Bedside critical ultrasound as a key to the diagnosis of obstructive atelectasis complicated with acute cor pulmonale and differentiation from pulmonary embolism: A case report.

Acute attack of dyspnea may be combined with acute cor pulmonale (ACP). Rapid and accurate identification of the etiology of ACP is the key to its diagnosis and treatment. Echocardiography is a better imaging tool in the assessment of right ventricular function. Under the guidance of the theory of cardiopulmonary interaction, ultrasonography can detect lung lesions, which causes ACP. We report the case of a 67-year-old man who received mechanical ventilation for acute respiratory failure. Right ventricular dysfunction was detected by echocardiography. Lung ultrasound showed a high risk of pulmonary embolism. However, obstructive atelectasis should not be ruled out after increasing back area ultrasonography. To avoid pitfalls, combined cardiac and lung ultrasound should be used carefully and strictly.

Cor pulmonale: the role of traditional and advanced echocardiography in the acute and chronic settings.

Cor pulmonale is the condition in which the right ventricle undergoes morphological and/or functional changes due to diseases that affect the lungs, the pulmonary circulation, or the breathing process. Depending on the speed of onset of the pathological condition and subsequent effects on the right ventricle, it is possible to distinguish the acute cor pulmonale from the chronic type of disease. Echocardiography plays a central role in the diagnostic and therapeutic work-up of these patients, because of its non-invasive nature and wide accessibility, providing its greatest usefulness in the acute setting. It also represents a valuable tool for tracking right ventricular function in patients with cor pulmonale, assessing its stability, deterioration, or improvement during follow-up. In fact, not only it provides parameters with prognostic value, but also it can be used to assess the efficacy of treatment. This review attempts to provide the current standards of an echocardiographic evaluation in both acute and chronic cor pulmonale, focusing also on the findings present in the most common pathologies causing this condition.

Usefulness of Right Ventricular Longitudinal Shortening Fraction to Detect Right Ventricular Dysfunction in Acute Cor Pulmonale Related to COVID-19.

OBJECTIVE: To compare two-dimensional-speckle tracking echocardiographic parameters (2D-STE) and classic echocardiographic parameters of right ventricular (RV) systolic function in patients with coronavirus disease 2019 (COVID-19)-related acute respiratory distress syndrome (CARDS) complicated or not by acute cor pulmonale (ACP). DESIGN: Prospective, between March 1, 2020 and April 15, 2020. SETTING: Intensive care unit of Amiens University Hospital (France). PARTICIPANTS: Adult patients with moderate-to-severe CARDS under mechanical ventilation for fewer than 24 hours. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Tricuspid annular displacement (TAD) parameters (TAD-septal, TAD-lateral, and RV longitudinal shortening fraction [RV-LSF]), RV global longitudinal strain (RV-GLS), and RV free wall longitudinal strain (RVFWLS) were measured using transesophageal echocardiography with a dedicated software and compared with classic RV systolic parameters (RV-FAC, S' wave, and tricuspid annular plane systolic excursion [TAPSE]). RV systolic dysfunction was defined as RV-FAC <35%. Twenty-nine consecutive patients with moderate-to-severe CARDS were included. ACP was diagnosed in 12 patients (41%). 2D-STE parameters were markedly altered in the ACP group, and no significant difference was found between patients with and without ACP for classic RV parameters (RV-FAC, S' wave, and TAPSE). In the ACP group, RV-LSF (17% [14%-22%]) had the best correlation with RV-FAC (r = 0.79, p < 0.001 v r = 0.27, p = 0.39 for RVGLS and r = 0.28, p = 0.39 for RVFWLS). A RV-LSF cut-off value of 17% had a sensitivity of 80% and a specificity of 86% to identify RV systolic dysfunction. CONCLUSIONS: Classic RV function parameters were not altered by ACP in patients with CARDS, contrary to 2D-STE parameters. RV-LSF seems to be a valuable parameter to detect early RV systolic dysfunction in CARDS patients with ACP.

Novel Coronavirus-Induced Right Ventricular Failure and Point of Care Echocardiography: A Case Report.

Various cardiovascular complications have been reported in patients with coronavirus disease 2019. Common complications include acute myocardial injury, myocarditis, arrhythmia, pericarditis, heart failure, and shock. We present a case of cor pulmonale diagnosed with serial point of care ultrasound. Given the current shortage of personal protective equipment (PPE) and high infectivity of this virus, we acknowledge the utility of this tool in obtaining important clinical information while minimizing exposure and PPE consumption.

