Acute Cor Pulmonale Research Articles

Study to Explore the Association of the Renin-Angiotensin System and Right Ventricular Function in Mechanically Ventilated Patients.

Background: Right ventricular (RV) dysfunction is associated with pulmonary vasoconstriction in mechanically ventilated patients. Enhancing the activity of angiotensin-converting enzyme 2 (ACE2), a key enzyme of the renin-angiotensin system (RAS), using recombinant human ACE2 (rhACE2) could alleviate RAS-mediated vasoconstriction and vascular remodeling. Methods: This prospective observational study investigated the association between concentrations of RAS peptides (Ang II or Ang(1–7)) and markers of RV function, as assessed by echocardiography (ratio of RV to left ventricular end-diastolic area, interventricular septal motion, and pulmonary arterial systolic pressure (PASP)). Results: Fifty-seven mechanically ventilated patients were enrolled. Incidence rates of acute cor pulmonale (ACP) and pulmonary circulatory dysfunction (PCD) were consistent with previous studies. In the 45 evaluable participants, no notable or consistent changes in RAS peptides concentration were observed over the observation period, and there was no correlation between Ang II concentration and either PASP or RV size. The model of the predicted posterior distributions for the pre- and post-dose values of Ang II demonstrated no change in the likelihood of PCD after hypothetical dosing with rhACE2, thus meeting the futility criteria. Similar results were observed with the other RAS peptides evaluated. Conclusions: Pre-defined success criteria for an association between PCD and the plasma RAS peptides were not met in the mechanically ventilated unselected patients.

Severe Right Heart Failure in a Patient with Chronic Obstructive Lung Disease: A Diagnostic Challenge

A 55-year-old male was admitted for evaluation of severe dyspnoea and hypoxaemia. Physical examination upon admission showed elevated jugular venous pressure and an accentuated second heart sound. Chest radiograph showed cardiomegaly with increased bibasilar markings. Arterial blood gas analysis while breathing room air showed marked hypoxaemia. High resolution computed tomography angiography of the chest showed modestly enlarged mediastinal lymph nodes with discrete diffuse ground-glass attenuation especially at the lower lung zones. Positron emission tomography using 18F labelled 2-deoxy-D-glucose (FDG) demonstrated the mediastinal lymph nodes were FDG-avid. Transthoracic echocardiography showed dilated hypokinetic right heart chambers with bulging of the interventricular septum to the left, compatible with acute cor-pulmonale. From the tricuspid regurgitation jet measurement a systolic pulmonary artery pressure (PAP) of 48 mmHg was estimated. Patent foramen ovale was suspected on bubble test. Right heart catheterisation confirmed pulmonary arterial hypertension: mPAP 47 mmHg, pulmonary artery occlusion pressure 5 mmHg, cardiac index 1.1 L/min/m2, pulmonary vascular resistance (PVR) 959 dyne.sec.cm(-5). Pulmonary function tests showed a marked diffusing capacity for carbon monoxide (DLCO) decrease of 32% predicted but no obstructive lung deficit. Before an open lung biopsy could be scheduled the patient developed acute cardiogenic shock. At autopsy pulmonary veno-occlusive disease with marked pulmonary hypertension was diagnosed.

Association between the Right Ventricular Longitudinal Shortening Fraction and Mortality in Acute Respiratory Distress Syndrome Related to COVID-19 Infection: A Prospective Study.

Introduction: Right ventricular systolic dysfunction (RVsD) increases acute respiratory distress syndrome mortality in COVID-19 infection (CARDS). The RV longitudinal shortening fraction (RV-LSF) is an angle-independent and automatically calculated speckle-tracking parameter. We explored the association between RV-LSF and 30-day mortality in CARDS patients. Methods: Moderate-to-severe CARDS patients hospitalized at Amiens University Hospital with transesophageal echocardiography performed within 48 h of intensive care unit admission were included. RVsD was defined by an RV-LSF of <20%. The patients were divided into two groups according to the presence of RVsD. Using multivariate Cox regression, clinical and echocardiographic risk factors predicting 30-day mortality were evaluated. Results: Between 28 February 2020 and 1 December 2021, 86 patients were included. A total of 43% (n = 37/86) of the patients showed RVsD and 22% (n = 19/86) of the patients died. RV-LSF was observed in 26 (23.1–29.7)% of the no-RVsD function group and 16.5 (13.7–19.4)% (p < 0.001) of the RVsD group. Cardiogenic shock (n = 7/37 vs. 2/49, p = 0.03) and acute cor pulmonale (n = 18/37 vs. 10/49, p = 0.009) were more frequent in the RVsD group. The 30-day mortality was higher in the RVsD group (15/37 vs. 4/49, p = 0.001). In a multivariable Cox model, RV-LSF was an independent mortality factor (HR 4.45, 95%CI (1.43–13.8), p = 0.01). Conclusion: in a cohort of moderate-to-severe CARDS patients under mechanical ventilation, RVsD defined by the RV-LSF was associated with higher 30-day mortalities.

