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Khattar G, Mustafa A, Siddiqui FS, Gharib KE, Chapman W, Abu Baker S, Sattar SBA, Elsayegh D, El-Hage H, El Sayegh S, Chalhoub M. Pulmonary hypertension: An unexplored risk factor for stroke in patients with atrial fibrillation. J Stroke Cerebrovasc Dis 2023; 32:107247. [PMID: 37523879 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 06/21/2023] [Accepted: 07/04/2023] [Indexed: 08/02/2023] Open
Abstract
BACKGROUND Atrial fibrillation (Afib) is one of the most common and significant risk factors for stroke, with the CHADsVAsc score used as the tool for stroke risk assessment. Pulmonary hypertension (PH) has not been studied as an independent risk factor for stroke in individuals with Afib. METHODS In this retrospective case-control study, National Inpatient Sample Database was used to sample individuals with atrial fibrillation, and baseline demographics and comorbidities were collected using ICD-10 codes. Patients with missing data, age under 18, history of thromboembolic diseases, or stroke were excluded. Greedy propensity matching using R was performed to match patients with and without PH on age, race, gender, and 19 other comorbidities, including anticoagulation use. Binary logistic regression was performed after matching to assess whether PH was an independent risk factor for stroke. A p-value of <0.05 was considered statistically significant. RESULTS Of the 2,421,545 patients included in the study, 158,545 (6.5%) had PH. PH patients were more likely to be elderly, females, and smokers. Comorbidities were more common in the PH group. Patients with PH were more likely to have an ischemic stroke (3.6% vs. 2.9%, p<0.001), hemorrhagic stroke (2.2% vs. 0.7%, p<0.001), and transient ischemic attack (TIA) (2.3% vs. 0.7%, p<0.001). After matching, the presence of PH was associated with increased ischemic stroke (OR: 1.2 [1.1-1.2]; p<0.001), hemorrhagic stroke (OR: 2.4 [2.1-2.6]; p<0.001) and TIA (OR: 2.2 [2.0-2.4]; p<0.001). PH patients also had increased length of stay (β = 0.8; p<0.001) mortality (OR: 1.1 [1.0-1.2]; p<0.001). CONCLUSION Apart from demonstrating the deleterious effect of PH on mortality and length of hospital stay, this study is the first to report on such a large scale that PH independently increases the incidence of all types of strokes in patients with Afib.
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Affiliation(s)
- Georges Khattar
- Department of Internal Medicine, Staten Island University Hospital/Northwell Health, Staten Island, New York 10305, USA.
| | - Ahmad Mustafa
- Department of Internal Medicine, Staten Island University Hospital/Northwell Health, Staten Island, New York 10305, USA
| | - Fasih Sami Siddiqui
- Department of Internal Medicine, Staten Island University Hospital/Northwell Health, Staten Island, New York 10305, USA
| | - Khalil El Gharib
- Department of Internal Medicine, Staten Island University Hospital/Northwell Health, Staten Island, New York 10305, USA
| | - Wei Chapman
- Department of Internal Medicine, Staten Island University Hospital/Northwell Health, Staten Island, New York 10305, USA
| | - Saif Abu Baker
- Department of Internal Medicine, Staten Island University Hospital/Northwell Health, Staten Island, New York 10305, USA
| | - Saud Bin Abdul Sattar
- Department of Pulmonary and Critical Care, Staten Island University Hospital/Northwell Health, Staten Island, New York, USA
| | - Dany Elsayegh
- Department of Pulmonary and Critical Care, Staten Island University Hospital/Northwell Health, Staten Island, New York, USA
| | - Halim El-Hage
- Department of Pulmonary and Critical Care, Staten Island University Hospital/Northwell Health, Staten Island, New York, USA
| | - Suzanne El Sayegh
- Department of Internal Medicine, Staten Island University Hospital/Northwell Health, Staten Island, New York 10305, USA; Department of Nephrology, Staten Island University Hospital/Northwell Health, Staten Island, New York, USA
| | - Michel Chalhoub
- Department of Pulmonary and Critical Care, Staten Island University Hospital/Northwell Health, Staten Island, New York, USA
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2
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Moghaddam NM, Fathi M, Jame SZB, Darvishi M, Mortazavi M. Association of Glasgow coma scale and endotracheal intubation in predicting mortality among patients admitted to the intensive care unit. Acute Crit Care 2023; 38:113-121. [PMID: 36935540 PMCID: PMC10030249 DOI: 10.4266/acc.2022.00927] [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: 07/23/2022] [Accepted: 11/01/2022] [Indexed: 02/23/2023] Open
Abstract
