Septic cardiomyopathy: Diagnosis and management

Abstract

There is an extensive body of literature focused on sepsis-induced myocardial dysfunction, but results are conflicting and no objective definition of septic cardiomyopathy (SCM) has been established. SCM may be defined as a sepsis-associated acute syndrome of non-ischemic cardiac dysfunction with systolic and/or diastolic left ventricular (LV) dysfunction and/or right ventricular dysfunction. Physicians should consider this diagnosis in patients with sepsis-associated organ dysfunction, and particularly in cases of septic shock that require vasopressors. Echocardiography is currently the gold standard for diagnosis of SCM. Left ventricular ejection fraction is the most common parameter used to describe LV function in the literature, but its dependence on loading conditions, particularly afterload, limits its use as a measure of intrinsic myocardial contractility. Therefore, repeated echocardiography evaluation is mandatory. Evaluation of global longitudinal strain (GLS) may be more sensitive and specific for SCM than LV ejection fraction (LVEF). Standard management includes etiological treatment, adapted fluid resuscitation, use of vasopressors, and monitoring. Use of inotropes remains uncertain, and heart rate control could be an option in some patients.

Keywords: Echocardiography; Myocardial dysfunction; Septic cardiomyopathy; Septic shock.

Figure 1

Echo parameters used to diagnose SCM. LV: Left ventricular; RV: Right ventricle; SCM: Septic cardiomyopathy; TDI: Tissue Doppler imaging; TAPSE: Tricuspid annular plane systolic excursion.

Figure 2

Potential therapeutic options according to the severity of SCM. Green boxes represent therapies with strong recommendations, strong quality of evidence. Blue box represents therapies with strong recommendations, moderate quality of evidence. Yellow Boxes represent therapies with weak recommendations requiring confirmation in prospective clinical trials. Red Boxes represents therapies which should not be used due to weak recommendations, low quality of evidence. *Beta blockers could be discussed in patients with tachycardia with diastolic dysfunction, but are not recommended in cases of systolic dysfunction or cardiogenic shock. ^†Levosimendan should not be used due to lack of efficacy, poor safety profile, cost, and the limited availability. ECMO: Extracorporeal membrane oxygenation; SCM: Septic cardiomyopathy.