Arterial Vascular Pruning, Right Ventricular Size, and Clinical Outcomes in Chronic Obstructive Pulmonary Disease. A Longitudinal Observational Study.

Rationale: Cor pulmonale (right ventricular [RV] dilation) and cor pulmonale parvus (RV shrinkage) are both described in chronic obstructive pulmonary disease (COPD). The identification of emphysema as a shared risk factor suggests that additional disease characterization is needed to understand these widely divergent cardiac processes.Objectives: To explore the relationship between computed tomography measures of emphysema and distal pulmonary arterial morphology with RV volume, and their association with exercise capacity and mortality in ever-smokers with COPD enrolled in the COPDGene Study.Methods: Epicardial (myocardium and chamber) RV volume (RVEV), distal pulmonary arterial blood vessel volume (arterial BV5: vessels <5 mm2 in cross-section), and objective measures of emphysema were extracted from 3,506 COPDGene computed tomography scans. Multivariable linear and Cox regression models and the log-rank test were used to explore the association between emphysema, arterial BV5, and RVEV with exercise capacity (6-min-walk distance) and all-cause mortality.Measurements and Main Results: The RVEV was approximately 10% smaller in Global Initiative for Chronic Obstructive Lung Disease stage 4 versus stage 1 COPD (P < 0.0001). In multivariable modeling, a 10-ml decrease in arterial BV5 (pruning) was associated with a 1-ml increase in RVEV. For a given amount of emphysema, relative preservation of the arterial BV5 was associated with a smaller RVEV. An increased RVEV was associated with reduced 6-minute-walk distance and in those with arterial pruning an increased mortality.Conclusions: Pulmonary arterial pruning is associated with clinically significant increases in RV volume in smokers with COPD and is related to exercise capacity and mortality in COPD.Clinical trial registered with www.clinicaltrials.gov (NCT00608764).

Correlation of right atrial enlargement on ECG to right atrial volume by echocardiography in patients with pulmonary hypertension.

Previous attempts to validate ECG criteria for right atrial (RA) enlargement (RAE) have been limited by sample sizes and lack of accepted standards for measuring RA size. New guidelines have recommended that RA volume (RAV) be used to determine RA size. Since these guidelines were released, no studies have been published that correlate RAE by ECG to RAV using the new standards. We aimed to validate previously proposed ECG criteria for RAE, commonly called P pulmonale, and to establish whether a correlation exists between P wave amplitudes and RAV as determined by echocardiogram in patients from the pulmonary hypertension (PHT) clinic. We identified patients from the PHT clinic that had an echocardiogram and ECG done at most 30days apart. We defined increased P wave amplitude as ≥2mm in lead II and ≥1mm in lead V1. The RA was determined to be enlarged if the RAV index (RAVI) was ≥39mL/m2 for men and ≥33mL/m2 for women. Patients were stratified into four groups: those with P II≥2mm, those with P V1≥1mm, those that met both criteria, and those that met neither. Right atrial volumes were then compared. Sixty-three patients were included in the study (7 men, 56 women). Three men and 36 women had an ECG that met criteria for P pulmonale. Five men and 28 women had an enlarged RA on echocardiogram. Sixty-nine percent of ECGs that met criteria for RAE were associated with increased RAV by echocardiogram. The specificity of each of the ECG criteria for P pulmonale at detecting RAE was 100% for men. The criterion with the highest specificity among women was P II≥2mm AND P V1≥1mm (94%). The least specific criterion for women was P II≥2mm (70%). The sensitivity of each criterion was much lower. The most sensitive criteria for men and women were P V1≥1mm (66.6%) and P II≥2mm (48%), respectively. The correlation of P wave amplitude in leads II and V1 and RAVI was not statistically significant for any of the ECG criteria for P pulmonale. In patients from the PHT clinic, the specificity of P pulmonale for detecting RAE is high, but the sensitivity is relatively low. These results suggest that in PHT, P pulmonale can be used to confirm that the RA is enlarged, but it is not a reliable test for diagnosing RAE.

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.

Basic critical care echocardiography by pulmonary fellows: learning trajectory and prognostic impact using a minimally resourced training model*.

