Myocardial perfusion echocardiography: a novel use in the diagnosis of sepsis-induced left ventricular systolic impairment on the intensive care unit

Abstract

Impaired left ventricular systolic function secondary to sepsis can occur in up to 20% of patients with septic shock. The electrocardiogram (ECG) and echocardiographic changes it produces can be very similar to those occurring during acute coronary syndromes (ACS). Myocardial contrast echocardiography (MCE) allows assessment of myocardial perfusion. This technique can be performed at the bedside of the critically unwell patient. We describe a patient presenting with septic shock secondary to pneumonia. While sedated and ventilated in the intensive care unit, the patient developed marked ECG changes, a troponin rise and widespread left ventricular wall motion abnormality. The clinical picture suggested ACS or stress cardiomyopathy was unlikely and was more in keeping with a diagnosis of sepsis-induced left ventricular systolic dysfunction. To support this, resting and flash impulse MCE was performed which revealed normal perfusion in areas of both normal and abnormal wall motion. This suggested that the cardiac presentation was more likely to be due to left ventricular impairment secondary to sepsis and ACS therapy was discontinued. Pre-discharge ECG and transthoracic echocardiogram were normal. Percutaneous coronary angiography 6 weeks later was also normal. This is the first described case of MCE being used to aid in the decision-making process in distinguishing between ACS, stress cardiomyopathy, and left ventricular systolic impairment secondary to sepsis.

Elevated Cardiac Troponin T Levels in Critically Ill Patients with Sepsis

“…This is true even after other factors that might influence myocardial perfusion are accounted for, particularly the severity of illness and the presence of cardiovascular morbidity and risk factors. Prognostic findings have been reported [21][22][23][24][25][26][27][28][29][30] and are controversial. Hemodynamic perturbations in sepsis and its treatment might exacerbate underlying structural or coronary artery disease.…”

“…In addition, the reported increases in coronary perfusion that occur in these patients may mitigate the effects of other cardiac comorbidities. 23,34 In addition, vasopressors and other therapeutic agents in patients with sepsis may be directly cardiotoxic. 35 Left ventricular diastolic dysfunction and reduced left ventricle volumes also are independent predictors of mortality in patients with sepsis.…”

Echocardiography in the sepsis syndromes

“…Cardiac troponins show increases in both cases [56]. Myocardial perfusion ECHO may be a promising technique to allow for differential diagnosis [57].…”

Role of I-123 MIBG in sepsis-induced cardiomyopathy

“…9 LVEF alone precludes assessment of diastolic and RV dysfunction, which are commonly impaired in patients with sepsis. 3,10 These limitations have led to more common use of echocardiography with tissue Doppler technique, 11 contrast echocardiography, 12 and strain imaging. 13 These newer techniques, although extensively studied and showing substantial promise for non-septic conditions, lack strong documentation of their effectiveness for evaluation of sepsis.…”