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Acute respiratory distress syndrome (ARDS)-associated acute cor pulmonale and patent foramen ovale: a multicenter noninvasive hemodynamic study.

Legras A, Caille A, Begot E, Lhéritier G, Lherm T, Mathonnet A, Frat JP, Courte A, Martin-Lefèvre L, Gouëllo JP, Mercier E, Vignon P, ARCO and CRICS netwo - Crit Care (2015)

Bottom Line: ACP was present in 36 patients, PFO in 21 patients, both PFO and ACP in 8 patients and the 130 remaining patients had neither PFO nor ACP.Patients with ACP exhibited a restricted left ventricle (LV) secondary to RV dilatation and had concomitant RV dysfunction, irrespective of associated PFO, but preserved LV systolic function.Despite elevated sPAP, PFO shunting was associated with preserved RV systolic function.

View Article: PubMed Central - PubMed

Affiliation: Medical ICU, Teaching hospital of Tours, 2 Bd Tonnellé, 37044, Tours, cedex 9, France. a.legras@chu-tours.fr.

ABSTRACT

Introduction: Acute cor pulmonale (ACP) and patent foramen ovale (PFO) remain common in patients under protective ventilation for acute respiratory distress syndrome (ARDS). We sought to describe the hemodynamic profile associated with either ACP or PFO, or both, during the early course of moderate-to-severe ARDS using echocardiography.

Methods: In this 32-month prospective multicenter study, 195 patients with moderate-to-severe ARDS were assessed using echocardiography during the first 48 h of admission (age: 56 (SD: 15) years; Simplified Acute Physiology Score: 46 (17); PaO2/FiO2: 115 (39); VT: 6.5 (1.7) mL/kg; PEEP: 11 (3) cmH2O; driving pressure: 15 (5) cmH2O). ACP was defined by the association of right ventricular (RV) dilatation and systolic paradoxical ventricular septal motion. PFO was detected during a contrast study using agitated saline in the transesophageal bicaval view.

Results: ACP was present in 36 patients, PFO in 21 patients, both PFO and ACP in 8 patients and the 130 remaining patients had neither PFO nor ACP. Patients with ACP exhibited a restricted left ventricle (LV) secondary to RV dilatation and had concomitant RV dysfunction, irrespective of associated PFO, but preserved LV systolic function. Despite elevated systolic pulmonary artery pressure (sPAP), patients with isolated PFO had a normal RV systolic function. sPAP and PaCO2 levels were significantly correlated.

Conclusions: In patients under protective mechanical ventilation with moderate-to-severe ARDS, ACP was associated with LV restriction and RV failure, whether PFO was present or not. Despite elevated sPAP, PFO shunting was associated with preserved RV systolic function.

No MeSH data available.


Related in: MedlinePlus

Relationship between individual values of PaCO2 and systolic pulmonary artery pressure (sPAP) measured in moderate-to-severe ARDS patients under protective ventilation using continuous wave Doppler interrogation of tricuspid regurgitant jet, when present. ARDS, acute respiratory distress syndrome; PaCO2, partial pressure of arterial carbon dioxide.
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Fig1: Relationship between individual values of PaCO2 and systolic pulmonary artery pressure (sPAP) measured in moderate-to-severe ARDS patients under protective ventilation using continuous wave Doppler interrogation of tricuspid regurgitant jet, when present. ARDS, acute respiratory distress syndrome; PaCO2, partial pressure of arterial carbon dioxide.

Mentions: Respiratory and circulatory parameters were not statistically different between groups in these patients with moderate-to-severe ARDS who underwent protective ventilation and frequently received vasopressor support. Prone positioning was used more frequently in patients with isolated ACP than in other groups (Table 1). When compared to patients with isolated PFO or ACP, patients with both PFO and ACP exhibited greater RV dilatation, as reflected by a higher median RVEDA/LVEDA ratio (Table 2). LV end-systolic eccentricity index was significantly higher in ACP patients, irrespective of associated PFO. In contrast, LV end-diastolic eccentricity index did not differ between groups. Patients with ACP exhibited LV restriction, as reflected by a significantly lower median LV end-diastolic volume (LVEDV), and tended to have lower LVSV, whether PFO was associated or not (Table 2). LVEF was uniformly preserved across groups. In contrast, RV systolic function was reduced in ACP patients, irrespective of associated PFO, as reflected by significantly lower median values of RVFAC and TAPSE. Despite substantially elevated sPAP, patients with isolated PFO had preserved RV function, with similar median values of RVFAC and TAPSE than those of patients without PFO and ACP (Table 2). Median sPAP was significantly higher in patients with a PaCO2 > 60 mmHg (51 ± 13 vs. 42 ± 13 mmHg: P = 0.04). A significant correlation was found between sPAP and PaCO2 levels in the study population (r: 0.35; P = 0.0002) (Figure 1).Table 1


Acute respiratory distress syndrome (ARDS)-associated acute cor pulmonale and patent foramen ovale: a multicenter noninvasive hemodynamic study.

