Elsevier

Journal of Critical Care

Volume 29, Issue 4, August 2014, Pages 495-499
Journal of Critical Care

Sepsis/Infection
Correlation 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,☆☆

https://doi.org/10.1016/j.jcrc.2014.03.007Get rights and content

Abstract

Introduction

The prognostic implications of myocardial dysfunction in patients with sepsis and its association with mortality are controversial. Several tools have been proposed to evaluate cardiac function in these patients, but their usefulness beyond guiding therapy is unclear. We review the value of echocardiographic estimate of left ventricular ejection fraction (LVEF) in the setting of severe sepsis and/or septic shock and its correlation with 30-day mortality.

Methods

We conducted a systematic review and meta-analysis to evaluate the prognostic functionality of newly diagnosed LV systolic dysfunction by transthoracic echocardiography on critical ill patients admitted to the intensive care unit with severe sepsis or septic shock.

Results

A search of EMBASE and PubMed, Ovide MEDLINE, and Cochrane CENTRAL medical databases yielded 7 studies meeting inclusion criteria reporting on a total of 585 patients. The pooled sensitivity of depressed LVEF for mortality was 52% (95% confidence interval [CI], 29%-73%), and pooled specificity was 63% (95% CI, 53%-71%). Summary receiver operating characteristic curve showed an area under the curve of 0.62 (95% CI, 0.58-0.67). The overall mortality diagnostic odd ratio for septic patients with LV systolic dysfunction was 1.92 (95% CI, 1.27-2.899). Statistical heterogeneity of studies was moderate.

Conclusion

The presence of new LV systolic dysfunction associated with sepsis and defined as low LVEF is neither a sensitive nor a specific predictor of mortality. These findings are limited because of the heterogeneity and underpower of the studies. Further research into this method is warranted.

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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    None of the authors have any conflicts of interest to disclose.

    ☆☆

    The authors do not have any sources of funding to disclose.

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