Acute cardiac injury (ACI) in COVID-19 pneumonia

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Since the SARS-CoV2 break-out many reports focused on the role of cardiovascular system involvement in the patient’s outcome(1). However, few descriptions exist including only patients with severe ARDS admitted to general ICU. Methods We enrolled adult patients with severe ARDS related to COVID-19 infection consecutively admitted to ICU between February 2020 and March 2021. Acute cardiac injury was defined as a rise and fall of cTnI above the 99th percentile (i.e., ≥ 47 ng/L)(2). Hs-TnI was measured at admission and during ICU stay. Echocardiographic examinations were performed at ICU admission and at the time of worst cTnI. Left ventricular (LV) and right ventricular (RV) systolic dysfunction were defined respectively as LV ejection fraction (LVEF) &amp;lt; 50% and as tricuspid annular plane systolic excursion (TAPSE) &amp;lt; 16 mm. Results A total of 148 patients were included in the analysis. Acute cardiac injury was present in 65 (44.9%) cases at admission. Forty-seven (21.8%) patients had isolated depressed LVEF, 13 (9.0%) had isolated RV systolic dysfunction and 24 (16,4%) presented with biventricular systolic dysfunction. Eithy-two (56.1%) had a worsening of hs-TNI values during the admission of whom a consensual worsening of LVEF and TAPSE was observed in respectively 32 (21.8%) and 28 (19.2%) patients. Cardiac injury at ICU admission yielded an increased risk of in-hospital mortality (OR 1.30 [95% CI 0.71 – 2.38]) (Figure 1 – left panel) as well as the presence of impaired echocardiography (OR 1.85 [95% CI 1.01 – 3.40]) (Figure 1 – right panel). Worst hs-TNI correlated with worst procalcitonin (PCT) values (p &amp;lt;0.001 r20.81) in case of on-going septic shock and 85 % of patients with RV dysfunction had either evidence of pulmonary thrombus at CT scan or high inspiratory peak pressure (&amp;gt; 30 cmH2O) at mechanical ventilation (respectively, p &amp;lt; 0.001 and p &amp;lt;0.01). Bivariable analysis adjusted for the inverse probability of having an impaired echocardiographic exam confirmed the increased risk of in-hospital mortality in patients with cardiac injury (OR 2.01 [95% CI 1.28 – 3.15]) and in presence of altered echocardiography with RV dysfunction yielding a higher risk (OR 2.42 [95% CI 1.29 – 4.55]) compared with biventricular impairment (OR 1.86 [95% CI 0.87 – 4.00]) and isolated LV dysfunction (OR 1.30 [95% CI 0.77 – 2.19]) (Figure 2). Conclusion The use of echocardiography for the detection of cardiac dysfunction, has shown a greater correlation with mortality than the identification of acute cardiac damage using laboratory parameters. Of all the parameters obtained with the echocardiography, right ventricular dysfunction demonstrates the greatest correlation with mortality compared to left or biventricular dysfunction. However, the major cause of LV dysfunction in our population occurred during septic shock while RV dysfunction seemed to be due to pulmonary embolism and/or acute cor pulmonale ARDS-related.

Echocardiography findings in COVID-19 patients admitted to intensive care units: a multi-national observational study (the ECHO-COVID study).

