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Bagate F, Masi P, Boukantar M, Radu C, Saiydoun G, Fiore A, Chiaroni PM, Teiger E, Folliguet T, Gallet R, Mekontso Dessap A. Refractory cor pulmonale under extracorporeal membrane oxygenation for acute respiratory distress syndrome: the role of conversion to veno-pulmonary arterial assist-a case series. Front Med (Lausanne) 2024; 11:1348077. [PMID: 38725464 PMCID: PMC11079173 DOI: 10.3389/fmed.2024.1348077] [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: 12/01/2023] [Accepted: 04/05/2024] [Indexed: 05/12/2024] Open
Abstract
Introduction Pulmonary vascular dysfunction during severe acute respiratory distress syndrome (ARDS) may lead to right ventricle (RV) dysfunction and acute cor pulmonale (ACP). The occurrence/persistence of ACP despite conventional extracorporeal membrane oxygenation (ECMO) is a challenging situation. We explored the usefulness of a specific dual-lumen cannula that bypasses the RV, and on which a veno-pulmonary arterial assist (V-P ECMO) was mounted, in ARDS patients. Methods We report a case-series of ARDS patients put on conventional veno-arterial or veno-venous ECMO and presented refractory ACP as an indication for a reconfiguration to V-P ECMO using the ProtekDuo cannula. The primary endpoint was the mitigation of RV and pulmonary vascular dysfunction as assessed by the change in end-diastolic RV/left ventricle (LV) surface ratio. Results Six patients had their conventional ECMO reconfigured to V-P ECMO to treat refractory ACP. There was a decrease in end-diastolic RV/LV surface ratio, as well as end-systolic LV eccentricity index, and lactatemia immediately after V-P ECMO initiation. The resolution of refractory ACP was immediately achieved in four of our six (66%) patients. The V-P ECMO was weaned after a median of 26 [8-93] days after implantation. All but one patient were discharged home. We detected one case of severe hemolysis with V-P ECMO and two suspected cases of right-sided infective endocarditis. Conclusion V-P ECMO is useful to mitigate RV overload and to improve hemodynamics in case of refractory ACP despite conventional ECMO.
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Affiliation(s)
- François Bagate
- AP-HP, Hôpitaux Universitaires Henri Mondor, DHU A-TVB, Service de Médecine Intensive Réanimation, Créteil, France
- Université Paris Est Créteil, Faculté de Médecine, Groupe de recherche clinique CARMAS, Créteil, France
| | - Paul Masi
- AP-HP, Hôpitaux Universitaires Henri Mondor, DHU A-TVB, Service de Médecine Intensive Réanimation, Créteil, France
- Université Paris Est Créteil, Faculté de Médecine, Groupe de recherche clinique CARMAS, Créteil, France
| | - Madjid Boukantar
- APHP, Hôpitaux Universitaires Henri Mondor, Service de Cardiologie, Créteil, France
| | - Costin Radu
- APHP, Hôpitaux Universitaires Henri Mondor, Département de Chirurgie Cardiaque, Créteil, France
| | - Gabriel Saiydoun
- APHP, Hôpitaux Universitaires Henri Mondor, Département de Chirurgie Cardiaque, Créteil, France
| | - Antonio Fiore
- APHP, Hôpitaux Universitaires Henri Mondor, Département de Chirurgie Cardiaque, Créteil, France
| | | | - Emmanuel Teiger
- APHP, Hôpitaux Universitaires Henri Mondor, Service de Cardiologie, Créteil, France
| | - Thierry Folliguet
- APHP, Hôpitaux Universitaires Henri Mondor, Département de Chirurgie Cardiaque, Créteil, France
