Predictors of Prolonged Hospital Stay in Patients with Acute Pulmonary Thromboembolism- A Hospital Based Cohort Study.

AIMS AND OBJECTIVES: Patients with pulmonary thromboembolism (PTE) are commonly admitted to hospital and generally have a prolonged hospital stay in this part of the world. We aimed to determine different clinical and laboratory parameters that are associated with prolonged hospital stay in our set-up and to analyse effectiveness of Pulmonary Embolism Severity Index (PESI) score as a predictor of prolonged hospital stay in patients with PTE. MATERIALS AND METHODS: It was a hospital based observational prospective study. Confirmed cases of PTE defined as patients with evidence of thrombus on CT pulmonary angiogram (CTPA) were included in this study. Depending on the length of hospital stay, patients were divided into two cohorts: Shorter Hospital stay (less than mean i.e., < 10 Days) and Prolonged Hospital stay (longer than mean i.e., ≥ 10 Days). Logistic regression analysis was done to identify predictors of prolonged hospital stay. RESULTS: 150 patients were included in the study with 67 patients (44.67%) having shorter hospital stay (<10 days) and 83 patients (55.33%) having prolonged hospital stay (≥10 days). On multivariate regression analysis, parameters that were found to be statistically significant were hypotension at presentation, decreased level of consciousness, pco2 < 30 mmHg, presence of S1Q3T3 pattern on electrocardiogram (ECG) and high risk PESI (class III-V). CONCLUSION: PESI class can be effectively used to predict prolonged hospital stay in patients with pulmonary embolism. Patients with hypotension at presentation, decreased level of consciousness, pco2 less than 30 mmHg, and S1Q3T3 on ECG are more likely to have prolonged hospital stay in our healthcare setup.

Saddle pulmonary embolism in a pediatric patient with nephrotic syndrome and recent COVID-19 pneumonia: A case report.

The pediatric population accounts for a small portion of those with severe disease related to COVID-19. There are few published reports of hypercoagulable states in children with COVID-19. We describe an 11-year-old male with nephrotic syndrome who required inpatient treatment for COVID-19 pneumonia eight weeks prior. He returned to the emergency department with vomiting, tachypnea and was found to have a pulmonary embolism. In this case report, we discuss the risk factors for, presentation and evaluation of hypercoagulable state and its relation to COVID-19 in a pediatric patient.

Pulmonary artery to aorta ratio and risk of all-cause mortality in the general population: the Rotterdam Study.

A pulmonary artery to aorta ratio (PA:A) >1 is a proxy of pulmonary hypertension. It is not known whether this measure carries prognostic information in the general population and in individuals with chronic obstructive pulmonary disease (COPD).Between 2003 and 2006, 2197 participants from the population-based Rotterdam Study (mean±sd age 69.7±6.7 years; 51.3% female), underwent cardiac computed tomography (CT) scanning with PA:A quantification, defined as the ratio between the diameters of the pulmonary artery and the aorta. COPD was diagnosed based on spirometry or clinical presentation and obstructive lung function measured by a treating physician. Cox regression was used to investigate the risk of mortality.We observed no association between 1-sd increase of PA:A and mortality in the general population. Larger PA:A was associated with an increased risk of mortality in individuals with COPD, particularly in moderate-to-severe COPD (hazard ratio 1.36, 95% CI 1.03-1.79). We demonstrated that the risk of mortality in COPD was driven by severe COPD, and that this risk increased with decreasing diffusing capacity.Larger PA:A is not associated with mortality in an older general population, but is an independent determinant of mortality in moderate-to-severe COPD. Measuring PA:A in CT scans obtained for other indications may yield important prognostic information in individuals with COPD.

Elevated tricuspid regurgitant jet velocity, reduced forced expiratory volume in 1 second, and mortality in adults with sickle cell disease.

