Working Group on Cardiovascular Magnetic Resonance, Experimental and Clinical Research Center - a joint cooperation between the Charité Medical Faculty and the Max-Delbrück Center for Molecular Medicine; and HELIOS Hospital Berlin Buch, Department of Cardiology and Nephrology, DZHK (German Center for Cardiovascular Research) partner site, Berlin, Germany.
Department for Critical Care Medicine, HELIOS Hospital Berlin-Buch, Berlin, Germany.
ESC Heart Fail. 2022 Aug;9(4):2147-2156. doi: 10.1002/ehf2.13938. Epub 2022 May 19.
Sepsis-induced cardiomyopathy is a major complication of septic shock and contributes to its high mortality. This pilot study investigated myocardial tissue differentiation in critically ill, sedated, and ventilated patients with septic shock using cardiovascular magnetic resonance (MR).
Fifteen patients with septic shock were prospectively recruited from the intensive care unit. Individuals received a cardiac MR scan (1.5 T) within 48 h after initial catecholamine peak and a transthoracic echocardiography at 48 and 96 h after cardiac MR. Left ventricular ejection fraction was assessed using both imaging modalities. During cardiac MR imaging, balanced steady-state free precession imaging was performed for evaluation of cardiac anatomy and function in long-axis and short-axis views. Native T1 maps (modified Look-Locker inversion recovery 5 s(3 s)3 s), T2 maps, and extracellular volume maps were acquired in mid-ventricular short axis and assessed for average plane values. Patients were given 0.2 mmol/kg of gadoteridol for extracellular volume quantification and late gadolinium enhancement imaging. Critical care physicians monitored sedated and ventilated patients during the scan with continuous invasive monitoring and realized breathholds through manual ventilation breaks. Laboratory analysis included high-sensitive troponine T and N terminal pro brain natriuretic peptide levels. Twelve individuals with complete datasets were available for analysis (age 59.5 ± 16.9 years; 6 female). Nine patients had impaired systolic function with left ventricular ejection fraction (LVEF) < 50% (39.8 ± 5.7%), and three individuals had preserved LVEF (66.9 ± 6.7%). Global longitudinal strain was impaired in both subgroups (LVEF impaired: 11.0 ± 1.8%; LVEF preserved: 16.0 ± 5.8%; P = 0.1). All patients with initially preserved LVEF died during hospital stay; in-hospital mortality with initially impaired LVEF was 11%. Upon echocardiographic follow-up, LVEF improved in all previously impaired patients at 48 (52.3 ± 9.0%, P = 0.06) and 96 h (54.9 ± 7.0%, P = 0.02). Patients with impaired systolic function had increased T2 times as compared with patients with preserved LVEF (60.8 ± 5.6 ms vs. 52.2 ± 2.8 ms; P = 0.02). Left ventricular GLS was decreased in all study individuals with impaired LVEF (11.0 ± 1.8%) and less impaired with preserved LVEF (16.0 ± 5.8%; P = 0.01). T1 mapping showed increased T1 times in patients with LVEF impairment as compared with patients with preserved LVEF (1093.9 ± 86.6 ms vs. 987.7 ± 69.3 ms; P = 0.03). Extracellular volume values were elevated in patients with LVEF impairment (27.9 ± 2.1%) as compared with patients with preserved LVEF (22.7 ± 1.9%; P < 0.01).
Septic cardiomyopathy with impaired LVEF reflects inflammatory cardiomyopathy. Takotsubo-like contractility patterns occur in some cases. Cardiac MR is safely feasible in critically ill, sedated, and ventilated patients using extensive monitoring and experienced staff.
retrospectively registered (ISRCTN85297773).
脓毒症性心肌病是脓毒性休克的主要并发症，也是其高死亡率的主要原因。本研究旨在使用心血管磁共振（CMR）对患有脓毒性休克的重症、镇静和通气患者的心肌组织进行分化。
15 名脓毒性休克患者从重症监护病房前瞻性入组。个体在初始儿茶酚胺峰值后 48 小时内接受心脏 CMR 扫描（1.5T），并在心脏 CMR 后 48 和 96 小时进行经胸超声心动图检查。使用两种成像方式评估左心室射血分数。在心脏磁共振成像期间，使用平衡稳态自由进动成像进行长轴和短轴视图的心脏解剖和功能评估。获取中室短轴的原始 T1 图（改良 Look-Locker 反转恢复 5s(3s)3s）、T2 图和细胞外容积图，并评估平均平面值。患者接受 0.2mmol/kg 的钆特醇进行细胞外容积定量和晚期钆增强成像。重症监护医师在扫描过程中通过连续侵入性监测监测镇静和通气的患者，并通过手动通气中断实现屏气。实验室分析包括高敏肌钙蛋白 T 和 N 末端脑利钠肽前体水平。12 名具有完整数据集的个体可用于分析（年龄 59.5±16.9 岁；女性 6 名）。9 名患者存在左心室射血分数（LVEF）<50%的收缩功能障碍（39.8±5.7%），3 名患者存在保留 LVEF（66.9±6.7%）。两组的整体纵向应变均受损（LVEF 受损：11.0±1.8%；LVEF 保留：16.0±5.8%；P=0.1）。所有最初保留 LVEF 的患者在住院期间死亡；最初 LVEF 受损的住院死亡率为 11%。在超声心动图随访中，所有先前受损的患者在 48 小时（52.3±9.0%，P=0.06）和 96 小时（54.9±7.0%，P=0.02）时 LVEF 均有所改善。与保留 LVEF 的患者相比，收缩功能障碍患者的 T2 时间更长（60.8±5.6ms 与 52.2±2.8ms；P=0.02）。所有 LVEF 受损的研究个体的左心室 GLS 均降低（11.0±1.8%），保留 LVEF 的患者降低较少（16.0±5.8%；P=0.01）。与保留 LVEF 的患者相比，LVEF 受损患者的 T1 图显示 T1 时间增加（1093.9±86.6ms 与 987.7±69.3ms；P=0.03）。LVEF 受损患者的细胞外容积值升高（27.9±2.1%），而保留 LVEF 的患者为（22.7±1.9%；P<0.01）。
伴有 LVEF 受损的脓毒性心肌病反映了炎症性心肌病。在某些情况下会出现 Takotsubo 样收缩模式。使用广泛的监测和经验丰富的工作人员，在重症、镇静和通气的患者中使用心血管磁共振是安全可行的。
回顾性注册（ISRCTN85297773）。
