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Intensive Care Medicine

, Volume 42, Issue 5, pp 862–870 | Cite as

Acute cor pulmonale during protective ventilation for acute respiratory distress syndrome: prevalence, predictors, and clinical impact

  • Armand Mekontso DessapEmail author
  • Florence Boissier
  • Cyril Charron
  • Emmanuelle Bégot
  • Xavier Repessé
  • Annick Legras
  • Christian Brun-Buisson
  • Philippe Vignon
  • Antoine Vieillard-Baron
Seven-Day Profile Publication

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.

Keywords

ARDS Right ventricle Mechanical ventilation Echocardiography 

Notes

Acknowledgments

This study was funded by the nonprofit public organization Assistance Publique-Hôpitaux de Paris and a grant of the Société de Réanimation de Langue Française. We thank Dr. Florence Canoui-Poitrine for her statistical advices.

Compliance with ethical standards

Funding

The study was funded in part by a grant of the French Intensive Care Society (Société de Réanimation de Langue Française).

Conflicts of interest

The authors declare that they have no conficts of interest.

Supplementary material

134_2015_4141_MOESM1_ESM.doc (56 kb)
Supplementary material 1 (DOC 56 kb)

References

  1. 1.
    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 166:1310–1319CrossRefPubMedGoogle Scholar
  2. 2.
    Zapol WM, Snider MT (1977) Pulmonary hypertension in severe acute respiratory failure. N Engl J Med 296:476–480CrossRefPubMedGoogle Scholar
  3. 3.
    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 implications, and prognosis. Crit Care Med 29:1551–1555CrossRefPubMedGoogle Scholar
  4. 4.
    Lheritier G, Legras A, Caille A, Lherm T, Mathonnet A, Frat JP, Courte A, Martin-Lefevre L, Gouello JP, Amiel JB, Garot D, Vignon P (2013) Prevalence and prognostic value of acute cor pulmonale and patent foramen ovale in ventilated patients with early acute respiratory distress syndrome: a multicenter study. Intensive Care Med 39:1734–1742CrossRefPubMedGoogle Scholar
  5. 5.
    Boissier F, Katsahian S, Razazi K, Thille AW, Roche-Campo F, Leon R, Vivier E, Brochard L, Vieillard-Baron A, Brun-Buisson C, Mekontso Dessap A (2013) Prevalence and prognosis of cor pulmonale during protective ventilation for acute respiratory distress syndrome. Intensive Care Med 39:1725–1733CrossRefPubMedGoogle Scholar
  6. 6.
    Vieillard-Baron A, Page B, Augarde R, Prin S, Qanadli S, Beauchet A, Dubourg O, Jardin F (2001) Acute cor pulmonale in massive pulmonary embolism: incidence, echocardiographic pattern, clinical implications and recovery rate. Intensive Care Med 27:1481–1486CrossRefPubMedGoogle Scholar
  7. 7.
    Mekontso Dessap A, Charron C, Devaquet J, Aboab J, Jardin F, Brochard L, Vieillard-Baron A (2009) Impact of acute hypercapnia and augmented positive end-expiratory pressure on right ventricle function in severe acute respiratory distress syndrome. Intensive Care Med 35:1850–1858CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Legras A, Caille A, Begot E, Lheritier G, Lherm T, Mathonnet A, Frat JP, Courte A, Martin-Lefevre L, Gouello JP, Mercier E, Vignon P (2015) Acute respiratory distress syndrome (ARDS)-associated acute cor pulmonale and patent foramen ovale: a multicenter noninvasive hemodynamic study. Crit Care 19:174CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Bull TM, Clark B, McFann K, Moss M (2010) Pulmonary vascular dysfunction is associated with poor outcomes in patients with acute lung injury. Am J Respir Crit Care Med 182:1123–1128CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    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 38:1573–1582CrossRefPubMedGoogle Scholar
  11. 11.
    Ranieri VM, Rubenfeld GD, Thompson BT, Ferguson ND, Caldwell E, Fan E, Camporota L, Slutsky AS (2012) Acute respiratory distress syndrome: the Berlin definition. JAMA 307:2526–2533PubMedGoogle Scholar
  12. 12.
    Mekontso Dessap A, Bégot A, Charron C, Boissier F, Vignon P, Vieillard-Baron A (2014) Facteurs de risque de cœur pulmonaire aigu au cours du SDRA. Réanimation 24:S76–S79CrossRefGoogle Scholar
  13. 13.