Cardiopulmonary disease is the leading cause of mortality in adults with sickle cell disease (SCD). Elevated tricuspid regurgitant jet velocity (TRJV) and reduced forced expiratory volume in 1 second (FEV1 ) %predicted are associated with early mortality in SCD; however their relationship and combined effect on survival is unknown. We investigated the relationship between TRJV and FEV1 %predicted, and their combined effect on mortality, in a retrospective cohort of 189 adults with SCD who underwent both pulmonary function testing and echocardiography. Nineteen (9.9%) of 189 patients died over a median follow-up of 1.4 years; cardiopulmonary disease was the major cause of death in 52.6%. FEV1 %predicted was negatively associated with TRJV (Spearman rho, -0.34, P < 0.001). Individuals with FEV1 %predicted ≤70% were more likely to have an elevated TRJV ≥2.5 m/second, compared to those with FEV1 %predicted >70% [45.8% versus 17.1%; odds ratio (OR) 4.1 (95% Confidence interval ([CI] 2.1-8.0); P = 0.001]. In a multivariable cox regression model, the combination of TRJV ≥2.5 m/second and FEV1 %predicted ≤70% predicted earlier mortality [hazard ratio (HR) 4.97 (95% CI 1.30-18.91; P = 0.019)] after adjusting for age, sex, and nephropathy. Both FEV1 %predicted ≤70% and TRJV ≥2.5 m/second were independently associated with nephropathy [OR 4.48 (95% CI 1.51-13.31); P = 0.004] and [OR 3.27 (95% CI 1.19-9.00); P = 0.017], respectively. In conclusion, pulmonary and cardiac impairment are associated with, and contribute to mortality in SCD. Therapies aimed at improving reduced FEV1 %predicted and elevated TRJV could improve survival in patients with SCD. Am. J. Hematol. 92:125-130, 2017. © 2016 Wiley Periodicals, Inc.

Serum apelin as a novel non-invasive marker for subclinical cardiopulmonary complications in children and adolescents with sickle cell disease.

BACKGROUND: Cardiovascular involvement represents a leading cause of mortality and morbidity in sickle cell disease (SCD). Apelin is a peptide involved in the regulation of cardiovascular function. AIM: To determine serum apelin among 40 children and adolescents with SCD compared with 40 healthy controls and assess its relation to markers of hemolysis, iron overload as well as cardiopulmonary complications. METHODS: SCD patients, in steady state and asymptomatic for heart disease, were studied stressing on hydroxyurea/chelation therapy, hematological profile, serum ferritin and apelin levels. Full echocardiographic study including assessment of biventricular systolic function and pulmonary artery pressure was done. RESULTS: Apelin levels were significantly lower in SCD patients compared with controls (P<0.001). Cardiopulmonary complications were encountered in 30% of patients. Apelin was significantly decreased among patients with cardiopulmonary disease (P=0.006) whether those at risk of pulmonary hypertension (P=0.018) or patients with heart disease (P=0.043). Hydroxyurea-treated patients had higher apelin levels than untreated ones (P=0.001). Apelin was negatively correlated to lactate dehydrogenase, indirect bilirubin, serum ferritin, end systolic diameter, tricuspid regurgitant jet velocity, right ventricle systolic pressure, pulmonary vascular resistance and tissue Doppler imaging S wave. Apelin cutoff value of 1650ng/L could significantly detect the presence of cardiopulmonary complications in SCD with 90.9% sensitivity and 72.4% specificity. CONCLUSION: Apelin is a promising marker for screening of SCD patients at risk of cardiopulmonary disease because it is altered during the early subclinical stage of cardiac affection. A combination of apelin and echocardiography provides a reliable method to assess cardiopulmonary affection in young SCD patients.

Cardiorespiratory synchronism in estimation of regulatory and adaptive organism status.

The proposed method of quantitative estimation of regulatory and adaptive status (RAS) of human organism is based on complex responses of two major vegetative functions - breath and heart rates under organism exposure to a number of factors and diseases. It has been evidenced that during the follicular menstruation stage and during optimum readiness of female organism for childbirth RAS increases, however, stress impact can also cause RAS set off to decrease. Likewise, the possibility of quantitative organism stress resistance estimation is also presented. Under some pathological conditions (myocardial infarction, hypo-and hyperthyroidism, diabetes type 2), RAS goes down, and the degree of its restoration depends on the attained therapy effect. It is shown that RAS dynamics provides an innovative methodological approach to medication efficiency estimation based on its influence not only on the body organ or target function, but also on adaptive abilities of the organism.

Acute respiratory distress syndrome (ARDS)-associated acute cor pulmonale and patent foramen ovale: a multicenter noninvasive hemodynamic study.

