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Hendrickson KW, Cirulis MM, Burk RE, Lanspa MJ, Peltan ID, Marshall H, Groat D, Jephson A, Beesley SJ, Brown SM. Identifying predictors and determining mortality rates of septic cardiomyopathy and sepsis-related cardiogenic shock: A retrospective, observational study. PLoS One 2024; 19:e0299876. [PMID: 38662672 PMCID: PMC11045062 DOI: 10.1371/journal.pone.0299876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 02/16/2024] [Indexed: 04/28/2024] Open
Abstract
INTRODUCTION Septic shock is a severe form of sepsis that has a high mortality rate, and a substantial proportion of these patients will develop cardiac dysfunction, often termed septic cardiomyopathy (SCM). Some SCM patients may develop frank cardiac failure, termed sepsis-related cardiogenic shock (SeRCS). Little is known of SeRCS. This study describes baseline characteristics of patients with SCM and SeRCS compared to patients with septic shock without cardiac dysfunction. We compare clinical outcomes among SCM, SeRCS, and septic shock, and identify risk factors for the development of SCM and SeRCS. METHODS Septic patients admitted to the ICU with an echocardiogram obtained within 72 hours were included. Left ventricular ejection fraction of ≤55% was used to define SCM, and cardiac index ≤2.1 L/min/m2 among patients with SCM defined SeRCS. Machine learning was used to identify risk factors for development of SCM and SeRCS. Logistic regression was used to compare mortality among groups. RESULTS Among 1229 patients, 977 patients had septic shock without cardiac dysfunction, 207 had SCM, and 45 had SeRCS. In patients with septic shock, the strongest predictor for developing SCM and SeRCs was a prior history of cardiac dysfunction. Mortality did not significantly differ among the three groups. CONCLUSIONS SCM and SeRCS affect a minority of patients with septic shock, disproportionately affecting individuals with a history of cardiac disease. We did not identify a mortality difference associated with SCM or SeRCS. Additional work is needed to define further subtypes and treatment options for this patient population.
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Affiliation(s)
- Kathryn W. Hendrickson
- The Oregon Clinic Department of Pulmonary, Critical Care, and Sleep Medicine East, Portland, OR, United States of America
| | - Meghan M. Cirulis
- Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Salt Lake City, UT, United States of America
- Division of Pulmonary and Critical Care Medicine, University of Utah, Salt Lake City, UT, United States of America
| | - Rebecca E. Burk
- Renown Medical Group Department of Pulmonary and Critical Care Medicine, Reno, NV, United States of America
| | - Michael J. Lanspa
- Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Salt Lake City, UT, United States of America
- Division of Pulmonary and Critical Care Medicine, University of Utah, Salt Lake City, UT, United States of America
| | - Ithan D. Peltan
- Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Salt Lake City, UT, United States of America
- Division of Pulmonary and Critical Care Medicine, University of Utah, Salt Lake City, UT, United States of America
| | - Hunter Marshall
- Division of Pulmonary and Critical Care Medicine, University of Utah, Salt Lake City, UT, United States of America
| | - Danielle Groat
- Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Salt Lake City, UT, United States of America
- Intermountain Healthcare, Information and Analytics, Salt Lake City, UT, United States of America
| | - Al Jephson
- Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Salt Lake City, UT, United States of America
- Intermountain Healthcare, Information and Analytics, Salt Lake City, UT, United States of America
| | - Sarah J. Beesley
- Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Salt Lake City, UT, United States of America
- Division of Pulmonary and Critical Care Medicine, University of Utah, Salt Lake City, UT, United States of America
| | - Samuel M. Brown
- Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Salt Lake City, UT, United States of America
- Division of Pulmonary and Critical Care Medicine, University of Utah, Salt Lake City, UT, United States of America
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Morland K, Gerges C, Elwing J, Visovatti SH, Weatherald J, Gillmeyer KR, Sahay S, Mathai SC, Boucly A, Williams PG, Harikrishnan S, Minty EP, Hobohm L, Jose A, Badagliacca R, Lau EMT, Jing Z, Vanderpool RR, Fauvel C, Leonidas Alves J, Strange G, Pulido T, Qian J, Li M, Mercurio V, Zelt JGE, Moles VM, Cirulis MM, Nikkho SM, Benza RL, Elliott CG. Real-world evidence to advance knowledge in pulmonary hypertension: Status, challenges, and opportunities. A consensus statement from the Pulmonary Vascular Research Institute's Innovative Drug Development Initiative's Real-world Evidence Working Group. Pulm Circ 2023; 13:e12317. [PMID: 38144948 PMCID: PMC10739115 DOI: 10.1002/pul2.12317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 10/26/2023] [Accepted: 11/21/2023] [Indexed: 12/26/2023] Open
Abstract
This manuscript on real-world evidence (RWE) in pulmonary hypertension (PH) incorporates the broad experience of members of the Pulmonary Vascular Research Institute's Innovative Drug Development Initiative Real-World Evidence Working Group. We aim to strengthen the research community's understanding of RWE in PH to facilitate clinical research advances and ultimately improve patient care. Herein, we review real-world data (RWD) sources, discuss challenges and opportunities when using RWD sources to study PH populations, and identify resources needed to support the generation of meaningful RWE for the global PH community.