Legras A, Caille A, Begot E, Lhéritier G, Lherm T, Mathonnet A, Frat JP, Courte A, Martin-Lefèvre L, Gouëllo JP, Mercier E, Vignon P, ARCO and CRICS netwo - Crit Care (2015)

Relationship between individual values of PaCO2 and systolic pulmonary artery pressure (sPAP) measured in moderate-to-severe ARDS patients under protective ventilation using continuous wave Doppler interrogation of tricuspid regurgitant jet, when present. ARDS, acute respiratory distress syndrome; PaCO2, partial pressure of arterial carbon dioxide.
© Copyright Policy - open-access
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC4416307&req=5

Fig1: Relationship between individual values of PaCO2 and systolic pulmonary artery pressure (sPAP) measured in moderate-to-severe ARDS patients under protective ventilation using continuous wave Doppler interrogation of tricuspid regurgitant jet, when present. ARDS, acute respiratory distress syndrome; PaCO2, partial pressure of arterial carbon dioxide.
Mentions: Respiratory and circulatory parameters were not statistically different between groups in these patients with moderate-to-severe ARDS who underwent protective ventilation and frequently received vasopressor support. Prone positioning was used more frequently in patients with isolated ACP than in other groups (Table 1). When compared to patients with isolated PFO or ACP, patients with both PFO and ACP exhibited greater RV dilatation, as reflected by a higher median RVEDA/LVEDA ratio (Table 2). LV end-systolic eccentricity index was significantly higher in ACP patients, irrespective of associated PFO. In contrast, LV end-diastolic eccentricity index did not differ between groups. Patients with ACP exhibited LV restriction, as reflected by a significantly lower median LV end-diastolic volume (LVEDV), and tended to have lower LVSV, whether PFO was associated or not (Table 2). LVEF was uniformly preserved across groups. In contrast, RV systolic function was reduced in ACP patients, irrespective of associated PFO, as reflected by significantly lower median values of RVFAC and TAPSE. Despite substantially elevated sPAP, patients with isolated PFO had preserved RV function, with similar median values of RVFAC and TAPSE than those of patients without PFO and ACP (Table 2). Median sPAP was significantly higher in patients with a PaCO2 > 60 mmHg (51 ± 13 vs. 42 ± 13 mmHg: P = 0.04). A significant correlation was found between sPAP and PaCO2 levels in the study population (r: 0.35; P = 0.0002) (Figure 1).Table 1

Bottom Line: ACP was present in 36 patients, PFO in 21 patients, both PFO and ACP in 8 patients and the 130 remaining patients had neither PFO nor ACP.Patients with ACP exhibited a restricted left ventricle (LV) secondary to RV dilatation and had concomitant RV dysfunction, irrespective of associated PFO, but preserved LV systolic function.Despite elevated sPAP, PFO shunting was associated with preserved RV systolic function.

View Article: PubMed Central - PubMed

Affiliation: Medical ICU, Teaching hospital of Tours, 2 Bd Tonnellé, 37044, Tours, cedex 9, France. a.legras@chu-tours.fr.

ABSTRACT

Introduction: Acute cor pulmonale (ACP) and patent foramen ovale (PFO) remain common in patients under protective ventilation for acute respiratory distress syndrome (ARDS). We sought to describe the hemodynamic profile associated with either ACP or PFO, or both, during the early course of moderate-to-severe ARDS using echocardiography.

Methods: In this 32-month prospective multicenter study, 195 patients with moderate-to-severe ARDS were assessed using echocardiography during the first 48 h of admission (age: 56 (SD: 15) years; Simplified Acute Physiology Score: 46 (17); PaO2/FiO2: 115 (39); VT: 6.5 (1.7) mL/kg; PEEP: 11 (3) cmH2O; driving pressure: 15 (5) cmH2O). ACP was defined by the association of right ventricular (RV) dilatation and systolic paradoxical ventricular septal motion. PFO was detected during a contrast study using agitated saline in the transesophageal bicaval view.

Results: ACP was present in 36 patients, PFO in 21 patients, both PFO and ACP in 8 patients and the 130 remaining patients had neither PFO nor ACP. Patients with ACP exhibited a restricted left ventricle (LV) secondary to RV dilatation and had concomitant RV dysfunction, irrespective of associated PFO, but preserved LV systolic function. Despite elevated systolic pulmonary artery pressure (sPAP), patients with isolated PFO had a normal RV systolic function. sPAP and PaCO2 levels were significantly correlated.

Conclusions: In patients under protective mechanical ventilation with moderate-to-severe ARDS, ACP was associated with LV restriction and RV failure, whether PFO was present or not. Despite elevated sPAP, PFO shunting was associated with preserved RV systolic function.

No MeSH data available.


Related in: MedlinePlus