Left ventricular performance in septic shock: Reversible segmental and global abnormalities

Abstract Left ventricular dysfunction has been implicated in the pathogenesis of septic shock, but little is known about its natural history, cause, and prognostic significance. Left ventricular performance was assessed by serial radionuclide and hemodynamic studies in 35 patients with culture-proven septic shock. The mean age (±S.D.) of the group was 64 ± 18 years; 16 of the subjects were women, and 15 had antecedent heart disease. On the first study, the left ventricular stroke work index was depressed in 33 (94%) patients, and nineteen (54%) had a left ventricular ejection fraction less than 0.48. Twenty-two (63%) of the patients had segmental and four had generalized wall motion abnormalities. Conventional hemodynamic parameters were of no value in predicting the patients who had a depressed left ventricular ejection fraction or segmental abnormalities. Patients with underlying heart disease had a much higher frequency (87%) of segmental dysfunction than those without underlying heart disease (45%; p = 0.016), but no differences were noted in the left ventricular ejection fraction or left ventricular stroke work index of these two groups. Segmental abnormalities and low ejection fractions were seen more often in patients with a large left ventricular end-diastolic volume index. Only five subjects had a systemic vascular resistance index > 2580 dynes · sec · cm −5 per m 2 , and the correlation between systemic vascular resistance index and left ventricular ejection fraction was poor. No difference was found in the mean coronary perfusion pressure of those with segmental abnormalities and those with normal wall motion. Thus, a depressed left ventricular ejection fraction and segmental dysfunction could not be attributed to volume depletion, to an increased systemic vascular resistance index, or to a reduction in coronary perfusion pressure. Repeat studies in 22 surviving patients showed new depression of the left ventricular ejection fraction in one patient, normalization of left ventricular ejection fraction in five, and reversal of segmental dysfunction in three. No differences were noted in the left ventricular ejection fraction, left ventricular stroke work index, or frequency of segmental dysfunction between survivors and nonsurvivors. Reversible left ventricular dysfunction is common in septic shock and is most often segmental in nature.