title: Acute cor pulmonale during protective ventilation for acute respiratory distress syndrome: prevalence, predictors, and clinical impact.
abstract: BACKGROUND
  Increased right ventricle (RV) afterload during acute respiratory distress syndrome (ARDS) may induce acute cor pulmonale (ACP).
  
  
  OBJECTIVE
  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.
  
  
  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.
authors.affiliation: Service de Réanimation Médicale, DHU ATVB, Hôpitaux Universitaire Henri Mondor, Assistance Publique-Hôpitaux de Paris, 51 Av Mal de Lattre de Tassigny, 94010, Créteil Cedex, France. armand.dessap@aphp.fr.|Groupe de Recherche Clinique CARMAS, Institut Mondor de Recherche Biomédicale, Faculté de Médecine de Créteil, Université Paris Est Créteil Val de Marne, 94010, Créteil, France. armand.dessap@aphp.fr.
authors.forename: Armand
authors.initials: A
authors.lastname: Mekontso Dessap
authors.affiliation: Service de Réanimation Médicale, DHU ATVB, Hôpitaux Universitaire Henri Mondor, Assistance Publique-Hôpitaux de Paris, 51 Av Mal de Lattre de Tassigny, 94010, Créteil Cedex, France.|Groupe de Recherche Clinique CARMAS, Institut Mondor de Recherche Biomédicale, Faculté de Médecine de Créteil, Université Paris Est Créteil Val de Marne, 94010, Créteil, France.
authors.forename: Florence
authors.initials: F
authors.lastname: Boissier
authors.affiliation: Service de Réanimation, Pôle Thorax-Maladies Cardiovasculaires-Abdomen-Métabolisme, Hôpital Ambroise Paré, Assistance Publique - Hôpitaux de Paris, 92104, Boulogne-Billancourt, France.
authors.forename: Cyril
authors.initials: C
authors.lastname: Charron
authors.affiliation: Réanimation polyvalente, Hôpital Dupuytren, Centre hospitalier et universitaire de Limoges, 87042, Limoges, France.|Centre d'Investigation Clinique - INSERM 1435, Hôpital Dupuytren, CHU Limoges, Limoges, France.|University of Limoges, Limoges, France.
authors.forename: Emmanuelle
authors.initials: E
authors.lastname: Bégot
authors.affiliation: Service de Réanimation, Pôle Thorax-Maladies Cardiovasculaires-Abdomen-Métabolisme, Hôpital Ambroise Paré, Assistance Publique - Hôpitaux de Paris, 92104, Boulogne-Billancourt, France.
authors.forename: Xavier
authors.initials: X
authors.lastname: Repessé
authors.affiliation: Réanimation médicale, CHU de Tours, 37044, Tours, France.
authors.forename: Annick
authors.initials: A
authors.lastname: Legras
authors.affiliation: Service de Réanimation Médicale, DHU ATVB, Hôpitaux Universitaire Henri Mondor, Assistance Publique-Hôpitaux de Paris, 51 Av Mal de Lattre de Tassigny, 94010, Créteil Cedex, France.|Groupe de Recherche Clinique CARMAS, Institut Mondor de Recherche Biomédicale, Faculté de Médecine de Créteil, Université Paris Est Créteil Val de Marne, 94010, Créteil, France.
authors.forename: Christian
authors.initials: C
authors.lastname: Brun-Buisson
authors.affiliation: Réanimation médicale, CHU de Tours, 37044, Tours, France.
authors.forename: Philippe
authors.initials: P
authors.lastname: Vignon
authors.affiliation: Service de Réanimation, Pôle Thorax-Maladies Cardiovasculaires-Abdomen-Métabolisme, Hôpital Ambroise Paré, Assistance Publique - Hôpitaux de Paris, 92104, Boulogne-Billancourt, France.|Faculté de Medicine, Université de Versailles Saint-Quentin en Yvelines, 78280, Saint-Quentin en Yvelines, France.|Equipe 5 (EpReC, Epidémiologie Rénale et Cardiovasculaire), Centre de recherche en épidémiologie et santé des populations - INSERM U-1018, 94807, Villejuif, France.
authors.forename: Antoine
authors.initials: A
authors.lastname: Vieillard-Baron
mesh_terms: D000208:Acute Disease; D017548:Echocardiography, Transesophageal; D005260:Female; D006801:Humans; D007362:Intensive Care Units; D008297:Male; D008875:Middle Aged; D011237:Predictive Value of Tests; D015995:Prevalence; D011379:Prognosis; D011446:Prospective Studies; D011660:Pulmonary Heart Disease / Q000000981:diagnostic imaging / Q000453:epidemiology / Q000209:etiology*; D012121:Respiration, Artificial / Q000009:adverse effects*; D012128:Respiratory Distress Syndrome / Q000628:therapy*; D012307:Risk Factors; D016896:Treatment Outcome
keywords: ARDS; Echocardiography; Mechanical ventilation; Right ventricle