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Santa Cruz R, Matesa A, Gómez A, Nadur J, Pagano F, Prieto D, Bolaños O, Solis B, Yusta S, González-Velásquez E, Estenssoro E, Cavalcanti A. Mortality Due to Acute Respiratory Distress Syndrome in Latin America. Crit Care Med 2024; 52:1275-1284. [PMID: 38635486 DOI: 10.1097/ccm.0000000000006312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/20/2024]
Abstract
OBJECTIVES Mortality due to acute respiratory distress syndrome (ARDS) is a major global health problem. Knowledge of epidemiological data on ARDS is crucial to design management, treatment strategies, and optimize resources. There is ample data regarding mortality of ARDS from high-income countries; in this review, we evaluated mortality due to ARDS in Latin America. DATA SOURCES We searched in PubMed, Cochrane Central Register of Controlled Trials, Web of Science, and Latin American and Caribbean Health Science Literature databases from 1967 to March 2023. STUDY SELECTION We searched prospective or retrospective observational studies and randomized controlled trials conducted in Latin American countries reporting ARDS mortality. DATA EXTRACTION Three pairs of independent reviewers checked all studies for eligibility based on their titles and abstracts. We performed meta-analysis of proportions using a random-effects model. We performed sensitivity analyses including studies with low risk of bias and with diagnosis using the Berlin definition. Subgroup analysis comparing different study designs, time of publication (up to 2000 and from 2001 to present), and studies in which the diagnosis of ARDS was made using Pa o2 /F io2 less than or equal to 200 and regional variations. Subsequently, we performed meta-regression analyses. Finally, we graded the certainty of the evidence (Grading of Recommendations Assessment, Development, and Evaluation). DATA SYNTHESIS Of 3315 articles identified, 32 were included (3627 patients). Mortality was 52% in the pooled group (low certainty of evidence). In the sensitivity analysis (according to the Berlin definition), mortality was 46% (moderate certainty of evidence). In the subgroup analysis mortality was 53% (randomized controlled trials), 51% (observational studies), 66% (studies published up to 2000), 50% (studies after 2000), 44% (studies with Pa o2 /F io2 ≤ 200), 56% (studies from Argentina/Brazil), and 40% (others countries). No variables were associated with mortality in the meta-regression. CONCLUSIONS ARDS mortality in Latin America remains high, as in other regions. These results should constitute the basis for action planning to improve the prognosis of patients with ARDS (PROSPERO [CRD42022354035]).
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Affiliation(s)
- Roberto Santa Cruz
- Hospital General Ramos Mejía, Ciudad Autónoma de Buenos Aires, Argentina
- Universidad de Magallanes, Escuela de Medicina, Punta Arenas, Chile
- Instituto Universitario Ciencias de la Salud, Fundación Barceló, Argentina
| | - Amelia Matesa
- Clínica Basilea, Ciudad Autónoma de Buenos Aires, Argentina
| | - Antonella Gómez
- Hospital de Clínicas, Montevideo, Uruguay
- UDELAR, Universidad de la República, Montevideo, Uruguay
| | - Juan Nadur
- Hospital General Ramos Mejía, Ciudad Autónoma de Buenos Aires, Argentina
- Clínica CIAREC (Clínica de Internación Aguda en Rehabilitación y Cirugía), Buenos Aires, Argentina
| | - Fernando Pagano
- Hospital General Ramos Mejía, Ciudad Autónoma de Buenos Aires, Argentina
| | - Daniel Prieto
- Hospital General Ramos Mejía, Ciudad Autónoma de Buenos Aires, Argentina
| | | | - Beatriz Solis
- Universidad de Magallanes, Escuela de Medicina, Punta Arenas, Chile
| | - Sara Yusta
- Universidad de Magallanes, Escuela de Medicina, Punta Arenas, Chile
| | | | - Elisa Estenssoro
- Dirección de Investigación, Escuela de Gobierno, Ministerio de Salud de la Provincia de Buenos Aires, Argentina
- Facultad de Ciencias Médicas, Universidad Nacional de La Plata, Buenos Aires, Argentina
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Kounis NG, Gogos C, de Gregorio C, Hung MY, Kounis SN, Tsounis EP, Assimakopoulos SF, Pourmasumi S, Mplani V, Servos G, Dousdampanis P, Plotas P, Michalaki MA, Tsigkas G, Grammatikopoulos G, Velissaris D, Koniar I. "When," "Where," and "How" of SARS-CoV-2 Infection Affects the Human Cardiovascular System: A Narrative Review. Balkan Med J 2024; 41:7-22. [PMID: 38173173 PMCID: PMC10767774 DOI: 10.4274/balkanmedj.galenos.2023.2023-10-25] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 11/26/2023] [Indexed: 01/05/2024] Open
Abstract
