Acute Cor Pulmonale Research Articles

Prone Positioning Unloads the Right Ventricle in Severe ARDS

Despite airway pressure limitation, acute cor pulmonale persists in a minority of ARDS patients. Insufficient airway pressure limitation, hypercapnia, or both may be responsible. Because prone positioning (PP) has been shown to be a safe way to reduce airway pressure and to improve alveolar ventilation, we decided to assess its effect on right ventricular (RV) pressure overload in ARDS patients. Between January 1998 and December 2006, we studied 42 ARDS patients treated by PP to correct severe oxygenation impairment (Pao2/fraction of inspired oxygen ratio, <100 mm Hg). RV function was evaluated by bedside transesophageal echocardiography, before and after 18 h of prone-position ventilation. RV enlargement was measured by RV/left ventricular (LV) end-diastolic area ratio in the long axis. Septal dyskinesia was quantified by measuring short-axis systolic eccentricity of the LV. Before PP, 21 patients (50%) had acute cor pulmonale, defined by RV enlargement associated with septal dyskinesia (group 1), whereas 21 patients had a normal RV (group 2). PP was accompanied by a significant decrease in airway pressure and Paco2. In group 1, this produced a significant decrease in mean (+/-SD) RV enlargement (from 0.91+/-0.22 to 0.61+/-0.21) after 18 h of PP (p=0.000) and a significant reduction in mean septal dyskinesia (from 1.5+/-0.2 to 1.1+/-0.1) after 18 h of PP (p=0.000). In the most severe forms of ARDS, PP was an efficient means of controlling RV pressure overload.

Heart???lung interactions

Assessment of cardiovascular stability using ventilation-induced changes in measured physiological variables, referred to as functional hemodynamic monitoring, usually requires measurement of ventilation-induced changes in venous return. Thus, it is important to understand the determinants of these complex heart-lung interactions. Several animal and human studies have recently documented that ventricular interdependence plays an important role during positive-pressure breathing, causing acute cor pulmonale. With the use of lower tidal volume ventilation in patients with acute respiratory failure, the incidence of acute cor pulmonale is decreasing proportionally. When present, however, it induces a stroke volume variation that is 180 degrees out of phase with that seen in hypovolemic states, such that left ventricular stroke volume increases during inspiration rather than decreasing as seen in hypovolemia. Further, when either tidal volume or positive end-expiratory pressure levels are varied, both stroke volume variation and pulse pressure variation are affected in a predictable manner. The greater the swing in intrathoracic pressure, the greater the change in venous return. Functional hemodynamic monitoring is becoming more prevalent. For it to be used effectively, the operator needs to have a solid understanding of how ventilation induces both pulse pressure variation and stroke volume variation in that specific patient.

FATAL ACUTE COR PULMONALE CAUSED BY MICROSCOPIC TUMOR EMBOLI FROM TRANSITIONAL CELL CARCINOMA OF THE BLADDER

INTRODUCTION:Acute cor pulmonale is an uncommon manifestation of microscopic tumor embolism (MTE). MTE usually presents as subacute cor pulmonale, described as rapid development of right heart failure due to tumor emboli in the lung. This manifestation, most often due to adenocarcinoma, has been described in patients with various malignancies including breast, gastric, prostate and liver. We present a case of fatal acute cor pulmonale from transitional cell carcinoma (TCC) of the bladder, which has rarely been reported in the literature.

Prone Positioning for a Morbidly Obese Patient with Acute Respiratory Distress Syndrome: An Opportunity to Explore Intrinsic Positive End-expiratory Pressure–Lower Inflexion Point Interdependence

Prone Positioning for a Morbidly Obese Patient with Acute Respiratory Distress Syndrome: An Opportunity to Explore Intrinsic Positive End-expiratory Pressure–Lower Inflexion Point Interdependence

Electrophysiological study of infant and adult rats under acute intoxication with fluoroacetamide