BACKGROUND We assessed predictors of mortality in the intensive care unit (ICU) and investigated if Glasgow coma scale (GCS) is associated with mortality in patients undergoing endotracheal intubation (EI). METHODS From February 2020, we performed a 1-year study on 2,055 adult patients admitted to the ICU of two teaching hospitals. The outcome was mortality during ICU stay and the predictors were patients' demographic, clinical, and laboratory features. RESULTS EI was associated with a decreased risk for mortality compared with similar patients (adjusted odds ratio [AOR], 0.32; P=0.030). This shows that EI had been performed correctly with proper indications. Increasing age (AOR, 1.04; P<0.001) or blood pressure (AOR, 1.01; P<0.001), respiratory problems (AOR, 3.24; P<0.001), nosocomial infection (AOR, 1.64; P=0.014), diabetes (AOR, 5.69; P<0.001), history of myocardial infarction (AOR, 2.52; P<0.001), chronic obstructive pulmonary disease (AOR, 3.93; P<0.001), immunosuppression (AOR, 3.15; P<0.001), and the use of anesthetics/sedatives/hypnotics for reasons other than EI (AOR, 4.60; P<0.001) were directly; and GCS (AOR, 0.84; P<0.001) was inversely related to mortality. In patients with trauma surgeries (AOR, 0.62; P=0.014) or other surgical categories (AOR, 0.61; P=0.024) undergoing EI, GCS had an inverse relation with mortality (accuracy=82.6%, area under the receiver operator characteristic curve=0.81). CONCLUSIONS A variety of features affected the risk for mortality in patients admitted to the ICU. Considering GCS score for EI had the potential of affecting prognosis in subgroups of patients such as those with trauma surgeries or other surgical categories.
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Affiliation(s)
- Nader Markazi Moghaddam
- Department of Health Management and Economics, Faculty of Medicine, AJA University of Medical Sciences, Tehran, Iran
- Critical Care Quality Improvement Research Center, Shahid Modarres Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad Fathi
- Critical Care Quality Improvement Research Center, Shahid Modarres Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Department of Anesthesiology, Faculty of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Sanaz Zargar Balaye Jame
- Department of Health Management and Economics, Faculty of Medicine, AJA University of Medical Sciences, Tehran, Iran
| | - Mohammad Darvishi
- Infectious Diseases and Tropical Medicine Research Center (IDTMRC), Department of Aerospace and Subaquatic Medicine, AJA University of Medical Sciences, Tehran, Iran
| | - Morteza Mortazavi
- Department of Health Management and Economics, Faculty of Medicine, AJA University of Medical Sciences, Tehran, Iran
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Longitudinal Validation of Right Ventricular Pressure Monitoring for the Assessment of Right Ventricular Systolic Dysfunction in a Large Animal Ischemic Model. Crit Care Explor 2023; 5:e0847. [PMID: 36699251 PMCID: PMC9851694 DOI: 10.1097/cce.0000000000000847] [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] [Indexed: 01/27/2023] Open
Abstract
Right ventricular (RV) dysfunction is a major cause of morbidity and mortality in intensive care and cardiac surgery. Early detection of RV dysfunction may be facilitated by continuous monitoring of RV waveform obtained from a pulmonary artery catheter. The objective is to evaluate the extent to which RV pressure monitoring can detect changes in RV systolic performance assess by RV end-systolic elastance (Ees) following the development of an acute RV ischemic in a porcine model. HYPOTHESIS RV pressure monitoring can detect changes in RV systolic performance assess by RV Ees following the development of an acute RV ischemic model. METHODS AND MODELS Acute ischemic RV dysfunction was induced by progressive embolization of microsphere in the right coronary artery to mimic RV dysfunction clinically experienced during cardiopulmonary bypass separation caused by air microemboli. RV hemodynamic performance was assessed using RV pressure waveform-derived parameters and RV Ees obtained using a conductance catheter during inferior vena cava occlusions. RESULTS Acute ischemia resulted in a significant reduction in RV Ees from 0.26 mm Hg/mL (interquartile range, 0.16-0.32 mm Hg/mL) to 0.14 mm Hg/mL (0.11-0.19 mm Hg/mL; p < 0.010), cardiac output from 6.3 L/min (5.7-7 L/min) to 4.5 (3.9-5.2 L/min; p = 0.007), mean systemic arterial pressure from 72 mm Hg (66-74 mm Hg) to 51 mm Hg (46-56 mm Hg; p < 0.001), and mixed venous oxygen saturation from 65% (57-72%) to 41% (35-45%; p < 0.001). Linear mixed-effect model analysis was used to assess the relationship between Ees and RV pressure-derived parameters. The reduction in RV Ees best correlated with a reduction in RV maximum first derivative of pressure during isovolumetric contraction (dP/dtmax) and single-beat RV Ees. Adjusting RV dP/dtmax for heart rate resulted in an improved surrogate of RV Ees. INTERPRETATION AND CONCLUSIONS Stepwise decreases in RV Ees during acute ischemic RV dysfunction were accurately tracked by RV dP/dtmax derived from the RV pressure waveform.
