Cor pulmonale: the role of traditional and advanced echocardiography in the acute and chronic settings

Echocardiographic Findings in Critically Ill COVID-19 Patients Treated With and Without Extracorporeal Membrane Oxygenation

OBJECTIVES

To describe echocardiographic findings among mechanically ventilated patients with COVID-19 acute respiratory distress syndrome, comparing those with and without venovenous extracorporeal membrane oxygenation (VV ECMO) support.

DESIGN

Single-center, retrospective cohort study.

SETTING

Intensive care unit (ICU) of a quaternary academic center.

PARTICIPANTS

Patients with COVID-19 admitted between March 2020 and June 2021 receiving mechanical ventilation, with an echocardiogram within 72 hours of admission.

INTERVENTIONS

Admission and follow-up echocardiograms during ICU stay.

MEASUREMENTS

Patient characteristics and echocardiographic findings were analyzed. Mortality odds ratio (OR) for right ventricular (RV) systolic dysfunction and acute cor pulmonale (ACP) was calculated.

MAIN RESULTS

Among 242 patients, 145 (60%) received VV ECMO. Median (IQR) PaO2/FiO2 was 76 (65-95) and 98 (85-140) in ECMO and non-ECMO patients, respectively (p ≤ 0.001). Initial echocardiograms showed no significant differences in left ventricular systolic dysfunction (10% v 15 %, p = 0.31) and RV systolic dysfunction (38% v. 27%, p = 0.27) between ECMO and non-ECMO patients. ACP was more frequent in the ECMO group at baseline (41% v. 26 %, p = 0.02). During the ICU stay, patients on ECMO exhibited a higher prevalence of RV systolic dysfunction (55% v 34%, p = 0.001) and ACP (51% v 26%, p = 0.002). RV systolic dysfunction (OR 1.99; 95% CI 1.09-3.63) and ACP (OR 2.95; 95% CI 1.55-5.62) on the follow-up echocardiograms were associated with higher odds of ICU mortality.

CONCLUSIONS

The prevalence of echocardiographic abnormalities, in particular RV dysfunction, was frequent among patients with COVID-19 receiving VV ECMO support and was associated with worse clinical outcomes.

Right ventricular dysfunction in the critically ill. Echocardiographic evaluation

Right ventricular dysfunction is common in critically ill patients, and is associated with increased mortality. Its diagnosis moreover remains challenging. In this review, we aim to outline the potential mechanisms underlying abnormal biomechanics of the right ventricle and the different injury phenotypes. A comprehensive understanding of the pathophysiology and natural history of right ventricular injury can be informative for the intensivist in the diagnosis and management of this condition, and may serve to guide individualized treatment strategies. We describe the main recommended parameters for assessing right ventricular systolic and diastolic function. We also define how to evaluate cardiac output and pulmonary circulation pressures with echocardiography, with a focus on the diagnosis of acute cor pulmonale and relevant applications in critical disorders such as distress, septic shock, and right ventricular infarction.

Navigating Pediatric Cor Pulmonale: A Comprehensive Review of Diagnosis and Management

Pediatric cor pulmonale, characterized by right ventricular dysfunction due to chronic pulmonary hypertension, presents significant diagnostic and management challenges. This comprehensive review delves into this complex condition's etiology, clinical presentation, diagnostic strategies, and management. Key etiological factors include congenital heart defects, chronic lung diseases, and pulmonary vascular disorders. Early diagnosis, facilitated by imaging, hemodynamic assessments, and laboratory investigations, is crucial for effective intervention. Pediatric cor pulmonale management encompasses pharmacological treatments, such as vasodilators, diuretics, and inotropic agents, and non-pharmacological interventions, including oxygen therapy, mechanical ventilation, and surgical options. Long-term follow-up is essential to monitor disease progression and adjust treatment strategies accordingly. Multidisciplinary care involving pediatric cardiologists, pulmonologists, and critical care specialists is paramount to address the multifaceted needs of these patients. The review highlights the importance of early recognition and comprehensive care, offering insights into current best practices and future research and clinical practice directions. Advances in understanding the pathophysiology of pediatric cor pulmonale and emerging therapies promise to improve patient outcomes, underscoring the need for continued collaboration and innovation in this field.

Echocardiography findings in amniotic fluid embolism: a systematic review of the literature

PURPOSE

Amniotic fluid embolism (AFE) is a leading cause of obstetrical cardiac arrest and maternal morbidity. The pathogenesis of hemodynamic collapse is thought to be from right ventricular (RV) failure; however, there is a paucity of data documenting echocardiography findings in this population. We undertook a systematic review of the literature to evaluate the echocardiography findings in patients with AFE.

SOURCES

We retrieved all case reports and case series reporting AFE in Embase and MEDLINE from inception to 20 November 2021. Studies reporting AFE diagnosed by fulfilling at least one of three different proposed AFE criteria and echocardiography findings during hospitalization were included. Patient and echocardiographic data were retrieved, and univariate logistic regression analysis was performed for outcomes of interest. Bias was assessed using the Joanna Briggs Institute clinical appraisal tool for case series.