Coronavirus disease 2019 (COVID-19) is caused by the novel severe acute respiratory coronavirus-2 (SARS-CoV-2). Several explanations for the development of cardiovascular complications during and after acute COVID-19 infection have been hypothesized. The COVID-19 pandemic, caused by SARS-CoV-2, has emerged as one of the deadliest pandemics in modern history. The myocardial injury in COVID-19 patients has been associated with coronary spasm, microthrombi formation, plaque rupture, hypoxic injury, or cytokine storm, which have the same pathophysiology as the three clinical variants of Kounis syndrome. The angiotensin-converting enzyme 2 (ACE2), reninaldosterone system (RAAS), and kinin-kallikrein system are the main proposed mechanisms contributing to cardiovascular complications with the COVID-19 infection. ACE receptors can be found in the heart, blood vessels, endothelium, lungs, intestines, testes, neurons, and other human body parts. SARS-CoV-2 directly invades the endothelial cells with ACE2 receptors and constitutes the main pathway through which the virus enters the endothelial cells. This causes angiotensin II accumulation downregulation of the ACE2 receptors, resulting in prothrombotic effects, such as hemostatic imbalance via activation of the coagulation cascade, impaired fibrinolysis, thrombin generation, vasoconstriction, endothelial and platelet activation, and pro-inflammatory cytokine release. The KKS system typically causes vasodilation and regulates tissue repair, inflammation, cell proliferation, and platelet aggregation, but SARS-CoV-2 infection impairs such counterbalancing effects. This cascade results in cardiac arrhythmias, cardiac arrest, cardiomyopathy, cytokine storm, heart failure, ischemic myocardial injuries, microvascular disease, Kounis syndrome, prolonged COVID, myocardial fibrosis, myocarditis, new-onset hypertension, pericarditis, postural orthostatic tachycardia syndrome, pulmonary hypertension, stroke, Takotsubo syndrome, venous thromboembolism, and thrombocytopenia. In this narrative review, we describe and elucidate when, where, and how COVID-19 affects the human cardiovascular system in various parts of the human body that are vulnerable in every patient category, including children and athletes.
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Affiliation(s)
- Nicholas G. Kounis
- Department of Cardiology, University of Patras Medical School, Rio, Greece
| | - Christos Gogos
- Clinic of Cardiology, COVID-19 Unit, Papageorgiou General Hospital, Pavlos Melas, Greece
| | - Cesare de Gregorio
- Department of Clinical and Experimental Medicine, University of Messina Medical School, Messina, Italy
| | - Ming-Yow Hung
- Division of Cardiology, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan
| | | | - Efthymios P. Tsounis
- Division of Gastroenterology, Department of Internal Medicine, Medical School, University Hospital of Patras, Rio, Greece
| | - Stelios F. Assimakopoulos
- Department of Internal Medicine, Division of Infectious Diseases, University of Patras Medical School, Rio, Greece
| | - Soheila Pourmasumi
- Social Determinants of Health Research Center, Rafsanjan University of Medical Sciences, Rafsanjan, Iran
| | - Virginia Mplani
- Intensive Care Unit, Patras University Hospital, Rio, Greece
| | - George Servos
- Pediatric Cardiology Unit, “P. & A. Kyriakou” Children’s Hospital, Athina, Greece
| | | | - Panagiotis Plotas
- Department of Cardiology, University of Patras Medical School, Rio, Greece
| | - Marina A. Michalaki
- Department of Internal Medicine, Division of Endocrinology, University of Patras, School of Health Sciences, Rio, Greece
| | - Grigorios Tsigkas
- Department of Cardiology, University of Patras Medical School, Rio, Greece
| | | | - Dimitrios Velissaris
- Department of Internal Medicine, University of Patras Medical School, Rio, Greece
| | - Ioanna Koniar
- Electrophysiology and Device Department, University Hospital of South Manchester NHS Foundation Trust, Manchester, United Kingdom
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Wang C, Hao W. Cardiac arrhythmia and immune response in COVID-19 patients. Allergol Immunopathol (Madr) 2023; 51:63-70. [PMID: 37422781 DOI: 10.15586/aei.v51i4.883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 04/15/2023] [Indexed: 07/11/2023]
Abstract
The coronavirus disease 2019 (COVID-19) pandemic has presented substantial challenges for providing health care due to the numerous complications on the respiratory and cardiovascular systems of people. Cardiac arrhythmia is one of the cardiac complications, and it was observed in COVID-19 patients. Moreover, arrhythmia and cardiac arrest are common in COVID-19 patients in the intensive care unit. The occurrence of cardiac arrhythmia in COVID-19 patients is associated with hypoxia, cytokine storm, myocardial ischemia and inflammatory disease such as congestive heart failure. It is necessary to know the occurrence and mechanisms of tachyarrhythmia and bradyarrhythmia in patients with COVID-19 infection for their proper management. This review provides an overview of the association between COVID-19 and arrhythmias by detailing possible pathophysiological mechanisms.