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4
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Rosenthal VD, Jin Z, Memish ZA, Daboor MA, Al-Ruzzieh MA, Hussien NH, Guclu E, Olmez-Gazioglu E, Ogutlu A, Agha HM, El-Sisi A, Fathalla AA, Yildizdas D, Yildizdas HY, Ozlu F, Horoz OO, Omar AA, Belkebir S, Kanaa A, Jeetawi R, El-Kholy AA, Bayani V, Alwakil W, Abdulaziz-Alkhawaja S, Swar SF, Magray TA, Alsayegh AA, Yin R. Risk factors for mortality in ICU patients in 10 middle eastern countries: The role of healthcare-associated infections. J Crit Care 2022; 72:154149. [PMID: 36108349 DOI: 10.1016/j.jcrc.2022.154149] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 09/03/2022] [Accepted: 09/03/2022] [Indexed: 12/15/2022]
Abstract
PURPOSE The International Nosocomial Infection Control Consortium (INICC) found a high mortality rate in ICUs of the Middle East (ME). Our goal was to identify mortality risk factor (RF) in ICUs of the ME. MATERIALS From 08/01/2003 to 02/12/2022, we conducted a prospective cohort study in 236 ICUs of 77 hospitals in 44 cities in 10 countries of ME. We analyzed 16 independent variables using multiple logistic regression. RESULTS 66,440 patients, hospitalized during 652,167 patient-days, and 13,974 died. We identified following mortality RF: Age (adjusted odds ratio (aOR):1.02;p < 0.0001) rising risk 2% yearly; length of stay (LOS) (aOR:1.02;p < 0.0001) rising the risk 2% per day; central line (CL)-days (aOR:1.01;p < 0.0001) rising risk 1% per day; mechanicalventilator (MV) utilization-ratio (aOR:14.51;p < 0.0001); CL-associated bloodstream infection (CLABSI) acquisition (aOR):1.49;p < 0.0001); ventilator-associated pneumonia (VAP) acquisition (aOR:1.50;p < 0.0001); female gender (OR:1.14;p < 0.0001); hospitalization at a public-hospital (OR:1.31;p < 0.0001); and medical-hospitalization (aOR:1.64;p < 0.0001). High-income countries showed lowest risk (aOR:0.59;p < 0.0001). CONCLUSION Some identified RF are unlikely to change, such as country income-level, facility ownership, hospitalization type, gender, and age. Some can be modified; LOS, CL-use, MV-use, CLABSI, VAP. So, to lower the mortality risk in ICUs, we recommend focusing on strategies to shorten the LOS, reduce CL and MV-utilization, and use evidence-based recommendations to prevent CLABSI and VAP.
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Affiliation(s)
- Victor Daniel Rosenthal
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL, USA; International Nosocomial Infection Control Consortium, Miami, FL, USA.
| | - Zhilin Jin
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Ziad A Memish
- King Saud Medical City, Ministry of Health, Riyadh, Saudi Arabia
| | | | | | | | - Ertugrul Guclu
- Sakarya University Training and Research Hospital, Sakarya, Turkey
| | | | - Aziz Ogutlu
- Sakarya University Training and Research Hospital, Sakarya, Turkey
| | | | - Amal El-Sisi
- Cairo University Specialized Pediatric Hospital, Cairo, Egypt
| | | | | | | | - Ferda Ozlu
- Cukurova University, Balcali Hospital, Adana, Turkey
| | | | - Abeer Aly Omar
- Infection Control Directorate, Ministry of Health, Kuwait City, Kuwait
| | | | - Alaa Kanaa
- An Najah National University, Nablus, Palestine
| | | | | | - Victor Bayani
- Dar Alfouad Hospital, 6th of October City, 6th of October City, Egypt
| | - Wafaa Alwakil
- Dar Alfouad Hospital, 6th of October City, 6th of October City, Egypt
| | - Safaa Abdulaziz-Alkhawaja
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL, USA; Dar Alfouad Hospital, 6th of October City, 6th of October City, Egypt
| | | | | | | | - Ruijie Yin
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL, USA
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5
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Kamenshchikov NO, Berra L, Carroll RW. Therapeutic Effects of Inhaled Nitric Oxide Therapy in COVID-19 Patients. Biomedicines 2022; 10:biomedicines10020369. [PMID: 35203578 PMCID: PMC8962307 DOI: 10.3390/biomedicines10020369] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 01/26/2022] [Accepted: 01/26/2022] [Indexed: 01/08/2023] Open
Abstract
The global COVID-19 pandemic has become the largest public health challenge of recent years. The incidence of COVID-19-related acute hypoxemic respiratory failure (AHRF) occurs in up to 15% of hospitalized patients. Antiviral drugs currently available to clinicians have little to no effect on mortality, length of in-hospital stay, the need for mechanical ventilation, or long-term effects. Inhaled nitric oxide (iNO) administration is a promising new non-standard approach to directly treat viral burden while enhancing oxygenation. Along with its putative antiviral affect in COVID-19 patients, iNO can reduce inflammatory cell-mediated lung injury by inhibiting neutrophil activation, lowering pulmonary vascular resistance and decreasing edema in the alveolar spaces, collectively enhancing ventilation/perfusion matching. This narrative review article presents recent literature on the iNO therapy use for COVID-19 patients. The authors suggest that early administration of the iNO therapy may be a safe and promising approach for the treatment of COVID-19 patients. The authors also discuss unconventional approaches to treatment, continuous versus intermittent high-dose iNO therapy, timing of initiation of therapy (early versus late), and novel delivery systems. Future laboratory and clinical research is required to define the role of iNO as an adjunct therapy against bacterial, viral, and fungal infections.