| | - Romain Gallet
- APHP, Hôpitaux Universitaires Henri Mondor, Service de Cardiologie, Créteil, France
- U955-IMRB, Equipe 03, Inserm, Univ Paris Est Créteil (UPEC), Ecole Nationale Vétérinaire d’Alfort (EnVA), Maisons-Alfort, France
| | - Armand Mekontso Dessap
- AP-HP, Hôpitaux Universitaires Henri Mondor, DHU A-TVB, Service de Médecine Intensive Réanimation, Créteil, France
- Université Paris Est Créteil, Faculté de Médecine, Groupe de recherche clinique CARMAS, Créteil, France
- INSERM U955, Institut Mondor de Recherche Biomédicale, Créteil, France
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Petit M, Bouaoud M, Jullien E, Joseph A, Evrard B, Charron C, Daulasim A, Legras A, Gourraud M, Goudelin M, Vignon P, Vieillard-Baron A. Right ventricular injury in patients with COVID-19-related ARDS eligible for ECMO support: a multicenter retrospective study. Ann Intensive Care 2024; 14:40. [PMID: 38532049 DOI: 10.1186/s13613-024-01256-8] [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: 11/17/2023] [Accepted: 01/29/2024] [Indexed: 03/28/2024] Open
Abstract
BACKGROUND Coronavirus disease 2019 (COVID-19)-related acute respiratory distress syndrome (ARDS) is associated with high mortality. Extracorporeal membrane oxygenation (ECMO) has been proposed in this setting, but optimal criteria to select target patients remain unknown. Our hypothesis is that evaluation of right ventricular (RV) function could be helpful. The aims of our study were to report the incidence and outcomes of patients eligible for ECMO according to EOLIA criteria, and to identify a subgroup of patients with RV injury, which could be a target for ECMO. METHODS Retrospective observational study involving 3 French intensive care units (ICUs) of teaching hospitals. Patients with confirmed SARS-CoV-2 infection between March 2020 and March 2021, presenting ARDS and with available echocardiography, were included. Patients were classified in three groups according to whether or not they met the EOLIA criteria and the presence of RV injury (RVI) ("EOLIA -", "EOLIA + RVI -" and "EOLIA + RVI + "). RVI was defined by the association of RV to left ventricular end-diastolic area ratio > 0.8 and paradoxical septal motion. Kaplan-Meier survival curves were used to analyze outcome as well as a Cox model for 90 day mortality. RESULTS 915 patients were hospitalized for COVID-19, 418 of them with ARDS. A total of 283 patients with available echocardiography were included. Eighteen (6.3%) patients received ECMO. After exclusion of these patients, 107 (40.5%) were classified as EOLIA -, 126 (47.5%) as EOLIA + RVI -, and 32 (12%) as EOLIA + RVI + . Ninety-day mortality was 21% in the EOLIA-group, 44% in the EOLIA + RVI-group, and 66% in the EOLIA + RVI + group (p < 0.001). After adjustment, RVI was statistically associated with 90-day mortality (HR = 1.92 [1.10-3.37]). CONCLUSIONS Among COVID-19-associated ARDS patients who met the EOLIA criteria, those with significant RV pressure overload had a particularly poor outcome. This subgroup may be a more specific target for ECMO. This represented 12% of our cohort compared to 60% of patients who met the EOLIA criteria only. How the identification of this high-risk subset of patients translates into patient-centered outcomes remains to be evaluated.