    Le Gall JR, Lemeshow S, Saulnier F (1993) A new Simplified Acute Physiology Score (SAPS II) based on a European/North American multicenter study. JAMA 270:2957–2963CrossRefPubMedGoogle Scholar
  14. 14.
    [No authors listed] (1992) American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference: definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. Crit Care Med 20:864–874 Google Scholar
  15. 15.
    Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean NC, Dowell SF, File TM Jr, Musher DM, Niederman MS, Torres A, Whitney CG (2007) Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis 44[Suppl 2]:27–72CrossRefGoogle Scholar
  16. 16.
    Marik PE (2001) Aspiration pneumonitis and aspiration pneumonia. N Engl J Med 344:665–671CrossRefPubMedGoogle Scholar
  17. 17.
    Vieillard-Baron A, Charron C, Chergui K, Peyrouset O, Jardin F (2006) Bedside echocardiographic evaluation of hemodynamics in sepsis: is a qualitative evaluation sufficient? Intensive Care Med 32(10):1547–1552CrossRefPubMedGoogle Scholar
  18. 18.
    Jardin F, Dubourg O, Bourdarias JP (1997) Echocardiographic pattern of acute cor pulmonale. Chest 111:209–217CrossRefPubMedGoogle Scholar
  19. 19.
    Lemeshow S, Hosmer DW Jr (1982) A review of goodness of fit statistics for use in the development of logistic regression models. Am J Epidemiol 115:92–106PubMedGoogle Scholar
  20. 20.
    Timsit JF, Fosse JP, Troche G, De Lassence A, Alberti C, Garrouste-Orgeas M, Bornstain C, Adrie C, Cheval C, Chevret S (2002) Calibration and discrimination by daily Logistic Organ Dysfunction Scoring comparatively with daily Sequential Organ Failure Assessment Scoring for predicting hospital mortality in critically ill patients. Crit Care Med 30:2003–2013CrossRefPubMedGoogle Scholar
  21. 21.
    Espana PP, Capelastegui A, Gorordo I, Esteban C, Oribe M, Ortega M, Bilbao A, Quintana JM (2006) Development and validation of a clinical prediction rule for severe community-acquired pneumonia. Am J Respir Crit Care Med 174:1249–1256CrossRefPubMedGoogle Scholar
  22. 22.
    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 13:952–956CrossRefPubMedGoogle Scholar
  23. 23.
    Chiumello D, Carlesso E, Cadringher P, Caironi P, Valenza F, Polli F, Tallarini F, Cozzi P, Cressoni M, Colombo A, Marini JJ, Gattinoni L (2008) Lung stress and strain during mechanical ventilation for acute respiratory distress syndrome. Am J Respir Crit Care Med 178:346–355CrossRefPubMedGoogle Scholar
  24. 24.
    Terragni PP, Rosboch G, Tealdi A, Corno E, Menaldo E, Davini O, Gandini G, Herrmann P, Mascia L, Quintel M, Slutsky AS, Gattinoni L, Ranieri VM (2007) Tidal hyperinflation during low tidal volume ventilation in acute respiratory distress syndrome. Am J Respir Crit Care Med 175:160–166CrossRefPubMedGoogle Scholar
  25. 25.
    Duggan M, McCaul CL, McNamara PJ, Engelberts D, Ackerley C, Kavanagh BP (2003) Atelectasis causes vascular leak and lethal right ventricular failure in uninjured rat lungs. Am J Respir Crit Care Med 167:1633–1640CrossRefPubMedGoogle Scholar
  26. 26.
    Nieszkowska A, Lu Q, Vieira S, Elman M, Fetita C, Rouby JJ (2004) Incidence and regional distribution of lung overinflation during mechanical ventilation with positive end-expiratory pressure. Crit Care Med 32:1496–1503CrossRefPubMedGoogle Scholar
  27. 27.
    Schmitt JM, Vieillard-Baron A, Augarde R, Prin S, Page B, Jardin F (2001) Positive end-expiratory pressure titration in acute respiratory distress syndrome patients: impact on right ventricular outflow impedance evaluated by pulmonary artery Doppler flow velocity measurements. Crit Care Med 29:1154–1158CrossRefPubMedGoogle Scholar
  28. 28.
    Mekontso Dessap A, Voiriot G, Zhou T, Marcos E, Dudek SM, Jacobson JR, Machado R, Adnot S, Brochard L, Maitre B, Garcia JG (2012) Conflicting physiological and genomic cardiopulmonary effects of recruitment maneuvers in murine acute lung injury. Am J Respir Cell Mol Biol 46:541–550CrossRefPubMedPubMedCentralGoogle Scholar
  29. 29.
