Armand Mekontso Dessap1,2, Florence Boissier3,4, Cyril Charron5, Emmanuelle Bégot6,7,8, Xavier Repessé5, Annick Legras9, Christian Brun-Buisson3,4, Philippe Vignon9, Antoine Vieillard-Baron5,10,11. 1. Service de Réanimation Médicale, DHU ATVB, Hôpitaux Universitaire Henri Mondor, Assistance Publique-Hôpitaux de Paris, 51 Av Mal de Lattre de Tassigny, 94010, Créteil Cedex, France. armand.dessap@aphp.fr. 2. Groupe de Recherche Clinique CARMAS, Institut Mondor de Recherche Biomédicale, Faculté de Médecine de Créteil, Université Paris Est Créteil Val de Marne, 94010, Créteil, France. armand.dessap@aphp.fr. 3. Service de Réanimation Médicale, DHU ATVB, Hôpitaux Universitaire Henri Mondor, Assistance Publique-Hôpitaux de Paris, 51 Av Mal de Lattre de Tassigny, 94010, Créteil Cedex, France. 4. Groupe de Recherche Clinique CARMAS, Institut Mondor de Recherche Biomédicale, Faculté de Médecine de Créteil, Université Paris Est Créteil Val de Marne, 94010, Créteil, France. 5. Service de Réanimation, Pôle Thorax-Maladies Cardiovasculaires-Abdomen-Métabolisme, Hôpital Ambroise Paré, Assistance Publique - Hôpitaux de Paris, 92104, Boulogne-Billancourt, France. 6. Réanimation polyvalente, Hôpital Dupuytren, Centre hospitalier et universitaire de Limoges, 87042, Limoges, France. 7. Centre d'Investigation Clinique - INSERM 1435, Hôpital Dupuytren, CHU Limoges, Limoges, France. 8. University of Limoges, Limoges, France. 9. Réanimation médicale, CHU de Tours, 37044, Tours, France. 10. Faculté de Medicine, Université de Versailles Saint-Quentin en Yvelines, 78280, Saint-Quentin en Yvelines, France. 11. Equipe 5 (EpReC, Epidémiologie Rénale et Cardiovasculaire), Centre de recherche en épidémiologie et santé des populations - INSERM U-1018, 94807, Villejuif, France.
Abstract
RATIONALE: Increased right ventricle (RV) afterload during acute respiratory distress syndrome (ARDS) may induce acute cor pulmonale (ACP). OBJECTIVES: To determine the prevalence and prognosis of ACP and build a clinical risk score for the early detection of ACP. METHODS: This was a prospective study in which 752 patients with moderate-to-severe ARDS receiving protective ventilation were assessed using transesophageal echocardiography in 11 intensive care units. The study cohort was randomly split in a derivation (n = 502) and a validation (n = 250) cohort. MEASUREMENTS AND MAIN RESULTS: ACP was defined as septal dyskinesia with a dilated RV [end-diastolic RV/left ventricle (LV) area ratio >0.6 (≥1 for severe dilatation)]. ACP was found in 164 of the 752 patients (prevalence of 22 %; 95 % confidence interval 19-25 %). In the derivation cohort, the ACP risk score included four variables [pneumonia as a cause of ARDS, driving pressure ≥18 cm H2O, arterial oxygen partial pressure to fractional inspired oxygen (PaO2/FiO2) ratio <150 mmHg, and arterial carbon dioxide partial pressure ≥48 mmHg]. The ACP risk score had a reasonable discrimination and a good calibration. Hospital mortality did not differ between patients with or without ACP, but it was significantly higher in patients with severe ACP than in the other patients [31/54 (57 %) vs. 291/698 (42 %); p = 0.03]. Independent risk factors for hospital mortality included severe ACP along with male gender, age, SAPS II, shock, PaO2/FiO2 ratio, respiratory rate, and driving pressure, while prone position was protective. CONCLUSIONS: We report a 22 % prevalence of ACP and a poor outcome of severe ACP. We propose a simple clinical risk score for early identification of ACP that could trigger specific therapeutic strategies to reduce RV afterload.
RATIONALE: Increased right ventricle (RV) afterload during acute respiratory distress syndrome (ARDS) may induce acute cor pulmonale (ACP). OBJECTIVES: To determine the prevalence and prognosis of ACP and build a clinical risk score for the early detection of ACP. METHODS: This was a prospective study in which 752 patients with moderate-to-severe ARDS receiving protective ventilation were assessed using transesophageal echocardiography in 11 intensive care units. The study cohort was randomly split in a derivation (n = 502) and a validation (n = 250) cohort. MEASUREMENTS AND MAIN RESULTS: ACP was defined as septal dyskinesia with a dilated RV [end-diastolic RV/left ventricle (LV) area ratio >0.6 (≥1 for severe dilatation)]. ACP was found in 164 of the 752 patients (prevalence of 22 %; 95 % confidence interval 19-25 %). In the derivation cohort, the ACP risk score included four variables [pneumonia as a cause of ARDS, driving pressure ≥18 cm H2O, arterial oxygen partial pressure to fractional inspired oxygen (PaO2/FiO2) ratio <150 mmHg, and arterial carbon dioxide partial pressure ≥48 mmHg]. The ACP risk score had a reasonable discrimination and a good calibration. Hospital mortality did not differ between patients with or without ACP, but it was significantly higher in patients with severe ACP than in the other patients [31/54 (57 %) vs. 291/698 (42 %); p = 0.03]. Independent risk factors for hospital mortality included severe ACP along with male gender, age, SAPS II, shock, PaO2/FiO2 ratio, respiratory rate, and driving pressure, while prone position was protective. CONCLUSIONS: We report a 22 % prevalence of ACP and a poor outcome of severe ACP. We propose a simple clinical risk score for early identification of ACP that could trigger specific therapeutic strategies to reduce RV afterload.
Entities:
Keywords:
ARDS; Echocardiography; Mechanical ventilation; Right ventricle
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