Vasopressin in Patients with Septic Shock and Dynamic Left Ventricular Outflow Tract Obstruction

Borggrefe, Martin; Novotný, Aleš; Suk, Daniel; Matoušek, Vojtěch; Malý, Michal; Brožek, Tomáš; Tavazzi, Guido

doi:10.1007/s10557-020-06998-8

Cited by 10 publications

(7 citation statements)

References 10 publications

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“…In a recent single-center study of 527 patients with septic shock on vasopressor support, severe LVOTO was identified in 10 individuals (1.9%) with an average gradient of 78 mmHg, accompanying SAM, and severe mitral valve regurgitation. The authors used vasopressin at doses higher than routinely suggested (mean 0.06 IU/min, range 0.03–0.09 IU/min) to successfully reduce the dose of norepinephrine and improve the obstructive gradient in all patients [24]. Another recent case report demonstrated the successful use of intravenous esmolol to treat a patient with LVOTO in septic shock [25].…”

Section: Physiologicmentioning

confidence: 99%

Imaging of left ventricular outflow tract obstruction in hypertrophic cardiomyopathy

Stewart¹,

Elagizi²,

Gilliland³

2023

Current Opinion in Cardiology

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Purpose of reviewThe current article reviews obstructive forms of hypertrophic cardiomyopathy and associated morphologic cardiac abnormalities. It focuses on echocardiographic imaging of the left ventricular (LV) outflow tract obstruction, its evaluation, prognostication, and differentiation from other conditions mimicking obstructive hypertrophic cardiomyopathy.Recent findingsSymptomatic patients with LV outflow tract (LVOT) gradients at least 50 mmHg on maximally tolerated medical therapy are candidates for advanced therapies. Resting echocardiography may only identify 30% of patients with obstructive physiology. Provocative maneuvers are essential for symptomatic patients with hypertrophic cardiomyopathy (HCM). Exercise echocardiography is recommended if they fail to provoke a gradient. Although dynamic LV tract obstruction is seen with obstructive HCM, it is not specific to this condition and exists in other physiologic and pathophysiologic states. Careful clinical evaluation and imaging techniques aid in the differentiation of HCM from these conditions.SummaryImaging plays an integral role in the diagnosis, prognosis, and risk stratification of HCM patients. Newer imaging technologies, including 3D transthoracic echocardiography, 3D transesophageal, speckle-derived 2D strain, and cardiac MRI, allow for a better hemodynamic understanding of systolic anterior motion and LV tract obstruction. Evolving techniques, that is, artificial intelligence, will undoubtedly further increase diagnostic capabilities. Newer medical therapies are available with the hope that this will lead to better patient management.

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Section: Physiologicmentioning

confidence: 99%

Imaging of left ventricular outflow tract obstruction in hypertrophic cardiomyopathy

Stewart¹,

Elagizi²,

Gilliland³

2023

Current Opinion in Cardiology

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“…redundant anterior or posterior leaflet, papillary muscle displacement and anterior MV displacement, increase the forces acting to draw the valve towards the interventricular septum. Factors enhancing global or regional LV contractility such as distributive shock (particularly with volume depletion), Takotsubo cardiomyopathy or LAD infarction (both potentially leading to apical akinesis and hyperkinetic basal segments) may also cause LVOT obstruction [ 1 , 46 , 49 – 51 ]. Lastly, deviation of the interventricular septum towards the LV cavity, as is seen in acute cor pulmonale, predisposes individuals to SAM [ 52 , 53 ].…”

Section: Mr In Critical Illnessmentioning

confidence: 99%

Mitral regurgitation in the critically ill: the devil is in the detail

Duncan,

Bowcock,

Pathan

et al. 2023

Ann. Intensive Care

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Mitral regurgitation (MR) is common in the critically unwell and encompasses a heterogenous group of conditions with diverging therapeutic strategies. MR may present acutely with haemodynamic instability or more insidiously with failure to wean from mechanical ventilation. Critical illness is associated with marked physiological stress and haemodynamic changes that dynamically influence the severity and implication of MR. The expanding role of critical care echocardiography uniquely positions the intensivist to apply advanced bedside valvular assessment to recognise haemodynanically significant MR, manipulate and optimise cardiopulmonary physiology and identify patients requiring urgent cardiology and surgical referral. This review will consider common clinical scenarios, therapeutic strategies and the pearls and pitfalls of echocardiographic assessment and quantification in the critically unwell.

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“…Fluid loading may increase preload excessively, whereas high doses of vasopressors may compromise diastolic function. 24,25…”

Section: Impaired Cardiac Functionmentioning

confidence: 99%

Should Vasopressors Be Started Early in Septic Shock?

Cioccari

Jakob

Takala

2021

Semin Respir Crit Care Med

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Sepsis can influence blood volume, its distribution, vascular tone, and cardiac function. Persistent hypotension or the need for vasopressors after volume resuscitation is part of the definition of septic shock. Since increased positive fluid balance has been associated with increased morbidity and mortality in sepsis, timing of vasopressors in the treatment of septic shock seems crucial. However, conclusive evidence on timing and sequence of interventions with the goal to restore tissue perfusion is lacking. The aim of this narrative review is to depict the pathophysiology of hypotension in sepsis, evaluate how common interventions to treat hypotension interfere with physiology, and to give a resume of the results from clinical studies focusing on targets and timing of vasopressor in sepsis. The majority of studies comparing early versus late administration of vasopressors in septic shock are rather small, single-center, and retrospective. The range of “early” is between 1 and 12 hours. The available studies suggest a mean arterial pressure of 60 to 65 mm Hg as a threshold for increased risk of morbidity and mortality, whereas higher blood pressure targets do not seem to add further benefits. The data, albeit mostly from observational studies, speak for combining vasopressors with fluids rather “early” in the treatment of septic shock (within a 0–3-hour window). Nevertheless, the optimal resuscitation strategy should take into account the source of infection, the pathophysiology, the time and clinical course preceding the diagnosis of sepsis, and also comorbidities and sepsis-induced organ dysfunction.

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Vasopressin in Patients with Septic Shock and Dynamic Left Ventricular Outflow Tract Obstruction

Cited by 10 publications

References 10 publications

Imaging of left ventricular outflow tract obstruction in hypertrophic cardiomyopathy

Imaging of left ventricular outflow tract obstruction in hypertrophic cardiomyopathy

Mitral regurgitation in the critically ill: the devil is in the detail

Should Vasopressors Be Started Early in Septic Shock?

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