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Affiliation(s)
- Kellie Morland
- Global Medical AffairsUnited Therapeutics CorporationResearch Triangle ParkNorth CarolinaUSA
| | - Christian Gerges
- Department of Internal Medicine II, Division of CardiologyMedical University of ViennaViennaAustria
| | - Jean Elwing
- Division of Pulmonary, Critical Care, and Sleep MedicineUniversity of CincinnatiCincinnatiOhioUSA
| | - Scott H. Visovatti
- Division of Cardiovascular MedicineThe Ohio State UniversityColumbusOhioUSA
| | - Jason Weatherald
- Department of Medicine, Division of Pulmonary MedicineUniversity of AlbertaEdmontonCanada
| | - Kari R. Gillmeyer
- The Pulmonary CenterBoston University Chobian & Avedisian School of MedicineBostonMassachusettsUSA
- Center for Healthcare Organization & Implementation ResearchVA Bedford Healthcare System and VA Boston Healthcare SystemBedfordMassachusettsUSA
| | - Sandeep Sahay
- Division of Pulmonary, Critical Care & Sleep MedicineHouston Methodist HospitalHoustonTexasUSA
| | - Stephen C. Mathai
- Division of Pulmonary and Critical Care MedicineJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Athénaïs Boucly
- Faculté de MédecineUniversité Paris‐SaclayLe Kremlin‐BicêtreFrance
- Service de Pneumologie et Soins Intensifs Respiratoires, Centre de Référence de l'Hypertension Pulmonaire, Hôpital BicêtreAssistance Publique Hôpitaux de ParisLe Kremlin BicêtreFrance
- National Heart and Lung InstituteImperial CollegeLondonUK
| | - Paul G. Williams
- Center of Chest Diseases & Critical CareMilpark HospitalJohannesburgSouth Africa
| | | | - Evan P. Minty
- Department of Medicine & O'Brien Institute for Public HealthUniversity of CalgaryCalgaryCanada
| | - Lukas Hobohm
- Department of CardiologyUniversity Medical Center of the Johannes Gutenberg University MainzMainzGermany
- Center for Thrombosis and Hemostasis (CTH)University Medical Center of the Johannes Gutenberg University MainzMainzGermany
| | - Arun Jose
- Division of Pulmonary, Critical Care, and Sleep MedicineUniversity of CincinnatiCincinnatiOhioUSA
| | - Roberto Badagliacca
- Department of Clinical, Anesthesiological and Cardiovascular Sciences, Sapienza University of RomePoliclinico Umberto IRomeItaly
| | - Edmund M. T. Lau
- Department of Respiratory Medicine, Royal Prince Alfred HospitalUniversity of SydneyCamperdownNew South WalesAustralia
- Faculty of Medicine and HealthUniversity of SydneyCamperdownNew South WalesAustralia
| | - Zhi‐Cheng Jing
- State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College HospitalChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | | | - Charles Fauvel
- Service de Cardiologie, Centre de Compétence en Hypertension Pulmonaire 27/76, Centre Hospitalier Universitaire Charles Nicolle, INSERM EnVI U1096Université de RouenRouenFrance
| | - Jose Leonidas Alves
- Pulmonary Division, Heart InstituteUniversity of São Paulo Medical SchoolSão PauloBrazil
| | - Geoff Strange
- School of MedicineThe University of Notre Dame AustraliaPerthWestern AustraliaAustralia
| | - Tomas Pulido
- Ignacio Chávez National Heart InstituteMéxico CityMexico
| | - Junyan Qian
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC‐DID), Ministry of Science & Technology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH), Key Laboratory of Rheumatology and Clinical ImmunologyMinistry of EducationBeijingChina
| | - Mengtao Li
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC‐DID), Ministry of Science & Technology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH), Key Laboratory of Rheumatology and Clinical ImmunologyMinistry of EducationBeijingChina
| | - Valentina Mercurio
- Department of Translational Medical SciencesFederico II UniversityNaplesItaly
| | - Jason G. E. Zelt
- Department of Medicine, Faculty of MedicineUniversity of OttawaOttawaCanada
| | - Victor M. Moles
- Division of Cardiovascular MedicineUniversity of MichiganAnn ArborMichiganUSA
| | - Meghan M. Cirulis
- Division of Pulmonary and Critical Care MedicineUniversity of UtahSalt Lake CityUtahUSA
- Department of Pulmonary and Critical Care MedicineIntermountain Medical Center MurraySalt Lake CityUtahUSA
| | | | - Raymond L. Benza
- Mount Sinai HeartIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - C. Gregory Elliott
- Division of Pulmonary and Critical Care MedicineUniversity of UtahSalt Lake CityUtahUSA
- Department of Pulmonary and Critical Care MedicineIntermountain Medical Center MurraySalt Lake CityUtahUSA
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3
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Lanspa MJ, Dugar SP, Prigmore HL, Boyd JS, Rupp JD, Lindsell CJ, Rice TW, Qadir N, Lim GW, Shiloh AL, Dieiev V, Gong MN, Fox SW, Hirshberg EL, Khan A, Kornfield J, Schoeneck JH, Macklin N, Files DC, Gibbs KW, Prekker ME, Parsons-Moss D, Bown M, Olsen TD, Knox DB, Cirulis MM, Mehkri O, Duggal A, Tenforde MW, Patel MM, Self WH, Brown SM. Early Serial Echocardiographic and Ultrasonographic Findings in Critically Ill Patients With COVID-19. CHEST Crit Care 2023; 1:100002. [PMID: 38014378 PMCID: PMC10030437 DOI: 10.1016/j.chstcc.2023.100002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/24/2023]
Abstract
Background Cardiac function of critically ill patients with COVID-19 generally has been reported from clinically obtained data. Echocardiographic deformation imaging can identify ventricular dysfunction missed by traditional echocardiographic assessment. Research Question What is the prevalence of ventricular dysfunction and what are its implications for the natural history of critical COVID-19? Study Design and Methods This is a multicenter prospective cohort of critically ill patients with COVID-19. We performed serial echocardiography and lower extremity vascular ultrasound on hospitalization days 1, 3, and 8. We defined left ventricular (LV) dysfunction as the absolute value of longitudinal strain of < 17% or left ventricle ejection fraction (LVEF) of < 50%. Primary clinical outcome was inpatient survival. Results We enrolled 110 patients. Thirty-nine (35.5%) died before hospital discharge. LV dysfunction was present at admission in 38 patients (34.5%) and in 21 patients (36.2%) on day 8 (P = .59). Median baseline LVEF was 62% (interquartile range [IQR], 52%-69%), whereas median absolute value of baseline LV strain was 16% (IQR, 14%-19%). Survivors and nonsurvivors did not differ statistically significantly with respect to day 1 LV strain (17.9% vs 14.4%; P = .12) or day 1 LVEF (60.5% vs 65%; P = .06). Nonsurvivors showed worse day 1 right ventricle (RV) strain than survivors (16.3% vs 21.2%; P = .04). Interpretation Among patients with critical COVID-19, LV and RV dysfunction is common, frequently identified only through deformation imaging, and early (day 1) RV dysfunction may be associated with clinical outcome.
