Intensive Care Medicine

, Volume 39, Issue 10, pp 1734–1742 | Cite as

Prevalence and prognostic value of acute cor pulmonale and patent foramen ovale in ventilated patients with early acute respiratory distress syndrome: a multicenter study

  • Gwenaëlle Lhéritier
  • Annick Legras
  • Agnès Caille
  • Thierry Lherm
  • Armelle Mathonnet
  • Jean-Pierre Frat
  • Anne Courte
  • Laurent Martin-Lefèvre
  • Jean-Paul Gouëllo
  • Jean-Bernard Amiel
  • Denis Garot
  • Philippe VignonEmail author



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.


ARDS 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

134_2013_3017_MOESM1_ESM.mp4 (482 kb)
Supplementary material 1 (MP4 482 kb) Loop 1. Transesophageal echocardiography in a ventilated patient with ARDS: four-chamber view of the heart disclosing an enlarged right ventricle
134_2013_3017_MOESM2_ESM.mp4 (476 kb)
Supplementary material 2 (MP4 476 kb) Loop 2. Transesophageal echocardiography in a ventilated patient with ARDS: short-axis view of the heart disclosing an enlarged right ventricle associated with paradoxical septal motion. These two findings are consistent with acute cor pulmonale

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

134_2013_3017_MOESM4_ESM.avi (72.5 mb)
Supplementary material 4 (AVI 74254 kb)