A study was conducted of acute intoxication of infant and adult Wistar rats with fluoroacetamide (FAA), an inhibitor of oxidative metabolism. FAA was administered orally to adult rats at 1/2 LD(50) and subcutaneously to infant rats at LD(100) or 1/10 LD(50). Electrocardiogram (ECG), respiration and motor activity were registered for 7 days. Clinical analysis of ECG and the heart rate variability (HRV) was carried out to assess the state of the vegetative nervous system. In adult rats, FAA caused marked disturbances in the activity of cardiovascular and respiratory systems, including the development of a potentially lethal acute cor pulmonale. Conversely, there were no significant changes of cardiac function and respiration in infant rats; they died because of extreme emaciation accompanied by retardation of development. In adult rats, bursts of associated cardiac and respiratory tachyarrhythmia, as well as regular high amplitude spasmodic sighs having a deca-second rhythm were observed. In both infant and adult rats, FAA caused short-term enhancement of humoral (metabolic) and sympathetic activities, followed by a gradual and stable predominance of parasympathetic influence on HRV. Under conditions of FAA inhibition of the tricarboxylic acid cycle, the observed physiological reactions may be explained by activation of alternative metabolic pathways. This is also supported by a lack of ontogenetically caused inhibition of spontaneous motor activity in infant rats poisoned with FAA, which highlights the significance of the alternative metabolic pathways for implementation of deca-second and minute rhythms and a lack of a rigid dependence of these rhythms upon activity of neuronal networks.

13: Extracorporeal life support is a viable bridge to lung transplantation in patients with acute cor pulmonale and end stage pulmonary fibrosis: A case series

13: Extracorporeal life support is a viable bridge to lung transplantation in patients with acute cor pulmonale and end stage pulmonary fibrosis: A case series

Is there a safe plateau pressure in ARDS? The right heart only knows

Airway pressure limitation is now a largely accepted strategy in adult respiratory distress syndrome (ARDS) patients; however, some debate persists about the exact level of plateau pressure which can be safely used. The objective of the present study was to examine if the echocardiographic evaluation of right ventricular function performed in ARDS may help to answer to this question. For more than 20 years, we have regularly monitored right ventricular function by echocardiography in ARDS patients, during two different periods, a first (1980-1992) where airway pressure was not limited, and a second (1993-2006) where airway pressure was limited. By pooling our data, we can observe the effect of a large range of plateau pressure upon mortality rate and incidence of acute cor pulmonale. In this whole group of 352 ARDS patients, mortality rate and incidence of cor pulmonale were 80 and 56%, respectively, when plateau pressure was > 35 cmH(2)O; 42 and 32%, respectively, when plateau pressure was between 27 and 35 cmH(2)O; and 30 and 13%, respectively, when plateau pressure was < 27 cmH(2)O. Moreover, a clear interaction between plateau pressure and cor pulmonale was evidenced: whereas the odd ratio of dying for an increase in plateau pressure from 18-26 to 27-35 cm H(2)O in patients without cor pulmonale was 1.05 (p = 0.635), it was 3.32 in patients with cor pulmonale (p < 0.034). We hypothesize that monitoring of right ventricular function by echocardiography at bedside might help to control the safety of plateau pressure used in ARDS.

Mehrschicht-Spiral-CT bei vermuteter und inzidenteller akuter Lungenembolie: prognostischer Wert morphologischer Herzparameter

Evaluation of the prognostic value of morphological cardiac parameters in patients with suspected and incidental acute pulmonary embolism (PE) using multidetector-row chest CT (MSCT). 2335 consecutive MSCT scans were evaluated for the presence of PE. The arterial enhancement and analysability of pulmonary arteries and the heart were assessed as parameters of the scan quality. The diastolic right and left ventricular short axes (RV (D), LV (D)) and the interventricular septal deviation (ISD) were measured in all PE-positive patients and the echocardiography reports were reviewed. The clinical data assessment included cardio-respiratory and other co-morbidities, systemic anticoagulant therapy (ACT), and the 30-day outcome. Predictors of acute cor pulmonale and the short-term outcome were calculated by univariate and multivariate logistic regressions including odds ratios (OR) and ROC analyses using positive (PPV) and negative predictive values (NPV). 90 patients with acute PE were included (36 with clinically suspected PE, 54 with incidental PE). 26 patients had cardio-respiratory co-morbidities. Four patients underwent systemic thrombolysis, 43 underwent anticoagulation in therapeutic doses, 19 underwent anticoagulation in prophylactic doses, and 24 patients did not undergo ACT. 15 of 41 patients had echocardiographic evidence of acute cor pulmonale. 8 patients died within 30 days. The RV (D) was the best independent predictor of acute cor pulmonale (p = 0,002, OR = 9.16, PPV = 0.68, NPV = 1 at 4.49 cm cut off) and short-term outcome (p = 0,0005, OR = 2.82, PPV = 0.23, NPV = 0.98 at 4.75 cm cut off). The RV (D)/LV (D) ratio had a PPV of 0.85 for cor pulmonale. The RV (D) and RV (D)/LV (D) ratio were suitable for identifying patients with acute cor pulmonale and for benign short-term prognosis. Further studies should prospectively address the combined use of CT-morphological and clinical parameters for the prediction of patient outcome.