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Affiliation(s)
- Matthieu Petit
- Medical Intensive Care Unit, Ambroise Paré Hospital, APHP, 9 Avenue Charles de Gaulles, Boulogne-Billancourt, France
- Paris-Saclay University, UVSQ, Inserm, CESP, 94807, Villejuif, France
| | - Misylias Bouaoud
- Intensive Care Unit, University Hospital of Tours, Tours, France
| | - Edouard Jullien
- Medical Intensive Care Unit, Ambroise Paré Hospital, APHP, 9 Avenue Charles de Gaulles, Boulogne-Billancourt, France
| | - Adrien Joseph
- Medical Intensive Care Unit, Ambroise Paré Hospital, APHP, 9 Avenue Charles de Gaulles, Boulogne-Billancourt, France
| | - Bruno Evrard
- Medical-Surgical Intensive Care Unit and Inserm CIC 1435, Dupuytren Teaching Hospital, 87000, Limoges, France
| | - Cyril Charron
- Medical Intensive Care Unit, Ambroise Paré Hospital, APHP, 9 Avenue Charles de Gaulles, Boulogne-Billancourt, France
| | - Anousone Daulasim
- Medical Intensive Care Unit, Ambroise Paré Hospital, APHP, 9 Avenue Charles de Gaulles, Boulogne-Billancourt, France
| | - Annick Legras
- Intensive Care Unit, University Hospital of Tours, Tours, France
| | - Maeva Gourraud
- Intensive Care Unit, University Hospital of Tours, Tours, France
| | - Marine Goudelin
- Medical-Surgical Intensive Care Unit and Inserm CIC 1435, Dupuytren Teaching Hospital, 87000, Limoges, France
| | - Philippe Vignon
- Medical-Surgical Intensive Care Unit and Inserm CIC 1435, Dupuytren Teaching Hospital, 87000, Limoges, France
| | - Antoine Vieillard-Baron
- Medical Intensive Care Unit, Ambroise Paré Hospital, APHP, 9 Avenue Charles de Gaulles, Boulogne-Billancourt, France.
- Paris-Saclay University, UVSQ, Inserm, CESP, 94807, Villejuif, France.
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Penaud V, Duburcq T, Bureau C, Salmon Gandonnière C, Arrestier R, Henri S, Dres M, Jacquier S, Prost ND, Giraud R, Ricard JD, Roux D, Uhel F, Legouis D, Verney C. Kidney Increase Natriuresis but Not Glomerular Filtration Under Veno-venous ECMO, a Retrospective Study. J Intensive Care Med 2024; 39:146-152. [PMID: 37632128 DOI: 10.1177/08850666231195755] [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] [Indexed: 08/27/2023]
Abstract
PURPOSE Acute kidney injury is a frequent complication of acute respiratory distress syndrome (ARDS). We aim to study the evolution of kidney function in patients presenting severe ARDS and requiring veno-venous extracorporeal membrane oxygenation (VV ECMO). METHODS We conducted a multicenter retrospective study, including adult patients requiring VV ECMO for ARDS. The primary outcome was the evolution of the serum creatinine level after VV ECMO initiation. Secondary outcomes were change in urine output, and urine biochemical parameters after VV ECMO initiation. RESULTS One hundred and two patients were included. VV ECMO was initiated after a median of 6 days of mechanical ventilation, mainly for ARDS caused by COVID-19 (73%). Serum creatinine level did not significantly differ after VV ECMO initiation (P = .20). VV ECMO was associated with a significant increase in daily urine output (+6.6 mL/kg/day, [3.8;9.3] P < .001), even after adjustment for potential confounding factors; with an increase in natriuresis. The increase in urine output under VV ECMO was associated with a reduced risk of receiving kidney replacement therapy (OR 0.4 [0.2;0.8], P = .026). CONCLUSIONS VV ECMO initiation in severe ARDS is associated with an increase in daily urine output and natriuresis, without change in glomerular filtration rate.