PRINCIPAL FINDINGS

Eighty publications reporting on 84 patients were included in the final review. Fifty-five out of 82 patients with data (67%) showed RV dysfunction, including 11/82 (13%) with biventricular dysfunction; 14/82 (17%) had normal systolic function. No data on RV or left ventricular function were reported for two patients. The presence of RV dysfunction on echocardiography was associated with cardiac arrest (odds ratio [OR], 3.66; 95% confidence interval [CI], 1.39 to 9.67; P = 0.009), and a composite risk of cardiac arrest, maternal death or use of extracorporeal membrane oxygenation (OR, 3.86; 95% CI, 1.43 to 10.4; P = 0.007). A low risk of bias was observed in 15/84 (18%) cases.

CONCLUSIONS

Right ventricular dysfunction on echocardiography is a common finding in AFE and is associated with a high risk of cardiac arrest. The finding of RV dysfunction on echocardiography may help diagnose AFE and help triage the highest risk patients with AFE.

STUDY REGISTRATION

PROSPERO (CRD42021271323); registered 1 September 2021.

The Combination Clinical Value of Plasma Brain Natriuretic Peptide and Serum HbAlc in the Diagnosis of Chronic Pulmonary Heart Disease

Objective. To analyze the combination clinical value of plasma brain natriuretic peptide and serum glycated hemoglobin (HbAlc) in chronic pulmonary heart disease. Methods. A total of 200 patients with chronic pulmonary heart disease admitted to our hospital from January 2021 to January 2022 were selected as the observation group, and 200 healthy subjects were selected as the control group during the same period. All subjects were examined by an ECG vector map and plasma BNP, and HbAlc levels were detected to analyze the value and clinical significance of each index in single diagnosis and combined diagnosis. Results. Plasma BNP and HbAlc levels in the observation group were significantly higher than those in the control group ( $P<0.05$ ). There were 154 BNP positive, 146 HbAlc positive, 164 parallel combined diagnosis positive, and 132 serial combined diagnosis positive. Sensitivity of series combination diagnosis was significantly higher than other indexes ( $P<0.05$ ); especially, parallel combination diagnosis was significantly higher than other indexes ( $P<0.05$ ). Besides, area under the ROC curve of parallel combination diagnosis and series combination diagnosis was significantly higher than that of each index alone diagnosis ( $P<0.05$ ). Conclusion. In the diagnosis of chronic pulmonary heart disease, the combination of plasma BNP and HbAlc can effectively improve the diagnostic specificity and sensitivity, as well as improve the area under the ROC curve.

The frequency of pulmonary hypertension in chronic obstructive pulmonary disease of geriatric patients: a narrative literature review

Background

Pulmonary hypertension (PH) is a serious complication with complex pathogenesis in the natural history of chronic obstructive pulmonary disease COPD, with a progressively increasing frequency with a meanwhile decreasing in functional capacity.

Purpose

Assessment of the incidence, pathogenesis, peculiarities, and complications of PH in COPD in geriatric population worldwide.

Methods

We performed an analysis of randomized, retrospective, and prospective clinical, case-control and observational studies, published at the international level, according to the subject studied and target population. Four hundred ninety-seven full articles were identified after the search through engine Google Search and databases PubMed, Hinari, SpringerLink, and Scopus (Elsevier) according to the keywords and subsequent filters.

Results

Depending on various factors, like the population examined, the definition used for mPAP (mPAP> 20 mm Hg or ≥25 mm Hg), the severity of the lung disease, and the method of measuring PAP, a varied incidence of COPD patients with PH complication was discovered, namely 10–91%. PH prevalence increases with the COPD severity. The presence of PH is associated with acute exacerbations of COPD, reduced survival, and increasing expenses for healthcare programs. Mild to moderate levels of PH (mPAP 25–34 mm Hg) are relatively common in COPD and usually are associated with severe airflow obstruction or parenchymal destruction. Only a minority of patients (1–5%) have severe PH (mPAP ≥35 mm Hg).

Conclusions

Diagnosis of PH in COPD is difficult, especially in a mild form, and requires a clinical approach associated with a comprehensive set of investigations for confirming the etiology, evaluation of the functional and hemodynamical impairment severity, and important factors in the appropriate treatment election.

Clinical Features and Outcomes of Acute Exacerbation in Chronic Obstructive Pulmonary Disease Patients with Pulmonary Heart Disease: A Multicenter Observational Study

Purpose

To identify clinical features and outcomes associated with pulmonary heart disease among patients with chronic obstructive pulmonary disease exacerbation (COPD), which may help reduce economic burden accrued over hospital stay and shorten length of stay (LOS).

Patients and Methods

Totally, 4386 patients with acute exacerbation of COPD (AECOPD) classified into pulmonary heart disease (PHD) group and non-pulmonary heart disease group, were included from the ACURE registry, a prospective multicenter patient registry study. Clinical features and outcomes were compared between groups.

Results

PHD patients had a more severe profile, including having higher scores of COPD assessment test and modified British Medical Research Council, worse lung function, more patients hospitalized more than once in the past year due to acute exacerbation of COPD, and more comorbidities. Furthermore, drug cost was higher and length of stay was longer in AECOPD patients with PHD.

