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

Annick Legras, Agnès Caille, Emmanuelle Begot, Gwenaëlle Lhéritier, Thierry Lherm, Armelle Mathonnet, Jean-Pierre Frat, Anne Courte, Laurent Martin-Lefèvre, Jean-Paul Gouëllo, Emmanuelle Mercier, Philippe Vignon

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. 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 Physiologic Score: 46 [17]; PaO2/FiO2: 11 [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. 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. 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.