Analyse du peptide natriurétique de type B comme marqueur du cœur pulmonaire aigu dans le syndrome de détresse respiratoire aiguë

Objective The aim of this study was to evaluate the accuracy of the BNP as a marker of acute cor pulmonale in patients with ARDS. Study design Prospective clinical trial. Patients and methods At day 2 or 3 after the onset of the ARDS, an echocardiography was performed. Patients with left ventricular dysfunction were excluded. Right ventricular area (RVA) and RVA/LVA ratio were measured. ACP was defined as RVA/LVA > 0.6 associated with septal dyskinesia. Simultaneously, 5 ml of blood was collected for BNP measurement. Results 26 patients were studied. BNP levels were higher in 10 patients with ACP: 585.5 [189–4830] vs 145.5 [36.5–346] pg/ml ( P = 0.01) but in those with creatinine clearance < 90 ml/min: 602 [331–3530] vs 125 [39–189] pg/ml ( P = 0.007). BNP was correlated with RVA (r = 0.5; p = 0.01), RVA/LVA ratio (r = 0.61; p = 0.001), sPAP (r = 0.58; p = 0.002) and with age, cardiac index and creatinine clearance (r = 0.61; p = 0.001). In multivariate analysis, BNP was only correlated with creatinine clearance ( p = 0.03), and RVA ( p = 0.06). Conclusion In ARDS patients without left ventricular dysfunction, BNP level is more elevated in patients with acute cor pulmonale than patients without cor pulmonale.

Bedside echocardiographic evaluation of hemodynamics in sepsis: is a qualitative evaluation sufficient?

Transesophageal echocardiography (TEE) has proven its efficiency in assessing hemodynamics in patients by its ability to evaluate cardiac function and fluid responsiveness. Classically, it requires quantitative measurements, whereas in routine practice TEE is used in our unit especially as a qualitative procedure. We assessed the accuracy of this qualitative central hemodynamic evaluation obtained by TEE at the bedside. Prospective study conducted in a medical ICU between September 2004 and April 2005. All TEE examinations performed in consecutive patients hospitalized for septic shock and mechanically ventilated for an associated acute lung injury were eligible for evaluation. Intensivists trained in echocardiography were asked to classify (a) respiratory changes in the superior vena cava (SVC), (b) left ventricular (LV) systolic function, (c) right ventricular (RV) end-diastolic size, and (d) shape and kinetics of the interventricular septum (IVS). A post-hoc quantitative evaluation was then performed by a trained investigator unaware of the patients' status. We evaluated 83 examinations in 30 patients. Qualitative evaluation was easily able to distinguish patients with significant or nonsignificant SVC respiratory changes, normal, moderately or markedly depressed LV systolic function, and nondilated or dilated right ventricle. Acute cor pulmonale was also well recognized. By its ability accurately to evaluate hemodynamic status qualitative TEE could be useful for intensivists in managing circulatory failure in septic shock, rendering the more time-consuming quantitative evaluation useless.

A human model of chronic obstructive pulmonary disease

Expiratory flow-limitation (EFL) during exercise enforces slowing of the velocity of shortening of expiratory muscles, which according to the muscles' force velocity characteristics will increase the force (measured as pressure) that they develop. It has been suggested that high expiratory pressures might have adverse circulatory effects. To investigate this further we have studied normal subjects during incremental or constant workload exercise with a Starling resistor in the expiratory line which limited flow to ∼1 Vs. We found that this intervention: 1) caused a marked increase in expiratory pressures; 2) limited maximal exercise workload (W m a x ) to 67% of control W m a x ; 3) led to intolerable dyspnea, attributable largely to expiratory muscle recruitment; 4) caused CO 2 retention not entirely explicable by a reduction in minute ventilation, thus implicating an increased alveolar dead space; 5) shifted blood from trunk to extremities, possibly accounting for the increased dead space and hypercapnia; 6) decreased cardiac output by 10% and systemic O 2 delivery by 15%. EFL during exercise reproduces the main clinical features of COPD, namely, exercise intolerance, prominent dyspnea and carbon dioxide retention and produces a condition similar to acute cor pulmonale. Thus it is a human model of how COPD leads to impairment of ventilatory pump function that is safe and repeatable. The results suggest that patients with COPD who recruit expiratory muscles excessively may limit exercise by decreasing systemic O 2 delivery.