Conclusion

AECOPD patients with PHD had a more severe profile and worse clinical outcomes, including higher drug cost and longer LOS. PHD is an independent risk factor of drug cost and LOS. Complicated with PHD in COPD/AECOPD patients with PHD means heavier disease burden and worse prognosis. It merits further study to focus on PHD management in COPD/AECOPD patients.

Value of ST-T changes and heart rate variability in pulmonary heart disease during 24 h dynamic electrocardiography examination

PURPOSE

This study was designed to analyze the value of 24 h dynamic electrocardiography (DCG) examination in the diagnosis of pulmonary heart disease (PHD).

METHODS

Ninety cases of patients with PHD were included as the observation group, and 50 cases of healthy patients were enrolled as the healthy group. Both groups received DCG examination.

RESULTS

The proportion of ST depression and elevation as well as the magnitude and duration of ST depression differed significantly between the observation and healthy group (P < 0.05), and the magnitude of ST elevation in patients of the observation group with decompensated heart failure was greater than that of patients with compensated cardiac function and the healthy group (P < 0.05). The incidence rates of sinus bradycardia (SB), ventricular premature beats (VPB), paroxysmal ventricular tachycardia (PVT), and ventricular fibrillation (VF) in patients in the observation group with decompensated heart failure were higher than those of patients with compensated cardiac function and the healthy group (P < 0.05). The differences in standard deviation of the NN (R-R) intervals (SDNN) and standard deviation of average NN intervals (SDANN) between the three groups were significant, and the root mean square of successive RR intervals (RMSSD) of patients in the observation group with decompensated heart failure were lower than those of the healthy group (P < 0.05). The differences in deceleration capacity (DC), left ventricular ejection fraction (LVEF), and heart rate variability (HRV) between the three groups were significant (P < 0.05).

CONCLUSION

The results obtained by DCG examination can help clinical assessment of cardiac function in the decompensated or compensated stage, which can assist in judging the condition of PHD and guide clinical treatment.

The role of echocardiography in amniotic fluid embolism: a case series and review of the literature

PURPOSE

Amniotic fluid embolism (AFE) is a rare, but often fatal condition characterized by sudden hemodynamic instability and coagulopathy occurring during labour or in the early postpartum period. As the mechanisms leading to shock and the cardiovascular effects of AFE are incompletely understood, the purpose of this case series is to describe how AFE presents on echocardiography and review limited reports in the literature.

CLINICAL FEATURES

We describe three cases of AFE at the Jewish General Hospital, a tertiary care centre in Montreal, Canada. All cases met the Clark diagnostic criteria, which comprise 1) sudden cardiorespiratory arrest or both hypotension and respiratory compromise, 2) disseminated intravascular coagulation, 3) clinical onset during labour or within 30 min of delivery of the placenta, and 4) absence of fever. Two patients had a cardiac arrest and the third developed significant hypotension and hypoxia. In all patients, point-of-care echocardiography at the time of shock revealed signs of right ventricular failure including a D-shaped septum, acute pulmonary hypertension, and right ventricular systolic dysfunction.

CONCLUSION

This case series and literature review of AFE emphasizes the importance of echocardiography in elucidating the etiology of maternal shock. The presence of right ventricular failure may be considered an important criterion to diagnose AFE.

Time interval between E and E' waves can predict complicated clinical course in patients with acute pulmonary embolism

PURPOSE

Acute pulmonary embolism is a life-threatening cardiothoracic emergency leading to right ventricle systolic and diastolic dysfunction. In the present study, we investigated the right ventricle diastolic function and its predictive value in patients with acute pulmonary embolism.

MATERIAL AND METHODS

Were prospectively recruited in this study 621 patients diagnosed with acute pulmonary embolism between December 2015 and June 2019. Among them, 173 were excluded, leaving 448 patients for follow-up. Transthoracic echocardiography was performed for the evaluation of the right ventricle systolic and diastolic indices. At 30-day follow-up, the patients were allocated either into the benign or in the complicated clinical course group.

RESULTS

The group with complicated clinical course had higher value of pulmonary artery systolic pressure (PASP), right/left ventricle diameter ratio, E-wave velocity, E/A ratio, A' wave velocity, E/E' ratio, and time interval between E and E' waves (P < .05), but lower values of tricuspid annular plane systolic excursion, A-wave velocity, isovolumetric relaxation time, deceleration time, E', and E'/A' (P < .05). Complicated clinical course was associated with shorter isovolumetric relaxation time (r = .564, P < .001), E/E' (r = .495, P < .001), and TE-E' (r = .596, P < .001). Receiver operator characteristic curve analysis showed that TE-E' had the largest area under curve (TE-E' 0.82, IVRT 0.77, E/E' 0.72). A cut-off value of TE-E' = 70 milliseconds had an 81.1% sensitivity and 71.4% specificity for the prediction of the complicated clinical course.

CONCLUSION

The assessment of the right ventricle diastolic function could predict the complicated clinical course in patients with acute pulmonary embolism.