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Affiliation(s)
- Chunlian Wang
- Institute for Prevention and Control of Chronic Non-communicable Diseases, Harbin Center for Disease Control and Prevention, Harbin, China
| | - Wenqiang Hao
- The Second Ward of Internal Medicine, The Second Hospital of Heilongjiang Province, Harbin, China; ;
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Zhu P, Zhu J, Tong S, She X, Qi Z, Xu Q, Shi Z, Si L, Hou M, Gan G, Pan C. Clinical characteristics of patients with a risk of pulmonary artery hypertension secondary to ARDS in a high-altitude area. BMJ Open Respir Res 2023; 10:e001475. [PMID: 37524522 PMCID: PMC10391833 DOI: 10.1136/bmjresp-2022-001475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 07/14/2023] [Indexed: 08/02/2023] Open
Abstract
BACKGROUND Hypoxaemia plays an important role in the development of pulmonary artery hypertension (PAH). Patients with acute respiratory distress syndrome (ARDS) in a high-altitude area have different pathophysiological characteristics from those patients in the plains. The goal of our study was to explore the clinical characteristics of PAH secondary to ARDS in a high-altitude area. METHODS This was a prospective study conducted in the affiliated Hospital of Qinghai University. Two investigators independently assessed pulmonary artery pressure (PAP) and right ventricular function by transthoracic echocardiography. Basic information and clinical data of the patients who were enrolled were collected. A multivariable logistic regression model was used to evaluate the risk factors for PAH secondary to ARDS in the high-altitude area. RESULTS The incidence of PAH secondary to ARDS within 48 hours in the high-altitude area was 44.19%. Partial pressure of oxygen/fraction of inspired oxygen <165.13 mm Hg was an independent risk factor for PAH secondary to ARDS in the high-altitude area. Compared with the normal PAP group, the right ventricular basal dimensions were significantly larger and the right ventricular tricuspid annular plane systolic excursion was lower in the PAH group (right ventricular basal dimensions: 45.47±2.60 vs 40.67±6.12 mm, p=0.019; tricuspid annular plane systolic excursion (TAPSE): 1.82±0.40 vs 2.09±0.32 cm, p=0.021). The ratio of TAPSE to systolic PAP was lower in the PAH group (0.03±0.01 vs 0.08±0.03 cm/mm Hg, p<0.001). CONCLUSIONS The incidence of PAH in patients with ARDS in our study is high. PAH secondary to ARDS in a high-altitude area could cause right ventricular dysfunction. TRIAL REGISTRATION NUMBER NCT05166759.
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Affiliation(s)
- Peng Zhu
- Department of Critical Care Medicine, Qinghai University Affiliated Hospital, Xining, Qinghai, China
| | - Jing Zhu
- Department of Cardiology, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Shijun Tong
- Department of Critical Care Medicine, Qinghai University Affiliated Hospital, Xining, Qinghai, China
| | - Xiaobin She
- Department of Critical Care Medicine, Qinghai University Affiliated Hospital, Xining, Qinghai, China
| | - Zhenyuan Qi
- Department of Critical Care Medicine, Qinghai University Affiliated Hospital, Xining, Qinghai, China
| | - Qianjin Xu
- Department of Critical Care Medicine, Qinghai University Affiliated Hospital, Xining, Qinghai, China
| | - Zhongshan Shi
- Department of Critical Care Medicine, People's Hospital of Golmud City, Golmud, Qinghai, China
| | - Lining Si
- Department of Critical Care Medicine, Qinghai University Affiliated Hospital, Xining, Qinghai, China
| | - Ming Hou
- Department of Critical Care Medicine, Qinghai University Affiliated Hospital, Xining, Qinghai, China
| | - Guifen Gan
- Department of Critical Care Medicine, Qinghai University Affiliated Hospital, Xining, Qinghai, China
| | - Chun Pan
- Department of Critical Care Medicine, Health Management Center, University of Electronic Science and Technology of China Sichuan Provincial People's Hospital, Chengdu, Sichuan, China
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Alblaihed L, Brady WJ, Al-Salamah T, Mattu A. Dysrhythmias associated with COVID-19: Review and management considerations. Am J Emerg Med 2023; 64:161-168. [PMID: 36563500 PMCID: PMC9721478 DOI: 10.1016/j.ajem.2022.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 11/21/2022] [Accepted: 12/01/2022] [Indexed: 12/12/2022] Open
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which causes coronavirus disease 2019 (COVID-19), is known to affect the cardiovascular system. Cardiac manifestations in COVID-19 can be due to direct damage to the myocardium and conduction system as well as by the disease's effect on the various organ systems. These manifestations include acute coronary syndrome, ST- segment elevations, cardiomyopathy, and dysrhythmias. Some of these dysrhythmias can be detrimental to the patient. Therefore, it is important for the emergency physician to be aware of the different arrhythmias associated with COVID-19 and how to manage them. This narrative review discusses the pathophysiology underlying the various arrhythmias associated with COVID-19 and their management considerations.