INTRODUCTION: Acute cor pulmonale (ACP) and patent foramen ovale (PFO) remain common in patients under protective ventilation for acute respiratory distress syndrome (ARDS). We sought to describe the hemodynamic profile associated with either ACP or PFO, or both, during the early course of moderate-to-severe ARDS using echocardiography. METHODS: In this 32-month prospective multicenter study, 195 patients with moderate-to-severe ARDS were assessed using echocardiography during the first 48 h of admission (age: 56 (SD: 15) years; Simplified Acute Physiology Score: 46 (17); PaO2/FiO2: 115 (39); VT: 6.5 (1.7) mL/kg; PEEP: 11 (3) cmH2O; driving pressure: 15 (5) cmH2O). ACP was defined by the association of right ventricular (RV) dilatation and systolic paradoxical ventricular septal motion. PFO was detected during a contrast study using agitated saline in the transesophageal bicaval view. RESULTS: ACP was present in 36 patients, PFO in 21 patients, both PFO and ACP in 8 patients and the 130 remaining patients had neither PFO nor ACP. Patients with ACP exhibited a restricted left ventricle (LV) secondary to RV dilatation and had concomitant RV dysfunction, irrespective of associated PFO, but preserved LV systolic function. Despite elevated systolic pulmonary artery pressure (sPAP), patients with isolated PFO had a normal RV systolic function. sPAP and PaCO2 levels were significantly correlated. CONCLUSIONS: In patients under protective mechanical ventilation with moderate-to-severe ARDS, ACP was associated with LV restriction and RV failure, whether PFO was present or not. Despite elevated sPAP, PFO shunting was associated with preserved RV systolic function.

[Fatal outcome of bilateral pulmonary embolism combined with ascending varicophlebitis of the lower limb: case report]. / Letális kimenetelu kétoldali tüdoembólia és aszcendáló varicophlebitis együttes elofordulása.

The authors review the history and risk factors of thrombophlebitis of the lower limb, and describe the main points of surgical and conservative treatment of varicophlebitis. They present the case of a 71-year-old woman who had ascending varicophlebitis and bilateral pulmonary embolism. The authors draw attention to important points: patients must be followed after phlebitis of the lower limb, and their thrombotic factors must be examined to prevent the new thromboembolic events.

[Cor pulmonale and pulmonary hypertension. Update after the world conference in Nice]. / Cor pulmonale und pulmonale Hypertonie. Update nach der Weltkonferenz in Nizza.

Pulmonary hypertension (PH) is a common phenomenon which may occur as a consequence of various diseases (e.g. heart failure, chronic lung diseases and pulmonary embolism), as a distinct disease of the small pulmonary arterioles or a combination of both. Independent from the origin, PH has an important impact on patient symptoms and prognosis. Establishment of an exact diagnosis and classification as well as an understanding of the hemodynamic interrelationships provide the basis for often challenging treatment decisions. Recently, the fifth World Symposium on PH took place in Nice, France, where important standards and definitions were specified. The most relevant results including the rating of novel treatment options are summarized in this article.

Take a deep breath: understanding pulmonary arterial hypertension.

Many people throughout the world are living with a severe pulmonary disease, known as pulmonary arterial hypertension. This disease has various etiologies and is often not diagnosed appropriately or early in the disease process, leading to limited, long-term survival. Fortunately in the past 20 years, medications and other options have been developed that provide patients with life-prolonging treatments that also increase their quality of life. Pathophysiology, disease identification and classification, and treatment options, focusing on current pharmacological treatments, are discussed in this article.

[Activation of neurohormonal system as an independent mechanism of heart remodeling in patients with chronic obstructive pulmonary disease].

AIM: To evaluate the contribution of activation of cytokines and renin-angiotensin-aldosterone system to heart remodeling in patients with chronic obstructive pulmonary disease in the course of a 2 year study and to estimate its relation to severe pulmonary hypertension. MATERIALS AND METHODS: 117 patients with COPD underwent measurement of TNFα, IL-6 levels and renin levels, spirometry and echocardiography (mean pressure in pulmonary artery, MPPA)). The data obtainedwere compared with the degree of remodeling of right and left ventricles. After 2 years 30 and 33 of the 63 patients were referred to groups with aggressive and moderate remodeling of the right ventricle respectively. Regressive analysis was used to detect predictors of aggressive remodeling. RESULTS: Initial remodeling severity and rate showed stronger correlation with TNFα, IL-6 levels and renin levels than with MPPA. Multifactor analysis demonstrated that renin activity and creatinine level were the most reliable predictors of remodeling (p = 0.041 and 0.049 respectively). CONCLUSION: Neurohormonal and imunno-inflammatory changes stimulate remodeling of right and left heart chambers. They independently affect myocardium and their influence is only partly mediated through exacerbation of pulmonary hypertension.

Diagnosis and treatment of right ventricular failure secondary to acutely increased right ventricular afterload (acute cor pulmonale): a clinical consensus statement of the Association for Acute CardioVascular Care of the European Society of Cardiology.