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Affiliation(s)
- Nikolay O. Kamenshchikov
- Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, 634012 Tomsk, Russia
- Correspondence:
| | - Lorenzo Berra
- Department of Anaesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA 02114, USA;
- Department of Anaesthesia, Harvard Medical School, Boston, MA 02115, USA;
| | - Ryan W. Carroll
- Department of Anaesthesia, Harvard Medical School, Boston, MA 02115, USA;
- Division of Pediatric Critical Care Medicine, Massachusetts General Hospital, Boston, MA 02114, USA
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6
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Critical Care Management of Decompensated Right Heart Failure in Pulmonary Arterial Hypertension Patients - An Ongoing Approach. J Crit Care Med (Targu Mures) 2021; 7:170-183. [PMID: 34722920 PMCID: PMC8519386 DOI: 10.2478/jccm-2021-0020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Accepted: 06/21/2021] [Indexed: 11/20/2022] Open
Abstract
Despite substantial advancements in diagnosis and specific medical therapy in pulmonary arterial hypertension patients’ management, this condition continues to represent a major cause of mortality worldwide. In pulmonary arterial hypertension, the continuous increase of pulmonary vascular resistance and rapid development of right heart failure determine a poor prognosis. Against targeted therapy, patients inexorable deteriorate over time. Pulmonary arterial hypertension patients with acute right heart failure who need intensive care unit admission present a complexity of the disease pathophysiology. Intensive care management challenges are multifaceted. Awareness of algorithms of right-sided heart failure monitoring in intensive care units, targeted pulmonary hypertension therapies, and recognition of precipitating factors, hemodynamic instability and progressive multisystem organ failure requires a multidisciplinary pulmonary hypertension team. This paper summarizes the management strategies of acute right-sided heart failure in pulmonary arterial hypertension adult cases based on recently available data.
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7
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Bauchmuller K, Condliffe R, Southern J, Billings C, Charalampopoulos A, Elliot CA, Hameed A, Kiely DG, Sabroe I, Thompson AAR, Raithatha A, Mills GH. Critical care outcomes in patients with pre-existing pulmonary hypertension: insights from the ASPIRE registry. ERJ Open Res 2021; 7:00046-2021. [PMID: 33834051 PMCID: PMC8021802 DOI: 10.1183/23120541.00046-2021] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 01/31/2021] [Indexed: 11/16/2022] Open
Abstract
Pulmonary hypertension (PH) is a life-shortening condition characterised by episodes of decompensation precipitated by factors such as disease progression, arrhythmias and sepsis. Surgery and pregnancy also place additional strain on the right ventricle. Data on critical care management in patients with pre-existing PH are scarce. We conducted a retrospective observational study of a large cohort of patients admitted to the critical care unit of a national referral centre between 2000–2017 to establish acute mortality, evaluate predictors of in-hospital mortality and establish longer term outcomes in survivors to hospital discharge. 242 critical care admissions involving 206 patients were identified. Hospital survival was 59.3%, 94% and 92% for patients admitted for medical, surgical or obstetric reasons, respectively. Medical patients had more severe physiological and laboratory perturbations than patients admitted following surgical or obstetric interventions. Higher APACHE II (Acute Physiology and Chronic Health Evaluation) score, age and lactate, and lower oxygen saturation measure by pulse oximetry/inspiratory oxygen fraction (SpO2/FiO2) ratio, platelet count and sodium level were identified as independent predictors of hospital mortality. An exploratory risk score, OPALS (oxygen (SpO2/FiO2) ≤185; platelets ≤196×109·L−1; age ≥37.5 years; lactate ≥2.45 mmol·L−1; sodium ≤130.5 mmol·L−1), identified medical patients at increasing risk of hospital mortality. One (11%) out of nine patients who were invasively ventilated for medical decompensation and 50% of patients receiving renal replacement therapy left hospital alive. There was no significant difference in exercise capacity or functional class between follow-up and pre-admission in patients who survived to discharge. These data have clinical utility in guiding critical care management of patients with known PH. The exploratory OPALS score requires validation. Critical care survival is worse in PH patients admitted for medical rather than surgical/obstetric indications. Nevertheless, many show longer term survival and functional recovery. Markers of severity of acute illness at admission are prognostic.https://bit.ly/2YX9Fw9
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Affiliation(s)
- Kris Bauchmuller
- Dept of Critical Care, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK.,These authors contributed equally
| | - Robin Condliffe