PurposeSeverely ill patients affected by coronavirus disease 2019 (COVID-19) develop circulatory failure. We aimed to report patterns of left and right ventricular dysfunction in the first echocardiography following admission to intensive care unit (ICU).MethodsRetrospective, descriptive study that collected echocardiographic and clinical information from severely ill COVID-19 patients admitted to 14 ICUs in 8 countries. Patients admitted to ICU who received at least one echocardiography between 1st February 2020 and 30th June 2021 were included. Clinical and echocardiographic data were uploaded using a secured web-based electronic database (REDCap).ResultsSix hundred and seventy-seven patients were included and the first echo was performed 2 [1, 4] days after ICU admission. The median age was 65 [56, 73] years, and 71% were male. Left ventricle (LV) and/or right ventricle (RV) systolic dysfunction were found in 234 (34.5%) patients. 149 (22%) patients had LV systolic dysfunction (with or without RV dysfunction) without LV dilatation and no elevation in filling pressure. 152 (22.5%) had RV systolic dysfunction. In 517 patients with information on both paradoxical septal motion and quantitative RV size, 90 (17.4%) had acute cor pulmonale (ACP). ACP was associated with mechanical ventilation (OR > 4), pulmonary embolism (OR > 5) and increased PaCO2. Exploratory analyses showed that patients with ACP and older age were more likely to die in hospital (including ICU).ConclusionAlmost one-third of this cohort of critically ill COVID-19 patients exhibited abnormal LV and/or RV systolic function in their first echocardiography assessment. While LV systolic dysfunction appears similar to septic cardiomyopathy, RV systolic dysfunction was related to pressure overload due to positive pressure ventilation, hypercapnia and pulmonary embolism. ACP and age seemed to be associated with mortality in this cohort.Supplementary InformationThe online version contains supplementary material available at 10.1007/s00134-022-06685-2.

Driving pressure versus right ventricular echocardiography parameters as a predictive for acute respiratory distress syndrome outcome

Background: Acute respiratory distress syndrome (ARDS) is an inflammatory disease that affects the lung in a heterogeneous manner , so that ,even ideal body weight (IBW) based tidal volume may apply different lung stress and strain according to the available aerated lung areas. Airway driving pressure (DP) is the difference between airway plateau pressure (P plat) and positive endexpiratory pressure (PEEP), it can be used as a bedside surrogate for lung stress in several previous studies. Acute corpulmonale manifested by pulmonary hypertension and right ventricular dysfunction occurs as a consequence for ARDS with a prevalence ( 25% to 61%) in different studies. Objectives : This study was designed to show he clinical value of airway driving pressure and right heart echocardiography parameters in predicting ARDS outcome , and to correlate between airway pressures and right ventricle parameters. Methodology : fifty ARDS patients were diagnosed by Berlin criteria and monitored for airway pressures including DP and Pplat on day 0, day 3 and day 7. transthoracic echocardiography was used to assess RV parameters on day 0 and day 7 . According the ICU mortality patients are divided into survivors and nonsurvivors.

A Comparative Analysis of Catheter Directed Thrombolysis with Anticoagulation Alone or Systemic tPA in Acute Pulmonary Embolism with Cor Pulmonale.

Pulmonary embolism (PE) with cor pulmonale causes considerable mortality and morbidity. Randomized trials have failed to show a mortality difference between treatment modalities including anticoagulation (AC), Catheter directed thrombolysis (CDT) and systemic tPA (tissue plasminogen activator). This is a cross-sectional retrospective case-control study utilizing the 2017 National Inpatient Sample (NIS). Patients admitted with acute PE with cor pulmonale were divided into groups based on whether they received anticoagulation, CDT or systemic tPA based on appropriate ICD-10 PCS codes. The AC group and CDT group were compared using univariate and multivariate analyses after adjusting for age, gender, race, comorbidities, insurance status and Charlson comorbidity index (CCI). Secondary outcomes included factors influencing length of stay (LOS) and total charges incurred. Similar analyses were done to compare the CDT group with the tPA group. In 2017, 13240 patients were admitted with acute PE and cor pulmonale, of whom 18% underwent CDT, 10% underwent systemic tPA and 72% underwent AC alone. Patients who received CDT over AC alone were significantly younger (61.5 vs. 65.5, p = 0.00). Mortality rate overall was 4.8% with tPA group, CDT group and AC alone group having a 11.2%, 3.0% and 4.4% mortality rate respectively. On multivariate analyses, there was no significant mortality difference between the CDT and AC groups (aOR 0.61, 0.34-1.1 95%CI, p = 0.103). Patients with liver disease had significantly higher mortality while obese patients had a significantly lower mortality after adjusting for treatment strategy and confounders. Length of stay (LOS) was not significantly different between the groups however, compared to AC alone, patients who underwent CDT or tPA incurred significantly higher total hospital charges. CDT offers an attractive alternative to tPA therapy; however, our study does not show an in-hospital mortality benefit. More studies are required to guide patient selection prior to establishing treatment protocols.

