Septic Cardiomyopathy: Definition, Diagnosis & Management (ECMO Focus)

Overview & Impact

  • Context: Common in ICU sepsis/septic shock; talk by an ECMO consultant (25–30 min).

  • Incidence/Prevalence: Reported variably (10–70%) due to inconsistent definitions and criteria.

  • Outcomes: When diagnosed, mortality increases 2–3×; not included in common ICU scores (SAPS, APACHE, SOFA).

Pathophysiology & Features

  • Not CAD: Distinguished from atherosclerotic ischemia.

  • Onset/Pattern: Acute, may be LV, RV, or biventricular.

  • Proposed Mechanisms: Myocardial depressants/endotoxins, adrenergic hyperstimulation, myocardial edema (fluids), mitochondrial dysfunction, calcium dysregulation.

  • Septic Shock Confounders: Altered preload/afterload/contractility, vasoactive drugs, organ supports (RRT, NO).

Diagnosis (Echocardiography-Centred)

  • Primary Tool: Transthoracic echo preferred; TEE if needed.

  • LV Systolic Function (beyond EF):

    • LVOT VTI, TDI S′ (mitral annulus), MAPSE (>1.2 cm suggests normal EF).

    • Global Longitudinal Strain (GLS): Around −20% indicates good contractility.

  • Diastolic Function:

    • TDI e′ (septal/lateral) for relaxation.

    • E/e′ ratio (higher suggests elevated LV filling pressure).

  • RV Assessment: TAPSE and RV FAC alongside TDI.

Why Patients Fare Poorly

  • Host Factors: Older age, comorbidities, medications, sepsis/endocarditis, ischemia.

  • Perioperative/ICU Factors: Inadequate myocardial protection, bleeding risk, vasoplegia, prolonged bypass (contextual).

Pharmacologic Management (Current Signals)

  • Levosimendan: Mixed/negative data (including author’s ECMO-CRRT cohort and prior trials).

  • Dobutamine: Can cause tachycardia/hypotension; limited benefit.

  • Rate Control (Esmolol/Landiolol/Ivabradine): Conflicting RCT/meta-analytic results; no consistent outcome benefit.

Mechanical Circulatory Support (VA-ECMO)

  • Rationale: Reversible acute failure; supports circulation while myocardium recovers.

  • Evidence Highlights:

    • Early single-centre data (small n) showed EF recovery.

    • Multicentre controlled study (2020): In refractory septic cardiogenic shock (EF <35%), 90-day mortality lower with VA-ECMO (≈60% vs 25% control; significant).

    • Meta-analyses/observational syntheses: ~37–42% survival in carefully selected patients; better when EF very low and selection is rigorous.

  • Key Principle: Early identification, early referral, careful case-by-case selection (age, reversibility, echo profile).

Practical Takeaways

  • Three Messages:

    1. Septic cardiomyopathy is common by day 3–4 of septic shock and raises mortality.

    2. Echo-led diagnosis using VTI, TDI (S′/e′), MAPSE, GLS, and RV indices—do not rely on EF alone.

    3. VA-ECMO can be life-saving in selected cases; apply individualized criteria and team review.

Escalation Concept (Author’s Framework)

  • Stepwise: Fluids/antibiotics → norepinephrine → (consider) beta-blockers/dobutamine/levosimendan (context-dependent) → VA-ECMO at the top for refractory septic cardiomyopathy.

 

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