IJCS | Volume 31, Nº6, November / December 2018

647 Jorge et al. Myocardial dysfunction and mortality in sepsis Int J Cardiovasc Sci. 2018;31(6)643-651 Review Article in the target populations of the studies. The isolated presence of diastolic dysfunction is already in itself a marker of poor prognosis. Redfield et al. 37 demonstrated by multivariate analysis that the isolated presence of any degree of diastolic dysfunction was strongly predictive of mortality, while Flu et al. 38 showed that isolated diastolic dysfunction was associated with a higher risk of cardiovascular events in 30 days and cardiovascular mortality in the long term in patients undergoing open vascular surgery. 38 Nevertheless, little is known about how the presence of diastolic dysfunction increases the risk of mortality in sepsis, but a very plausible hypothesis is that the abnormal relaxation of the LV potentiated by tachycardia induced by sepsis and/or decreased complacency could promote changes in cardiac hemodynamics in such a way that the normal cardiac output could only be maintained through increased LV filling pressures and greater atrial participation in ventricular filling. 39 Onc e t he l e f t ven t r i cu l a r p r e s su r e r i s e s disproportionately in response to a relatively small increase in volemia, such patients can progress with pulmonary venous congestion secondary to an overload of fluids required for volume resuscitation and enhanced by the widespread increase in capillary permeability secondary to endothelial dysfunction induced by sepsis. 40 Regardless of the limitations presented, diastolic dysfunction has been singled out as an independent predictor of mortality by studies with tissue Doppler techniques for the evaluation of the properties of relaxation of the myocardium. Sturgess et al., 41 in a prospective observational study with patients admitted to intensive care with septic shock, concluded that after adjustment for disease severity, presence of cardiac disease, volemic management, and degree of diastolic dysfunction, the ratio between the speed of early diastolic transmitral flow by pulsed Doppler (E) and e’ – the E/e’ ratio – was an important independent predictor of in- hospital survival that allowed a better discrimination of survivors and nonsurvivors than cardiac biomarkers. 41 Landesberg et al., in a study including 262 patients with severe sepsis and septic shock, observed that diastolic dysfunction was not only common but also represented an important predictor of mortality in this context. The authors observed that patients with isolated systolic dysfunction (LVEF ≤ 50%; 9%of the patients) and diastolic dysfunction (e’ < 8 cm/s; 40% of the patients) alone or associated with systolic dysfunction (14% of the patients) showed a significantly higher mortality than those without any type of dysfunction. In this study, a septal e’ < 8 cm/s was considered an independent predictor of mortality. 42 Mourad et al. 43 followed 72 patients with cancer admitted with septic shock to an intensive care unit and found that early diastolic dysfunction was a strong independent predictor of mortality in these patients and, once again, a lateral e’ < 8 cm/s was an echocardiographic parameter independently associated with mortality. 43 In 2014, Landesberg et al. 44 evaluated a new cohort of patients with severe sepsis and septic shock to investigate the manifestation of myocardial dysfunction that best correlates with troponin elevations and explain its association with mortality in sepsis. The authors concluded that diastolic dysfunction and RV dilation were the echocardiographic characteristics that best correlated with troponin levels and best independent predictors of in-hospital mortality than this biomarker, suggesting a potential contribution of these cardiac mechanical properties in the elevation of troponin levels and association with mortality in this clinical context. Once again, a septal e’ < 8 cm/s was an important risk marker of mortality. 45 More recently, Rolando et al., in a prospective observational study with 53 patients with a mean age of 74 years, observed that diastolic dysfunction was present in 83% of this population and that the E/e’ ratio was the index of diastolic dysfunction that best correlated with decreased hospital survival on multivariate analysis. 45 These findings have been corroborated by a meta- analysis comprising 16 studies and 1,507 patients with severe sepsis or septic shock, in which both a lower e’ and a higher E/e’ ratio had a significant association with mortality. 46 Right ventricular dysfunction and mortality Right ventricular systolic dysfunction, characterized by reduced contractility, increased right atrial pressure, and reduced venous return, has been reported in 30 to 50% of the patients during sepsis. 47 This complication may occur isolated or in association with left ventricular systolic dysfunction, justifying in the latter case the maintenance of filling pressures in the left side within the limits of normality, even in the presence of important contractility deficit. 20 Similar to what occurs with the LV, the RV ejection fraction (RVEF) is directly dependent on the coupling between contractility and afterload, but different from the