To the Editor:
Right ventricular (RV) dysfunction occurs frequently in acute respiratory distress syndrome (ARDS) and is associated with hemodynamic compromise, organ failure, and increased mortality.
1- Vieillard-Baron A
- Matthay M
- Teboul JL
- et al.
Experts' opinion on management of hemodynamics in ARDS patients: Focus on the effects of mechanical ventilation.
,2- Sato R
- Dugar S
- Cheungpasitporn W
- et al.
The impact of right ventricular injury on the mortality in patients with acute respiratory distress syndrome: A systematic review and meta-analysis.
The complex RV geometry, inadequate views with transthoracic imaging, and the lack of a consensual definition of RV dysfunction in critically ill patients have resulted in varied reporting in the literature on this important correlation.
3- Dugar SP
- Vallabhajosyula S.
Right ventricle in sepsis: Clinical and research priority.
A systematic literature search of the Cochrane Central Register of Controlled Trials, Embase, and Medline was performed. The inclusion criteria were: (1) interventional and observational studies; (2) patients (≥18 years) with ARDS based on the American European consensus conference or the Berlin definition who underwent RV assessment with either transthoracic or transesophageal echocardiography (TTE or TEE) or the pulmonary artery catheter.
The authors' search strategy identified 2,435 articles, and after excludingduplication evaluated 118 full-text manuscripts (e Suppl. Figure S1). Thirteen studies met the inclusion criteria (e Suppl. Table S1).
4- Monchi M
- Bellenfant F
- Cariou A
- et al.
Early predictive factors of survival in the acute respiratory distress syndrome. A multivariate analysis.
, 5- Vieillard-Baron A
- Schmitt JM
- Augarde R
- et al.
Acute cor pulmonale in acute respiratory distress syndrome submitted to protective ventilation: Incidence, clinical implications, and prognosis.
, 6- Osman D
- Monnet X
- Castelain V
- et al.
Incidence and prognostic value of right ventricular failure in acute respiratory distress syndrome.
, 7- Bull TM
- Clark B
- McFann K
- et al.
Pulmonary vascular dysfunction is associated with poor outcomes in patients with acute lung injury.
, 8- Fichet J
- Moreau L
- Genee O
- et al.
Feasibility of right ventricular longitudinal systolic function evaluation with transthoracic echocardiographic indices derived from tricuspid annular motion: A preliminary study in acute respiratory distress syndrome.
, 9- Lheritier G
- Legras A
- Caille A
- et al.
Prevalence and prognostic value of acute cor pulmonale and patent foramen ovale in ventilated patients with early acute respiratory distress syndrome: A multicenter study.
, 10- Boissier F
- Katsahian S
- Razazi K
- et al.
Prevalence and prognosis of cor pulmonale during protective ventilation for acute respiratory distress syndrome.
, 11- Legras A
- Caille A
- Begot E
- et al.
Acute respiratory distress syndrome (ARDS)-associated acute cor pulmonale and patent foramen ovale: A multicenter noninvasive hemodynamic study.
, 12- Lazzeri C
- Cianchi G
- Bonizzoli M
- et al.
Right ventricle dilation as a prognostic factor in refractory acute respiratory distress syndrome requiring veno-venous extracorporeal membrane oxygenation.
, 13- Mekontso Dessap A
- Boissier F
- Charron C
- et al.
Acute cor pulmonale during protective ventilation for acute respiratory distress syndrome: Prevalence, predictors, and clinical impact.
, 14- See KC
- Ng J
- Siow WT
- et al.
Frequency and prognostic impact of basic critical care echocardiography abnormalities in patients with acute respiratory distress syndrome.
, 15- Bonizzoli M
- Cipani S
- Lazzeri C
- et al.
Speckle tracking echocardiography and right ventricle dysfunction in acute respiratory distress syndrome a pilot study.
, 16- Zeiton T
- Elsayed HM
- Hassan O
- et al.
Clinical risk score for the diagnosis of acute cor pulmonale in acute respiratory distress syndrome.
Heterogeneity was found in the parameters used to define RV dysfunction in ARDS. The definition of RV dysfunction included single (five studies),
4- Monchi M
- Bellenfant F
- Cariou A
- et al.
Early predictive factors of survival in the acute respiratory distress syndrome. A multivariate analysis.
,5- Vieillard-Baron A
- Schmitt JM
- Augarde R
- et al.
Acute cor pulmonale in acute respiratory distress syndrome submitted to protective ventilation: Incidence, clinical implications, and prognosis.
,7- Bull TM
- Clark B
- McFann K
- et al.
Pulmonary vascular dysfunction is associated with poor outcomes in patients with acute lung injury.
,14- See KC
- Ng J
- Siow WT
- et al.
Frequency and prognostic impact of basic critical care echocardiography abnormalities in patients with acute respiratory distress syndrome.
