Vasopressin in Patients with Septic Shock and Dynamic Left Ventricular Outflow Tract Obstruction

Abstract

Purpose

Left ventricular outflow tract obstruction (LVOTO) is a relatively uncommon but severe condition that may lead to hemodynamic impairment. It can be elicited by morphological (left ventricular hypertrophy, sigmoid septum, prominent papillary muscle, prolonged anterior mitral valve leaflet) and functional (hypovolemia, low afterload, hypercontractility, catecholamines) factors. We sought to determine the incidence of the most severe form of LVOTO in septic shock patients and describe the therapeutic effects of vasopressin.

Methods

Over a period of 29 months, 527 patients in septic shock were screened for LVOTO. All were mechanically ventilated and treated according to sepsis bundles, including pre-load optimization and norepinephrine infusion. Vasopressin was added in addition to norepinephrine to reduce the adrenergic burden and decrease LVOTO.

Results

Ten patients were diagnosed with the most severe form of LVOTO, including systolic anterior mitral valve motion (SAM) and severe mitral regurgitation (MR) with pulmonary oedema. The median norepinephrine dosage to obtain a mean arterial pressure of ≥70 mmHg was 0.58 mcg/Kg/min (IQR 0.40–0.78). All patients had a hyper-contractile left ventricle, septal hypertrophy, significant LVOTO (peak gradient 78 [56–123] mmHg) associated with SAM and severe MR with pulmonary oedema. Vasopressin (median 4 IU/h) allowed a significant reduction of norepinephrine (0.18 [0.14–0.30] mcg/kg/min; p = 0.01), LVOT gradient (35 [24–60] mmHg; p = 0.01) and MR with a significant paO2/FiO2 increase (174 [125–213] mmHg; p = 0.01).

Conclusion

Vasopressin allowed a reduction of norepinephrine with subsequent LVOTO reduction and hemodynamic improvement of the most severe form of LVOTO, which represented 1.9% of all septic shock patients.

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Fig. 1

Abbreviations

AVP:

arginine vasopressin

LVOTO:

left ventricular outflow tract obstruction

CW:

continuous wave Doppler

NE:

norepinephrine

MR:

mitral regurgitation

SAM:

systolic anterior mitral valve motion

EF_LV:

ejection fraction of left ventricle

HR:

heart rate

VTI:

velocity-time integral

BMI:

body mass index

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Funding

Support was provided through the grant project NV 18–06-00417 of the Czech Ministry of Health.

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Authors

Contributions

MB designed the study and performed the echocardiography. AN, DS, VM, MM and TB collected and analysed the clinical data. GT supervised the study and together with all authors contributed to the development of the manuscript.

Corresponding author

Correspondence to Martin Balik.

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Conflict of Interest

None for all authors.

Ethics Approval

University Hospital Ethical Board on 6 October 2017 (No. 1691/16S-IV).

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Written informed consent from the next of kin.

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ClinicalTrials.gov Identifier: NCT03029169, registered on 24 Jan 2017.

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Balik, M., Novotny, A., Suk, D. et al. Vasopressin in Patients with Septic Shock and Dynamic Left Ventricular Outflow Tract Obstruction. Cardiovasc Drugs Ther (2020). https://doi.org/10.1007/s10557-020-06998-8

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Keywords

  • Septic shock
  • Left ventricular outflow tract obstruction
  • Arginine vasopressin
  • Norepinephrine
  • Supraventricular arrhythmia
  • Atrial fibrillation