OBJECTIVES: The spread of basic critical care echocardiography may be limited by training resources. Another barrier is the lack of information about the learning trajectory and prognostic impact of individual basic critical care echocardiography domains like acute cor pulmonale determination and left ventricular function estimation. We thus developed a minimally resourced training model and studied the latter outcomes. DESIGN: Prospective observational study. SETTING: Twenty-bed medical ICU. SUBJECTS: Echocardiography-naive trainees enrolled in the first year of our Pulmonary Medicine Fellowship Program from September 2012 to September 2013. INTERVENTIONS: We described the learning trajectory in six basic critical care echocardiography domains (adequate views, pericardial effusion, acute cor pulmonale, left ventricular ejection fraction, mitral regurgitation, and inferior vena cava variability) and correlated abnormalities in selected basic critical care echocardiography domains with clinical outcomes (mortality and length of stay). MEASUREMENTS AND MAIN RESULTS: Three-hundred forty-three basic critical care echocardiography scans were done for 318 patients by seven fellows (median of 40 scans per fellow; range, 34-105). Only one-third patients had normal basic critical care echocardiography studies. Accuracy in various basic critical care echocardiography domains was high (> 90%), especially beyond the first 30 examinations. Acute cor pulmonale was associated with ICU mortality when adjusted for Acute Physiology and Chronic Health Evaluation II score and presence of sepsis, whereas mitral regurgitation was associated with longer hospitalization only on univariate analysis. CONCLUSIONS: Basic critical care echocardiography training using minimal resources is feasible. New trainees can achieve reasonable competency in most basic critical care echocardiography domains after performing about 30 examinations within the first year. The relatively high prevalence of abnormalities and the significant association of acute cor pulmonale with ICU mortality support the need for basic critical care echocardiography training.

Ultrasonic evaluation of the heart.

PURPOSE OF REVIEW: To discuss the role of echocardiography for the hemodynamic evaluation of critically ill patients. RECENT FINDINGS: In addition to its crucial role in evaluating heart abnormalities as in the classical cardiological approach, echocardiography is now frequently used by intensivists for noninvasive hemodynamic evaluation of the critically ill patient. Using echocardiography, it is possible to measure cardiac output, intravascular pressures and volumes, systolic and diastolic function of both ventricles, and preload responsiveness. This not only allows characterization of the precise nature of hemodynamic alterations in patients with circulatory and respiratory failure, but also provides guidance for hemodynamic optimization and optimization of ventilatory settings. There are now many data showing how echocardiography can be useful in detecting otherwise unrecognized myocardial depression in sepsis and right ventricular dysfunction in mechanically ventilated patients. The main limitation of echocardiography for hemodynamic monitoring is its intermittent nature. Hence, echocardiography is often combined with other monitoring devices, allowing continuous measurement of flow and triggering new echocardiographic evaluations. SUMMARY: Echocardiography has now become an important tool for hemodynamic evaluation of the critically ill patient. Echocardiography should be performed in most patients with circulatory and respiratory failure.

Chest ultrasound in acute respiratory distress syndrome.

PURPOSE OF REVIEW: This review discusses the role of chest ultrasound in diagnosis and management of acute respiratory distress syndrome (ARDS) and the most recent technical progresses in this field. RECENT FINDINGS: Clinically, suspected ARDS can be easily confirmed by lung ultrasonography through the recognition of a typical pattern characterized by B-lines, spared areas, pleural line thickening, and subpleural consolidations. A visual score based on number and thickness of B-lines permits a semiquantitative evaluation of the amount of extravascular lung water and lung density. Recently, a quantitative lung ultrasound method has been proposed. The heart may be also involved in ARDS either primarily or by the application of positive pressure ventilation. The incidence of acute cor pulmonale during ARDS is, even if under protective ventilation, not negligible. The use of echocardiography combined with lung ultrasound is important for early detection of cor pulmonale, identification of the best ventilator strategy to preserve heart-to-lung interaction, and prediction of weaning success. SUMMARY: An ultrasound-integrated approach combining lung ultrasound and echocardiography should be recommended as a suitable technique to manage ARDS during diagnosis, mechanical ventilation setting, and weaning.

[Two-dimensional ultrasound speckle tracking imaging in detection of myocardial torsion for patients with chronic pulmonary heart disease].

OBJECTIVE: To evaluate the application of two-dimensional ultrasound speckle tracking imaging (STI) in assessment of myocardial torsion and left ventricular function for patients with chronic pulmonary heart disease (CPHD). METHODS: Thirty six patients with CPHD and 38 normal subjects were enrolled in the study,and STI examinations were performed. The left ventricular short-axis views (mitral level,apical level) were observed,the rotation angles of the standardized time point were measured at each short-axis views and the corresponding left ventricular torsion angles were calculated. Simultaneously, the basal rotation peak, apical rotation peak, left ventricular twist peak, end-systolic basal rotation value, end-systolic apical rotation value and end-systolic left ventricular twist value were recorded. The correlations of left ventricular ejection fraction (LVEF) with left ventricular torsion peak, end-systolic left ventricular twist value in patients were analyzed. RESULTS: Compared to normal controls, the basal rotation peak, apical rotation peak, left ventricular twist peak, end-systolic basal rotation value, end-systolic apical rotation value and end-systolic left ventricular twist value were significantly lower (P<0.01) in CPHD patients. The LVEF was highly correlated with left ventricular twist peak and end-systolic left ventricular twist value in CPHD patients (r=0.967, 0.952,P<0.001). CONCLUSION: STI is sensitive to detect left ventricular myocardial torsion change; left ventricular torsion peak and end-systolic left ventricular twist value can be used to assess the left ventricular function in patients with CPHD.