  1. 1.
    Ware LB, Matthay MA (2000) The acute respiratory distress syndrome. New Engl J Med 342:1334–1349PubMedCrossRefGoogle Scholar
  2. 2.
    Zapol W, Snider M (1977) Pulmonary hypertension in severe acute respiratory failure. N Engl J Med 296:476–480PubMedCrossRefGoogle Scholar
  3. 3.
    Jardin F, Farcot JC, Boisante L, Curien N, Margairaz A, Bourdarias JP (1981) Influence of positive end-expiratory pressure on left ventricular performance. N Engl J Med 304:387–392PubMedCrossRefGoogle Scholar
  4. 4.
    Jardin F, Delorme G, Hardy A, Auvert B, Beauchet A, Bourdarias JP (1990) Reevaluation of hemodynamic consequences of positive pressure ventilation: emphasis on cyclic right ventricular afterloading by mechanical lung inflation. Anesthesiology 72:966–970PubMedCrossRefGoogle Scholar
  5. 5.
    Jardin F, Dubourg O, Bourdarias JP (1997) Echocardiographic pattern of acute cor pulmonale. Chest 111:209–217PubMedCrossRefGoogle Scholar
  6. 6.
    Mekontso Dessap A, Boissier F, Leon R, Carreira S, Roche Campo F, Lemaire F, Brochard L (2010) Prevalence and prognosis of shunting across patent foramen ovale during acute respiratory distress syndrome. Crit Care Med 38:1786–1792PubMedCrossRefGoogle Scholar
  7. 7.
    Vieillard-Baron A, Schmitt JM, Augarde R, Fellahi JL, Prin S, Page B, Beauchet A, Jardin F (2001) Acute cor pulmonale in acute respiratory distress syndrome submitted to protective ventilation: incidence, clinical implication, and prognosis. Crit Care Med 29:1551–1555PubMedCrossRefGoogle Scholar
  8. 8.
    Jardin F, Gueret P, Dubourg O, Farcot JC, Margairaz A, Bourdarias JP (1985) Two-dimensional echocardiographic evaluation of right ventricular size and contractility in acute respiratory failure. Crit Care Med 13:952–956PubMedCrossRefGoogle Scholar
  9. 9.
    Monchi M, Bellenfant F, Cariou A, Joly LM, Thebert D, Laurent I, Dhainaut JF, Brunet F (1998) Early predictive factors of survival in the acute respiratory distress syndrome. A multivariate analysis. Am J Respir Crit Care Med 158:1076–1081PubMedCrossRefGoogle Scholar
  10. 10.
    Osman D, Monnet X, Castelain V, Anguel N, Warszawski J, Teboul JL, Richard C, For the French Pulmonary Artery Catheter Group (2009) Incidence and prognostic value of right ventricular failure in acute respiratory distress syndrome. Intensive Care Med 35:69–76PubMedCrossRefGoogle Scholar
  11. 11.
    Konstantinides S, Geibel A, Kasper W, Olschewski M, Blümel L, Just H (1998) Patent foramen ovale is an important predictor of adverse outcome in patients with major pulmonary embolism. Circulation 97:1946–1951PubMedCrossRefGoogle Scholar
  12. 12.
    Bernard GR, Artigas A, Brigham KL, Carlet J, Falke K, Hudson L, Lamy M, Legall JR, Morris A, Spragg R, The Consensus Committee (1994) The American-European consensus conference of ARDS. Am J Respir Crit Care Med 149:818–824PubMedCrossRefGoogle Scholar
  13. 13.
    Vignon P, AitHssain A, François B, Preux PM, Pichon N, Clavel M, Frat JP, Gastinne H (2008) Echocardiographic assessment of pulmonary artery occlusion pressure in ventilated patients: a transoesophageal study. Crit Care 12:R18PubMedCrossRefGoogle Scholar
  14. 14.
    Richard JC, Girault C, Leteurtre S, Leclerc F et le groupe d’experts de la SRLF (2005) Prise en charge ventilatoire du syndrome de détresse respiratoire aiguë de l’adulte et de l’enfant (nouveau-né exclu). Recommandations d’experts de la Société de Réanimation de Langue Française.
  15. 15.
    Vignon P, Mayo P (2011) Echocardiography in the critically ill: an overview. In: De Backer D, Cholley BP, Slama M, Vieillard-Baron A, Vignon P (eds) Hemodynamic monitoring using echocardiography in the critically ill, 1st edn. Springer, Berlin, pp 1–9CrossRefGoogle Scholar
  16. 16.
    Mayo P, Beaulieu Y, Doelken P, Feller-Kopman D, Harrod C, Kaplan A, Oropello J, Vieillard-Baron A, Axler O, Lichtenstein D, Maury E, Slama M, Vignon P (2009) American College of Chest Physicians/La Société de Réanimation de Langue Française statement on competence in critical care ultrasonography. Chest 135:1050–1060PubMedCrossRefGoogle Scholar
  17. 17.
    Gin KG, Fenwick JC, Pollick C, Thompson CR (1993) The diagnostic utility of contrast echocardiography in patients with refractory hypoxemia. Am Heart J 125:1136–1141PubMedCrossRefGoogle Scholar
  18. 18.
    Vedrinne JM, Duperret S, Bizollon T, Magnin C, Motin J, Trepo C, Ducerf C (1997) Comparison of transesophageal and transthoracic contrast echocardiography for detection of an intrapulmonary shunt in liver disease. Chest 111:1236–1240PubMedCrossRefGoogle Scholar
  19. 19.
    Currie PJ, Seward JB, Chan K-L, Fyfe DA, Hagler DJ, Mair DD, Reeder GS, Nishimura RA, Tajik AJ (1985) Continuous wave Doppler estimation of right ventricular pressure: a simultaneous Doppler-catheterization study in 127 patients. J Am Coll Cardiol 6:750–756PubMedCrossRefGoogle Scholar
  20. 20.
    Ferguson ND, Fan E, Camporota L, Antonelli M, Anzueto A, Beale R, Brochard L, Brower R, Esteban A, Gattinoni L, Rhodes A, Slutsky AS, Vincent JL, Rubenfeld GD, Thompson BT, Ranieri VM (2012) The Berlin definition of ARDS: an expanded rationale, justification, and supplementary material. Intensive Care Med 38:1573–1582PubMedCrossRefGoogle Scholar
  21. 21.
    Whittenberger J, Mc Gregor M, Berglund E, Borst HG (1960) Influence of state of inflation of the lung on pulmonary vascular resistance. J Appl Physiol 15:878–882PubMedGoogle Scholar
  22. 22.
    Jardin F, Vieillard-Baron A (2007) Is there a safe plateau pressure in ARDS? The right heart only knows. Intensive Care Med 33:444–447PubMedCrossRefGoogle Scholar
  23. 23.
    Balanos GM, Talbot NP, Dorrington KL, Robins PA (2003) Human pulmonary resistance vascular response to 4 h of hypercapnia and hypocapnia measured using Doppler echocardiography. J Appl Physiol 94:1543–1551PubMedGoogle Scholar
  24. 24.
    Rose CE, Van Benthuysen K, Jackson JT, Tucker CE, Kaiser DL, Grover RF, Weil JV (1983) Right ventricular performance during increased afterload impaired by hypercapnic acidosis in conscious dogs. Circ Res 52:76–84PubMedCrossRefGoogle Scholar
  25. 25.
    Mekontso-Dessap A, Charron C, Devaquet J, Aboab J, Jardin F, Brochard L, Vieillard-Baron A (2009) Impact of hypercapnia and augmented positive end-expiratory pressure on right ventricle function in severe acute respiratory distress syndrome. Intensive Care Med 35:1850–1858PubMedCrossRefGoogle Scholar
  26. 26.
    Vieillard-Baron A, Charron C, Caille V, Belliard G, Page B, Jardin F (2007) Prone positioning unloads the right ventricle in severe ARDS. Chest 132:1440–1446PubMedCrossRefGoogle Scholar
  27. 27.
    Gin KG, Huckell VF, Pollick C (1993) Femoral vein delivery of contrast medium enhances transthoracic echocardiographic detection of patent foramen ovale. J Am Coll Cardiol 22:1994–2000PubMedCrossRefGoogle Scholar
  28. 28.
    Woods TD, Patel A (2006) A critical review of patent foramen ovale detection using saline contrast echocardiography: when bubbles lie. J Am Soc Echocardiogr 19:215–222PubMedCrossRefGoogle Scholar
  29. 29.
    Beppu S, Tanabe K, Shimizu T, Ishikura F, Nakatani S, Terasawa A, Matsuda H, Miyatake K (1991) Contrast enhancement of Doppler signals by sonicated albumin for estimating right ventricular systolic pressure. Am J Cardiol 67:1148–1150PubMedCrossRefGoogle Scholar
  30. 30.
    Vieillard-Baron A, Prin S, Chergui K, Dubourg O, Jardin F (2002) Echo-Doppler demonstration of acute cor pulmonale at the bedside in the medical intensive care unit. Am J Respir Crit Care Med 166:1310–1319PubMedCrossRefGoogle Scholar
  31. 31.
    Kerut EK, Norfleet WT, Plotnick GD, Giles TD (2001) Patent foramen ovale: a review of associated conditions and the impact of physiological size. J Am Coll Cardiol 38:613–623PubMedCrossRefGoogle Scholar
  32. 32.
    Hara H, Virmani R, Ladich E, Mackey-Bojack S, Titus J, Reisman M, Gray W, Nakamura M, Mooney M, Poulose A, Schwartz RS (2005) Patent foramen ovale: current pathology, pathophysiology, and clinical status. J Am Coll Cardiol 46:1768–1776PubMedCrossRefGoogle Scholar
  33. 33.
    Rossaint R, Falke KJ, Lopez F, Slama K, Pison U, Zapol WM (1993) Inhaled nitric oxide for the adult respiratory distress syndrome. N Engl J Med 328:399–405PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg and ESICM 2013