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Affiliation(s)
- Leen Alblaihed
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 S Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201, United States of America,Corresponding author
| | - William J. Brady
- Department of Emergency Medicine, University of Virginia School of Medicine, Charlottesville, VA 22908, United States of America
| | - Tareq Al-Salamah
- Department of Emergency Medicine, College of Medicine, King Saud University, PO Box 7805, Riyadh 11472, Saudi Arabia
| | - Amal Mattu
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 S Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201, United States of America
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Acute Respiratory Distress Syndrome: Focus on Viral Origin and Role of Pulmonary Lymphatics. Biomedicines 2021; 9:biomedicines9111732. [PMID: 34829961 PMCID: PMC8615541 DOI: 10.3390/biomedicines9111732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 11/01/2021] [Accepted: 11/17/2021] [Indexed: 11/30/2022] Open
Abstract
Acute respiratory distress syndrome (ARDS) is a serious affection of the lung caused by a variety of pathologies. Great interest is currently focused on ARDS induced by viruses (pandemic influenza and corona viruses). The review describes pulmonary changes in ARDS and specific effects of the pandemic viruses in ARDS, and summarizes treatment options. Because the known pathogenic mechanisms cannot explain all aspects of the syndrome, the contribution of pulmonary lymphatics to the pathology is discussed. Organization and function of lymphatics in a healthy lung and in resorption of pulmonary edema are described. A future clinical trial may provide more insight into the role of hyaluronan in ARDS but the development of promising pharmacological treatments is unlikely because drugs play no important role in lymphedema therapy.
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Stevens RP, Paudel SS, Johnson SC, Stevens T, Lee JY. Endothelial metabolism in pulmonary vascular homeostasis and acute respiratory distress syndrome. Am J Physiol Lung Cell Mol Physiol 2021; 321:L358-L376. [PMID: 34159794 PMCID: PMC8384476 DOI: 10.1152/ajplung.00131.2021] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 06/08/2021] [Accepted: 06/15/2021] [Indexed: 12/27/2022] Open
Abstract
Capillary endothelial cells possess a specialized metabolism necessary to adapt to the unique alveolar-capillary environment. Here, we highlight how endothelial metabolism preserves the integrity of the pulmonary circulation by controlling vascular permeability, defending against oxidative stress, facilitating rapid migration and angiogenesis in response to injury, and regulating the epigenetic landscape of endothelial cells. Recent reports on single-cell RNA-sequencing reveal subpopulations of pulmonary capillary endothelial cells with distinctive reparative capacities, which potentially offer new insight into their metabolic signature. Lastly, we discuss broad implications of pulmonary vascular metabolism on acute respiratory distress syndrome, touching on emerging findings of endotheliitis in coronavirus disease 2019 (COVID-19) lungs.
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Affiliation(s)
- Reece P Stevens
- Department of Physiology and Cell Biology, College of Medicine, University of South Alabama, Mobile, Alabama
- Center for Lung Biology, College of Medicine, University of South Alabama, Mobile, Alabama
| | - Sunita S Paudel
- Department of Physiology and Cell Biology, College of Medicine, University of South Alabama, Mobile, Alabama
- Center for Lung Biology, College of Medicine, University of South Alabama, Mobile, Alabama
| | - Santina C Johnson
- Department of Pharmacology, College of Medicine, University of South Alabama, Mobile, Alabama
- Department of Biomolecular Engineering, College of Medicine, University of South Alabama, Mobile, Alabama
| | - Troy Stevens
- Department of Physiology and Cell Biology, College of Medicine, University of South Alabama, Mobile, Alabama
- Center for Lung Biology, College of Medicine, University of South Alabama, Mobile, Alabama
| | - Ji Young Lee
- Department of Physiology and Cell Biology, College of Medicine, University of South Alabama, Mobile, Alabama
- Department of Internal Medicine, College of Medicine, University of South Alabama, Mobile, Alabama
- Division of Pulmonary and Critical Care Medicine, College of Medicine, University of South Alabama, Mobile, Alabama
- Center for Lung Biology, College of Medicine, University of South Alabama, Mobile, Alabama
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Janagill M, Pooni PA, Bhargava S, Chhabra ST. Role of Sildenafil in Management of Pediatric Acute Respiratory Distress Syndrome. J Pediatr Intensive Care 2021; 12:148-153. [PMID: 37082473 PMCID: PMC10113007 DOI: 10.1055/s-0041-1730900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 03/30/2021] [Indexed: 10/21/2022] Open
Abstract
AbstractAcute respiratory distress syndrome (ARDS) has high mortality and multiple therapeutic strategies have been used to improve the outcome. Inhaled nitric oxide (INO), a pulmonary vasodilator, is used to improve oxygenation. This study was conducted to determine the role of sildenafil, an oral vasodilator, to improve oxygenation and mortality in pediatric ARDS (PARDS). The prevalence of pulmonary hypertension in PARDS was studied as well. Inclusion criteria included children (1–18 years) with ARDS requiring invasive ventilation admitted to the pediatric intensive care unit of a teaching hospital in Northern India over a 1-year period of time. Thirty-five patients met the inclusion criteria. Cardiologist performed a detailed echocardiogram to determine pulmonary arterial pressure (PAP). Patients with persistent hypoxemia were started on oral sildenafil. The majority (77%) patients had a primary pulmonary etiology of PARDS. Elevated PAP (>25 mm Hg) was detected in 54.3% patients at admission. Sildenafil was given to 20 patients who had severe and persistent hypoxemia. Oxygenation improved in most patients after the first dose with statistically significant improvement in PaO2/FiO2 ratios at both 12 and 24 hours following initiation of therapeutic dosing of sildenafil. Improvement in oxygenation occurred irrespective of initial PAP. Outcomes included a total of 57.1% patients discharged, 28.6% discharged against medical advice (DAMA), and a 14.3% mortality rate. Mortality was related to the severity of PARDS and not the use of sildenafil. This is the first study to determine the effect of sildenafil in PARDS. Sildenafil led to improvement in oxygenation in nearly all the cases without affecting mortality. Due to unavailability of INO in most centers of developing countries, sildenafil may be considered as an inexpensive alternative in cases of persistent hypoxemia in PARDS. We recommend additional randomized controlled trials to confirm the effect of sildenafil in PARDS as determined in this study.
