Septic shock and reversible right ventricle dysfunction

ABSTRACT

Background: Right ventricle involvement during sepsis is often misunderstood, although it is described that an altered performance of the right ventricle is present in 2/3 of cases of moderate to severe forms of sepsis. Clinical Case 30 years old woman without known cardiovascular risk factors with a history of multiple psychiatric disorders. Access to the emergency departement of our hospital complaining asthenia and hypotension. The patient underwent cardiological evaluation with EKG findings of sinus tachycardia and diffuse ST-T anomalies and bidimensional echocardiogram negative for biventricular kinetic anomalies. Laboratory evidence of creatinine 2.07 mg/dl, slight increase in inflammation indices (CRP 38 mg/dl) and anemia (HB 9.2 g/l). Swab for SARS-COV2 was negative. The patient was then admitted to the local department of Medicine. During hospitalization, evidence of hypotension and progressive worsening of inflammation indices. Due to addominal pain, the patient underwent EGDS showing hiatal hernia. Subsequent onset of fever, with negative urine culture and positive blood cultures for S. Epidermidis. In addition, due to the detection of involuntary movements of the limbs and eyelids she was subjected to cerebral MRI in suspicion of encephalitis, that was excluded. At a subsequent cardiological and echocardiographic evaluation, finding of “Hypocontractile right ventricle, volume overload of the right sections with paradoxical movement of the interventricular septum, PAPs 50 mmHg”. On chestabdomen CT scan “absence of focal pulmonary lesions and bilateral pleural effusions, patent pulmonary circulation, absence of thrombotic filling defects”. The patient was therefore transferred to our cardiology departement with diagnosis of septic shock. During hospitalization, evidence of hypokalemia, long QT interval (> 500 msec) and self-limiting polymorphic ventricular tachycardia. After long-term therapy with inotropics and antibiotics, we found a significant clinical improvement with echocardiographic evidence of complete recovery of right ventricular performance. The case described is a paradigmatic example of reversible alteration of right ventricle systolic function during septic shock (severe sepsis). The different pathogenetic determinants, however, are still debated. There are two possible hypotheses inflammatory myocardial right ventricle involvement (myocarditis) or vasculitic involvement of right ventricle, sustained by inflammatory stress and bacteremia.