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Affiliation(s)
- Michael J Lanspa
- Shock Trauma ICU, Intermountain Medical Center, Salt Lake City, UT
| | | | | | - Jeremy S Boyd
- Vanderbilt Health, Vanderbilt University, Nashville, TN
| | - Jordan D Rupp
- Vanderbilt Health, Vanderbilt University, Nashville, TN
| | | | - Todd W Rice
- Vanderbilt Comprehensive Care Clinic, Nashville, TN
| | - Nida Qadir
- University of California, Los Angeles, Los Angeles, CA
| | - George W Lim
- University of California, Los Angeles, Los Angeles, CA
| | | | | | | | | | | | - Akram Khan
- Oregon Health and Science University, Portland, OR
| | | | | | | | | | | | | | | | - Mikaele Bown
- Shock Trauma ICU, Intermountain Medical Center, Salt Lake City, UT
| | - Troy D Olsen
- Shock Trauma ICU, Intermountain Medical Center, Salt Lake City, UT
| | - Daniel B Knox
- Shock Trauma ICU, Intermountain Medical Center, Salt Lake City, UT
| | - Meghan M Cirulis
- Shock Trauma ICU, Intermountain Medical Center, Salt Lake City, UT
| | | | | | | | | | | | - Samuel M Brown
- Shock Trauma ICU, Intermountain Medical Center, Salt Lake City, UT
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Scarpato BM, Locke BW, Bledsoe J, Knox DB, Conner K, Stoddard GJ, Cirulis MM, Elliott CG, Dodson MW. The association between pulmonary artery enlargement and mortality in an Emergency Department population undergoing computed tomography pulmonary angiography. Pulm Circ 2023; 13:e12225. [PMID: 37063745 PMCID: PMC10090800 DOI: 10.1002/pul2.12225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 03/16/2023] [Accepted: 04/03/2023] [Indexed: 04/18/2023] Open
Abstract
Findings of an enlarged pulmonary artery diameter (PAd) and increased pulmonary artery to ascending aorta ratio (PA:AA) on contrast-enhanced computed tomography pulmonary angiography (CTPA) are associated with increased mortality in particular groups of patients with cardiopulmonary disease. However, the frequency and prognostic significance of these incidental findings has not been studied in unselected patients evaluated in the Emergency Department (ED). This study aims to determine the prevalence and associated prognosis of enlarged pulmonary artery measurements in an ED cohort. We measured PA and AA diameters on 990 CTPA studies performed in the ED. An enlarged PA diameter was defined as >27 mm in females and >29 mm in males, while an increased PA:AA was defined as >0.9. Poisson regression was performed to calculate prevalence ratios for relevant comorbidities, and multivariable Cox regression was performed to calculate hazard ratios (HR) for mortality of patients with enlarged pulmonary artery measurements. An enlarged PAd was observed in 27.9% of 990 patients and was more commonly observed in older patients and in patients with obesity or heart failure. Conversely, PA:AA was increased in 34.2% of subjects, and was more common in younger patients and those with peripheral vascular disease or obesity. After controlling for age, sex, and comorbidities, both enlarged PAd (HR 1.29, 95% CI 1.00-1.68, p = 0.05) and PA:AA (HR 1.70, 95% CI 1.31-2.22 p < 0.01) were independently associated with mortality. In sum, enlarged PAd and increased PA:AA are common in patients undergoing CTPAs in the ED setting and both are independently associated with mortality.