Acute right ventricular failure secondary to acutely increased right ventricular afterload (acute cor pulmonale) is a life-threatening condition that may arise in different clinical settings. Patients at risk of developing or with manifest acute cor pulmonale usually present with an acute pulmonary disease (e.g. pulmonary embolism, pneumonia, and acute respiratory distress syndrome) and are managed initially in emergency departments and later in intensive care units. According to the clinical setting, other specialties are involved (cardiology, pneumology, internal medicine). As such, coordinated delivery of care is particularly challenging but, as shown during the COVID-19 pandemic, has a major impact on prognosis. A common framework for the management of acute cor pulmonale with inclusion of the perspectives of all involved disciplines is urgently needed.

Right heart failure in the intensive care unit.

PURPOSE OF REVIEW: This review summarizes the approach to and recent developments in the evaluation and treatment of acute right heart failure in the ICU. Right heart failure, defined as failure of the right ventricle to provide sufficient blood flow through the pulmonary circulation at normal central venous pressure, is a common problem caused by a combination of increased right-ventricular afterload and right-ventricular contractile dysfunction. RECENT FINDINGS: Management of acute right heart failure continues to be challenging because of insufficient understanding of its pathophysiology, a lack of guidelines, and few available tools. Recent research has contributed to an improved understanding of its mechanisms, helping to guide therapy and suggest future options. Right-ventricular assist devices are emerging as a promising approach to treatment when optimization of hemodynamics and conventional medical therapy fail. SUMMARY: Right heart failure causes venous congestion and systemic hypoperfusion. Once right heart failure is identified, the primary goal is to alleviate any reversible cause of excessive load or right-ventricular contractile failure. When the underlying abnormalities cannot be alleviated, trials of diuretic, vasodilator, or inotropic therapy may be required. Invasive monitoring helps guide therapy. Medically refractory right heart failure may potentially be treated with right-ventricular assist devices.

The specific characteristics in children with obstructive sleep apnea and cor pulmonale.

BACKGROUND: The prevalence of obstructive sleep apnea (OSA) in the pediatric population is currently estimated at 1-2% of all children. The purpose of this study was to investigate the clinical and hemodynamic characteristics in pediatric patients with cor pulmonale and OSA. METHODS: Thirty children with the diagnosis of OSA were included. These patients consisted of 26 male and 4 female children with a mean age of 7 ± 4 years old. Five of those children were found to be associated with cor pulmonale, and 25 had OSA but without cor pulmonale. RESULTS: The arousal index was much higher in children with OSA and cor pulmonale. The children with OSA and cor pulmonale had much lower mean and minimal oxygen saturation and a higher incidence of bradycardia events. All 5 patients with OSA and cor pulmonale underwent an adenotonsillectomy, and the pulmonary arterial pressure dropped significantly after the surgery. CONCLUSION: This study demonstrated that the OSA pediatric patients with cor pulmonale had the different clinical manifestations and hemodynamic characteristics from those without cor pulmonale. The adenotonsillectomy had excellent results in both the OSA pediatric patients with and without cor pulmonale.

[Pulmonary heart disease--cardiologist's point of view]. / Przewlekle serce plucne--punkt widzenia kardiologa.

This paper presents cardiologist's point of view on definition, diagnosis and treatment of pulmonary heart disease. Difficulties in interpretation of definition in clinical praxis and the role of medical history, physical examination, lung function tests, gasometry, chest X-ray and ECG in initial diagnosis of pulmonary heart disease are described. Author underlines the importance of echocardiographic study and pulmonary hemodynamics in confirmation of diagnosis and in differential diagnosis of "out of proportion" pulmonary hypertension. The current results of specific for pulmonary artery hypertension vasodilatory treatment in patients with pulmonary heart disease are discussed.

[Investigation on response of the patient-reported outcome scale of the main-symptoms of chronic obstructive pulmonary disease complicated with pulmonary heart disease].

OBJECTIVE: To select appropriate descriptors for response of the patient-reported outcome (PRO) scale for the main symptoms of patients with chronic obstructive pulmonary disease (COPD) complicated with pulmonary heart disease. METHODS: A cross-sectional investigation was carried out. Five equidistant ordinal descriptive words in the PRO scale of main symptoms for COPD complicated with pulmonary heart disease were selected. There were 32 alternative words in the questionnaire. Thirty respondents were required to place each descriptive word on a 10-centimeter line according to where they considered each descriptive word should be placed. Then, the line was measured by ruler; average, standard deviation and median were calculated by excel software; the authors finally chose the five equidistant words which accurately reflect the degree of main symptoms. RESULTS: The five most appropriate descriptive words were selected; they were "never", "seldom", "half-partly sometimes", "very often" and "always". CONCLUSION: These selected decorated words are suitable for the PRO scale for patients with COPD complicated with pulmonary heart disease.