Isolated unilateral pulmonary artery atresia in an adult presenting with cor pulmonale.

Unilateral pulmonary artery atresia (UPAA) is a rare embryonic vascular malformation, leading to general presentations of exertional dyspnoea, pneumonia and haemoptysis. Our patient, a man in his early 30s, presented with a history of progressive breathlessness over a period of 2 years. History showed multiple admissions for pneumonia over his childhood and adolescence. Physical examination revealed a loud P2, an ejection systolic murmur and coarse crepitations in multiple lung fields. Severe pulmonary artery hypertension was noted on two-dimensional echocardiography. CT studies confirmed right pulmonary artery atresia with aspergilloma and bronchiectasis. With this diagnosis of UPAA, this case report intends to raise awareness among clinicians to consider this as a rare cause of cor pulmonale in an adult.

[Role of echocardiography in the hemodynamic monitorization of critical patients]. / Papel de la ecocardiografía en la monitorización hemodinámica de los pacientes críticos.

The use of echocardiography in intensive care units in shock patients allows us to measure various hemodynamic variables in an accurate and a non-invasive manner. By using echocardiography not only as a diagnostic technique but also as a tool for continuous hemodynamic monitorization, the intensivist can evaluate various aspects of shock states, such as cardiac output and fluid responsiveness, myocardial contractility, intracavitary pressures, heart-lung interaction and biventricular interdependence. However, to date there has been little guidance orienting echocardiographic hemodynamic parameters in the intensive care unit, and intensivists are usually not familiar with this tool. In this review, we describe some of the most important hemodynamic parameters that can be obtained at the patient bedside with transthoracic echocardiography in critically ill patients.

Etiology, characteristics and occurrence of heart diseases in rural Lesotho (ECHO-Lesotho): A retrospective echocardiography cohort study.

BACKGROUND: In 2019, 600'000 people in Africa died of heart failure and heart diseases will increase on the continent. It is crucial to understand the regional etiologies and risk factors for heart failure and underlying heart diseases. However, echocardiography data from rural Africa are scarce and from Lesotho non-existent. This study aims to examine the occurrence, characteristics and etiology of heart failure and heart diseases using echocardiography data from a referral hospital in rural Lesotho. METHODS: We conducted a retrospective cohort study at Seboche Mission Hospital, the only referral hospital in Butha-Buthe district (Lesotho) with an echocardiography department. We included data from all individuals referred to the department between January 2020 and May 2021. From non-hospitalized patients echocardiographic diagnosis, sex and age were available, from hospitalized patients additional sociodemographic and clinical data could be extracted. RESULTS: In the study period, a total of 352 echocardiograms were conducted; 213 had abnormal findings (among them 3 children). The majority of adult participants (130/210; 64%) were female and most frequent heart diseases were hypertensive (62/210, 30%), valvular (39/210, 19%) and chronic pulmonary (37/210, 18%). Heart failure represented 11% of hospitalizations in the same period. Among the 126 hospitalized heart failure patients, the most common etiology was chronic pulmonary heart disease (32/126; 25%). Former mine workers and people with a history of tuberculosis were more likely to have a chronic pulmonary heart disease. CONCLUSIONS: The leading cause of heart disease in this setting is hypertension. However, in contrast to other African epidemiological studies, chronic pulmonary heart disease is unexpectedly common. There is an urgent need to improve awareness and knowledge about lung diseases, make diagnostic and therapeutic options available and increase prevention.

Differentiation between acute and chronic cor pulmonales with midventricular systolic strain of the right ventricle in the emergency department.