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Affiliation(s)
- Brittany M. Scarpato
- Division of Pulmonary and Critical Care MedicineUniversity of UtahSalt Lake CityUtahUSA
- Department of Pulmonary and Critical Care MedicineIntermountain Medical CenterMurrayUtahUSA
| | - Brian W. Locke
- Division of Pulmonary and Critical Care MedicineUniversity of UtahSalt Lake CityUtahUSA
- Department of Pulmonary and Critical Care MedicineIntermountain Medical CenterMurrayUtahUSA
| | - Joseph Bledsoe
- Division of Emergency MedicineIntermountain Medical CenterMurrayUtahUSA
- Department of Emergency MedicineStanford MedicineStanfordCaliforniaUSA
| | - Daniel B. Knox
- Department of Pulmonary and Critical Care MedicineIntermountain Medical CenterMurrayUtahUSA
| | - Karen Conner
- Division of RadiologyIntermountain Medical CenterMurrayUtahUSA
| | | | - Meghan M. Cirulis
- Division of Pulmonary and Critical Care MedicineUniversity of UtahSalt Lake CityUtahUSA
- Department of Pulmonary and Critical Care MedicineIntermountain Medical CenterMurrayUtahUSA
- Department of Pulmonary and Critical Care MedicinePulmonary Hypertension Care Center, Intermountain Medical CenterUtahMurrayUSA
| | - Charles Gregory Elliott
- Department of Pulmonary and Critical Care MedicineIntermountain Medical CenterMurrayUtahUSA
- Department of Pulmonary and Critical Care MedicinePulmonary Hypertension Care Center, Intermountain Medical CenterUtahMurrayUSA
| | - Mark W. Dodson
- Department of Pulmonary and Critical Care MedicineIntermountain Medical CenterMurrayUtahUSA
- Department of Pulmonary and Critical Care MedicinePulmonary Hypertension Care Center, Intermountain Medical CenterUtahMurrayUSA
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Dodson MW, Cirulis MM, Elliott CG. Analysis of family histories suggests shared genetic risk for chronic thromboembolic pulmonary hypertension and venous thromboembolism. Pulm Circ 2022; 12:e12170. [DOI: 10.1002/pul2.12170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 11/05/2022] [Accepted: 12/02/2022] [Indexed: 12/12/2022] Open
Affiliation(s)
- Mark W. Dodson
- Department of Pulmonary and Critical Care Medicine Intermountain Medical Center Murray Utah
- Division of Pulmonary and Critical Care Medicine University of Utah Salt Lake City Utah
| | - Meghan M. Cirulis
- Department of Pulmonary and Critical Care Medicine Intermountain Medical Center Murray Utah
- Division of Pulmonary and Critical Care Medicine University of Utah Salt Lake City Utah
| | - C. Gregory Elliott
- Department of Pulmonary and Critical Care Medicine Intermountain Medical Center Murray Utah
- Division of Pulmonary and Critical Care Medicine University of Utah Salt Lake City Utah
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Dodson MW, Cirulis MM, Li H, Yue Z, Brown LM, Elliott CG. Frequency of Thrombotic Risk Factors in Patients with Chronic Thromboembolic Pulmonary Hypertension and Acute Pulmonary Embolism: A Case-Control Study. Clin Appl Thromb Hemost 2022; 28:10760296211073277. [PMID: 35000431 PMCID: PMC8744163 DOI: 10.1177/10760296211073277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a serious complication of acute pulmonary embolism (PE) which remains underdiagnosed. A better understanding of risk factors for CTEPH would improve our ability to predict which PE survivors are at risk. Several medical conditions-including malignancy, splenectomy, thyroid hormone supplementation, the presence of an intravascular device, inflammatory bowel disease, osteomyelitis, and non-O blood group-have been associated with increased risk of CTEPH, primarily in studies comparing patients with CTEPH to individuals with non-thrombotic conditions. Because many of these conditions increase thrombosis risk, it remains unclear whether their association with CTEPH reflects a general effect on thrombosis risk, or a specific effect on the risk of developing CTEPH as an outcome of thrombosis. We performed a case-control study comparing the frequencies of these conditions in patients with CTEPH versus patients with acute PE who did not develop CTEPH. The conditions studied were equally frequent in the CTEPH and PE cohorts, although there was a trend towards an increased frequency of splenectomy and non-O blood group among the CTEPH cohort. Thus, other than the possible exceptions of splenectomy and non-O blood group, the investigated medical conditions do not appear likely to increase the risk of CTEPH as an outcome of acute PE, and thus are unlikely to be useful in predicting CTEPH risk among PE survivors.
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Affiliation(s)
- Mark W Dodson
- 7061Intermountain Medical Center, Murray, Utah, USA.,14434University of Utah, Salt Lake City, Utah, USA
| | - Meghan M Cirulis
- 7061Intermountain Medical Center, Murray, Utah, USA.,14434University of Utah, Salt Lake City, Utah, USA
| | - Haojia Li
- University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Zhang Yue
- University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Lynette M Brown
- 7061Intermountain Medical Center, Murray, Utah, USA.,14434University of Utah, Salt Lake City, Utah, USA
| | - C Gregory Elliott
- 7061Intermountain Medical Center, Murray, Utah, USA.,14434University of Utah, Salt Lake City, Utah, USA
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Lanspa MJ, Cirulis MM, Wiley BM, Olsen TD, Wilson EL, Beesley SM, Brown SM, Hirshberg EL, Grissom CK. Response. Chest 2021; 160:e319-e320. [PMID: 34488980 PMCID: PMC8727847 DOI: 10.1016/j.chest.2021.04.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 04/10/2021] [Indexed: 10/20/2022] Open
Affiliation(s)
- Michael J Lanspa
- Critical Care Echocardiography Service, Intermountain Medical Center, Murray, UT; Division of Pulmonary and Critical Care Medicine, University of Utah, Salt Lake City, UT.
| | - Meghan M Cirulis
- Critical Care Echocardiography Service, Intermountain Medical Center, Murray, UT; Division of Pulmonary and Critical Care Medicine, University of Utah, Salt Lake City, UT
| | - Brandon M Wiley
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Troy D Olsen
- Critical Care Echocardiography Service, Intermountain Medical Center, Murray, UT
| | - Emily L Wilson
- Critical Care Echocardiography Service, Intermountain Medical Center, Murray, UT
| | - Sarah M Beesley
- Critical Care Echocardiography Service, Intermountain Medical Center, Murray, UT; Division of Pulmonary and Critical Care Medicine, University of Utah, Salt Lake City, UT
| | - Samuel M Brown
- Critical Care Echocardiography Service, Intermountain Medical Center, Murray, UT; Division of Pulmonary and Critical Care Medicine, University of Utah, Salt Lake City, UT
| | - Eliotte L Hirshberg
- Critical Care Echocardiography Service, Intermountain Medical Center, Murray, UT; Division of Pulmonary and Critical Care Medicine, University of Utah, Salt Lake City, UT; Division of Pediatric Critical Care, Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Colin K Grissom
- Critical Care Echocardiography Service, Intermountain Medical Center, Murray, UT; Division of Pulmonary and Critical Care Medicine, University of Utah, Salt Lake City, UT
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Lanspa MJ, Olsen TD, Wilson EL, Beesley SM, Brown SM, Hirshberg EL, Grissom CK, Cirulis MM, Wiley BM. Response. Chest 2021; 159:1685-1686. [PMID: 34022006 PMCID: PMC8500995 DOI: 10.1016/j.chest.2020.11.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 11/25/2020] [Indexed: 10/21/2022] Open
Affiliation(s)
- Michael J Lanspa
- Critical Care Echocardiography Service, Intermountain Medical Center, Murray, UT; Division of Pulmonary and Critical Care Medicine, Salt Lake City, UT.
