Early hemodynamic phenotyping in sepsis using transthoracic echocardiography: A proof-of-concept study in a north African ICU

BACKGROUND: Cardiovascular dysfunction in sepsis is heterogeneous and contributes to poor outcomes. Hemodynamic phenotyping may delineate pathophysiologically distinct subgroups with implications for prognosis and individualized management. No studies have evaluated such phenotypes in African intensive care units (ICUs). We aimed to explore cardiovascular phenotypes in patients with sepsis using clinical and echocardiographic variables. METHODS: We conducted a post-hoc exploratory analysis of two prospective ICU cohorts. Adults with sepsis and acute circulatory failure in whom fluid responsiveness was assessed were included. All patients underwent transthoracic echocardiography (TTE) within 24 h of ICU admission. Eight hemodynamic variables-heart rate (HR), diastolic arterial pressure (DABP), mean arterial pressure (MABP), left-ventricular ejection fraction (LVEF), LVOT velocity-time integral (VTI), lateral e', E/e', and tricuspid annular plane systolic excursion (TAPSE)-were standardized and clustered using k-means. Thirty-day ICU outcomes were evaluated with Kaplan-Meier curves and Cox models. RESULTS: Seventy-eight patients were analyzed. Three cardiovascular phenotypes emerged: (i) Hemodynamically optimized (n = 25): lower HR, near-normal MABP/DABP, higher VTI and LVEF; (ii) Vasoplegic (n = 27): low MABP/DABP with preserved systolic indices; and (iii) Myocardial depressed (n = 26): reduced VTI, LVEF, TAPSE, and lower e'. Thirty-day ICU mortality differed significantly across phenotypes (28% vs 59% vs 69%; p < 0.001). In the adjusted Cox model (reference = hemodynamically optimized), the Myocardial depressed phenotype had a higher hazard of ICU death (HR 2.90; 95% CI 1.24-6.79; p = 0.014). CONCLUSIONS: In this first echocardiography-informed phenotyping study from an African ICU, early cardiovascular phenotypes were identifiable and associated with distinct 30-day outcomes. TRIAL REGISTRATION: NCT05538637 and NCT06313671.