- Sheffield Pulmonary Vascular Disease Unit, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK.,Dept of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK.,These authors contributed equally
| | - Jennifer Southern
- Dept of Critical Care, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK.,These authors contributed equally
| | - Catherine Billings
- Sheffield Pulmonary Vascular Disease Unit, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | | | - Charlie A Elliot
- Sheffield Pulmonary Vascular Disease Unit, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Abdul Hameed
- Sheffield Pulmonary Vascular Disease Unit, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK.,Dept of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - David G Kiely
- Sheffield Pulmonary Vascular Disease Unit, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK.,Dept of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Ian Sabroe
- Sheffield Pulmonary Vascular Disease Unit, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - A A Roger Thompson
- Sheffield Pulmonary Vascular Disease Unit, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK.,Dept of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Ajay Raithatha
- Dept of Critical Care, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Gary H Mills
- Dept of Critical Care, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK.,Dept of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK.,These authors contributed equally
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The contemporary pulmonary artery catheter. Part 2: measurements, limitations, and clinical applications. J Clin Monit Comput 2021; 36:17-31. [PMID: 33646499 PMCID: PMC7917533 DOI: 10.1007/s10877-021-00673-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 02/08/2021] [Indexed: 12/25/2022]
Abstract
Nowadays, the classical pulmonary artery catheter (PAC) has an almost 50-year-old history of its clinical use for hemodynamic monitoring. In recent years, the PAC evolved from a device that enabled intermittent cardiac output measurements in combination with static pressures to a monitoring tool that provides continuous data on cardiac output, oxygen supply and-demand balance, as well as right ventricular performance. In this review, which consists of two parts, we will introduce the difference between intermittent pulmonary artery thermodilution using bolus injections, and the contemporary PAC enabling continuous measurements by using a thermal filament which heats up the blood. In this second part, we will discuss in detail the measurements of the contemporary PAC, including continuous cardiac output measurement, right ventricular ejection fraction, end-diastolic volume index, and mixed venous oxygen saturation. Limitations of all of these measurements are highlighted as well. We conclude that thorough understanding of measurements obtained from the PAC is the first step in successful application of the PAC in daily clinical practice.
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Management of Severe Pulmonary Hypertensive Disease for Surgical and Nonsurgical Procedures. Int Anesthesiol Clin 2019; 56:e28-e55. [PMID: 30204604 DOI: 10.1097/aia.0000000000000202] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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10
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Nowroozpoor A, Malekmohammad M, Seyyedi SR, Hashemian SM. Pulmonary Hypertension in Intensive Care Units: An Updated Review. TANAFFOS 2019; 18:180-207. [PMID: 32411259 PMCID: PMC7210574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Pulmonary hypertension (PH) is a condition associated with high morbidity and mortality. Patients with PH who require critical care usually have severe right ventricular (RV) dysfunction. Although different groups of PH have different etiologies, pulmonary vascular dysfunction is common in these groups. PH can lead to increased pulmonary artery pressure, which can ultimately cause RV failure. Clinicians should be familiar with the presentations of this disease and diagnostic tools. The contributing factors, if present (e.g., sepsis), and coexisting conditions (e.g., arrhythmias) should be identified and addressed accordingly. The preload should be optimized by fluid administration, diuretics, and dialysis, if necessary. On the other hand, the RV afterload should be reduced to improve the RV function with pulmonary vasodilators, such as prostacyclins, inhaled nitric oxide, and phosphodiesterase type 5 inhibitors, especially in group 1 PH. Inotropes are also used to improve RV contractility, and if inadequate, use of ventricular assist devices and extracorporeal life support should be considered in suitable candidates. Moreover, vasopressors should be used to maintain systemic blood pressure, albeit cautiously, as they increase the RV afterload. Measures should be also taken to ensure adequate oxygenation. However, mechanical ventilation is avoided in RV failure. In this study, we reviewed the pathophysiology, manifestations, diagnosis, monitoring, and management strategies of PH, especially in intensive care units.