Acute Cor Pulmonale from Massive Bilateral Pulmonary Emboli

In the United States, pulmonary embolism (PE) is a common cause of morbidity and mortality. Several authors have described the EKG changes associated with PE, the presence of a S1 Q3 T3 is suggestive of right heart strain and cor pulmonale. We present a case of 62 y/o male on day number 20 s/p radical cysto-prostatectomy and neobladder for Urothelial Cell Carcinoma, who after a long automobile trip developed acute cor pulmonale from a lethal pulmonary embolism.

What role does the right side of the heart play in circulation?

Right ventricular failure (RVF) is an underestimated problem in intensive care. This review explores the physiology and pathophysiology of right ventricular function and the pulmonary circulation. When RVF is secondary to an acute increase in afterload, the picture is one of acute cor pulmonale, as occurs in the context of acute respiratory distress syndrome, pulmonary embolism and sepsis. RVF can also be caused by right myocardial dysfunction. Pulmonary arterial catheterization and echocardiography are discussed in terms of their roles in diagnosis and treatment. Treatments include options to reduce right ventricular afterload, specific pulmonary vasodilators and inotropes.

MICROEMBOLI OF TRANSITIONAL CELL CARCINOMA (TCC) CAUSING RAPIDLY PROGRESSIVE DYSPNEA AND RIGHT HEART FAILURE

INTRODUCTION: Tumor microemboli to the pulmonary vasculature is described in many different cancers. This case illustrates the diagnostic and clinical challenges associated with acute cor pulmonale and rapidly progressing dyspnea in a man with a history of treated bladder cancer.

Pulmonary embolization as primary manifestation of hepatocellular carcinoma with intracardiac penetration: A case report

Intracardiac manifestation of hepatocellular carcinoma (HCC) is a rare condition and an uncommon finding even at autopsy. Pulmonary tumor embolism as a presenting feature of HCC has been published only twice previously. In our case report, a 63-year-old man presented with high fever and six episodes of recurrent pneumonias during the last half year. Echocardiography was performed, a solid mass was found in the right atrium. Transesophageal echocardiography proved a tumor mass in the inferior vena cava (IVC) extending into the right atrium, abdominal ultrasound revealed tumor mass in the IVC and a solid tumor in the liver. Combined liver and heart surgery was attempted in order to remove the tumor mass from both the liver and the right atrium. Acute cor pulmonale occurred during tumor removal from the right atrium and the patient expired. In addition to local factors the possibility of embolization should arise in the background of recurrent pneumonia. Occult carcinoma must be included in possible causes of recurrent pulmonary embolism. Searching for primary malignancy should include HCC as frequent cause of hypercoagulability. In case of HCC, echocardiography is suggested because of the possibility of expansion in IVC or right atrium and tumor-embolization.

Severity assessment of acute pulmonary embolism: Role of CT angiography

Helical CT has gained wide acceptance in the noninvasive diagnosis of acute pulmonary embolism (APE) and has therefore largely replaced conventional pulmonary angiography as well as ventilation perfusion scan in the work-up of patients suspected of nonsevere pulmonary embolism (PE). Massive PE is life-threatening; its occurrence may require aggressive treatment such as thrombolysis or embolectomy. Identification of patients suffering from major thromboembolic events based solely on clinical grounds may, however, be difficult. Acute right heart failure is the principal cause of circulatory collapse and death for patients with massive PE, and rapid and specific diagnosis and therapy are required in such patients. Bedside echocardiography, a commonly performed first-line examination, demonstrates signs of cor pulmonale, if present, and can identify large central thrombi. However, echocardiography has limitations. In this review, our goal is to discuss the potential role of CT in assessing patients with severe APE. CT evaluation is based on the direct quantification of pulmonary arterial bed obstruction using various scores and the evaluation of morphological heart changes indicating acute cor pulmonale.