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Affiliation(s)
- Monika Janagill
- Department of Pediatrics, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
| | - Puneet Aulakh Pooni
- Department of Pediatrics, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
| | - Siddharth Bhargava
- Department of Pediatrics, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
| | - Shibba Takkar Chhabra
- Department of Pediatrics, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
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Sato R, Dugar S, Cheungpasitporn W, Schleicher M, Collier P, Vallabhajosyula S, Duggal A. The impact of right ventricular injury on the mortality in patients with acute respiratory distress syndrome: a systematic review and meta-analysis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:172. [PMID: 34020703 PMCID: PMC8138512 DOI: 10.1186/s13054-021-03591-9] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 04/29/2021] [Indexed: 01/07/2023]
Abstract
BACKGROUND Previous studies have found various incidences of right ventricular (RV) injury and its association with clinical outcome in patients with acute respiratory distress syndrome (ARDS). In this systematic review and meta-analysis, we aimed to investigate the impact of the presence of RV injury on mortality in patients with ARDS. METHOD We searched Medline, Embase, and the Cochrane Central Register of Controlled Trials for studies investigating the association between RV injury and mortality. Two authors independently evaluated whether studies meet eligibility criteria and extracted the selected patients' and studies' characteristics and outcomes. RV injury was diagnosed by trans-thoracic echocardiogram (TTE), trans-esophageal echocardiogram (TEE) and PAC (pulmonary artery catheter) in the included studies. The primary outcome was the association between mortality and the presence of RV injury in patients with ARDS. The overall reported mortality was defined as either the intensive care unit (ICU) mortality, in-hospital mortality, or mortality within 90 days, and short-term mortality was defined as ICU-mortality, in-hospital mortality, or mortality within 30 days. RESULTS We included 9 studies (N = 1861 patients) in this meta-analysis. RV injury that included RV dysfunction, RV dysfunction with hemodynamic compromise, RV failure, or acute cor-pulmonale was present in 21.0% (391/1,861). In the pooled meta-analysis, the presence of RV injury in patients with ARDS was associated with significantly higher overall mortality (OR 1.45, 95% CI 1.13-1.86, p-value = 0.003, I2 = 0%), as well as short-term mortality (OR 1.48, 95% CI 1.14-1.93, p-value = 0.003, I2 = 0%). CONCLUSION In this systematic review and meta-analysis including 1861 patients with ARDS, the presence of RV injury was significantly associated with increased overall and short-term mortality. TRIAL REGISTRATION The protocol was registered at PROSPERO (CRD42020206521).
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Affiliation(s)
- Ryota Sato
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, USA
| | - Siddharth Dugar
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, USA. .,Cleveland Clinic Lerner College of Medicine, Case Western University Reserve University, Cleveland, OH, USA.
| | - Wisit Cheungpasitporn
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Mary Schleicher
- The Cleveland Clinic Floyd D. Loop Alumni Library, Cleveland Clinic, Cleveland, OH, USA
| | - Patrick Collier
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Saraschandra Vallabhajosyula
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA.,Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA.,Center for Clinical and Translational Science, Mayo Clinic Graduate School of Biomedical Sciences, Rochester, MN, USA.,Section of Interventional Cardiology, Division of Cardiovascular Medicine, Department of Medicine, Emory University of School of Medicine, Atlanta, GA, USA
| | - Abhijit Duggal
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, USA.,Cleveland Clinic Lerner College of Medicine, Case Western University Reserve University, Cleveland, OH, USA
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Cain MT, Smith NJ, Barash M, Simpson P, Durham LA, Makker H, Roberts C, Falcucci O, Wang D, Walker R, Ahmed G, Brown SA, Nanchal RS, Joyce DL. Extracorporeal Membrane Oxygenation with Right Ventricular Assist Device for COVID-19 ARDS. J Surg Res 2021; 264:81-89. [PMID: 33789179 PMCID: PMC7969863 DOI: 10.1016/j.jss.2021.03.017] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 03/02/2021] [Accepted: 03/10/2021] [Indexed: 01/08/2023]
Abstract
Background: Right ventricular failure is an underrecognized consequence of COVID-19 pneumonia. Those with severe disease are treated with extracorporeal membrane oxygenation (ECMO) but with poor outcomes. Concomitant right ventricular assist device (RVAD) may be beneficial. Methods: A retrospective analysis of intensive care unit patients admitted with COVID-19 ARDS (Acute Respiratory Distress Syndrome) was performed. Nonintubated patients, those with acute kidney injury, and age > 75 were excluded. Patients who underwent RVAD/ECMO support were compared with those managed via invasive mechanical ventilation (IMV) alone. The primary outcome was in-hospital mortality. Secondary outcomes included 30-d mortality, acute kidney injury, length of ICU stay, and duration of mechanical ventilation. Results: A total of 145 patients were admitted to the ICU with COVID-19. Thirty-nine patients met inclusion criteria. Of these, 21 received IMV, and 18 received RVAD/ECMO. In-hospital (52.4 versus 11.1%, P = 0.008) and 30-d mortality (42.9 versus 5.6%, P= 0.011) were significantly lower in patients treated with RVAD/ECMO. Acute kidney injury occurred in 15 (71.4%) patients in the IMV group and zero RVAD/ECMO patients (P< 0.001). ICU (11.5 versus 21 d, P= 0.067) and hospital (14 versus 25.5 d, P = 0.054) length of stay were not significantly different. There were no RVAD/ECMO device complications. The duration of mechanical ventilation was not significantly different (10 versus 5 d, P = 0.44). Conclusions: RVAD support at the time of ECMO initiation resulted in the no secondary end-organ damage and higher in-hospital and 30-d survival versus IMV in specially selected patients with severe COVID-19 ARDS. Management of severe COVID-19 ARDS should prioritize right ventricular support.