Incidence, prevalence and prognostic implications of right-sided heart failure in acute respiratory distress syndrome: A prospective observational study

: Acute respiratory distress syndrome is a heterogeneous disease which involves both the alveoli and pulmonary vessels. Acute cor pulmonale was initially considered as a marker of severity but its impact on outcome is still controversial. : This was a prospective observational study conducted over a period of nine months in ICU of a tertiary care center in India. Out of 2028 patient admitted in ICU 64 patients with ARDS (Berlins definition) underwent transthoracic echocardiography within 3 days of admission after diagnosis.: Acute cor pulmonale(ACP) was detected in 23 (36%) patients. Patients with ACP have greater the severity of disease and higher APACHE score as compared to those without ACP.Ph, PCO and P/F ratio appears to be the independent risk factor in patients for ACP in ARDS.Patients with ACP in ARDS had a higher incidence of shock and mortality(43.5%). ACP is quite common in ARDS. Due to its effect on the outcome, it appears to be a major factor in deciding ventilatory strategy in patients with ARDS. Right ventricle protective approach of ventilation keeps lung and heart connected.

Approach to echocardiography in ARDS patients in the prone position: A systematic review.

Echocardiography is commonly utilized in patients with acute respiratory distress syndrome (ARDS) for assessment of cardiac function, volume status, and the potential development of acute cor pulmonale. In severe ARDS, prone positioning is frequently used, which imposes technical challenges during transthoracic echocardiography (TTE) image acquisition. Moreover, prone positioning can affect cardiopulmonary function in ways that are reflected on the echocardiographic findings in this position. Historically, a transesophageal approach was recommended when a patient is prone, with few studies reporting utility of TTE in this setting. However, recent publications have begun to address this knowledge gap. This review explores recent literature addressing the use of TTE in prone patients with ARDS, with a special focus on the cardiopulmonary effects of proning and potential solutions to the technical difficulties that arise in this position.

Right Ventricular Function in Acute Respiratory Distress Syndrome: Impact on Outcome, Respiratory Strategy and Use of Veno-Venous Extracorporeal Membrane Oxygenation.

Acute respiratory distress syndrome (ARDS) is characterized by protein-rich alveolar edema, reduced lung compliance and severe hypoxemia. Despite some evidence of improvements in mortality over recent decades, ARDS remains a major public health problem with 30% 28-day mortality in recent cohorts. Pulmonary vascular dysfunction is one of the pivot points of the pathophysiology of ARDS, resulting in a certain degree of pulmonary hypertension, higher levels of which are associated with morbidity and mortality. Pulmonary hypertension develops as a result of endothelial dysfunction, pulmonary vascular occlusion, increased vascular tone, extrinsic vessel occlusion, and vascular remodeling. This increase in right ventricular (RV) afterload causes uncoupling between the pulmonary circulation and RV function. Without any contractile reserve, the right ventricle has no adaptive reserve mechanism other than dilatation, which is responsible for left ventricular compression, leading to circulatory failure and worsening of oxygen delivery. This state, also called severe acute cor pulmonale (ACP), is responsible for excess mortality. Strategies designed to protect the pulmonary circulation and the right ventricle in ARDS should be the cornerstones of the care and support of patients with the severest disease, in order to improve prognosis, pending stronger evidence. Acute cor pulmonale is associated with higher driving pressure (≥18 cmH2O), hypercapnia (PaCO2 ≥ 48 mmHg), and hypoxemia (PaO2/FiO2 < 150 mmHg). RV protection should focus on these three preventable factors identified in the last decade. Prone positioning, the setting of positive end-expiratory pressure, and inhaled nitric oxide (INO) can also unload the right ventricle, restore better coupling between the right ventricle and the pulmonary circulation, and correct circulatory failure. When all these strategies are insufficient, extracorporeal membrane oxygenation (ECMO), which improves decarboxylation and oxygenation and enables ultra-protective ventilation by decreasing driving pressure, should be discussed in seeking better control of RV afterload. This review reports the pathophysiology of pulmonary hypertension in ARDS, describes right heart function, and proposes an RV protective approach, ranging from ventilatory settings and prone positioning to INO and selection of patients potentially eligible for veno-venous extracorporeal membrane oxygenation (VV ECMO).