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Affiliation(s)
- Victor Penaud
- Médecine Intensive Réanimation, AP-HP, Hôpital Louis Mourier, DMU ESPRIT, Colombes, France
| | | | - Côme Bureau
- Médecine Intensive et Réanimation - R3S, AP-HP, Hôpital Pitié-Salpêtrière, Paris Sorbonne Université, Paris, France
- Sorbonne Université, INSERM_1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
| | - Charlotte Salmon Gandonnière
- Université François Rabelais, CHRU de Tours, Médecine Intensive Réanimation, INSERM CIC 1415, CRICS-TriggerSep Research Network, Tours, France
| | - Romain Arrestier
- Médecine Intensive Réanimation, AP-HP, Hôpitaux Universitaires Henri-Mondor, Université Paris Est Créteil, Créteil, France
| | - Samuel Henri
- Médecine Intensive Réanimation, CHU Lille, Lille, France
| | - Martin Dres
- Médecine Intensive et Réanimation - R3S, AP-HP, Hôpital Pitié-Salpêtrière, Paris Sorbonne Université, Paris, France
- Sorbonne Université, INSERM_1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
| | - Sophie Jacquier
- Université François Rabelais, CHRU de Tours, Médecine Intensive Réanimation, INSERM CIC 1415, CRICS-TriggerSep Research Network, Tours, France
| | - Nicolas De Prost
- Médecine Intensive Réanimation, AP-HP, Hôpitaux Universitaires Henri-Mondor, Université Paris Est Créteil, Créteil, France
| | - Raphael Giraud
- Département de Soins Intensifs, Hôpitaux Universitaires de Genève, Genève, Suisse
| | - Jean-Damien Ricard
- Médecine Intensive Réanimation, AP-HP, Hôpital Louis Mourier, DMU ESPRIT, Colombes, France
- Université Paris Cité, UMR1137 IAME, INSERM, Paris, France
| | - Damien Roux
- Médecine Intensive Réanimation, AP-HP, Hôpital Louis Mourier, DMU ESPRIT, Colombes, France
- Université Paris Cité, INSERM UMR-S1151, CNRS UMR-S8253, Institut Necker-Enfants Malades, Paris, France
| | - Fabrice Uhel
- Médecine Intensive Réanimation, AP-HP, Hôpital Louis Mourier, DMU ESPRIT, Colombes, France
- Université Paris Cité, INSERM UMR-S1151, CNRS UMR-S8253, Institut Necker-Enfants Malades, Paris, France
| | - David Legouis
- Département de Soins Intensifs, Hôpitaux Universitaires de Genève, Genève, Suisse
- Département de physiologie cellulaire, Faculté de Médecine, Université de Genève, Genève, Suisse
| | - Charles Verney
- Médecine Intensive Réanimation, AP-HP, Hôpital Louis Mourier, DMU ESPRIT, Colombes, France
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Bowcock E, Huang S, Yeo R, Walisundara D, Duncan CF, Pathan F, Strange G, Playford D, Orde S. The value of right ventricular to pulmonary arterial coupling in the critically ill: a National Echocardiography Database of Australia (NEDA) substudy. Ann Intensive Care 2024; 14:10. [PMID: 38228991 DOI: 10.1186/s13613-024-01242-0] [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: 09/13/2023] [Accepted: 01/02/2024] [Indexed: 01/18/2024] Open
Abstract
BACKGROUND Right ventricular (RV) function is tightly coupled to afterload, yet echocardiographic indices of RV function are frequently assessed in isolation. Normalizing RV function for afterload (RV-PA coupling) using a simplified ratio of tricuspid annular plane systolic excursion (TAPSE)/ tricuspid regurgitant velocity (TRV) could help to identify RV decompensation and improve risk stratification in critically ill patients. This is the first study to explore the distribution of TAPSE/TRV ratio and its prognostic relevance in a large general critical care cohort. METHODS We undertook retrospective analysis of echocardiographic, clinical, and mortality data of intensive care unit (ICU) patients between January 2012 and May 2017. A total of 1077 patients were included and stratified into tertile groups based on TAPSE/TRV ratio: low (< 5.9 mm.(m/s)-1), middle (≥ 5.9-8.02 mm.(m/s)-1), and high (≥ 8.03 mm.(m/s)-1). The distribution of the TAPSE/TRV ratio across ventricular function subtypes of normal, isolated left ventricular (LV), isolated RV, and biventricular dysfunction was explored. The overall prognostic relevance of the TAPSE/TRV ratio was tested, including distribution across septic, cardiovascular, respiratory, and neurological subgroups. RESULTS Higher proportions of ventricular dysfunctions were seen in low TAPSE/TRV tertiles. TAPSE/TRV ratio is impacted by LV systolic function but to a lesser extent than RV dysfunction or biventricular dysfunction. There was a strong inverse relationship between TAPSE/TRV ratio and survival. After multivariate analysis, higher TAPSE/TRV ratios (indicating better RV-PA coupling) were independently associated with lower risk of death in ICU (HR 0.927 [0.872-0.985], p < 0.05). Kaplan-Meier analysis demonstrated higher overall survival in middle and high tertiles compared to low tertiles (log rank p < 0.0001). The prognostic relevance of TAPSE/TRV ratio was strongest in respiratory and sepsis subgroups. Patients with TAPSE/TRV < 5.9 mm (m/s)-1 had a significantly worse prognosis than those with higher TAPSE/TRV ratios. CONCLUSION The TAPSE/TRV ratio has prognostic relevance in critically ill patients. The prognostic power may be stronger in respiratory and septic subgroups. Larger prospective studies are needed to investigate the role of TAPSE/TRV in pre-specified subgroups including its role in clinical decision-making.