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Affiliation(s)
- Michael T Cain
- Department of Surgery, Division of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Nathan J Smith
- Department of Surgery, Division of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin.
| | - Mark Barash
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Pippa Simpson
- Department of Pediatrics, Division of Quantitative Health Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Lucian A Durham
- Department of Surgery, Division of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Hemanckur Makker
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Christopher Roberts
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Octavio Falcucci
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Dong Wang
- Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Rebekah Walker
- Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee, Wisconsin; Department of Medicine, Division of General Internal Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Gulrayz Ahmed
- Department of Medicine, Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Sherry-Ann Brown
- Cardio-Oncology Program, Division of Cardiovascular Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Rahul S Nanchal
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - David L Joyce
- Department of Surgery, Division of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin.
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11
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Revercomb L, Hanmandlu A, Wareing N, Akkanti B, Karmouty-Quintana H. Mechanisms of Pulmonary Hypertension in Acute Respiratory Distress Syndrome (ARDS). Front Mol Biosci 2021; 7:624093. [PMID: 33537342 PMCID: PMC7848216 DOI: 10.3389/fmolb.2020.624093] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 12/09/2020] [Indexed: 12/19/2022] Open
Abstract
Background: Acute respiratory distress syndrome (ARDS) is a severe and often fatal disease. The causes that lead to ARDS are multiple and include inhalation of salt water, smoke particles, or as a result of damage caused by respiratory viruses. ARDS can also arise due to systemic complications such as blood transfusions, sepsis, or pancreatitis. Unfortunately, despite a high mortality rate of 40%, there are limited treatment options available for ARDS outside of last resort options such as mechanical ventilation and extracorporeal support strategies. Aim of review: A complication of ARDS is the development of pulmonary hypertension (PH); however, the mechanisms that lead to PH in ARDS are not fully understood. In this review, we summarize the known mechanisms that promote PH in ARDS. Key scientific concepts of review: (1) Provide an overview of acute respiratory distress syndrome; (2) delineate the mechanisms that contribute to the development of PH in ARDS; (3) address the implications of PH in the setting of coronavirus disease 2019 (COVID-19).
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Affiliation(s)
- Lucy Revercomb
- Department of BioSciences, Rice University, Houston, TX, United States
- Department of Biochemistry and Molecular Biology, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Ankit Hanmandlu
- Department of Biochemistry and Molecular Biology, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Nancy Wareing
- Department of Biochemistry and Molecular Biology, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Bindu Akkanti
- Divisions of Critical Care, Pulmonary and Sleep Medicine, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Harry Karmouty-Quintana
- Department of Biochemistry and Molecular Biology, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States
- Divisions of Critical Care, Pulmonary and Sleep Medicine, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States
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12
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Pagnesi M, Baldetti L, Beneduce A, Calvo F, Gramegna M, Pazzanese V, Ingallina G, Napolano A, Finazzi R, Ruggeri A, Ajello S, Melisurgo G, Camici PG, Scarpellini P, Tresoldi M, Landoni G, Ciceri F, Scandroglio AM, Agricola E, Cappelletti AM. Pulmonary hypertension and right ventricular involvement in hospitalised patients with COVID-19. Heart 2020; 106:1324-1331. [PMID: 32675217 PMCID: PMC7476272 DOI: 10.1136/heartjnl-2020-317355] [Citation(s) in RCA: 113] [Impact Index Per Article: 28.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 06/30/2020] [Accepted: 07/01/2020] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE To assess the prevalence, characteristics and prognostic value of pulmonary hypertension (PH) and right ventricular dysfunction (RVD) in hospitalised, non-intensive care unit (ICU) patients with coronavirus disease 2019 (COVID-19). METHODS This single-centre, observational, cross-sectional study included 211 patients with COVID-19 admitted to non-ICU departments who underwent a single transthoracic echocardiography (TTE). Patients with poor acoustic window (n=11) were excluded. Clinical, imaging, laboratory and TTE findings were compared in patients with versus without PH (estimated systolic pulmonary artery pressure >35 mm Hg) and with versus without RVD (tricuspid annular plane systolic excursion <17 mm or S wave <9.5 cm/s). The primary endpoint was in-hospital death or ICU admission. RESULTS A total of 200 patients were included in the final analysis (median age 62 (IQR 52-74) years, 65.5% men). The prevalence of PH and RVD was 12.0% (24/200) and 14.5% (29/200), respectively. Patients with PH were older and had a higher burden of pre-existing cardiac comorbidities and signs of more severe severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection (radiological lung involvement, laboratory findings and oxygenation status) compared with those without PH. Conversely, patients with RVD had a higher burden of pre-existing cardiac comorbidities but no evidence of more severe SARS-CoV-2 infection compared with those without RVD. The presence of PH was associated with a higher rate of in-hospital death or ICU admission (41.7 vs 8.5%, p<0.001), while the presence of RVD was not (17.2 vs 11.7%, p=0.404). CONCLUSIONS Among hospitalised non-ICU patients with COVID-19, PH (and not RVD) was associated with signs of more severe COVID-19 and with worse in-hospital clinical outcome. TRIAL REGISTRATION NUMBER NCT04318366.
