3-3.1) is also relatively low: only 29% of patients had intermediate high risk of pulmonary hypertension. These findings are also limited as we were only able to measure TRVmax in 42% of patients, due to incomplete or absent TR Doppler signal in 58% of patients.Finally, we agree with the notion that the definition of RV dysfunction in ARDS should include multiple parameters that holistically assess RV size, function, and coupling to the pulmonary circulation but also include downstream consequences on organ congestion/LV function and cardiac output. However, these parameters should be chosen carefully: septal dyskinesia was previously included in definitions of RV dysfunction in ARDS but has recently been disregarded (5), perhaps due to its subjective nature. Current ...

show abstract

Hyperdynamic Left Ventricular Ejection Fraction in ICU Patients With Sepsis

Abstract: To evaluate the cause and prognosis of hyperdynamic left ventricular ejection fraction in critically ill patients with sepsis.

Cited by 32 publications

References 27 publications

A multicenter prospective cohort study of cardiac ultrasound phenotypes in patients with sepsis: Study protocol for a multicenter prospective cohort trial

A multicenter prospective cohort study of cardiac ultrasound phenotypes in patients with sepsis: Study protocol for a multicenter prospective cohort trial

Sex-specific differences in cardiac function, inflammation and injury during early polymicrobial sepsis

The authors reply

Contact Info

Product

Resources

About