Abnormal Right Ventricular Free Wall Strain Prior to Prone Ventilation May Be Associated With Worse Outcome of Patients With COVID-19-Associated Acute Respiratory Distress Syndrome.

We investigated the effect of prone ventilation on right ventricular (RV) function of intubated patients with COVID-19–associated acute respiratory distress syndrome by measuring both conventional RV functional variables (namely, tricuspid annular peak systolic velocity, tricuspid annular plane systolic excursion, and fractional area change) and right ventricular free wall strain (RVFWS) using transthoracic speckle-tracking echocardiography at baseline (before prone positioning), 18 hours after prone positioning, and 1 hour after supine repositioning. We found that transthoracic echocardiography was feasible in a considerable proportion (nine patients, 75% of our cohort) of patients undergoing prone ventilation. Also, abnormal as opposed to normal RVFWS values (in the absence of conventional variables of RV dysfunction) at baseline were associated with higher mortality (100% vs 20%; p = 0.048). Finally, we found that, among patients without acute cor pulmonale or conventional markers of RV dysfunction, one session of prone ventilation may not affect right myocardial strain.

Echocardiographic 60-day mortality markers in patients hospitalized in intensive care for COVID-19

BackgroundCoronavirus disease COVID-19 produces a predominantly pulmonary affection, being cardiac involvement an important component of the multiorganic dysfunction. At the moment there are few reports about the behavior of echocardiographic images in the patients who have the severe forms of the disease. ObjectiveIdentify the echocardiographic prognostic markers for death within 60 days in patients hospitalized in intensive care. MethodsA single-center prospective cohort was made with patients hospitalized in intensive care for COVID-19 confirmed via polymerase chain reaction who got an echocardiogram between May and October 2020. A Cox multivariate model was plotted reporting the HR and confidence intervals with their respective p values for clinical and echocardiographic variables. ResultsOut of the 326 patients included, 153 patients got an echocardiogram performed on average 6.8 days after admission. The average age was 60.7, 47 patients (30.7%) were females and 67 (44.7%) registered positive troponin. 91 patients (59.5%) died. The univariate analysis identified TAPSE, LVEF, pulmonary artery systolic pressure, acute cor pulmonale, right ventricle diastolic dysfunction, and right ventricular dilatation as variables associated with mortality. The multivariate model identified that the acute cor pulmonale with HR= 4.05 (CI 95% 1.09 - 15.02, p 0.037), the right ventricular dilatation with HR= 3.33 (CI 95% 1.29 - 8.61, p 0.013), and LVEF with HR= 0.94 (CI 95% 0.89 - 0.99, p 0.020) were associated with mortality within 60 days. ConclusionsIn patients hospitalized in the intensive care unit for COVID-19, the LVEF, acute cor pulmonale and right ventricular dilatation are prognostic echocardiographic markers associated with death within 60 days.

Echocardiographic markers of mortality at 60 days in patients with COVID-19 in the intensive care unit

Abstract Introduction Coronavirus disease (COVID)-19 predominantly produces its effects through lung damage, but an important component of multi-organ dysfunction is cardiac involvement. We have few reports that inform about the behavior of echocardiographic images of patients with the most severe forms of the disease. Purpose The present work aims to identify prognostic markers for 60-day mortality in patients hospitalized in intensive care based on echocardiographic findings. Methodology A single-center retrospective cohort was conducted. Hospitalized patients were included in one of the nine intensive care units for COVID-19 confirmed by RT-PCR from May to October 2020. Patients with previous conditions that determined a limitation of the therapeutic effort, those who died before 24 hours and pregnant women were excluded. Portable echocardiograms were performed by two expert cardiologists following the recommendations for isolation and personal protection. The time to death was evaluated as outcome. A Cox proportional hazards model was constructed, HR and 95% confidence intervals with their p values. The study was approved by the institutional ethics committee. Results Of 326 patients included, 153 patients had an echocardiogram. The mean age was 60.7 years, 47 (30.7%) were female and 67 (44.7%) had positive troponin. 91 patients (59.5%) not survive, the mean long of stay was 8.4 (SD: 4.2) days. 111 (72.5%) had shock, 128 (83.7%) severe ARDS (PaO2 / FiO2 &amp;lt;100 mmHg), 142 (92.8%) required invasive ventilatory support, and 86 (56.2%) acute kidney injury. 27 (17.6%) patients had acute pulmonary embolism, 16 (10.4%) acute myocardial infarction and 9 (5.9%) myocarditis. The mean right ventricular ejection fraction was 37%, TAPSE was decreased in 16 cases (10.4%). 41 cases (26.8%) had right diastolic dysfunction. 34/48 (71%) cases had pulmonary hypertension. The average LVEF was 59.3% and 74 (48.4%) had some left ventricular diastolic dysfunction. 12 (7.8%) had left ventricular segmental wall motion abnormality and 16 (10.4%) had pericardial effusion. Univariate analysis identified TAPSE, PSAP, acute cor pulmonale and right ventricular dilatation as variables related to the outcome of mortality. The multivariate Cox model (Table 2) documented that acute cor pulmonale with a HR of 12.8 (95% CI 3.51 - 46.63, p&amp;lt;0.001) and right ventricular dilation with a HR of 4, 87 (95% CI 1.36–17.46, P 0.016) were associated with mortality. Conclusions In patients hospitalized in the intensive care unit for COVID-19, acute cor pulmonale and right ventricular dilatation behaved as independent predictors of in-hospital death. Funding Acknowledgement Type of funding sources: None. Table 1. Baselines characteristicsTable 2. Multivariate analisys

