Sepsis/InfectionCorrelation of left ventricular systolic dysfunction determined by low ejection fraction and 30-day mortality in patients with severe sepsis and septic shock: A systematic review and meta-analysis☆,☆☆
Introduction
Left ventricular (LV) dysfunction associated with sepsis is a phenomenon that has been described decades ago [1] but has gained more recognition recently because of the widespread use of echocardiography in the intensive care unit (ICU) [2], [3]. Its mechanism is not clear because of its multifactorial nature and clinical factors including dynamic adaptation of the cardiovascular system to the disease process, host response, and resuscitation [4]. Cellular, extracellular, and molecular mechanisms have been postulated as explanation for myocardial injury such as alterations in coronary blow flow, inflammation, cytokines, or calcium dysregulation [5], [6], [7].
Numerous studies have described different types of myocardial dysfunction in sepsis, and a variety of echocardiographic parameters have been developed to assess LV function [8]. Among these parameters, ejection fraction (EF) is most commonly used to evaluate LV systolic function. At present, the most accepted definition of myocardial dysfunction in sepsis is based solely on an LVEF of less than 45% to 50% in the absence of previously diagnosed cardiac disease that demonstrates reversibility upon remission on patients without prior cardiomyopathy [3]. Moreover, the use of more technological advanced methods to evaluate myocardial tissue properties has improved recognition of more subtle myocardial function abnormalities [9], [10]. Preliminary data on LV diastolic dysfunction evaluated by tissue Doppler imaging have demonstrated association with mortality; however, the evidence at this point is limited [11], [12]. On the contrary, despite larger pooled data, the presence of LV systolic dysfunction and its association to poor outcome remain controversial. Vieillard-Baron et al found that reversible acute LV dysfunction defined as LV hypokinesis was not associated with a worse prognosis [13]; however, Furian et al demonstrated a poor prognosis with the presence of LV dysfunction in this scenario [14]. The presence of low LVEF and its correlation with mortality in sepsis remain unclear [1], [13], [14]. We conducted a systematic review and meta-analysis to determine whether LV systolic dysfunction associated with sepsis and diagnosed by a low LVEF demonstrated with transthoracic echocardiography (TTE) has a prognostic value in critically ill septic patients.
Section snippets
Search strategy
We conducted a search of several medical databases including EMBASE and PubMed, Ovid MEDLINE, Cochrane CENTRAL and Web of Science, African Index Medicus, IndMed, Pantelemion, Western Pacific Index Medicus, KoreaMed, LILACS, IMSEAR, and EMRO, with search terms sepsis or septic, Cardiac output or echo* or TTE and heart failure, heart disease, or ejection fraction (see Appendix 1 for full search strategy). References of included and potentially relevant studies were inspected manually for
Literature search
The database search yielded 1504 records; and manual inspection of references, an additional 1 article. Nine hundred seventy-six articles remained after removing duplicates. All abstracts were screened; and of these, 156 were deemed potentially relevant, and full text was obtained. Of these, 143 were excluded for addressing different end points, animal studies, and pediatric cases, leaving 15 articles for inclusion in qualitative synthesis. Seven of these articles contained sufficient
Discussion
This systematic review demonstrated that the studies that have investigated the effect of sepsis-induced LV systolic dysfunction as a determinant of mortality in critical ill patients show that it is a poor prognostic tool when defined as low LVEF. Individual study multivariable regression analysis did not show correlation with mortality [4], [18], [19], [22], except for one study that showed correlation of mortality with the presence of severe LVEF depression [18]. This conclusion is somewhat
Acknowledgments
All authors take responsibility for the content of the manuscript including data and analysis. All authors were involved in the analysis of data and writing of the manuscript, and meet criteria for authorship as defined by Journal of Critical Care. All authors report no conflicts of interest relevant to this article.
The authors would like to thank Patricia J. Erwin, librarian, for assistance with the electronic literature search.
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2022, Journal of Intensive MedicineCitation Excerpt :Increased LVEF and hyperkinesia might be associated with a higher mortality rate because this may reflect persistent profound vasoplegia.[19,78,79] The results regarding the prognostic value of LVEF in patients with severe sepsis and septic shock are conflicting and a recent meta-analysis did not find any association between mortality and LVEF[52,81–85] or TDI S’ wave.[35] According to several studies and a meta-analysis, GLS could be a significant predictor of higher mortality.[86–88]
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None of the authors have any conflicts of interest to disclose.
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The authors do not have any sources of funding to disclose.