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Affiliation(s)
- Armin Nowroozpoor
- Clinical Tuberculosis and Epidemiology Research Center, NRITLD, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Majid Malekmohammad
- Tracheal Diseases Research Center, National Research Institute of Tuberculosis and Lung Disease (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Seyyed Reza Seyyedi
- Lung Transplantation Research Center, Department of Cardiology, National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Seyed Mohammadreza Hashemian
- Clinical Tuberculosis and Epidemiology Research Center, NRITLD, Shahid Beheshti University of Medical Sciences, Tehran, Iran,,Correspondence to: Hashemian SMR, Address: Clinical Tuberculosis and Epidemiology Research Center, NRITLD, Shahid Beheshti University of Medical Sciences, Tehran, Iran Email address:
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11
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Right ventricular load adaptability metrics in patients undergoing left ventricular assist device implantation. J Thorac Cardiovasc Surg 2019; 157:1023-1033.e4. [DOI: 10.1016/j.jtcvs.2018.08.095] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Revised: 07/31/2018] [Accepted: 08/10/2018] [Indexed: 11/21/2022]
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12
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Tremblay JA, Couture ÉJ, Albert M, Beaubien-Souligny W, Elmi-Sarabi M, Lamarche Y, Denault AY. Noninvasive Administration of Inhaled Nitric Oxide and its Hemodynamic Effects in Patients With Acute Right Ventricular Dysfunction. J Cardiothorac Vasc Anesth 2018; 33:642-647. [PMID: 30206010 DOI: 10.1053/j.jvca.2018.08.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The authors aimed to assess the hemodynamic effects and demonstrate the feasibility of inhaled nitric oxide (iNO) in hemodynamically unstable patients with acute right ventricular (RV) dysfunction and to explore the safety profile of this approach. DESIGN Retrospective cohort study. SETTING Intensive care unit (ICU) of 2 tertiary care centers between January 2013 and 2017. PARTICIPANTS All patients with RV dysfunction in whom iNO was initiated without invasive mechanical ventilation. INTERVENTION Noninvasive administration of iNO. MEASUREMENTS AND MAIN RESULTS Eighteen patients received the intervention during the study period; 8 of these patients had a pulmonary artery catheter and 2 had a pulse contour analysis device. Median (interquartile range) iNO concentration was 20 (20-20) ppm, and therapy duration was 24 (12-46) hours. Most patients received iNO through nasal prongs (66.7%) or a high-flow nasal cannula (27.8%). Within 1 hour, iNO reduced pulmonary vascular resistance from 219.1 to 165.4 dyn•s/cm5 (n = 7; p < 0.001), mean pulmonary artery pressure from 28.4 to 25.3 mmHg (n = 8; p = 0.01), and central venous pressure from 17.5 to 13.1 mmHg (n = 16; p = 0.001). Indexed cardiac output increased from 2.0 to 2.6 L/min/m2 (n = 9; p = 0.004). ICU mortality was 27.78%, and median ICU length of stay was 7 (5-9) days. Two significant bleeding episodes requiring intervention and 1 acute kidney injury occurred during iNO therapy. No headache was reported. CONCLUSION Noninvasively administered iNO was associated with favorable hemodynamic effects in ICU patients with acute RV dysfunction. These results suggest the safety and feasibility of this therapy for which further prospective study is warranted.
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Affiliation(s)
- Jan-Alexis Tremblay
- Department of Medicine, Division of Critical Care, Université de Montréal, Montreal, QC, Canada
| | - Étienne J Couture
- Department of Medicine, Division of Critical Care, Université de Montréal, Montreal, QC, Canada
| | - Martin Albert
- Department of Medicine, Division of Critical Care, Université de Montréal, Montreal, QC, Canada; Department of Medicine and Critical Care, Sacré-Coeur Hospital and Montreal Heart Institute, Montreal, QC, Canada
| | | | - Mahsa Elmi-Sarabi
- Department of Anesthesiology and Division of Critical Care, Montreal Heart Institute, Université de Montréal, Montreal, QC, Canada
| | - Yoan Lamarche
- Department of Medicine and Critical Care, Sacré-Coeur Hospital and Montreal Heart Institute, Montreal, QC, Canada; Department of Cardiac Surgery Montreal Heart Institute, Université de Montréal, Montreal, QC, Canada
| | - André Y Denault
- Department of Anesthesiology and Division of Critical Care, Montreal Heart Institute, Université de Montréal, Montreal, QC, Canada; Division of Critical Care, Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada.