[The value of RV(6) > RV(5) of ECG in diagnosis of pneumocardiac disease complicated by left ventricular hypertrophy in coal-workers with pneumoconiosis].

OBJECTIVE: This thesis will discuss the value of RV(6) > RV(5) of ECG in diagnosis of pneumocardiac disease complicated by left ventricular hypertrophy in coal-workers with pneumoconiosis through the analysis of the ECG characteristics in the postmortem examination of coal-workers with pneumoconiosis. METHODS: Three data groups will be formed on the basis of the ECG data in the case 47 postmortem examination of coal-workers with pneumocardiac disease complicated by left ventricular hypertrophy, and they are right deviation group with ECG cardiac electric axis more than 90 degrees (case 16), no deviation group with ECG cardiac electric axis between 30 degrees and 90 degrees (case 16) and left deviation group with ECG cardiac electric axis between 30 degrees and -30 degrees (case 15). The method that this thesis adopted is to compare the thickness of the right and left ventricle walls of the three groups, their ratio and the detectable ratio of ECG RV(6) > RV(5). RESULTS: The detectable rate of the thickness of right ventricle front wall, the thickness of the left ventricle wall, the thickness of the left ventricle wall to the thickness of right ventricle wall and ECG RV(6) > RV(5) in left deviation group is obviously higher than those of the no deviation group and right deviation group. The differences between the three groups are of statistics significance (P < 0.01); the detectable rate of the thickness of right ventricle front wall, the thickness of the left ventricle wall, the thickness of the left ventricle wall to the thickness of right ventricle wall and ECG RV(6) > RV(5) in no deviation group is obviously higher than those of the right deviation group. The differences are of statistics significance (P < 0.01). In case 47 that pneumocardiac disease complicated by left ventricular hypertrophy in coal-workers with pneumoconiosis, the ECG shows 20 cases of ECG RV(6) > RV(5). There are altogether 3 kinds of ECG types: (1) 14 cases of ECG RV(6) > RV(5); (2) 4 cases of left ventricular hypertrophy; (3) 2 cases of right ventricular hypertrophy. CONCLUSIONS: The left deviation of ECG cardiac electric axis and ECG RV(6) > RV(5) can be used as indications to diagnosis of pneumocardiac disease complicated by left ventricular hypertrophy in coal-workers with pneumoconiosis.

[The value of terminal force of P wave in V1 lead in the diagnosis of coal-worker's pneumoconiosis with pulmonary heart disease complicated by left ventricular hypertrophy].

OBJECTIVE: To determine the value of terminal force of P wave in V1 lead (Ptf-V1) in the diagnosis of coal-workers' pneumoconiosis with pulmonary heart disease complicated by left ventricular hypertrophy. METHODS: Select the coal-worker with pneumoconiosis postmortem examination cases which were pathologically diagnosed as pulmonary heart disease complicated by left ventricular hypertrophy and can measure Ptf-V1. Select 14 cases with ECG left axis deviation, no deviation and right axis deviation. Measure and analyze the Ptf-V1 value, the thickness of left and right ventricular wall. RESULTS: There's obvious discrepancy in ventricular wall thickness mean in ECG left axis deviation, no deviation and right axis deviation groups, the discrepancy have statistical significance (F1 = 32.18, P < 0.01, F2 = 8.02, P < 0.01). The left ventricular wall is thicker in ECG left axis deviation group [(1.81 +/- 0.18) cm] than in no deviation [(1.47 +/- 0.15) cm] and right axis deviation groups [(1.39 +/- 0.10) cm], the discrepancy have statistical significance with (P < 0.01). The right ventricular wall is thicker in ECG left axis deviation group [(0.79 +/- 0.14) cm] than in no deviation group [(0.58 +/- 0.14) cm], the discrepancy have statistical significance with (P < 0.01). The right ventricular wall is thicker in ECG right axis deviation group [(0.71 +/- 0.14) cm] than in no deviation group, the discrepancy have statistical significance with (P < 0.05). ECG left axis deviation Ptf-V1 relevance ratio 85.71% is higher than in no deviation (35.70%) and right axis deviation groups (28.57%), the discrepancy have statistical significance with (P < 0.01). The Ptf-V1 absolute value is positively related with left ventricular wall thickness in ECG left axis deviation and no deviation groups (r1 = 0.92, P < 0.01, r2 = 0.93, P < 0.01). CONCLUSION: Pft-V1 absolute value is the criterion index of left ventricular morphosis and function especially left atrium loading change. ECG Ptf-V1 combined with ECG left axis deviation is valuable to the diagnosis of coal-workers with pneumoconiosis complicated by left ventricular hypertrophy.