    Vieillard-Baron A, Loubieres Y, Schmitt JM, Page B, Dubourg O, Jardin F (1999) Cyclic changes in right ventricular output impedance during mechanical ventilation. J Appl Physiol 87:1644–1650PubMedGoogle Scholar
  30. 30.
    Amato MB, Meade MO, Slutsky AS, Brochard L, Costa EL, Schoenfeld DA, Stewart TE, Briel M, Talmor D, Mercat A, Richard JC, Carvalho CR, Brower RG (2015) Driving pressure and survival in the acute respiratory distress syndrome. N Engl J Med 372:747–755CrossRefPubMedGoogle Scholar
  31. 31.
    Balanos GM, Talbot NP, Dorrington KL, Robbins PA (2003) Human pulmonary vascular response to 4 h of hypercapnia and hypocapnia measured using Doppler echocardiography. J Appl Physiol 94:1543–1551CrossRefPubMedGoogle Scholar
  32. 32.
    Nuckton TJ, Alonso JA, Kallet RH, Daniel BM, Pittet JF, Eisner MD, Matthay MA (2002) Pulmonary dead-space fraction as a risk factor for death in the acute respiratory distress syndrome. N Engl J Med 346:1281–1286CrossRefPubMedGoogle Scholar
  33. 33.
    Kallet RH, Zhuo H, Liu KD, Calfee CS, Matthay MA (2014) The association between physiologic dead-space fraction and mortality in subjects with ARDS enrolled in a prospective multi-center clinical trial. Respir Care 59:1611–1618CrossRefPubMedPubMedCentralGoogle Scholar
  34. 34.
    Rabinovitch M, Gamble W, Nadas AS, Miettinen OS, Reid L (1979) Rat pulmonary circulation after chronic hypoxia: hemodynamic and structural features. Am J Physiol 236:818–827Google Scholar
  35. 35.
    Benzing A, Mols G, Brieschal T, Geiger K (1997) Hypoxic pulmonary vasoconstriction in nonventilated lung areas contributes to differences in hemodynamic and gas exchange responses to inhalation of nitric oxide. Anesthesiology 86:1254–1261CrossRefPubMedGoogle Scholar
  36. 36.
    Vieillard-Baron A, Price LC, Matthay MA (2013) Acute cor pulmonale in ARDS. Intensive Care Med 39:1836–1838CrossRefPubMedPubMedCentralGoogle Scholar
  37. 37.
    Rivara MB, Bajwa EK, Januzzi JL, Gong MN, Thompson BT, Christiani DC (212) Prognostic significance of elevated cardiac troponin-T levels in acute respiratory distress syndrome patients. PloS One 7:e40515 Google Scholar
  38. 38.
    Brun-Buisson C, Minelli C, Bertolini G, Brazzi L, Pimentel J, Lewandowski K, Bion J, Romand JA, Villar J, Thorsteinsson A, Damas P, Armaganidis A, Lemaire F (2004) Epidemiology and outcome of acute lung injury in European intensive care units. Results from the ALIVE study. Intensive Care Med 30:51–61CrossRefPubMedGoogle Scholar
  39. 39.
    Vieillard-Baron A, Girou E, Valente E, Brun-Buisson C, Jardin F, Lemaire F, Brochard L (2000) Predictors of mortality in acute respiratory distress syndrome. Focus on the role of right heart catheterization. Am J Respir Crit Care Med 161:1597–1601PubMedGoogle Scholar
  40. 40.
    Guerin C, Reignier J, Richard JC, Beuret P, Gacouin A, Boulain T, Mercier E, Badet M, Mercat A, Baudin O, Clavel M, Chatellier D, Jaber S, Rosselli S, Mancebo J, Sirodot M, Hilbert G, Bengler C, Richecoeur J, Gainnier M, Bayle F, Bourdin G, Leray V, Girard R, Baboi L, Ayzac L (2013) Prone positioning in severe acute respiratory distress syndrome. N Engl J Med 368:2159–2168CrossRefPubMedGoogle Scholar
  41. 41.
    Vieillard-Baron A, Charron C, Caille V, Belliard G, Page B, Jardin F (2007) Prone positioning unloads the right ventricle in severe ARDS. Chest 132:1440–1446CrossRefPubMedGoogle Scholar
  42. 42.
    Jozwiak M, Teboul JL, Anguel N, Persichini R, Silva S, Chemla D, Richard C, Monnet X (2013) Beneficial hemodynamic effects of prone positioning in patients with acute respiratory distress syndrome. Am J Respir Crit Care Med 188:1428–1433CrossRefPubMedGoogle Scholar
  43. 43.
    Osman D, Monnet X, Castelain V, Anguel N, Warszawski J, Teboul JL, Richard C (2009) Incidence and prognostic value of right ventricular failure in acute respiratory distress syndrome. Intensive Care Med 35:69–76CrossRefPubMedGoogle Scholar
  44. 44.
    Wiedemann HP, Wheeler AP, Bernard GR, Thompson BT, Hayden D, deBoisblanc B, Connors AF Jr, Hite RD, Harabin AL (2006) Comparison of two fluid-management strategies in acute lung injury. N Engl J Med 354:2564–2575CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg and ESICM 2015