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13
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French S, Amsallem M, Ouazani N, Li S, Kudelko K, Zamanian RT, Haddad F, Chung L. Non-invasive right ventricular load adaptability indices in patients with scleroderma-associated pulmonary arterial hypertension. Pulm Circ 2018; 8:2045894018788268. [PMID: 29938590 PMCID: PMC6056794 DOI: 10.1177/2045894018788268] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Scleroderma-associated pulmonary arterial hypertension (SSc-PAH) is associated
with worse outcome than idiopathic pulmonary arterial hypertension (IPAH),
potentially due to worse right ventricular adaptation to load as suggested by
pressure–volume loop analysis. The value of non-invasive load-adaptability
metrics has not been fully explored in SSc-PAH. This study sought to assess
whether patients with incident SSc-PAH have worse echocardiographic
load-adaptability metrics than patients with IPAH. Twenty-two patients with
incident SSc-PAH were matched 1:1 with IPAH based on pulmonary vascular
resistance. Echocardiographic load-adaptability indices were divided into:
surrogates of ventriculo-arterial coupling (e.g. right ventricular area
change/end-systolic area), indices reflecting the proportionality of load
adaptation (e.g. tricuspid regurgitation velocity-time integral normalized for
average right ventricular radius), and simple ratios (e.g. tricuspid annular
plane systolic excursion/right ventricular systolic pressure). The prognostic
value of these indices for clinical worsening (i.e. death, transplant, or
hospitalization for heart failure) at one year was explored. The two groups were
comprised of patients of similar age, with similar cardiac index, pulmonary
resistance, capacitance and NT-proBNP levels (p > 0.10).
There was no difference in baseline right ventricular dimension, function or
load-adaptability indices. At one year, eight (36.4%) SSc-PAH patients had
experienced clinical worsening (eight hospitalizations and two deaths) versus
one hospitalization in the IPAH group. Load adaptation at one year in survivors
was not worse in SSc-PAH (p > 0.33). Patients with IPAH
responded better to therapy than SSc-PAH in terms of reduction of right
ventricular areas at one year (p < 0.05). Right ventricular
load-adaptability echocardiographic indices do not appear to capture the
increased risk of negative outcomes at one year associated with SSc-PAH.
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Affiliation(s)
- Sarah French
- 1 Division of Internal Medicine, Stanford University Medical Center, USA
| | - Myriam Amsallem
- 2 Division of Cardiovascular Medicine, Stanford University Medical Center, USA.,3 Research and Innovation Unit, INSERM U999, DHU Torino, Paris Sud University, Marie Lannelongue Hospital, France
| | - Nadia Ouazani
- 2 Division of Cardiovascular Medicine, Stanford University Medical Center, USA
| | - Shufeng Li
- 4 Division of Biostatistics, Stanford University Medical Center, USA
| | - Kristina Kudelko
- 5 Division of Pulmonary and Critical Care Disease, Stanford University Medical Center, USA
| | - Roham T Zamanian
- 5 Division of Pulmonary and Critical Care Disease, Stanford University Medical Center, USA.,6 Vera Moulton Wall Center for Pulmonary Hypertension at Stanford, Palo Alto, USA
| | - Francois Haddad
- 2 Division of Cardiovascular Medicine, Stanford University Medical Center, USA
| | - Lorinda Chung
- 7 Division of Rheumatology, Stanford University Medical Center, USA.,8 Division of Rheumatology, Palo Alto VA Healthcare System, Palo Alto, USA
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14
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Amsallem M, Boulate D, Aymami M, Guihaire J, Selej M, Huo J, Denault AY, McConnell MV, Schnittger I, Fadel E, Mercier O, Zamanian RT, Haddad F. Load Adaptability in Patients With Pulmonary Arterial Hypertension. Am J Cardiol 2017; 120:874-882. [PMID: 28705377 DOI: 10.1016/j.amjcard.2017.05.053] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Revised: 05/15/2017] [Accepted: 05/31/2017] [Indexed: 11/19/2022]
Abstract
Right ventricular (RV) adaptation to pressure overload is a major prognostic factor in patients with pulmonary arterial hypertension (PAH). The objectives were first to define the relation between RV adaptation and load using allometric modeling, then to compare the prognostic value of different indices of load adaptability in PAH. Both a derivation (n = 85) and a validation cohort (n = 200) were included. Load adaptability was assessed using 3 approaches: (1) surrogates of ventriculo-arterial coupling (e.g., RV area change/end-systolic area), (2) simple ratio of function and load (e.g., tricuspid annular plane systolic excursion/right ventricular systolic pressure), and (3) indices assessing the proportionality of adaptation using allometric pressure-function or size modeling. Proportional hazard modeling was used to compare the hazard ratio for the outcome of death or lung transplantation. The mean age of the derivation cohort was 44 ± 11 years, with 80% female and 74% in New York Heart Association class III or IV. Mean pulmonary vascular resistance index (PVRI) was 24 ± 11 with a wide distribution (1.6 to 57.5 WU/m2). Allometric relations were observed between PVRI and RV fractional area change (R2 = 0.53, p < 0.001) and RV end-systolic area indexed to body surface area right ventricular end-systolic area index (RVESAI) (R2 = 0.29, p < 0.001), allowing the derivation of simple ratiometric load-specific indices of RV adaptation. In right heart parameters, RVESAI was the strongest predictor of outcomes (hazard ratio per SD = 1.93, 95% confidence interval 1.37 to 2.75, p < 0.001). Although RVESAI/PVRI0.35 provided small incremental discrimination on multivariate modeling, none of the load-adaptability indices provided stronger discrimination of outcome than simple RV adaptation metrics in either the derivation or the validation cohort. In conclusion, allometric modeling enables quantification of the proportionality of RV load adaptation but offers small incremental prognostic value to RV end-systolic dimension in PAH.