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MESH Headings
- Betacoronavirus/isolation & purification
- COVID-19
- Comorbidity
- Coronavirus Infections/complications
- Coronavirus Infections/diagnosis
- Coronavirus Infections/epidemiology
- Coronavirus Infections/physiopathology
- Correlation of Data
- Echocardiography/methods
- Female
- Hospitalization/statistics & numerical data
- Humans
- Hypertension, Pulmonary/diagnosis
- Hypertension, Pulmonary/epidemiology
- Hypertension, Pulmonary/etiology
- Italy/epidemiology
- Male
- Middle Aged
- Outcome Assessment, Health Care
- Pandemics
- Pneumonia, Viral/complications
- Pneumonia, Viral/diagnosis
- Pneumonia, Viral/epidemiology
- Pneumonia, Viral/physiopathology
- Prevalence
- SARS-CoV-2
- Severity of Illness Index
- Ventricular Dysfunction, Right/diagnosis
- Ventricular Dysfunction, Right/epidemiology
- Ventricular Dysfunction, Right/etiology
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Affiliation(s)
- Matteo Pagnesi
- Cardiac Intensive Care Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Luca Baldetti
- Cardiac Intensive Care Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Alessandro Beneduce
- Interventional Cardiology Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Francesco Calvo
- Cardiac Intensive Care Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Mario Gramegna
- Cardiac Intensive Care Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Vittorio Pazzanese
- Cardiac Intensive Care Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Giacomo Ingallina
- Cardiovascular Imaging Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Antonio Napolano
- Cardiovascular Imaging Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Renato Finazzi
- Department of General Medicine and Advanced Care, San Raffaele Scientific Institute, Milan, Italy
| | - Annalisa Ruggeri
- Hematology and Bone Marrow Transplantation Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Silvia Ajello
- Cardio-Thoracic Intensive Care Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Giulio Melisurgo
- Cardio-Thoracic Intensive Care Unit, San Raffaele Scientific Institute, Milan, Italy
| | | | - Paolo Scarpellini
- Department of Infectious Disease, San Raffaele Scientific Institute, Milan, Italy
| | - Moreno Tresoldi
- Department of General Medicine and Advanced Care, San Raffaele Scientific Institute, Milan, Italy
| | - Giovanni Landoni
- Vita-Salute San Raffaele University, Milan, Italy
- Department of Anesthesia and Intensive Care, San Raffaele Scientific Institute, Milan, Italy
| | - Fabio Ciceri
- Hematology and Bone Marrow Transplantation Unit, San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - Anna Mara Scandroglio
- Cardio-Thoracic Intensive Care Unit, San Raffaele Scientific Institute, Milan, Italy
- Department of Anesthesia and Intensive Care, San Raffaele Scientific Institute, Milan, Italy
| | - Eustachio Agricola
- Cardiovascular Imaging Unit, San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
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13
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Dherange P, Lang J, Qian P, Oberfeld B, Sauer WH, Koplan B, Tedrow U. Arrhythmias and COVID-19: A Review. JACC Clin Electrophysiol 2020; 6:1193-1204. [PMID: 32972561 PMCID: PMC7417167 DOI: 10.1016/j.jacep.2020.08.002] [Citation(s) in RCA: 90] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 07/31/2020] [Accepted: 08/04/2020] [Indexed: 12/15/2022]
Abstract
Current understanding of the impact of coronavirus disease-2019 (COVID-19) on arrhythmias continues to evolve as new data emerge. Cardiac arrhythmias are more common in critically ill COVID-19 patients. The potential mechanisms that could result in arrhythmogenesis among COVID-19 patients include hypoxia caused by direct viral tissue involvement of lungs, myocarditis, abnormal host immune response, myocardial ischemia, myocardial strain, electrolyte derangements, intravascular volume imbalances, and drug sides effects. To manage these arrhythmias, it is imperative to increase the awareness of potential drug-drug interactions, to monitor QTc prolongation while receiving COVID therapy and provide special considerations for patients with inherited arrhythmia syndromes. It is also crucial to minimize exposure to COVID-19 infection by stratifying the need for intervention and using telemedicine. As COVID-19 infection continues to prevail with a potential for future surges, more data are required to better understand pathophysiology and to validate management strategies.