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Affiliation(s)
- Emma Bowcock
- Intensive Care Medicine, Nepean Hospital, Sydney, Australia.
- University of Sydney, Sydney, Australia.
| | - Stephen Huang
- Intensive Care Medicine, Nepean Hospital, Sydney, Australia
- University of Sydney, Sydney, Australia
| | - Rachel Yeo
- Intensive Care Medicine, Nepean Hospital, Sydney, Australia
| | | | - Chris F Duncan
- Intensive Care Medicine, Nepean Hospital, Sydney, Australia
| | - Faraz Pathan
- University of Sydney, Sydney, Australia
- Department of Cardiology, Nepean Hospital, Sydney, Australia
| | - Geoffrey Strange
- University of Sydney, Sydney, Australia
- The University of Notre Dame, Fremantle, Australia
| | | | - Sam Orde
- Intensive Care Medicine, Nepean Hospital, Sydney, Australia
- University of Sydney, Sydney, Australia
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Bachmann KF, Berger D, Moller PW. Interactions between extracorporeal support and the cardiopulmonary system. Front Physiol 2023; 14:1231016. [PMID: 37772062 PMCID: PMC10523013 DOI: 10.3389/fphys.2023.1231016] [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: 05/29/2023] [Accepted: 08/29/2023] [Indexed: 09/30/2023] Open
Abstract
This review describes the intricate physiological interactions involved in the application of extracorporeal therapy, with specific focus on cardiopulmonary relationships. Extracorporeal therapy significantly influences cardiovascular and pulmonary physiology, highlighting the necessity for clinicians to understand these interactions for improved patient care. Veno-arterial extracorporeal membrane oxygenation (veno-arterial ECMO) unloads the right ventricle and increases left ventricular (LV) afterload, potentially exacerbating LV failure and pulmonary edema. Veno-venous (VV) ECMO presents different challenges, where optimal device and ventilator settings remain unknown. Influences on right heart function and native gas exchange as well as end-expiratory lung volumes are important concepts that should be incorporated into daily practice. Future studies should not be limited to large clinical trials focused on mortality but rather address physiological questions to advance the understanding of extracorporeal therapies. This includes exploring optimal device and ventilator settings in VV ECMO, standardizing cardiopulmonary function monitoring strategies, and developing better strategies for device management throughout their use. In this regard, small human or animal studies and computational physiological modeling may contribute valuable insights into optimizing the management of extracorporeal therapies.
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Affiliation(s)
- Kaspar F. Bachmann
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of Anaesthesiology and Intensive Care, University of Tartu, Tartu, Estonia
| | - David Berger
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Per Werner Moller
- Department of Anaesthesia, SV Hospital Group, Institute of Clinical Sciences at the Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Webb L, Burton L, Manchikalapati A, Prabhakaran P, Loberger JM, Richter RP. Cardiac dysfunction in severe pediatric acute respiratory distress syndrome: the right ventricle in search of the right therapy. Front Med (Lausanne) 2023; 10:1216538. [PMID: 37654664 PMCID: PMC10466806 DOI: 10.3389/fmed.2023.1216538] [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: 05/04/2023] [Accepted: 07/21/2023] [Indexed: 09/02/2023] Open
Abstract
Severe acute respiratory distress syndrome in children, or PARDS, carries a high risk of morbidity and mortality that is not fully explained by PARDS severity alone. Right ventricular (RV) dysfunction can be an insidious and often under-recognized complication of severe PARDS that may contribute to its untoward outcomes. Indeed, recent evidence suggest significantly worse outcomes in children who develop RV failure in their course of PARDS. However, in this narrative review, we highlight the dearth of evidence regarding the incidence of and risk factors for PARDS-associated RV dysfunction. While we wish to draw attention to the absence of available evidence that would inform recommendations around surveillance and treatment of RV dysfunction during severe PARDS, we leverage available evidence to glean insights into potentially helpful surveillance strategies and therapeutic approaches.
