IJCS | Volume 31, Nº6, November / December 2018

DOI: 10.5935/2359-4802.20180045 643 REVIEW ARTICLE International Journal of Cardiovascular Sciences. 2018;31(6)643-651 Mailing Address: Antonio José Lagoeiro Jorge Rua Marques do Paraná, 303, 6º andar, Niterói, Postal Code: 24030-215, Rio de Janeiro, RJ - Brazil. E-mail: lagoeiro@cardiol.br, lagoeiro@globo.com From Echocardiographic Evaluation to Biomarkers Measurement: The Role of Myocardial Dysfunction in Mortality Associated with Sepsis Márcio da Silva Campista, Wolney de Andrade Martins, Mariana de Andrade Guedes, Antonio José Lagoeiro Jorge Universidade Federal Fluminense, Niterói, RJ - Brazil Manuscript received September 07, 2017, revised manuscript January 04, 2018, accepted January 16, 2018. Sepsis; Mortality; Biomarkers; Cardiac dysfunction. Keywords Abstract Sepsis remains the leading cause of mortality and critical illness worldwide. Myocardial dysfunction is one of the most clinically relevant manifestations of sepsis and results from a complex interaction among genetic, molecular, metabolic, and structural changes. Despite the prominence given to the occurrence of systolic dysfunction during sepsis, the association between diastolic dysfunction andmortality is controversial, while diastolic dysfunction and right ventricular dysfunction are identified as independent predictors of mortality in the most recent studies. Elevation of biomarkers during sepsismay result fromseveral mechanisms, and although the role of the B-type natriuretic peptide (BNP) and the N-terminal portion of its prohormone (NT-proBNP) as independent predictors of mortality is well defined, the same cannot be said about cardiac troponins due to conflicting results among currently available studies. The objective of the present review is to discuss the pathophysiological mechanisms of myocardial dysfunction induced by sepsis in adults and the role of echocardiography and cardiac biomarkers as tools for prognostic evaluation in this clinical setting. Introduction Sepsis is a set of physiological, pathological, and biochemical abnormalities that can occur in response to infection caused by any pathological agent. Despite the advances in the treatment and support of critically ill patients, sepsis continues to be the main cause of mortality and severe disease throughout the world, with an estimated incidence of 17 million cases per year. 1 Myocardial dysfunction is one of the manifestations of greater clinical relevance in sepsis and one of the organic dysfunctions that most early occurs in septic shock. 2 By definition, it consists of reversible systolic and/or diastolic dysfunction of the left ventricle (LV) and/or right ventricle (RV) (Figure 1). 3,4 In recent years, myocardial dysfunction induced by sepsis became a focus of exhaustive investigation as an independent predictor of mortality in this clinical context, especially after the growing use of biomarkers of myocardial injury as indicators of poor prognosis in cardiovascular diseases. 5 The objective of this review is to discuss the pathophysiological mechanisms of myocardial dysfunction induced by sepsis in adults and the role of echocardiography and cardiac biomarkers as tools for prognostic evaluation in this clinical scenario. Pathophysiology Sepsis-induced myocardial dysfunction is believed to result from a complex interaction among genetic, molecular, metabolic, and structural alterations that may have unique and independent contributions or very confusing and intricate interrelationships (Figure 2). 6 The involved factors include: - Action of myocardial depressants: the combined action of tumor necrosis factor-alpha (TNF- α ) with interleukin 1-beta (IL-1 β ) is cardiodepressant and can play an important role in the early reduction of myocardial contractility observed in the course of sepsis. 7 Furthermore, both induce the release of additional factors that may similarly affect the myocardial function, as for example, nitric oxide (NO), which in turn is also a cause of