Acute cor pulmonale in acute respiratory distress syndrome submitted to protective ventilation: incidence, clinical implications, and prognosis.
BACKGROUND
The incidence of acute cor pulmonale (ACP), a frequent and usually lethal complication of acute respiratory distress syndrome (ARDS) during traditional respiratory support, has never been re-evaluated since protective ventilation gained acceptance.


OBJECTIVE
We performed a longitudinal transesophageal echocardiographic (TEE) study to determine whether this incidence, and its severe implications for prognosis, might have changed in our unit as we altered respiratory strategy.


METHODS
Prospective open clinical study.


METHODS
Medical intensive care unit of a university hospital.


METHODS
Seventy-five consecutive ARDS patients given respiratory support with airway pressure limitation (plateau pressure < or =30 cm H2O).


METHODS
ACP was defined as a ratio of right ventricular end-diastolic area to left ventricular end-diastolic area in the long axis >0.6 associated with septal dyskinesia in the short axis during TEE examination.


RESULTS
Normal right ventricular function was present in 56 patients, whereas right ventricular dysfunction was observed in 19 patients after 2 days of respiratory support. ACP was associated with pulmonary artery hypertension, increased heart rate, and decreased stroke index. Significant impairment of left ventricular diastolic function was also seen. All echo-Doppler abnormalities were reversible in patients who recovered, and the mortality rate was the same in both groups (32%). However, ACP patients who recovered required a longer period of respiratory support. A multivariate analysis individualized Paco2 level as the sole factor independently associated with ACP, suggesting that ACP development in ARDS is influenced by the severity of lung damage and/or the respiratory strategy.


CONCLUSIONS
Evaluation of right ventricular function by TEE in a group of 75 ARDS patients submitted to protective ventilation revealed the persistence of a 25% incidence of ACP, resulting in detrimental hemodynamic consequences associated with tachycardia. However, ACP was reversible in patients who recovered and did not increase mortality.
Vieillard-Baron
A
A
Medical Intensive Care Unit, Department of Biostatistics, University Hospital Ambroise Paré, Assistance Publique Hôpitaux de Paris, Boulogne Cedex, France.
Schmitt
J M
JM
Augarde
R
R
Fellahi
J L
JL
Prin
S
S
Page
B
B
Beauchet
A
A
Jardin
F
F
D018806:APACHE; D017548:Echocardiography, Transesophageal; D005260:Female; D006439:Hemodynamics; D006801:Humans; D015994:Incidence; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D011446:Prospective Studies; D011660:Pulmonary Heart Disease / Q000000981:diagnostic imaging / Q000453:epidemiology / Q000209:etiology*; D012121:Respiration, Artificial; D012128:Respiratory Distress Syndrome / Q000150:complications* / Q000628:therapy