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Affiliation(s)
- Myriam Amsallem
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California; Cardiovascular Institute, Stanford University School of Medicine, Stanford, California; Division of Cardiothoracic Surgery, Marie Lannelongue Hospital, Le Plessis Robinson, France.
| | - David Boulate
- Division of Cardiothoracic Surgery, Marie Lannelongue Hospital, Le Plessis Robinson, France
| | - Marie Aymami
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California; Cardiovascular Institute, Stanford University School of Medicine, Stanford, California
| | - Julien Guihaire
- Division of Cardiothoracic Surgery, Marie Lannelongue Hospital, Le Plessis Robinson, France
| | - Mona Selej
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California; Division of Pulmonary and Critical Care Medicine, Stanford University School of Medicine, Stanford, California
| | - Jennie Huo
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California; Cardiovascular Institute, Stanford University School of Medicine, Stanford, California
| | - Andre Y Denault
- Department of Anesthesiology and Critical Care Division, Centre Hospitalier de l'Université de Montréal and Montreal Heart Institute, Montreal, Quebec, Canada
| | - Michael V McConnell
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California; Cardiovascular Institute, Stanford University School of Medicine, Stanford, California
| | - Ingela Schnittger
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California; Cardiovascular Institute, Stanford University School of Medicine, Stanford, California
| | - Elie Fadel
- Division of Cardiothoracic Surgery, Marie Lannelongue Hospital, Le Plessis Robinson, France
| | - Olaf Mercier
- Division of Cardiothoracic Surgery, Marie Lannelongue Hospital, Le Plessis Robinson, France
| | - Roham T Zamanian
- Division of Pulmonary and Critical Care Medicine, Stanford University School of Medicine, Stanford, California; Vera Moulton Wall Center at Stanford, Stanford University School of Medicine, Stanford, California
| | - Francois Haddad
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California; Cardiovascular Institute, Stanford University School of Medicine, Stanford, California
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15
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Amsallem M, Kuznetsova T, Hanneman K, Denault A, Haddad F. Right heart imaging in patients with heart failure: a tale of two ventricles. Curr Opin Cardiol 2016; 31:469-82. [PMID: 27467173 PMCID: PMC5133417 DOI: 10.1097/hco.0000000000000315] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
PURPOSE OF REVIEW The purpose is to describe the recent advances made in imaging of the right heart, including deformation imaging, tissue, and flow characterization by MRI, and molecular imaging. RECENT FINDINGS Recent developments have been made in the field of deformation imaging of the right heart, which may improve risk stratification of patients with heart failure and pulmonary hypertension. In addition, more attention has been given to load adaptability metrics of the right heart; these simplified indices, however, still face challenges from a conceptual point of view. The emergence of novel MRI sequences, such as native T1 mapping, allows better detection and quantification of myocardial fibrosis and could allow better prediction of postsurgical recovery of the right heart. Other advances in MRI include four-dimensional flow imaging, which may be particularly useful in congenital heart disease or for the detection of early stages of pulmonary vascular disease. SUMMARY The review will place the recent developments in right heart imaging in the context of clinical care and research.
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Affiliation(s)
- Myriam Amsallem
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Tatiana Kuznetsova
- Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven Department of Cardiovascular Sciences, University of Leuven, Belgium
| | - Kate Hanneman
- Department of Medical Imaging, Toronto General Hospital, University of Toronto, Toronto, ON, Canada
| | - Andre Denault
- Department of Anesthesiology and Critical Care Division, CHUM and Montreal Heart Institute, Montreal, QC, Canada
| | - François Haddad
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA
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16
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Haddad F, Elmi-Sarabi M, Fadel E, Mercier O, Denault AY. Pearls and pitfalls in managing right heart failure in cardiac surgery. Curr Opin Anaesthesiol 2016; 29:68-79. [DOI: 10.1097/aco.0000000000000284] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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