Microvascular alterations in patients with acute severe heart failure and cardiogenic shock

Backer, Daniel De; Créteur, Jacques; Dubois, Marc-Jacques; Sakr, Yasser; Vincent, Jean‐Louis

doi:10.1016/j.ahj.2003.07.006

Cited by 399 publications

(308 citation statements)

References 33 publications

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“…24 In several studies and in different types of shock, the presence of microcirculatory dysfunction has been associated with poor outcomes, including a higher frequency of organ failure and mortality. 14,15,25,26 In our small series of patients, the microcirculation was moderately to severely compromised, in line with previous studies of patients with severe sepsis and septic shock. 14,22,23 For example, Creteur et al 22 reported NIRS ascending slope values of 2.3 ± 1.3%Ásec -1 in patients with septic shock, a value similar to our findings.…”

Section: Discussionsupporting

confidence: 91%

Microcirculatory abnormalities in patients with severe influenza A (H1N1) infection

Salgado

Ortiz

Favory

et al. 2010

Can J Anesth/J Can Anesth

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Purpose This study was designed to evaluate the degree of microcirculatory abnormalities in patients with severe influenza A (H1N1) infection. Methods We assessed the sublingual microcirculation in seven consecutive patients with acute lung injury related to influenza A (H1N1) infection. The evaluation was carried out using sidestream dark field (SDF) imaging within the first 96 hr after the patients were admitted to the intensive care unit. Thenar oxygen saturation (StO 2 ) was also measured with near-infrared spectroscopy (NIRS) during a vascular occlusion test. In addition, the Lung Injury Score (LIS) and the APACHE II and SOFA scores were recorded. Results All patients received invasive mechanical ventilation and at least one of the following adjuvant therapies: inhaled nitric oxide (n = 4), extracorporeal membrane oxygenation (n = 1), prone position (n = 4), recruitment maneuver (n = 3), and hydrocortisone 50 mgÁhr -6

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Section: Discussionsupporting

confidence: 91%

Microcirculatory abnormalities in patients with severe influenza A (H1N1) infection

Salgado

Ortiz

Favory

et al. 2010

Can J Anesth/J Can Anesth

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“…De Backer et al 2 have shown that severe microvascular alterations are present in patients with acute heart failure. These alterations did not correlate with CI and probably demonstrated locally impaired tissue perfusion.…”

Section: Discussionmentioning

confidence: 99%

“…Impaired microvascular perfusion, as assessed by these methods, has been shown to be associated with worse intensive care unit survival. 2 Cardiac and vascular nitric oxide (NO) bioavailability is reduced in heart failure, contributing to contractile dysfunction, ventricular hypertrophy, and remodelling, as well as endothelial dysfunction. 3,4 Nitrates are powerful NO donors that are frequently administered to patients with acute heart failure.…”

Section: Introductionmentioning

confidence: 99%

“…the imbalance between tissue oxygen delivery and oxygen consumption. 2 Novel two-dimensional imaging techniques provide direct visualization of capillaries in tissues covered by a thin epithelial layer at the bedside. Using these techniques, changes in microvascular blood flow can be analysed in patients with a variety of disease states, including acute heart failure.…”

Section: Introductionmentioning

confidence: 99%

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Low‐dose nitroglycerin improves microcirculation in hospitalized patients with acute heart failure

Uil

Lagrand

Spronk

et al. 2009

European J of Heart Fail

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AimsImpaired tissue perfusion is often observed in patients with acute heart failure. We tested whether low-dose nitroglycerin (NTG) improves microcirculatory perfusion in patients admitted for acute heart failure. Methods and resultsIn 20 acute heart failure patients, NTG was given as intravenous infusion at a fixed dose of 33 mg/min. Using Sidestream Dark Field (SDF) imaging, sublingual microvascular perfusion was evaluated before (T0, average of two baseline measurements) and 15 min after initiation of NTG (T1). In a subgroup of seven patients, SDF measurements were repeated after NTG had been stopped for 20 min. Capillaries were defined as microvessels with a diameter of ,20 mm. Perfused capillary density (PCD) was determined as the parameter of tissue perfusion. Values are expressed as median and interquartile range (P25; P75). The median age of the subjects was 60 (52; 73) years, and 65% were male. Patients were stable before starting NTG. Nitroglycerin decreased central venous pressure [17 (13; 19) mmHg at T0 vs. 16 (13; 17) mmHg at T1, P ¼ 0.03] and pulmonary capillary wedge pressure [23 (18; 31) mmHg at T0 vs. 19 (16; 25) mmHg at T1, P ¼ 0.03]. It increased PCD [10.7 (9.9; 12.5) mm mm 22 at T0 vs. 12.4 (11.4; 13.6) mm mm 22 at T1, P ¼ 0.01]. After cessation of NTG, PCD returned to baseline values (P ¼ 0.04). ConclusionLow-dose NTG significantly reduces cardiac filling pressures and improves microvascular perfusion in patients admitted for acute heart failure.--

