Right ventricular failure in septic shock: characterization, incidence and impact on fluid responsiveness

Abstract

Objective Incidence of right ventricular (RV) failure in septic shock patients is not well known, and tricuspid annular plane systolic excursion (TAPSE) could be of limited value. We report the incidence of RV failure in patients with septic shock, its potential impact on the response to fluids, as well as TAPSE values. Design Ancillary study of the HEMOPRED prospective multicenter study includes patients under mechanical ventilation with circulatory failure. Setting This is a multicenter intensive care unit study Patients Two hundred and eighty-two patients with septic shock were analyzed. Patients were classified in three groups based on central venous pressure (CVP) and RV size (RV/LV end-diastolic area, EDA). In group 1, patients had no RV dilatation (RV/LVEDA < 0.6). In group 2, patients had RV dilatation (RV/LVEDA ≥ 0.6) with a CVP < 8 mmHg (no venous congestion). RV failure was defined in group 3 by RV dilatation and a CVP ≥ 8 mmHg. Pulse pressure variation (PPV) was systematically recorded. Interventions None. Measurements and main results In total, 41% of patients were in group 1, 17% in group 2 and 42% in group 3. A correlation between RV size and CVP was only observed in group 3. Higher RV size was associated with a lower response to passive leg raising for a given PPV. A large overlap of TAPSE values was observed between the 3 groups. 63.5% of patients with RV failure had a normal TAPSE. Conclusions RV failure, defined by critical care echocardiography (RV dilatation) and a surrogate of venous congestion (CVP ≥ 8 mmHg), was frequently observed in septic shock patients and negatively associated with response to a fluid challenge despite significant PPV. TAPSE was unable to discriminate patients with or without RV failure.

Could strain echocardiography help to assess systolic function in critically ill COVID-19 patients?

“…However, both in chronic heart failure and cardiac surgical patients, TAPSE has been shown to be less sensitive to detect right ventricular dysfunction and less accurate to predict outcome than right ventricular GLS [ 15 , 16 ]. In addition, in a recent study done in 282 critically ill patients with septic shock, TAPSE was unable to discriminate patients with or without right ventricular failure [ 17 ]. The lack of sensitivity of TAPSE and S’ to detect systolic dysfunction may be related to the fact that they only represent a small portion of the right ventricle (regional assessment of systolic function), as well as to the angle dependency of their measurements [ 18 , 19 ].…”

Prevalence and prognostic value of various types of right ventricular dysfunction in mechanically ventilated septic patients

“…RVF was defined as R/LVEDA ≥ 0.6 in combination with CVP ≥ 8 mmHg according to a recent study by Vieillard-Baron et al [ 10 ]. RVSD was defined as TAPSE < 16 mm or FAC < 35% [ 6 , 17 ].…”

“…Vieillard-Baron and his colleagues contended that RV dilation in combination with elevated central venous pressure (CVP) was a state of RV congestion and could unmask the occurrence of RV failure (RVF). They reported that RVF was more sensitive than TAPSE in the assessment of volume responsiveness in septic shock patients [ 10 ]. Prior studies have proven that RV dysfunction is associated with long-term prognosis in septic patients [ 11 – 13 ].…”

Percutaneous right ventricular assist device, rapid employment in right ventricular failure during septic shock

“…Right ventricular (RV) failure, defined by critical care echocardiography Right Ventricular dilatation) and a surrogate of venous congestion (Central Venous Pressure ≥ 8 mmHg), was frequently observed in septic shock patients and negatively associated with response to a fluid challenge despite significant pulse pressure variation (PPV) [ 1 ]. Right Heart Failure with invasive ventricular device is associated with significant morbidity and mortality.…”

“…Three groups of patients were compared according to RV size and CVP, a good surrogate of venous congestion. The study concluded that RV failure, defined by critical care echocardiography (RV dilatation) and a surrogate of venous congestion (CVP ≥ 8 mmHg), was frequently observed in septic shock patients and negatively associated with response to a fluid challenge despite significant PPV [ 1 ]. In this context, we propose for the ventilated septic shock patients with RV failure defined using critical care echocardiography (RV/LV end-diastolic area EDA ≥ 0.6) and a surrogate of venous congestion (CVP ≥ 8 mmHg), observed (42%) with a negative effect on the response to a fluid challenge, the rapid implantation of percutaneous right ventricular assist, with Protek Duo (TPD) device.…”