Cor pulmonale (CP) is defined as the structural and functional alternation of the right ventricle (RV) caused by primary disorders of the respiratory system. We aimed to differentiate acute CP complicated with massive pulmonary thromboembolism (PTE) from the chronic form due to severe chronic obstructive pulmonary disease (COPD) with strain analysis of RV in the emergency department. We included patients showing echocardiographic features of pulmonary hypertension in the emergency department. From March 2005 to July 2006, a total of 52 patients, 24 consecutive patients with acute CP (ten males, mean 69 ± 10 years) and 28 consecutive patients with chronic CP associated with severe COPD (22 males, mean 63 ± 14 years), were included. Echocardiographic data and strain analyses were obtained with GE Vivid 7. There was no statistical difference in age, fractional area change of RV, TR Vmax, and Tei index in both groups. However, more males were included in the chronic group. Midventricular systolic strain of RV was significantly increased in patients with acute CP. Regarding the midventricular systolic strain in the detection of acute CP by the receiver operating curve analysis, the best sensitivity and specificity were obtained when -12.2% was applied as the criterion (more than -12.2% for predicting an acute CP, the sensitivity, specificity, and accuracy were 83.3, 78.6, and 80.8%, respectively). Midventricular systolic strain of RV can be used in the differentiation between acute and chronic CPs in the emergency department.

Application of a new pulmonary artery obstruction score in the prognostic evaluation of acute pulmonary embolism: comparison with clinical and haemodynamic parameters.

PURPOSE: Evaluation of computed tomography (CT) pulmonary angiography parameters revealing pulmonary embolism (PE) severity with particular attention to pulmonary obstruction indexes. Comparison with clinical and hemodynamic data and determination of predictive role in the development of chronic pulmonary heart disease. MATERIALS AND METHODS: This retrospective study analyzes 45 not consecutive patients from November 2007 to December 2008 with CT angiography diagnosis of acute PE. Included in the study are patients at the first documented episode of acute PE, with 6 month follow-up. Patients with severe pre-existent cardiopulmonary pathology or neoplastic diseases were excluded from the study. CT angiography evaluated right ventricular (RV)/left ventricular (LV) ratio, obstruction index according to Qanadli and Total Clot Burden (Ghanima score). PE indexes were compared with Troponin I measurement and echocardiography result; at last hospitalization and intensive care time were reported. RESULTS: A significant association was found between Ghanima and Qanadli score: the two indexes are equivalent in quantification of pulmonary arterial obstruction (p<0.001). Among others CT parameters, the new Ghanima score evidenced the best accuracy to detect patients evolving to chronic pulmonary heart disease (76%). This value is higher than that of echocardiography (71%). Troponins showed highest accuracy (82%). CONCLUSIONS: Ghanima score can be used in emergency CT angiography diagnosis as prognostic marker for a quickly risk stratification of pulmonary heart disease or death in patients with acute PE. This approach allows to obtain, with just one test, both the diagnosis and a rather accurate acute PE risk stratification.

Diffuse interlobular septal thickening in a coal miner.

Diffuse interlobular septal thickening (DIST) is an abnormality seen on high-resolution CT (HRCT) scanning of the thorax. While DIST may be present to variable extents in a number of lung conditions, it is uncommon as a predominant finding except in a few entities. This report features an ex-coal miner, thought to have coal workers' pneumoconiosis (CWP), in whom the HRCT scan showed no evidence of CWP and instead showed DIST. The patient's condition progressed incessantly towards death from severe secondary pulmonary hypertension. The case links fatal pulmonary hypertension to DIST, a pattern not previously described in coal workers.

[The specific features of left cardiac cavity remodeling in patients with chronic obstructive pulmonary disease and chronic cor pulmonale].

AIM: To study left ventricular structural and functional changes in patients with chronic obstructive pulmonary disease (COPD) and chronic cor pulmonale (CCP) at different stages of a cardiac remodeling process. SUBJECTS AND METHODS: Echocardiography was used to examine 98 patients with COPD complicated by the development of CCP in a number of cases. The significant signs of CCP were absent in 19 patients; the signs of compensated and decompensated CCP in 41 and 38 patients, respectively. RESULTS: In the patients with COPD, the formation of CCP during remodeling of the heart involves its left cavities whose changes lie in the occurrence of left ventricular (LV) diastolic dysfunction, mainly of the restrictive type, in ventricular spherization, higher myocardial systolic tension, in tendencies towards increases in LV mass index, left atrial sizes, and in the indices reflecting LV systolic dysfunction. The LV diastolic dysfunction correlates with the degree of right ventricular hypertrophy and dilatation and the presence of complete right bundle-branch block. CONCLUSION: Progressive worsening of diagnostic filling of the left ventricle and its systolic function is an additional factor aggravating hemodynamic disorders in patients with COPD and CCP, which should be kept in mind on choosing an appropriate therapy for patients with CCP.