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“…Thus, one may intuitively consider that organ failure is related to microcirculatory dysfunction. In fact, degrees of microvascular abnormalities have been correlated with organ dysfunction and mortality in different pathological conditions (8)(9)(10)(11) . Additionally, microcirculatory alterations can be already detected in the very early stage of disease, and may persist regardless of macrohemodynamic status (12,13) .…”

Section: Introductionmentioning

confidence: 99%

Microcirculatory assessment in daily clinical practice - not yet ready but not too far!

Salgado

Favory

Backer

2010

Einstein (São Paulo)

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Shock is characterized by an alteration in tissue perfusion that may lead to tissue hypoxia. Recent guidelines recommend aggressive and early resuscitation therapy, but mortality rate is still unacceptably high. Unfortunately, traditional clinical surrogates used to guide resuscitation therapy poorly correlate with microcirculatory blood flow, a key determinant of tissue perfusion. New techniques that directly assess microcirculatory perfusion at the bedside have emerged as a complement to traditional macrohemodynamic parameters. These techniques have been supported by several studies showing microcirculatory alterations in different clinical settings. In addition, these microcirculatory alterations are related with outcome and persist regardless of arterial pressure normalization, being a better predictor of organ dysfunction and mortality than global hemodynamic and laboratory parameters. These findings allowed the concept of "microcirculatory-goal directed therapy", which is now in its preliminary phase, as the impact of many interventions still needs to be assessed. Finally, microcirculation assessment has also been explored in other medical fields such as perioperative, systemic arterial hypertension, heart failure, and hyperviscosity syndromes. In this review, we shortly present the characteristics of microcirculation and the main determinants of capillary blood flow, and we discuss advantages and limitations of some recently available techniques to evaluate microcirculation at the bedside, and how they could be useful for the general clinician in daily practice.Keywords: Shock; Resuscitation; Microcirculation/pathophysiology; Hemodynamics/physiology; Multiple organ failure/pathophysiology; Prognosis ReSUMOO choque é caracterizado por uma alteração na perfusão tecidual que pode levar à hipóxia tecidual. Diretrizes recentes recomendam uma terapia de ressuscitação hemodinâmica precoce e agressiva nos estados de choque, mas a taxa de mortalidade ainda é inaceitavelmente alta. Os parâmetros clínicos habituais usados para orientar a terapia de reanimação correlacionam-se mal com o fluxo sanguíneo capilar, um determinante essencial da perfusão tecidual. Novas técnicas que avaliam diretamente a perfusão da microcirculação à beira do leito surgem como um complemento aos parâmetros macro-hemodinâmicos tradicionais. Estas técnicas foram testadas em vários estudos que mostraram alterações microcirculatórias em diferentes situações clínicas de choque. Além disso, estas alterações microcirculatórias estão relacionadas ao prognóstico, e persistem independentemente da normalização da pressão arterial, sendo um melhor preditor de disfunção orgânica e mortalidade do que os parâmetros hemodinâmicos globais e laboratoriais. Estes achados permitiram lançar o conceito de "terapia dirigida por parâmetros microcirculatórios", atualmente em fase preliminar, uma vez que o impacto de muitas intervenções ainda precisa ser avaliado. Finalmente, a avaliação da microcirculação também foi explorada em outras áreas que não o choq...

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Microvascular alterations in patients with acute severe heart failure and cardiogenic shock

Cited by 399 publications

References 33 publications

Microcirculatory abnormalities in patients with severe influenza A (H1N1) infection

Microcirculatory abnormalities in patients with severe influenza A (H1N1) infection

Low‐dose nitroglycerin improves microcirculation in hospitalized patients with acute heart failure

Microcirculatory assessment in daily clinical practice - not yet ready but not too far!

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