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Right Ventricular Dysfunction in Early Sepsis and Septic Shock

Published:October 14, 2020DOI:https://doi.org/10.1016/j.chest.2020.09.274

      Background

      Sepsis is a frequently lethal state, commonly associated with left ventricular (LV) dysfunction. Right ventricular (RV) dysfunction in sepsis is less well understood.

      Research Question

      In septic patients, how common is RV dysfunction, and is it associated with worse outcomes?

      Study Design and Methods

      We measured echocardiographic parameters on critically ill patients with severe sepsis or septic shock within the first 24 hours of ICU admission. We defined RV dysfunction as fractional area change (FAC) less than 35% or tricuspid annulus systolic plane excursion (TAPSE) less than 1.6 cm. We defined LV systolic dysfunction as ejection fraction (EF) less than 45% or longitudinal strain greater than -19%. Using logistic regression, we assessed the relationship between 28-day mortality and presence of RV dysfunction and LV systolic dysfunction, controlling for receipt of vasopressors, receipt of fluid, mechanical ventilation, and the acute physiology and chronic health evaluation (APACHE II) score.

      Results

      We studied 393 patients. RV and LV dysfunction were common (48% and 63%, respectively). Mean echocardiographic values were: RV end-diastolic area, 22.4 ± 7.0 cm2; RV end-systolic area, 14.2 ± 6.0 cm2; RV FAC, 38 ± 11%; TAPSE, 1.8 ± .06 cm; RV longitudinal strain, -15.3 ± 6.5%; LV EF, 60% ± 14%; LV longitudinal strain, -16.5% ± 6.0%. Patients with RV dysfunction had higher 28-day mortality (31% vs 16%, P = .001). In our multivariable regression model, RV dysfunction was associated with increased mortality (OR, 3.4; CI, 1.7-6.8; P = .001), and LV systolic dysfunction was not (OR, 0.63; CI, 0.3 -1.2; P = .32)

      Interpretation

      Right ventricular dysfunction is present in nearly half of studied septic patients and is associated with over threefold higher 28-day mortality.

      Key Words

      Abbreviations:

      APACHE II (Acute Physiology and Chronic Health Evaluation score, version 2), E/e’ (ratio of early diastolic mitral inflow velocity to early diastolic mitral annular tissue velocity), EF (ejection fraction), FAC (fractional area change), LV (left ventricle), RV (right ventricle), SCM (septic cardiomyopathy), TAPSE (tricuspid annulus systolic plane excursion), TTE (transthoracic echocardiography)
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      Linked Article

      • Response
        CHESTVol. 159Issue 4
        • Preview
          We thank Pal et al for raising several important questions regarding septic cardiomyopathy. They note that most patients with right ventricular (RV) dysfunction had concomitant left ventricular (LV) dysfunction and that the challenge of determining if one ventricular dysfunction preceded the other. We observed substantial overlap among LV systolic dysfunction, LV diastolic dysfunction, and RV systolic dysfunction, which is consistent with previous comparable reports of early septic cardiomypoathy.
        • Full-Text
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      • Right Ventricular Dysfunction in Early Sepsis and Septic Shock: Learning From Acute Pulmonary Embolism
        CHESTVol. 160Issue 3
        • Preview
          We read with great interest the article published in CHEST (March 2021) by Lanspa and colleagues1 on the prognostic role of right ventricular dysfunction (RVD) in patients with sepsis. The study demonstrated that RVD, identified using transthoracic echocardiography (TTE), was present in nearly half of septic patients enrolled and was associated with over threefold higher 28-day mortality risk. In the study, RVD was defined as a right ventricular fractional area change (FAC) < 35% or a tricuspid annulus systolic planar excursion < 1.6 cm.
        • Full-Text
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      • Response
        CHESTVol. 160Issue 3
        • Preview
          We thank Drs Zuin, Rigatelli, Roncon, and Zuliani for their thoughtful read of our manuscript. They correctly note that the right/left ventricular end-diastolic diameter ratio (RV/LV) is a simpler measurement and correlates with mortality in pulmonary embolism, and they speculate that it might be similarly applicable in sepsis. In the 2008 Fremont study, RV/LV was only 72% sensitive and 58% specific for mortality from pulmonary embolism.1 The strongest predictors for mortality in that study were history of LV heart failure and hypotension, both over three times the odds of RV/LV.
        • Full-Text
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      • Sepsis-Induced Myocardial Dysfunction: “Right Ventricular Dysfunction” or “Biventricular Dysfunction”?
        CHESTVol. 159Issue 4
        • Preview
          We read with great interest the study by Lanspa et al1 in CHEST (March 2021) in which the authors report a very high incidence of right ventricular (RV) dysfunction in patients with severe sepsis or septic shock and its association with 28-day mortality rates. Although this seems plausible, we have some reservations about the interpretation of the results. First, the authors included all patients who had “RV dysfunction” (per criteria), which yielded 180 patients with RV dysfunction out of whom 145 had some form of left ventricular (LV) dysfunction (inclusive of LV systolic/diastolic dysfunction) as well (Fig 1 in the article).
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