Microvascular alterations in patients with acute severe heart failure and cardiogenic shock

doi:10.1016/j.ahj.2003.07.006

American Heart Journal

Volume 147, Issue 1, January 2004, Pages 91-99

https://doi.org/10.1016/j.ahj.2003.07.006 Get rights and content

Abstract

Background

Microvascular blood flow alterations may impair tissue oxygenation and may participate in the development of multiple organ failure in patients with severe heart failure. We hypothesized that microvascular blood flow alterations are present in patients with severe heart failure and cardiogenic shock.

Methods

We used an orthogonal polarization spectral imaging technique to investigate the sublingual microcirculation in 40 patients with acute severe heart failure, including 31 patients with cardiogenic shock, and in a control group of 15 patients who were examined the day before cardiac surgery. The effects of topical application of acetylcholine (10-2M) were also tested in 5 patients with cardiogenic shock. Five sublingual areas were recorded, allocated a random number, and later analyzed semiquantitatively. Data were analyzed with non-parametric tests and presented as medians (percentiles 25–75).

Results

The density of all the vessels was similar in the 3 groups. The proportion of perfused small (<20 μm) vessels was lower in patients with cardiac failure and cardiogenic shock than in control patients (63% [46%–65%] and 49% [38%–64%] vs 92% [90%–93%] , P <.001). The perfusion of large vessels was preserved in all groups. The proportion of perfused vessels was higher in patients who survived than in patients who did not survive in all vessels (90% [84%–93%] vs 81% [74%–87%] , P <.05) and in small vessels (64% [49%–68%] vs 43% [37%–62%], P <.05). The topical application of acetylcholine totally reversed these alterations

Conclusions

Microvascular blood flow alterations are frequently observed in patients with severe heart failure and are more severe in patients who do not survive.

Section snippets

Methods

After it was approved by the ethical committee of the Erasme University Hospital, this study included 40 patients with severe heart failure. A control group of 15 patients without significant heart failure was investigated the day before cardiac surgery for coronary artery disease (n = 6), valve replacement (n = 6), or both (n = 3). Patients were excluded when they had chronic heart failure (New York Heart Association class III or IV), complicated diabetes mellitus, or arterial hypertension,

Results

The clinical data of the 40 patients with severe cardiac failure/cardiogenic shock and the 15 control patients are presented in Table I, and their main hemodynamic and biochemical variables are presented in Table II. Mean arterial pressure, cardiac index, and DO2 were similar in patients with cardiac failure and cardiogenic shock, but patients with cardiogenic shock received more dobutamine. By definition, dopamine and norepinephrine and aortic counterpulsation were used only in patients with

Discussion

The use of OPS imaging techniques showed profound disturbances in microvascular blood flow in patients with cardiac failure and especially in patients with cardiogenic shock. These alterations included a decreased vascular density, especially in small vessels; a large number of non-perfused and intermittently perfused small vessels, and a marked heterogeneity between the areas. These alterations were more severe in patients who did not survive than in patients who survived.

These results are in

References (37)

V. Krejci et al.
Continuous measurements of microcirculatory blood flow in gastrointestinal organs during acute haemorrhage
Br J Anaesth
(2000)
K.S. Zhao et al.
Microvascular adjustments during irreversible hemorrhagic shock in rat skeletal muscle
Microvasc Res
(1985)
H. Wroblewski et al.
Evidence of increased microvascular resistance and arteriolar hyalinosis in skin in congestive heart failure secondary to idiopathic dilated cardiomyopathy
Am J Cardiol
(1992)
J.S. Hochman et al.
Early revascularization in acute myocardial infarction complicated by cardiogenic shock. SHOCK Investigators. Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock
N Engl J Med
(1999)
A. Geppert et al.
Multiple organ failure in patients with cardiogenic shock is associated with high plasma levels of interleukin-6
Crit Care Med
(2002)
P.M. Reilly et al.
The mesenteric hemodynamic response to circulatory shockan overview
Shock
(2001)
H. Kerger et al.
Systemic and microcirculatory effects of autologous whole blood resuscitation in severe hemorrhagic shock
Am J Physiol
(1999)
R. Dammers et al.
Microcirculatory effects of experimental acute limb ischaemia-reperfusion
Br J Surg
(2001)
R.S. McCuskey et al.
The microcirculation during endotoxemia
Cardiovasc Res
(1996)
C.G. Ellis et al.
Effect of a maldistribution of microvascular blood flow on capillary O(2) extraction in sepsis
Am J Physiol
(2002)

F. Christ et al.

The assessment of the microcirculatory effects of dobutamine using mercury in silastic strain gauge plethysmography in man

Postgrad Med J

(1991)

D. De Backer et al.

Microvascular blood flow is altered in patients with sepsis

Am J Respir Crit Care Med

(2002)

S.O. Freedlander et al.

Clinical observations on the capillary circulation

Arch Intern Med

(1922)

L.A. Kirschenbaum et al.

Microvascular response in patients with cardiogenic shock

Crit Care Med

(2000)

D. De Backer et al.

Assessment of the microcirculatory flow in patients in the intensive care unit

Curr Opin Crit Care

(2001)

M.D. Menger et al.

Role of microcirculation in transplantation

Microcirculation

(2000)

R. Drazenovic et al.

Regulation of perfused capillary density in canine intestinal mucosa during endotoxemia

J Appl Physiol

(1992)

A.G. Tsai et al.

Oxygen distribution and consumption by the microcirculation and the determinants of tissue survival

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Citation Excerpt :
In patients with cardiogenic shock, a decrease in the proportion of perfused vessels and perfused vascular density and an increase in heterogeneity were observed.[38] Microvascular alterations were more severe in patients with poor outcomes.[38–41] Differences in microvascular perfusion between survivors and non-survivors were observed not only at baseline[38–41] but also at later stages when repeated measurements of the microcirculation were obtained after hemodynamic stabilization.[39]
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Clinical investigationMicrovascular alterations in patients with acute severe heart failure and cardiogenic shock

Abstract

Background

Methods

Results

Conclusions

Section snippets

Methods

Results

Discussion

Br J Anaesth

Microvasc Res

Am J Cardiol

Early revascularization in acute myocardial infarction complicated by cardiogenic shock. SHOCK Investigators. Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock

N Engl J Med

Multiple organ failure in patients with cardiogenic shock is associated with high plasma levels of interleukin-6

Crit Care Med

The mesenteric hemodynamic response to circulatory shockan overview

Shock

Systemic and microcirculatory effects of autologous whole blood resuscitation in severe hemorrhagic shock

Am J Physiol

Microcirculatory effects of experimental acute limb ischaemia-reperfusion

Br J Surg

The microcirculation during endotoxemia

Cardiovasc Res

Effect of a maldistribution of microvascular blood flow on capillary O(2) extraction in sepsis

Am J Physiol

The assessment of the microcirculatory effects of dobutamine using mercury in silastic strain gauge plethysmography in man

Postgrad Med J

Microvascular blood flow is altered in patients with sepsis

Am J Respir Crit Care Med

Clinical observations on the capillary circulation

Arch Intern Med

Microvascular response in patients with cardiogenic shock

Crit Care Med

Assessment of the microcirculatory flow in patients in the intensive care unit

Curr Opin Crit Care

Role of microcirculation in transplantation

Microcirculation

Regulation of perfused capillary density in canine intestinal mucosa during endotoxemia

J Appl Physiol

Oxygen distribution and consumption by the microcirculation and the determinants of tissue survival

Clinical investigation
Microvascular alterations in patients with acute severe heart failure and cardiogenic shock