Right ventricular function in ARDS and mechanical respiration

The right ventricle is the stepchild of intensive care medicine. In diseases of the lung mainly when the relationship between ventilation and perfusion is disturbed, assisted respiration with positive end-expiratory pressure (PEEP) is essential to improve oxygenation. The serious damage to the lung parenchyma as seen in adult (acute) respiratory distress syndrome (ARDS) and pneumonia has considerable consequences for cardiac function. Whereas left ventricular function remains almost completely unaffected well into late stages of the disease, the right ventricle is subjected early to stress from the underlying disease and mechanical ventilation. The effects of therapeutic measures aimed at maintaining oxygenation and ventilation partially have negative consequences for right ventricular function and encourage the development of acute cor pulmonale. They can be the cause of right-sided heart failure.

Fulminantes Rechtsherzversagen bei pulmonaler mikroskopischer Tumorzellembolie - eine seltene Differenzialdiagnose

A 69-year-old man presented with progressive dyspnea, hemoptysis and fatigue for the previous 4 weeks. Chest radiograph and CT-scan were suggestive of lung cancer. The patient's condition worsened and within in few days he developed respiratory failure and acute cor pulmonale. Despite intensive care measures directed at suspected lung thromboembolism, the patient died on day 12. Autopsy revealed disseminated obstruction of small pulmonary arteries by microscopic tumor emboli. No signs of venous thromboembolism were found. Pulmonary tumor microembolism should be considered whenever a patient with malignancy presents with unexplained progressive dyspnea or pulmonary hypertension.

Echographic study of effects of inhaled nitric oxide on incidence of acute cor pulmonale during ARDS

Echographic study of effects of inhaled nitric oxide on incidence of acute cor pulmonale during ARDS

Invited commentary

The authors have presented an impressive review of their 2--year experience with managing acute pulmonary embolism (PE). Of 13 patients (out of 165 diagnosed with PE during the study period) with massive or submassive embolism, the majority diagnosed by computed-tomographic angiography (CTA), using an aggressive approach with cardiopulmonary bypass in all cases there was only one mortality (survival of 92%). Of 9 survivors who were evaluated, only 2 (14%) in short-term follow-up had evidence of persistent pulmonary hypertension. Although we do not have details regarding the patients who did not undergo operative intervention, these remarkable results nevertheless reflect clinical expertise and patient selection. The management and outcome of PE is inextricably linked with presentation, primary mode of diagnosis, and hemodynamic stability. In those patients who are intubated (such as those that occur intraoperatively), an acute drop in end-tidal CO2 may prompt the diagnosis. A quick transthoracic echocardiogram demonstrating acute right ventricular dilation will further support the diagnosis, as well as prompt aggressive intervention, even if there has been no hemodynamic compromise. More commonly, patients present to the ER or acutely on the ward. CTA has been advocated as being particularly useful in making the diagnosis in patients who have multiple potential etiologies for acute hypoxia (with or without hemodynamic changes). At this point in time, however, this has not been universally accepted as the equivalent of angiography. As the authors point out, pulmonary angiography can serve for both diagnostic and therapeutic purposes. Interventional approaches are not without risk, including precipitating cardiac arrest and if clot fragmentation rather than extraction is used, which would simply cause distal embolization with persistent acute or chronic pulmonary hypertension remaining, even if thrombolysis is added. In practice, of the patients not in frank shock, those that undergo CTA with demonstration of accessible central clot and acute cor pulmonale will tend to be taken directly to the OR, while those diagnosed by angiography will undergo interventional approaches. These issues are multipled when the patient presents in shock or arrest. Occasionally closed or open cardiac massages will break up the central clot, allowing some restoration of perfusion. This implies that a bulk of the thrombus will have fragmented, probably migrated distally, making operative extraction difficult or impossible. Unless the arrest occurred in the operating room or transesophageal echo demonstrates central clot, we would favor interventional approaches in this setting. The ideal situation would be to establish percutaneous bypass, thus buying time to consider all options. Even more ideally, institutions would have multipurpose suites capable of both angiography and operative procedures. Because of the acuity of the situation, and the need to rapidly make a treatment plan, cardiothoracic surgery should be immediately involved whenever the possibility of PE exists. Only a cardiothoracic surgeon can rapidly sort out all options, given the clinical scenario and the individual institution's capabilities.