| | - Troy D Olsen
- Critical Care Echocardiography Service, Intermountain Medical Center, Murray, UT
| | - Emily L Wilson
- Critical Care Echocardiography Service, Intermountain Medical Center, Murray, UT
| | - Sarah M Beesley
- Critical Care Echocardiography Service, Intermountain Medical Center, Murray, UT; Division of Pulmonary and Critical Care Medicine, Salt Lake City, UT
| | - Samuel M Brown
- Critical Care Echocardiography Service, Intermountain Medical Center, Murray, UT; Division of Pulmonary and Critical Care Medicine, Salt Lake City, UT
| | - Eliotte L Hirshberg
- Division of Pulmonary and Critical Care Medicine, Salt Lake City, UT; Department of Pediatrics, Division of Pediatric Critical Care, University of Utah, Salt Lake City, UT
| | - Colin K Grissom
- Division of Pulmonary and Critical Care Medicine, Salt Lake City, UT
| | - Meghan M Cirulis
- Division of Pulmonary and Critical Care Medicine, Salt Lake City, UT
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9
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Aberegg SK, Cirulis MM, Maddock SD, Freeman A, Keenan LM, Pirozzi CS, Raman SM, Schroeder J, Mann H, Callahan SJ. Clinical, Bronchoscopic, and Imaging Findings of e-Cigarette, or Vaping, Product Use-Associated Lung Injury Among Patients Treated at an Academic Medical Center. JAMA Netw Open 2020; 3:e2019176. [PMID: 33156346 PMCID: PMC7648253 DOI: 10.1001/jamanetworkopen.2020.19176] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
IMPORTANCE e-Cigarette, or vaping, product use-associated lung injury (EVALI) has caused more than 2800 illnesses and 68 deaths in the United States. Better characterization of this novel illness is needed to inform diagnosis and management. OBJECTIVE To describe the clinical features, bronchoscopic findings, imaging patterns, and outcomes of EVALI. DESIGN, SETTING, AND PARTICIPANTS This case series of 31 adult patients diagnosed with EVALI between June 24 and December 10, 2019, took place at an academic medical center in Salt Lake City, Utah. EXPOSURES e-Cigarette use, also known as vaping. MAIN OUTCOMES AND MEASURES Symptoms, laboratory findings, bronchoscopic results, imaging patterns, and clinical outcomes. RESULTS Data from 31 patients (median [interquartile range] age, 24 [21-31] years) were included in the study. Patients were primarily men (24 [77%]) and White individuals (27 [87%]) who used e-cigarette products containing tetrahydrocannabinol (THC) (29 [94%]). Patients presented with respiratory (30 [97%]), constitutional (28 [90%]), and gastrointestinal (28 [90%]) symptoms. Serum inflammatory markers were elevated in all patients. Bronchoscopy was performed in 23 of 28 inpatients (82%) and bronchoalveolar lavage (BAL) revealed the presence of lipid-laden macrophages (LLMs) in 22 of 24 cases (91%). BAL samples tested positive for Pneumocystis jirovecii (3 patients [13%]), rhinovirus (2 patients [8%]), human metapneumovirus and Aspergillus (1 patient each [4%]); all except human metapneumovirus were determined to be false-positives or clinically inconsequential. The exclusive or dominant computed tomography (CT) pattern was organizing pneumonia in 23 of 26 cases (89%). Patients received antibiotics (26 [84%]) and corticosteroids (24 [77%]), and all survived; 20 patients (65%) seen in follow-up showed marked improvement, but residual symptoms (13 [65%]), radiographic opacities (8 [40%]), and abnormal pulmonary function tests (8 of 18 [44%]) were common. CONCLUSIONS AND RELEVANCE In this case series, patients with EVALI characteristically presented with a flu-like illness with elevated inflammatory markers, LLMs on BAL samples, and an organizing pneumonia pattern on CT imaging. Bronchoscopic testing for infection had a high incidence of false-positive results. Patients had substantial residual abnormal results at early follow-up. These data suggest a limited role for bronchoscopy in typical presentations of EVALI without risk factors for alternative diagnoses and the need for careful longitudinal follow-up.
