Pulmonary vascular dysfunction in refractory acute respiratory distress syndrome before veno-venous extracorporeal membrane oxygenation.
BACKGROUND
Pulmonary vascular dysfunction has been described in patients with acute respiratory distress syndrome (ARDS). Veno-venous extracorporeal membrane oxygenation (VV-ECMO) is a well-established treatment for these patients. We hypothesized that severe pulmonary vascular dysfunction and cor pulmonale identified by echocardiography before cannulation in these patients were associated with worse survival.


METHODS
Echocardiography was used to identify pulmonary hypertension in 21 patients with refractory ARDS just before ECMO implantation. Survival was compared for those with and without cor pulmonale.


RESULTS
In our series, the overall mortality rate was 57.1% (12/21). Echocardiographic exams were transthoracic in 5 patients (23.8%), transesophageal in 4 patients (19%), and both (transthoracic and transesophageal) in the remaining 12 patients (57.1%). In our series, six patients (28.5%) showed LV dysfunction. Acute cor pulmonale was detectable in 2 patients (9.5%), while the remaining 19 patients showed moderate pulmonary dysfunction. Survivors had a higher pre-cannulation LV ejection fraction (EF) (P = 0.02) and tricuspid annular plane excursion (P = 0.04), and lower peak systolic pulmonary artery pressures (P = 0.02).


CONCLUSIONS
In patients with refractory ARDS immediately before ECMO implantation, the prevalence of acute cor pulmonale is low (9.5%). Survival is associated with higher LVEF and lower systolic pulmonary arterial pressure. These findings support the idea that echocardiographic assessment of pulmonary artery pressure in patients with refractory ARDS before VV-ECMO implantation may have value for risk-stratification.
Intensive Care Unit of Heart and Vessels Department, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy.
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Lazzeri
Intensive Care Unit and Regional ECMO Referral centre, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy.
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Cianchi
Intensive Care Unit and Regional ECMO Referral centre, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy.
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Bonizzoli
Intensive Care Unit and Regional ECMO Referral centre, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy.
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Batacchi
Intensive Care Unit and Regional ECMO Referral centre, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy.
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Terenzi
Intensive Care Unit of Heart and Vessels Department, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy.
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Bernardo
Intensive Care Unit of Heart and Vessels Department, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy.
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Valente
Intensive Care Unit of Heart and Vessels Department, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy.|Department of Experimental and Clinical Medicine, University of Florence, AOU Careggi, Fondazione Don Carlo Gnocchi IRCCS, Florence, Italy.
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Gensini
Intensive Care Unit and Regional ECMO Referral centre, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy.
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Peris
D000328:Adult; D000368:Aged; D004452:Echocardiography; D015199:Extracorporeal Membrane Oxygenation; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011660:Pulmonary Heart Disease / Q000209:etiology*; D012128:Respiratory Distress Syndrome / Q000503:physiopathology / Q000628:therapy*; D012189:Retrospective Studies; D018487:Ventricular Dysfunction, Left / Q000209:etiology