Authors and Affiliations

  • Armand Mekontso Dessap
    • 1
    • 2
    Email author
  • Florence Boissier
    • 1
    • 2
  • Cyril Charron
    • 3
  • Emmanuelle Bégot
    • 4
    • 5
    • 6
  • Xavier Repessé
    • 3
  • Annick Legras
    • 7
  • Christian Brun-Buisson
    • 1
    • 2
  • Philippe Vignon
    • 7
  • Antoine Vieillard-Baron
    • 3
    • 8
    • 9
  1. 1.Service de Réanimation Médicale, DHU ATVB, Hôpitaux Universitaire Henri MondorAssistance Publique–Hôpitaux de ParisCréteil CedexFrance
  2. 2.Groupe de Recherche Clinique CARMAS, Institut Mondor de Recherche Biomédicale, Faculté de Médecine de CréteilUniversité Paris Est Créteil Val de MarneCréteilFrance
  3. 3.Service de Réanimation, Pôle Thorax-Maladies Cardiovasculaires-Abdomen-Métabolisme, Hôpital Ambroise ParéAssistance Publique - Hôpitaux de ParisBoulogne-BillancourtFrance
  4. 4.Réanimation polyvalente, Hôpital DupuytrenCentre hospitalier et universitaire de LimogesLimogesFrance
  5. 5.Centre d’Investigation Clinique – INSERM 1435, Hôpital DupuytrenCHU LimogesLimogesFrance
  6. 6.University of LimogesLimogesFrance
  7. 7.Réanimation médicale CHU de ToursToursFrance
  8. 8.Faculté de MedicineUniversité de Versailles Saint-Quentin en YvelinesSaint-Quentin en YvelinesFrance
  9. 9.Equipe 5 (EpReC, Epidémiologie Rénale et Cardiovasculaire)Centre de recherche en épidémiologie et santé des populations – INSERM U-1018VillejuifFrance

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