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Affiliation(s)
- Scott K. Aberegg
- Division of Pulmonary and Critical Care Medicine, University of Utah Health, Salt Lake City
- Division of Respiratory, Critical Care, and Occupational Pulmonary Medicine, University of Utah School of Medicine, Salt Lake City
| | - Meghan M. Cirulis
- Division of Pulmonary and Critical Care Medicine, University of Utah Health, Salt Lake City
| | - Sean D. Maddock
- Division of Pulmonary and Critical Care Medicine, University of Utah Health, Salt Lake City
| | - Andrew Freeman
- Division of Pulmonary and Critical Care Medicine, University of Utah Health, Salt Lake City
| | - Lynn M. Keenan
- Division of Pulmonary and Critical Care Medicine, University of Utah Health, Salt Lake City
- George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, Utah
| | - Cheryl S. Pirozzi
- Division of Pulmonary and Critical Care Medicine, University of Utah Health, Salt Lake City
| | - Sanjeev M. Raman
- Division of Pulmonary and Critical Care Medicine, University of Utah Health, Salt Lake City
| | - Joyce Schroeder
- Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City
| | - Howard Mann
- Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City
| | - Sean J. Callahan
- Division of Pulmonary and Critical Care Medicine, University of Utah Health, Salt Lake City
- George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, Utah
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10
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Dodson MW, Sumner K, Carlsen J, Cirulis MM, Wilson EL, Gadre A, Fernandes TM, Brown LM, Best DH, Elliott CG. The Factor V Leiden variant and risk of chronic thromboembolic pulmonary hypertension. Eur Respir J 2020; 56:13993003.00774-2020. [PMID: 32444403 DOI: 10.1183/13993003.00774-2020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 04/26/2020] [Indexed: 11/05/2022]
Affiliation(s)
- Mark W Dodson
- Dept of Medicine, Intermountain Medical Center, Murray, UT, USA
| | - Kelli Sumner
- ARUP Institute of Clinical and Experimental Pathology, ARUP Laboratories, Salt Lake City, UT, USA
| | - Jadyn Carlsen
- ARUP Institute of Clinical and Experimental Pathology, ARUP Laboratories, Salt Lake City, UT, USA
| | - Meghan M Cirulis
- Dept of Medicine, Intermountain Medical Center, Murray, UT, USA.,Dept of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Emily L Wilson
- Dept of Medicine, Intermountain Medical Center, Murray, UT, USA
| | - Abhishek Gadre
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of California San Diego, La Jolla, CA, USA
| | - Timothy M Fernandes
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of California San Diego, La Jolla, CA, USA
| | - Lynette M Brown
- Dept of Medicine, Intermountain Medical Center, Murray, UT, USA.,Dept of Medicine, University of Utah, Salt Lake City, UT, USA
| | - D Hunter Best
- ARUP Institute of Clinical and Experimental Pathology, ARUP Laboratories, Salt Lake City, UT, USA.,Dept of Pathology, University of Utah, Salt Lake City, UT, USA.,Dept of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - C Gregory Elliott
- Dept of Medicine, Intermountain Medical Center, Murray, UT, USA.,Dept of Medicine, University of Utah, Salt Lake City, UT, USA
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11
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Affiliation(s)
- Meghan M Cirulis
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Utah School of Medicine, Salt Lake City
| | - Sean J Callahan
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Utah School of Medicine, Salt Lake City
| | - Scott K Aberegg
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Utah School of Medicine, Salt Lake City
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12
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Cirulis MM, Beesley SJ, Wilson EL, Stubben C, Olsen TD, Hirshberg EL, Smith LM, Lanspa MJ, Abraham TP, Grissom CK, Rondina MT, Brown SM. The peripheral blood transcriptome in septic cardiomyopathy: an observational, pilot study. Intensive Care Med Exp 2019; 7:57. [PMID: 31650252 PMCID: PMC6813402 DOI: 10.1186/s40635-019-0271-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 09/24/2019] [Indexed: 01/25/2023] Open
Abstract
Background Septic cardiomyopathy (SCM) is common in sepsis and associated with increased morbidity and mortality. Left ventricular global longitudinal strain (LV GLS), measured by speckle tracking echocardiography, allows improved identification of impaired cardiac contractility. The peripheral blood transcriptome may be an important window into SCM pathophysiology. We therefore studied the peripheral blood transcriptome and LV GLS in a prospective cohort of patients with sepsis. Results In this single-center observational pilot study, we enrolled adult patients (age > 18) with sepsis within 48 h of admission to the ICU. SCM was defined as LV GLS > − 17% based on echocardiograms performed within 72 h of admission. We enrolled 27 patients, 24 of whom had high-quality RNA results; 18 (75%) of 24 had SCM. The group was 50% female and had a median (IQR) age of 59.5 (48.5–67.0) years and admission APACHE II score of 21.0 (16.0–32.3). Forty-six percent had septic shock. After filtering for low-expression and non-coding genes, 15,418 protein coding genes were expressed and 73 had significantly different expression between patients with vs. without SCM. In patients with SCM, 43 genes were upregulated and 30 were downregulated. Pathway analysis identified enrichment in type 1 interferon signaling (adjusted p < 10−5). Conclusions In this hypothesis-generating study, SCM was associated with upregulation of genes in the type 1 interferon signaling pathway. Interferons are cytokines that stimulate the innate and adaptive immune response and are implicated in the early proinflammatory and delayed immunosuppression phases of sepsis. While type 1 interferons have not been implicated previously in SCM, interferon therapy (for viral hepatitis and Kaposi sarcoma) has been associated with reversible cardiomyopathy, perhaps suggesting a role for interferon signaling in SCM.
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Affiliation(s)
- Meghan M Cirulis
- Division of Respiratory, Critical Care, and Occupational Pulmonary Medicine, Department of Medicine, University of Utah, Salt Lake City, UT, USA. .,Pulmonary and Critical Care Division, Department of Medicine, Intermountain Medical Center, Shock Trauma Intensive Care Unit, 5121 South Cottonwood Street, Murray, UT, 84107 42, USA.