The impact of right ventricular injury on the mortality in patients with acute respiratory distress syndrome: a systematic review and meta-analysis

BackgroundPrevious studies have found various incidences of right ventricular (RV) injury and its association with clinical outcome in patients with acute respiratory distress syndrome (ARDS). In this systematic review and meta-analysis, we aimed to investigate the impact of the presence of RV injury on mortality in patients with ARDS.MethodWe searched Medline, Embase, and the Cochrane Central Register of Controlled Trials for studies investigating the association between RV injury and mortality. Two authors independently evaluated whether studies meet eligibility criteria and extracted the selected patients’ and studies’ characteristics and outcomes. RV injury was diagnosed by trans-thoracic echocardiogram (TTE), trans-esophageal echocardiogram (TEE) and PAC (pulmonary artery catheter) in the included studies. The primary outcome was the association between mortality and the presence of RV injury in patients with ARDS. The overall reported mortality was defined as either the intensive care unit (ICU) mortality, in-hospital mortality, or mortality within 90 days, and short-term mortality was defined as ICU-mortality, in-hospital mortality, or mortality within 30 days.ResultsWe included 9 studies (N = 1861 patients) in this meta-analysis. RV injury that included RV dysfunction, RV dysfunction with hemodynamic compromise, RV failure, or acute cor-pulmonale was present in 21.0% (391/1,861). In the pooled meta-analysis, the presence of RV injury in patients with ARDS was associated with significantly higher overall mortality (OR 1.45, 95% CI 1.13–1.86, p-value = 0.003, I2 = 0%), as well as short-term mortality (OR 1.48, 95% CI 1.14–1.93, p-value = 0.003, I2 = 0%).ConclusionIn this systematic review and meta-analysis including 1861 patients with ARDS, the presence of RV injury was significantly associated with increased overall and short-term mortality.Trial registration: The protocol was registered at PROSPERO (CRD42020206521).

Beyond the Ventilator - Cardiovascular Management in SARS-CoV-2 Infection

The novel corona virus, severe acute respiratory syndrome coronavirus 2 has spread worldwide since late 2019, with clinical manifestations of coronavirus disease 2019 (COVID-19) ranging from asymptomatic to respiratory impairment to multiorgan dysfunction with life-threatening cardiovascular complications. The mechanism of cardiovascular involvement is likely multifactorial, hypothesized to include direct myocardial injury, secondary injury due to the inflammatory response, and macro- and microthrombotic complications due to hypercoagulability. Acute cor pulmonale and pulmonary embolism are cardiovascular causes of serious morbidity and mortality, and myocarditis and Takotsubo syndrome have also been reported. It is not clear if arrhythmias represent a primary viral effect or a secondary effect of disease severity, though certain pharmacotherapies such as hydroxychloroquine may increase this risk. Point-of-care ultrasound and echocardiography are important tools for the screening and monitoring of these potential complications. Cardiovascular decompensation must be managed supportively with the escalation of vasoactive support, inhaled vasodilators, and consideration of mechanical circulatory support. Many questions remain and ongoing study is required to optimize care of the patient with cardiovascular complications of COVID.19.