Authors and Affiliations

  • Gwenaëlle Lhéritier
    • 1
  • Annick Legras
    • 2
    • 3
  • Agnès Caille
    • 4
    • 5
    • 6
  • Thierry Lherm
    • 7
  • Armelle Mathonnet
    • 8
  • Jean-Pierre Frat
    • 9
  • Anne Courte
    • 10
  • Laurent Martin-Lefèvre
    • 11
  • Jean-Paul Gouëllo
    • 12
  • Jean-Bernard Amiel
    • 1
  • Denis Garot
    • 2
    • 3
  • Philippe Vignon
    • 1
    • 13
    • 14
    • 15
    Email author
  1. 1.CHU LimogesRéanimation PolyvalenteLimogesFrance
  2. 2.CHU ToursRéanimation MédicaleToursFrance
  3. 3.INSERM CIC-ITToursFrance
  4. 4.INSERM CIC 202ToursFrance
  5. 5.Université François RabelaisToursFrance
  6. 6.CHU ToursToursFrance
  7. 7.CH ChartresRéanimation MédicaleChartresFrance
  8. 8.CHR OrléansRéanimation Médicale PolyvalenteOrléansFrance
  9. 9.CHU PoitiersRéanimation MédicalePoitiersFrance
  10. 10.CH Saint-BrieucRéanimation PolyvalenteSaint-BrieucFrance
  11. 11.CH La Roche-sur-YonRéanimation MédicaleLa Roche-sur-YonFrance
  12. 12.CH Saint-MaloRéanimation PolyvalenteSaint-MaloFrance
  13. 13.INSERM, CIC-P 0801LimogesFrance
  14. 14.Université de LimogesLimogesFrance
  15. 15.CHU DupuytrenRéanimation PolyvalenteLimoges CedexFrance

Personalised recommendations