The Challenging Diagnosis of Septic Cardiomyopathy

We read with interest the “septic heart” review in the February issue of CHEST. The authors highlight the urgent need for a clear definition of septic cardiomyopathy. The main challenges in this definition are the evaluation of the cardiovascular context (in particular, evaluation of cardiac function in the setting of highly variable preload and afterload conditions), and the lack of longitudinal echocardiography data starting from premorbid heart function with serial echocardiographic evaluations performed during the course of the critical illness and eventually following recovery. We applaud the authors1 for their efforts and fully endorse the need for a standardized definition of septic cardiomyopathy; however, at present, there are not enough data to support a precise definition of septic cardiomyopathy. The first characteristic proposed by the authors (Table 1) is a combination of left ventricular (LV) dilatation with normal/low filling pressure (LVFP). A dilated left ventricle has increased end-diastolic volume (and, in most cases, end-diastolic pressure). It seems unlikely that well-resuscitated patients with manifestations of septic cardiomyopathy can exhibit a dilated left ventricle without increased LVFP. Indeed, a meta-analysis reported significantly higher ratio of the E wave to e' wave obtained with tissue doppler imaging (E/e' - surrogate of LVFP) in patients with sepsis who were nonsurvivors. However, in the vast majority of the included studies, survivors also had abnormal E/e′ values, confirming the large prevalence of raised LVFP during sepsis.