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.

Keywords: Central venous pressure; Critical care echocardiography; Fluid responsiveness; Right ventricular failure; TAPSE.

Fig. 1

Individual values of CVP and RV/LV EDA among the 3 groups. Correlation (ρ) coefficients (p values in brackets) between CVP and RV/LV EDA were 0.023 (0.805), -0.102 (0.493) and 0.241 (0.008) in groups 1, 2 and 3, respectively

Fig. 2

Hemodynamic parameters according to the three defined groups

Fig. 3

Proportion of patients responsive to passive leg raising according to pulse pressure variation and RV/LV end-diastolic area ratio. The colored scale represents the proportion of patients responsive to PLR in the analyzed cohort. The warmer the color, the higher the proportion of patients responsive to PLR. The blue lines show the thresholds that are indicative of the reader. The distribution of RV/LV end-diastolic area ratio is shown under the x-axis, according to response to PLR (PLR-responsive patients in orange and the non-responsive ones in green)

Fig. 4

Distribution of TAPSE across the three defined groups (a) and its relationship with RV/LV end-diastolic area ratio (b)