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Affiliation(s)
- Lece Webb
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Luke Burton
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Ananya Manchikalapati
- Division of Pediatric Critical Care, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Priya Prabhakaran
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Jeremy M. Loberger
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Robert P. Richter
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, United States
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Brown TN, Brogan TV. Right ventricular dysfunction in patients with acute respiratory distress syndrome receiving venovenous extracorporeal membrane oxygenation. Front Cardiovasc Med 2023; 10:1027300. [PMID: 37265572 PMCID: PMC10229794 DOI: 10.3389/fcvm.2023.1027300] [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: 08/24/2022] [Accepted: 04/10/2023] [Indexed: 06/03/2023] Open
Abstract
Acute respiratory distress syndrome is characterized by non-cardiogenic pulmonary edema, decreased pulmonary compliance, and abnormalities in gas exchange, especially hypoxemia. Patients with acute respiratory distress syndrome (ARDS) who receive support with venovenous (V-V) extracorporeal membrane oxygenation (ECMO) usually have severe lung disease. Many patients with ARDS have associated pulmonary vascular injury which can result in elevated pulmonary vascular resistance and right heart dysfunction. Since V-V ECMO relies upon preserved cardiac function, right heart failure has important implications for patient evaluation, management, and outcomes. Worsening right heart function complicates ARDS and disease processes. Given the increasing use of ECMO to support patients with ARDS, an understanding of right ventricular-ECMO and cardiopulmonary interactions is essential for the clinician. A narrative review of the manifestations of right heart dysfunction, as well as diagnosis and management strategies for the patient with ARDS on ECMO, is provided.
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Affiliation(s)
- Tyler N. Brown
- Pediatric Critical Care Medicine, University of Washington School of Medicine, Seattle Children’s Hospital, Seattle, Washington, United States
| | - Thomas V. Brogan
- Department of Pediatrics, University of Washington School of Medicine, Seattle Children’s Hospital, Seattle, Washington, United States
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8
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Bos LDJ, Ware LB. Acute respiratory distress syndrome: causes, pathophysiology, and phenotypes. Lancet 2022; 400:1145-1156. [PMID: 36070787 DOI: 10.1016/s0140-6736(22)01485-4] [Citation(s) in RCA: 135] [Impact Index Per Article: 67.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 07/14/2022] [Accepted: 07/27/2022] [Indexed: 12/15/2022]
Abstract
Acute respiratory distress syndrome (ARDS) is a common clinical syndrome of acute respiratory failure as a result of diffuse lung inflammation and oedema. ARDS can be precipitated by a variety of causes. The pathophysiology of ARDS is complex and involves the activation and dysregulation of multiple overlapping and interacting pathways of injury, inflammation, and coagulation, both in the lung and systemically. Mechanical ventilation can contribute to a cycle of lung injury and inflammation. Resolution of inflammation is a coordinated process that requires downregulation of proinflammatory pathways and upregulation of anti-inflammatory pathways. The heterogeneity of the clinical syndrome, along with its biology, physiology, and radiology, has increasingly been recognised and incorporated into identification of phenotypes. A precision-medicine approach that improves the identification of more homogeneous ARDS phenotypes should lead to an improved understanding of its pathophysiological mechanisms and how they differ from patient to patient.
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Affiliation(s)
- Lieuwe D J Bos
- Intensive Care, Amsterdam UMC-location AMC, University of Amsterdam, Amsterdam, Netherlands
| | - Lorraine B Ware
- Vanderbilt University School of Medicine, Medical Center North, Vanderbilt University, Nashville, TN, USA.
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