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Affiliation(s)
- Parinita Dherange
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Joshua Lang
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Pierre Qian
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Blake Oberfeld
- Division of Cardiovascular Medicine, Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - William H Sauer
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Bruce Koplan
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Usha Tedrow
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
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14
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Oronsky B, Knox S, Cabrales P, Oronsky A, Reid TR. Desperate Times, Desperate Measures: The Case for RRx-001 in the Treatment of COVID-19. Semin Oncol 2020; 47:305-308. [PMID: 32718560 PMCID: PMC7341953 DOI: 10.1053/j.seminoncol.2020.07.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 06/23/2020] [Accepted: 07/01/2020] [Indexed: 01/10/2023]
Abstract
This article summarizes the likely attenuation properties of RRx-001 in COVID-19 based on its mechanism of action and the putative pathogenesis of the disease, which appears to activate inflammatory, oxidative, and immune cascades with the potential to culminate in acute respiratory distress syndrome, cytokine storm and death. An ongoing pandemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), COVID-19 appears to present with 3 major patterns of clinical symptomatology: (1) mild upper respiratory tract infection, (2) non–life-threatening pneumonia, and (3) severe pneumonia and acute respiratory distress syndrome that initially manifest as a mild prodrome lasting for 7–8 days before rapid clinical and radiological deterioration requiring ICU transfer. RRx-001 is a targeted nitric oxide donor. This small molecule, which has been evaluated in multiple Phase 1–2 clinical trials for cancer as well as a Phase 3 clinical trial for the treatment of small cell lung cancer called REPLATINUM (NCT03699956), is minimally toxic and demonstrates clear evidence of antitumor activity. During the course of these clinical trials it was noted that the rate of chronic obstructive pulmonary disease exacerbation and pneumonia in actively smoking small cell lung cancer patients treated with RRx-001 is less than 1%. Due to extensive history of tobacco use, 40%–70% of patients with lung cancer have chronic obstructive pulmonary disease and the expected rate of pulmonary infection in this population is 50%–70%, which was not observed in RRx-001 clinical trials. Moreover, in preclinical studies of pulmonary hypertension, RRx-001 was found to be comparable with or more effective than the FDA approved agent, Bosentan. The potential pulmonary protective effects of RRx-001 in patients with recurrent lung infections coupled with preclinical models demonstrating RRx-001-mediated reversal of pulmonary hypertension suggests RRx-001 may have therapeutic activity in patients with acute respiratory symptoms due to COVID 19. Clinical trials have been initiated to confirm the hypothesis that RRx-001 may be repurposed to treat SARS-CoV-2 infection.
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15
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Das SK, Choupoo NS, Saikia P, Lahkar A. Incidence Proportion of Acute Cor Pulmonale in Patients with Acute Respiratory Distress Syndrome Subjected to Lung Protective Ventilation: A Systematic Review and Meta-analysis. Indian J Crit Care Med 2017; 21:364-375. [PMID: 28701843 PMCID: PMC5492739 DOI: 10.4103/ijccm.ijccm_155_17] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
INTRODUCTION Reported incidence of acute cor pulmonale (ACP) in patients with acute respiratory distress syndrome (ARDS) varies from 10% to 84%, despite being subjected to lung protective ventilation according to the current guidelines. The objective of this review is to find pooled cumulative incidence of ACP in patients with ARDS undergoing lung protective ventilation. MATERIALS AND METHODS We searched MEDLINE, EMBASE, Cochrane Library, KoreaMed, LILACS, and WHO Clinical Trial Registry. Cross-sectional or cohort studies were included if they reported or provided data that could be used to calculate the incidence proportion of ACP. Inverse variance heterogeneity (IVhet) and random effect model were used for the main outcome and measures. RESULTS We included 16 studies encompassing 1661 patients. The cumulative incidence of ACP using IVhet analysis was 23% (95% confidence interval [CI] = 18%-28%) over 3 days of lung protective ventilation. Random effect analysis of 7 studies (1250 patients) revealed pooled odd ratio of mortality of 1.16 (95% CI = 0.80-1.67, P = 0.44) due to ACP. CONCLUSION Patients with ARDS have a 23% risk of developing ACP with lung protective ventilation. Findings of this review indicate the need of updating existing guidelines for ventilating ARDS patients to incorporate right ventricle protective strategy.
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Affiliation(s)
- Saurabh Kumar Das
- Department of Critical Care, Fortis Super Specialty Hospital, Shalimar Bagh, New Delhi, India
| | - Nang Sujali Choupoo
- Department of Anesthesiology and Critical Care, Post graduate Institute of Medical Education and Research - Dr. Ram Monohar Lohia Hospital, New Delhi, India
| | - Priyam Saikia
- Department of Anesthesia, Milton Keynes Hospital, NHS Foundation Trust, Standing Way, Eaglestone, Milton Keynes, MK6 5HS, UK
| | - Amitabh Lahkar
- Department of Anaesthesiology and Critical Care, Gauhati Medical College and Hospital, Guwahati, Assam, India
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