| | - Sarah J Beesley
- Division of Respiratory, Critical Care, and Occupational Pulmonary Medicine, Department of Medicine, University of Utah, Salt Lake City, UT, USA.,Pulmonary and Critical Care Division, Department of Medicine, Intermountain Medical Center, Shock Trauma Intensive Care Unit, 5121 South Cottonwood Street, Murray, UT, 84107 42, USA.,Critical Care Echocardiography Service, Intermountain Medical Center, Murray, UT, USA
| | - Emily L Wilson
- Pulmonary and Critical Care Division, Department of Medicine, Intermountain Medical Center, Shock Trauma Intensive Care Unit, 5121 South Cottonwood Street, Murray, UT, 84107 42, USA.,Critical Care Echocardiography Service, Intermountain Medical Center, Murray, UT, USA
| | - Chris Stubben
- Bioinformatics Shared Resource, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
| | - Troy D Olsen
- Pulmonary and Critical Care Division, Department of Medicine, Intermountain Medical Center, Shock Trauma Intensive Care Unit, 5121 South Cottonwood Street, Murray, UT, 84107 42, USA
| | - Eliotte L Hirshberg
- Division of Respiratory, Critical Care, and Occupational Pulmonary Medicine, Department of Medicine, University of Utah, Salt Lake City, UT, USA.,Pulmonary and Critical Care Division, Department of Medicine, Intermountain Medical Center, Shock Trauma Intensive Care Unit, 5121 South Cottonwood Street, Murray, UT, 84107 42, USA.,Critical Care Echocardiography Service, Intermountain Medical Center, Murray, UT, USA
| | - Lane M Smith
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston Salem, NC, USA
| | - Michael J Lanspa
- Division of Respiratory, Critical Care, and Occupational Pulmonary Medicine, Department of Medicine, University of Utah, Salt Lake City, UT, USA.,Pulmonary and Critical Care Division, Department of Medicine, Intermountain Medical Center, Shock Trauma Intensive Care Unit, 5121 South Cottonwood Street, Murray, UT, 84107 42, USA.,Critical Care Echocardiography Service, Intermountain Medical Center, Murray, UT, USA
| | - Theodore P Abraham
- Division of Cardiology, Department of Medicine, UCSF, San Francisco, CA, USA
| | - Colin K Grissom
- Pulmonary and Critical Care Division, Department of Medicine, Intermountain Medical Center, Shock Trauma Intensive Care Unit, 5121 South Cottonwood Street, Murray, UT, 84107 42, USA.,Critical Care Echocardiography Service, Intermountain Medical Center, Murray, UT, USA
| | - Matthew T Rondina
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston Salem, NC, USA.,Molecular Medicine Program, University of Utah, Salt Lake City, UT, USA
| | - Samuel M Brown
- Division of Respiratory, Critical Care, and Occupational Pulmonary Medicine, Department of Medicine, University of Utah, Salt Lake City, UT, USA.,Pulmonary and Critical Care Division, Department of Medicine, Intermountain Medical Center, Shock Trauma Intensive Care Unit, 5121 South Cottonwood Street, Murray, UT, 84107 42, USA.,Critical Care Echocardiography Service, Intermountain Medical Center, Murray, UT, USA
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13
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14
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Cirulis MM, Jorgensen LO, Day RW. Acute vasodilator testing: An opportunity to advance the precision care of pulmonary hypertension. Respir Med Case Rep 2019; 28:100911. [PMID: 31384547 PMCID: PMC6661416 DOI: 10.1016/j.rmcr.2019.100911] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2019] [Revised: 07/18/2019] [Accepted: 07/20/2019] [Indexed: 11/24/2022] Open
Abstract
The pulmonary arterial pressure of a child with severe pulmonary arterial hypertension immediately normalized while breathing nitric oxide during heart catheterization at 8 years of age. Her acute pulmonary vascular response to nitric oxide has persisted throughout her life. Her acute response to other medications has been similar to her long-term response to medications in the same class. Acute vasodilator testing with inhaled nitric oxide and other medications may be an opportunity to refine study design and advance precision care for patients with pulmonary hypertension.
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15
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Cirulis MM, Ryan JJ, Archer SL. Pathophysiology, incidence, management, and consequences of cardiac arrhythmia in pulmonary arterial hypertension and chronic thromboembolic pulmonary hypertension. Pulm Circ 2019; 9:2045894019834890. [PMID: 30747032 PMCID: PMC6410395 DOI: 10.1177/2045894019834890] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Arrhythmias are increasingly recognized as serious, end-stage complications of pre-capillary pulmonary hypertension, including pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH). Although arrhythmias contribute to symptoms, morbidity, in-hospital mortality, and possibly sudden death in PAH/CTEPH, there remains a paucity of epidemiologic, pathophysiologic, and outcome data to guide management of these patients. This review summarizes the most current evidence on the topic: from the molecular mechanisms driving arrhythmia in the hypertrophied or failing right heart, to the clinical aspects of epidemiology, diagnosis, and management.
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Affiliation(s)
- Meghan M Cirulis
- 1 Division of Pulmonary Medicine, Department of Medicine, University of Utah, Salt Lake City, UT, USA
- 2 Division of Cardiovascular Medicine, Department of Medicine, University of Utah, Salt Lake City, UT, USA
| | - John J Ryan
- 2 Division of Cardiovascular Medicine, Department of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Stephen L Archer
- 3 Department of Medicine, Queen's University, Kingston, ON, Canada
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16
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Cirulis MM, Liou TG, Ryan JJ. RV/LV ratio in severe sepsis and septic shock: Response to Letter to the Editor. J Crit Care 2018; 50:311-312. [PMID: 30502074 DOI: 10.1016/j.jcrc.2018.11.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Accepted: 11/20/2018] [Indexed: 11/18/2022]
Affiliation(s)
- Meghan M Cirulis
- Division of Respiratory, Critical Care and Occupational Pulmonary Medicine, Department of Medicine, University of Utah, Salt Lake City, UT, United States.
