Prevalence and prognostic value of acute cor pulmonale and patent foramen ovale in ventilated patients with early acute respiratory distress syndrome: a multicenter study
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We sought to determine the prevalence of and factors associated with acute cor pulmonale (ACP) and patent foramen ovale (PFO) at the early phase of acute respiratory distress syndrome (ARDS), and to assess their relation with mortality.
In this prospective multicenter study, 200 patients submitted to protective ventilation for early moderate to severe ARDS [PaO2/FIO2: 115 ± 39 with FIO2: 1; positive end-expiratory pressure (PEEP): 10.6 ± 3.1 cmH2O] underwent transthoracic (TTE) and transesophageal echocardiography (TEE) <48 h after admission. Echocardiograms were independently interpreted by two experts. Factors associated with ACP, PFO, and 28-day mortality were identified using multivariate regression analysis.
TEE depicted ACP in 45/200 patients [22.5%; 95 % confidence interval (CI) 16.9–28.9 %], PFO in 31 patients (15.5 %; 95 % CI 10.8–21.3 %), and both ACP and PFO in 9 patients (4.5 %; 95 % CI 2.1–8.4 %). PFO shunting was small and intermittent in 27 patients, moderate and consistent in 4 patients, and large or extensive in no instances. PaCO2 >60 mmHg was strongly associated with ACP [odds ratio (OR) 3.70; 95 % CI 1.32–10.38; p = 0.01]. No factor was independently associated with PFO, with only a trend for age (OR 2.07; 95 % CI 0.91–4.72; p = 0.08). Twenty-eight-day mortality was 23 %. Plateau pressure (OR 1.15; 95 % CI 1.05–1.26; p < 0.01) and air leaks (OR 5.48; 95 % CI 1.30–22.99; p = 0.02), but neither ACP nor PFO, were independently associated with outcome.
TEE screening allowed identification of ACP in one-fourth of patients submitted to protective ventilation for early moderate to severe ARDS. PFO shunting was less frequent and never large or extensive. ACP and PFO were not related to outcome.
KeywordsARDS Acute cor pulmonale Patent foramen ovale Interatrial shunt Echocardiography
We gratefully thank Isabelle Herafa and Paul Bourzeix for their invaluable help in the study. We are also indebted to Dr. Yves Roudaut and Dr. Vincent Hummel for their independent interpretation of chest radiographs. This work was supported by a bourse de recherche clinique de la Société de Réanimation de Langue Française (2008).
Conflicts of interest
The authors declare that they have no conflict of interest.
Supplementary material 3 (MP4 745 kb) Loop 3. Transesophageal echocardiography in a ventilated patient with ARDS: bicaval view disclosing a patent foramen ovale during a contrast study. Note that microcavitations fully opacified the right atrium and rapidly entered the left atrium through the foramen ovale
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