Pulmonary Embolism Mortality Associated with the Necessity of Being Hospitalized Outside the Canton of Residence in Ecuador

Introduction: Pulmonary embolism (PE) is a common cause of cardiovascular death, with hospital mortality rates in South America around 14%. However, there is limited information regarding Ecuador. Objectives: To present a survival analysis of Ecuadorian patients affected by PE. Methods: We performed a survival analysis study based on the retrospective review of the hospital discharges by PE in Ecuador from 2011 to 2018 through the Ecuadorian National Statistics and Census Institute databases. Results: We found 2974 cases of PE. From them, 505 (16.98%) patients deceased, 59.72% were females, 64.79% had an age ≥60 years with an average of 65.04 years, 19.80% were treated outside their canton of residence, and 7.57% were associated to acute cor pulmonale (ACP). Using the Cox regression model, being treated outside the canton of residence (HR 1.40, p<0.05) and age ≥60 years (HR 1.64, p<0.05) reduced the overall survival. Contrasting, the absence of ACP improved the OS (HR 0.68, p<0.05). Excluding patients aged ≥60 years, and with ACP, being treated outside the canton of residence increased the risk of death by PE (HR 1.77, p<0.05). However, this effect was non significative in patients ≥60 years of age and with ACP (p>0.05). Conclusion: Patients treated by PE outside their canton of residence had an increased risk of mortality during the in-hospital stay, especially those younger than 60 years without ACP.

Goal-directed ultrasound protocol in patients with nontraumatic undifferentiated shock in the emergency department: prospective dual centre study.

Early identification of the cause of shock is associated with better prognosis. The aim of this study was to explore the performances of an ultrasound protocol (echoSHOCK) to diagnose the cause of shock in the emergency department (ED). This was a prospective study performed in two EDs. Included patients were older than 18 years admitted with shock. After routine workup strategy, the suspected cause of shock and the planned treatment were reported. The echoSHOCK protocol, using only B mode, was then performed. After performing echoSHOCK, the investigator reported the same two items. echoSHOCK protocol that assessed: compressive pericardial effusion (tamponade), right ventricle dilatation and flattening of the septum, left ventricle dimension and systolic function, indices of hypovolemia. We defined four different causes for shock (tamponade, acute cor pulmonale, cardiogenic and hypovolemia). The primary endpoint was the degree of agreement of the routine workup and echoSHOCK with an expert panel. 85 patients [mean age of 73 (14) years] were included. Kappa coefficients between routine strategy and echoSHOCK for the cause of shock, with the expert panel were 0.33 (95% CI, 0.26-0.4) and 0.88 (95% CI, 0.83-0.93), respectively. Likewise, for the planned treatment, kappa were 0.21 (95% CI, 0.14-0.28) and 0.9 (95% CI, 0.85-0.94), respectively. The physician's confidence increased from 3.9 (2.1) before echoSHOCK to 9.3 (1.1) after, (P < 0.001). This study suggested that echoSHOCK significantly increased the ability to determine the cause of undifferentiated shock in the ED.

Acute cor pulmonale in patients with acute respiratory distress syndrome: A comprehensive review.

Acute respiratory distress syndrome (ARDS)-related acute cor pulmonale (ACP) is found in 8%-50% of all patients with ARDS, and is associated with adverse hemodynamic and survival outcomes. ARDS-related ACP is an echocardiographic diagnosis marked by combined right ventricular dilatation and septal dyskinesia, which connote simultaneous diastolic (volume) and systolic (pressure) overload respectively. Risk factors include pneumonia, hypercapnia, hypoxemia, high airway pressures and concomitant pulmonary disease. Current evidence suggests that ARDS-related ACP is amenable to multimodal treatments including ventilator adjustment (aiming for arterial partial pressure of carbon dioxide < 60 mmHg, plateau pressure < 27 cmH2O, driving pressure < 17 cmH2O), prone positioning, fluid balance optimization and pharmacotherapy. Further research is required to elucidate the optimal frequency and duration of routine bedside echocardiography screening for ARDS-related ACP, to more clearly delineate the diagnostic role of transthoracic echocardiography relative to transesophageal echocardiography, and to validate current and novel therapies.

Assessment of Right Ventricular Function With CT and Echocardiography in Patients With Severe Acute Respiratory Distress Syndrome on Extracorporeal Membrane Oxygenation.

