Federico Marchini

🫀 Sepsis-induced cardiomyopathy is not rare. It is under-recognized. And more importantly: 👉 It is dynamic, reversible… and frequently misinterpreted ⚠️ The clinical trap You see a septic patient with: ✔️ Hypotension ✔️ Vasoplegia ✔️ “Normal” or even high LVEF 👉 And you assume the heart is fine ❌ Wrong 🧠 What septic cardiomyopathy really is Sepsis-induced cardiomyopathy (SICM): ▪️ Acute, reversible myocardial dysfunction ▪️ Can affect LV, RV, systolic and/or diastolic function ▪️ Not related to coronary disease ▪️ Often unmasked after resuscitation 👉 It may appear hours to days after ICU admission 🔥 Phenotype matters! SICM is NOT one disease. It is a spectrum of hemodynamic phenotypes: 🟠 LV systolic dysfunction 🔵 Hyperdynamic vasoplegic state 🟣 RV failure 🟡 Persistent hypovolemia ⚪ Apparently “normal” profile 👉 Each requires a completely different treatment strategy 🚨 Why LVEF misleads you In sepsis: ➡️ LVEF depends on afterload ➡️ Vasoplegia can artificially increase LVEF ➡️ “Normal EF” ≠ normal contractility 👉 Ventriculo-arterial coupling is the real issue 🫀 Pathophysiology Sepsis affects the heart at every level: ▪️ Cytokine storm → myocardial depression ▪️ β-adrenergic downregulation → poor response to catecholamines ▪️ Calcium handling dysfunction → ↓ contractility ▪️ Mitochondrial failure → ↓ ATP ▪️ Microcirculatory dysfunction → impaired perfusion 👉 Yet: minimal cell death → reversibility is possible ⚡ Clinical reality SICM can: ✔️ Develop early OR late (up to 72h) ✔️ Mask or mimic other shock states ✔️ Coexist with AMI ✔️ Flip phenotype during resuscitation 👉 This is why single measurements are dangerous 🧩 Management principle There is no universal treatment Instead, Treat the phenotype, not the label Examples: 🟠 LV failure → consider inotropes (carefully) 🔵 Hyperkinetic vasoplegia → vasopressors, avoid overload 🟣 RV failure → ventilatory strategy + afterload reduction 🟡 Hypovolemia → guided fluids 👉 Echocardiography is the cornerstone 🚀 Where the field is going Future management will rely on: ▪️ Hemodynamic phenotyping ▪️ Biomarker + immune profiling ▪️ AI-guided decision making ▪️ Personalized therapy 👉 Not “one-size-fits-all sepsis bundles” anymore 🎯 Take-home Septic shock is not only a vascular disease, It is a cardiovascular syndrome with multiple phenotypes And if you miss the cardiac component You miss the patient ⚠️ 📚 Aissaoui N et al. (2025) European Heart Journal DOI: 10.1093/eurheartj/ehaf340