| | - Theodore G Liou
- Division of Respiratory, Critical Care and Occupational Pulmonary Medicine, Department of Medicine, University of Utah, Salt Lake City, UT, United States
| | - John J Ryan
- Division of Cardiovascular Medicine, Department of Medicine, University of Utah, Salt Lake City, UT, United States
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17
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Cirulis MM, Huston JH, Sardar P, Suksaranjit P, Wilson BD, Hatton ND, Liou TG, Ryan JJ. Right-to-left ventricular end diastolic diameter ratio in severe sepsis and septic shock. J Crit Care 2018; 48:307-310. [PMID: 30273910 DOI: 10.1016/j.jcrc.2018.09.025] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 09/14/2018] [Accepted: 09/22/2018] [Indexed: 12/19/2022]
Abstract
PURPOSE The ratio of right ventricular end-diastolic diameter (EDD) to left ventricular EDD (RV/LV) is a measure predictive of right ventricular failure. We hypothesized that an increase in RV/LV would be associated with poor prognosis in severe sepsis and septic shock. MATERIALS AND METHODS This is a retrospective chart review of patients with severe sepsis and septic shock admitted to a medical intensive care unit (ICU) at a single tertiary care hospital. Patients were identified by ICD-9 codes: 995.92 for severe sepsis and 785.52 for septic shock; and had to have an echocardiogram within 48 h of ICU admission. Increased RV/LV was defined as RV/LV ≥ 0.9. Left and right-sided chamber dimensions were measured according to American Society of Echocardiography guidelines. RESULTS We included 146 consecutive ICU patients admitted with septic shock (72) or severe sepsis (74). There was no significant difference in ICU mortality in patients with RV/LV ≥ 0.9 versus RV/LV < 0.9 (p = .49). CONCLUSIONS An increased RV/LV does not predict mortality in severe sepsis or septic shock.
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Affiliation(s)
- Meghan M Cirulis
- Division of Pulmonary Medicine, Department of Medicine, University of Utah, Salt Lake City, UT, United States
| | - Jessica H Huston
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University, Nashville, TN, United States; Division of Cardiovascular Medicine, Department of Medicine, University of Utah, Salt Lake City, UT, United States
| | - Partha Sardar
- Division of Cardiovascular Medicine, Department of Medicine, University of Utah, Salt Lake City, UT, United States
| | - Promporn Suksaranjit
- Division of Cardiovascular Medicine, Department of Medicine, University of Utah, Salt Lake City, UT, United States
| | - Brent D Wilson
- Division of Cardiovascular Medicine, Department of Medicine, University of Utah, Salt Lake City, UT, United States
| | - Nathan D Hatton
- Division of Pulmonary Medicine, Department of Medicine, University of Utah, Salt Lake City, UT, United States
| | - Theodore G Liou
- Division of Pulmonary Medicine, Department of Medicine, University of Utah, Salt Lake City, UT, United States
| | - John J Ryan
- Division of Cardiovascular Medicine, Department of Medicine, University of Utah, Salt Lake City, UT, United States.
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18
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Affiliation(s)
- Meghan M. Cirulis
- Division of Pulmonary Medicine (M.M.C.) and Division of Cardiovascular Medicine (J.J.R.), Department of Medicine, University of Utah, Salt Lake City
| | - John J. Ryan
- Division of Pulmonary Medicine (M.M.C.) and Division of Cardiovascular Medicine (J.J.R.), Department of Medicine, University of Utah, Salt Lake City
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Abstract
Amyloidosis involves extravascular deposition of fibrillar proteins within tissues and organs. Primary light chain amyloidosis represents the most common form of systemic amyloidosis involving deposition of monoclonal immunoglobulin light chains. Although pulmonary amyloid deposition is common in primary amyloidosis, clinically significant pulmonary amyloidosis is uncommon, and elevated pulmonary artery pressures are rarely observed in the absence of other underlying etiologies for pulmonary hypertension, such as elevated filling pressures secondary to cardiac amyloid. In this case report, we present a patient with primary light chain amyloidosis and pulmonary arterial hypertension in the setting of pulmonary vascular and right ventricular myocardial amyloid deposition.
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Affiliation(s)
- Meghan M Cirulis
- Division of Cardiovascular Medicine, Department of Medicine, University of Utah, Salt Lake City, Utah, USA; Internal Medicine-Pediatrics Residency Program, Department of Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Lyska L Emerson
- Division of Anatomic Pathology, Department of Pathology, University of Utah, Salt Lake City, Utah, USA
| | - David A Bull
- Division of Cardiothoracic Surgery, Department of Surgery, University of Utah, Salt Lake City, Utah, USA
| | - Nathan Hatton
- Division of Pulmonary Medicine, Department of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Jose Nativi-Nicolai
- Division of Cardiovascular Medicine, Department of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Gerhard C Hildebrandt
- Division of Hematology and Hematologic Malignancies, Department of Medicine, University of Utah, Huntsman Cancer Institute, Salt Lake City, Utah, USA
| | - John J Ryan
- Division of Cardiovascular Medicine, Department of Medicine, University of Utah, Salt Lake City, Utah, USA
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20
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Abstract
The use of anticoagulation as part of the treatment regimen in pulmonary arterial hypertension (PAH) remains a topic of debate. A recently published analysis of anticoagulation use in the Registry to Evaluate Early and Long-Term PAH Disease Management (REVEAL) study offers conflicting conclusions regarding the benefit of this therapeutic strategy. There remains no robust randomized trial in PAH weighing the risks versus benefits of including anticoagulation in treatment regimens, leaving clinicians to surmise value in individual patients. Reexamination of available data may help to provide guidance on this controversial topic in the absence of future dedicated investigations.
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Affiliation(s)
- Meghan M Cirulis
- Division of Cardiovascular Medicine, Department of Medicine, University of Utah, Salt Lake City, UT, USA
| | - John J Ryan
- Division of Cardiovascular Medicine, Department of Medicine, University of Utah, Salt Lake City, UT, USA
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