Changes in right ventricular size and function are frequently observed in patients with severe acute respiratory distress syndrome. The majority of patients who receive venovenous extracorporeal membrane oxygenation undergo chest CT and transthoracic echocardiography. The aims of this study were to compare the use of CT and transthoracic echocardiography to evaluate the right ventricular function and to determine the prevalence of acute cor pulmonale in this patient population. Observational, retrospective, single-center, cohort study. Severe respiratory failure and extracorporeal membrane oxygenation center. About 107 patients with severe acute respiratory distress syndrome managed with venovenous extracorporeal membrane oxygenation. Chest CT to evaluate right ventricular size and transthoracic echocardiography to evaluate right ventricular size and function. All 107 patients had a qualitative assessment of right ventricular size and function on transthoracic echocardiography. Quantitative measurements were available in 54 patients (50%) who underwent transthoracic echocardiography and in 107 of patients (100%) who received CT. Right ventricular dilatation was defined as a right ventricle end-diastolic diameter greater than left ventricular end-diastolic diameter upon visual assessment or an right ventricle end-diastolic diameter/left ventricular end-diastolic diameter and/or right ventricle cavity area/left ventricular cavity area of greater than 0.9. Right ventricle systolic function was visually estimated as being normal or impaired (visual right ventricular systolic impairment). The right ventricle was found to be dilated in 38/107 patients (36%) and in 58/107 patients (54%), using transthoracic echocardiography or CT right ventricle end-diastolic diameter/left ventricular end-diastolic diameter, respectively. When the CT right ventricle cavity/left ventricular cavity area criterion was used, the right ventricle was dilated in 19/107 patients (18%). About 33/107 patients (31%) exhibited visual right ventricular systolic impairment. Transthoracic echocardiography right ventricle end-diastolic diameter/left ventricular end-diastolic diameter showed good agreement with CT right ventricle cavity/left ventricular cavity area (R 2 = 0.57; p < 0.01). A CT right ventricle cavity/left ventricular cavity area greater than 0.9 provided the optimal cutoff for acute cor pulmonale on transthoracic echocardiography with an AUC of 0.78. Acute cor pulmonale was defined by the presence of a right ventricle "D-shape" and quantitative right ventricle dilatation on transthoracic echocardiography or a right ventricle cavity/left ventricular cavity area greater than 0.9 on CT. A diagnosis of acute cor pulmonale was made in 9/54 (14% patients) on transthoracic echocardiography and in 19/107 (18%) on CT. Changes in right ventricular size and function are common in patients with severe acute respiratory distress syndrome requiring venovenous extracorporeal membrane oxygenation with up to 18% showing imaging evidence of acute cor pulmonale. A CT right ventricular cavity /left ventricular cavity area greater than 0.9 is indicative of impaired right ventricular systolic function.

Severe COVID-19 with acute respiratory distress syndrome (ARDS) in a sickle cell disease adult patient: case report

BackgroundSickle-cell anaemia is a widespread genetic disease prevalent worldwide among African and African-American populations. The pathogenesis is most often revealed by pulmonary conditions, including acute thoracic syndrome, which is affecting the life expectancy of these populations. The global spread of CoV2-SARS infection with a respiratory tropism, endothelial damages and procoagulant status endangers the SCD population. However, with only a few case reports, consequences of the Covid-19 pandemic on SCD population remain poorly known.Case presentationWe report a case of a 33-year-old man with a history of homozygous SS homozygous sickle cell anemia who consulted on March 24, 2020 for febrile dyspnea 11 days after the onset of symptoms. A nasopharyngeal swab was positive for SARS-CoV-2. His respiratory status worsened rapidly in the emergency room and then in ICU leading to severe ARDS requiring intubation, curarization, and venovenous ECMO. Hematologically, severe hemolysis associated with major thrombocytopenia without documented spinal cord injury was noted. Several transfusion exchanges are performed. The evolution was finally slowly favorable and led to discharge from the intensive care unit and then from the hospital.ConclusionsThis case recalls the importance of an increased prevention policy against COVID-19among the SCD population. In addition, from a therapeutic point of view, it advocates (1) a high preventive anticoagulation from the outset according to the level of D-dimers (2) the use of venovenous ECMO in this particular case, whereas this technique has had rather disappointing results in acute chest syndromes. (3) Unexpectedly, our patient did not develop pulmonary arterial hypertension (PAH) and acute cor pulmonale (ACP), whereas this is a common feature of ARDS during SCD. These last two observations suggest a different pathophysiology of pulmonary disorders in SCD patients in the case of SARS COv2. It could be associated with marked hypoxemia secondary to pulmonary vascular vasodilation.