Thiago Furian

Ventricular dysfunction and dilation in severe sepsis and septic shock: Relation to endothelial function and mortality

PURPOSE The aim of this study was to evaluate echocardiography-based indices of myocardial function and markers of vascular inflammation and endothelial dysfunction in the early phases of severe sepsis. MATERIAL AND METHODS Forty-five adult patients (67% women; age 51 ± 18 years; Acute Physiology and Chronic Health Disease Classification System II score, 23 ± 7) admitted to the intensive care unit up to 24 hours after fulfilling criteria for severe sepsis or septic shock were studied. Clinical, laboratorial (endothelin 1 [ET1], vascular cellular adhesion molecule 1), and echocardiographic data were collected within the first 24 hours and again 72 hours and 7 days after admission. RESULTS Intrahospital mortality was 33% (15 deaths). Left ventricular (LV) dysfunction (LV ejection fraction <55%) was identified in 15 (33%) patients, whereas right ventricular (RV) dysfunction (RV tissue Doppler peak systolic velocity [RV-Sm] <12 cm/s) was present in 14 (30%) patients. LogET1 was increased in patients with LV dysfunction (2.3 ± 0.6 vs 1.8 ± 0.4 pg/mL; P = .01) and RV dysfunction (2.5 ± 0.5 vs 1.8 ± 0.4 pg/mL; P < .001) and had negative correlations with LV ejection fraction (r = -0.50; P = .002) and RV-Sm (r = -0.67; P < .001). Left ventricular end-diastolic diameter, RV-Sm, and diastolic dysfunction were able to discriminate survivors from nonsurvivors, and the combination of these parameters identified groups of very low and high risk. CONCLUSION Both LV and RV systolic dysfunctions are prevalent in severe sepsis, being directly associated with markers of endothelial dysfunction. Left ventricular nondilation, RV dysfunction, and diastolic dysfunction seem related to poor prognosis in this scenario.

Endothelial dysfunction assessed by brachial artery ultrasound in severe sepsis and septic shock

PURPOSE Noninvasive evaluation of endothelial function may be accomplished by ultrasound assessment of flow-mediated vasodilation (FMD) of the brachial artery. This study aims to investigate the role of FMD analysis on intrahospital prognosis of patients with sepsis. METHODS Adult patients admitted to the intensive care unit with severe sepsis or septic shock were consecutively included. Brachial artery FMD was measured upon admission, after 24 and 72 hours. A group of apparently healthy subjects paired for sex and age was used as controls. Patients were followed up to discharge or death. RESULTS We studied 42 patients (mean age, 51 ± 19 years) with sepsis predominantly of abdominal or respiratory etiology (75%). Acute Physiology And Chronic Health Evaluation II risk score was 23 ± 7, and intrahospital mortality rate was 33%. Flow-mediated vasodilation in septic patients was significantly lower than in healthy controls (1.5 ± 7% vs 6 ± 4%, P < .001). Most of the nonsurvivors (86%) showed a decline in sequential FMD analyses, whereas only 43% of survivors showed a reduction of FMD (P = .01). In nonsurvivors, FMD was significantly lower 72 hours after sepsis onset (-3.3% ± 10% vs 5.2% ± 4%; P < .05; time-group interaction P value = .03). CONCLUSIONS Brachial FMD is altered in septic patients with hemodynamic instability, and its deterioration may be an early marker of unfavorable prognosis.

Implications of the hemodynamic optimization approach guided by right heart catheterization in patients with severe heart failure.

OBJECTIVE To report the hemodynamic and functional responses obtained with clinical optimization guided by hemodynamic parameters in patients with severe and refractory heart failure. METHODS Invasive hemodynamic monitoring using right heart catheterization aimed to reach low filling pressures and peripheral resistance. Frequent adjustments of intravenous diuretics and vasodilators were performed according to the hemodynamic measurements. RESULTS We assessed 19 patients (age = 48+/-12 years and ejection fraction = 21+/-5%) with severe heart failure. The intravenous use of diuretics and vasodilators reduced by 12 mm Hg (relative reduction of 43%) pulmonary artery occlusion pressure (P<0.001), with a concomitant increment of 6 mL per beat in stroke volume (relative increment of 24%, P<0.001). We observed significant associations between pulmonary artery occlusion pressure and mean pulmonary artery pressure (r=0.76; P<0.001) and central venous pressure (r=0.63; P<0.001). After clinical optimization, improvement in functional class occurred (P< 0.001), with a tendency towards improvement in ejection fraction and no impairment to renal function. CONCLUSION Optimization guided by hemodynamic parameters in patients with refractory heart failure provides a significant improvement in the hemodynamic profile with concomitant improvement in functional class. This study emphasizes that adjustments in blood volume result in immediate benefits for patients with severe heart failure.

Shunt direita-esquerda através de forame oval patente sem hipertensão pulmonar

This article describes a patient presenting with dyspnea and platypnea and whose only clinical finding was presence of patent foramen ovale with a right to left shunt, without pulmonary hypertension, characteristic of the rare Platypnea-Orthodeoxya Syndrome, with very interesting pathophysiological findings and with therapeutic alternatives not yet defined.