,15- Bonizzoli M
- Cipani S
- Lazzeri C
- et al.
Speckle tracking echocardiography and right ventricle dysfunction in acute respiratory distress syndrome a pilot study.
comparative “OR” (one study),
8- Fichet J
- Moreau L
- Genee O
- et al.
Feasibility of right ventricular longitudinal systolic function evaluation with transthoracic echocardiographic indices derived from tricuspid annular motion: A preliminary study in acute respiratory distress syndrome.
or conjunctive parameters “AND” (seven studies).
6- Osman D
- Monnet X
- Castelain V
- et al.
Incidence and prognostic value of right ventricular failure in acute respiratory distress syndrome.
,9- Lheritier G
- Legras A
- Caille A
- et al.
Prevalence and prognostic value of acute cor pulmonale and patent foramen ovale in ventilated patients with early acute respiratory distress syndrome: A multicenter study.
, 10- Boissier F
- Katsahian S
- Razazi K
- et al.
Prevalence and prognosis of cor pulmonale during protective ventilation for acute respiratory distress syndrome.
, 11- Legras A
- Caille A
- Begot E
- et al.
Acute respiratory distress syndrome (ARDS)-associated acute cor pulmonale and patent foramen ovale: A multicenter noninvasive hemodynamic study.
, 12- Lazzeri C
- Cianchi G
- Bonizzoli M
- et al.
Right ventricle dilation as a prognostic factor in refractory acute respiratory distress syndrome requiring veno-venous extracorporeal membrane oxygenation.
, 13- Mekontso Dessap A
- Boissier F
- Charron C
- et al.
Acute cor pulmonale during protective ventilation for acute respiratory distress syndrome: Prevalence, predictors, and clinical impact.
,16- Zeiton T
- Elsayed HM
- Hassan O
- et al.
Clinical risk score for the diagnosis of acute cor pulmonale in acute respiratory distress syndrome.
These included size ratio (RV to LV end-diastolic area ratio), regional function (tricuspid annular plane systolic excursion [TAPSE], tricuspid annulus peak velocity), global function (RV free wall strain), pressure (right atrial pressure or central venous pressure higher than pulmonary capillary wedge pressure), pulmonary arterial systolic pressure, septal kinetics, and flow with stroke volume index. RV-to-LV end-diastolic area ratio was the most commonly used parameter (eight studies),
5- Vieillard-Baron A
- Schmitt JM
- Augarde R
- et al.
Acute cor pulmonale in acute respiratory distress syndrome submitted to protective ventilation: Incidence, clinical implications, and prognosis.
,9- Lheritier G
- Legras A
- Caille A
- et al.
Prevalence and prognostic value of acute cor pulmonale and patent foramen ovale in ventilated patients with early acute respiratory distress syndrome: A multicenter study.
, 10- Boissier F
- Katsahian S
- Razazi K
- et al.
Prevalence and prognosis of cor pulmonale during protective ventilation for acute respiratory distress syndrome.
, 11- Legras A
- Caille A
- Begot E
- et al.
Acute respiratory distress syndrome (ARDS)-associated acute cor pulmonale and patent foramen ovale: A multicenter noninvasive hemodynamic study.
, 12- Lazzeri C
- Cianchi G
- Bonizzoli M
- et al.
Right ventricle dilation as a prognostic factor in refractory acute respiratory distress syndrome requiring veno-venous extracorporeal membrane oxygenation.
, 13- Mekontso Dessap A
- Boissier F
- Charron C
- et al.
Acute cor pulmonale during protective ventilation for acute respiratory distress syndrome: Prevalence, predictors, and clinical impact.
, 14- See KC
- Ng J
- Siow WT
- et al.
Frequency and prognostic impact of basic critical care echocardiography abnormalities in patients with acute respiratory distress syndrome.
,16- Zeiton T
- Elsayed HM
- Hassan O
- et al.
Clinical risk score for the diagnosis of acute cor pulmonale in acute respiratory distress syndrome.
followed by septal dyskinesia (five studies)
9- Lheritier G
- Legras A
- Caille A
- et al.
Prevalence and prognostic value of acute cor pulmonale and patent foramen ovale in ventilated patients with early acute respiratory distress syndrome: A multicenter study.
, 10- Boissier F
- Katsahian S
- Razazi K
- et al.
Prevalence and prognosis of cor pulmonale during protective ventilation for acute respiratory distress syndrome.
, 11- Legras A
- Caille A
- Begot E
- et al.
Acute respiratory distress syndrome (ARDS)-associated acute cor pulmonale and patent foramen ovale: A multicenter noninvasive hemodynamic study.
,13- Mekontso Dessap A
- Boissier F
- Charron C
- et al.
Acute cor pulmonale during protective ventilation for acute respiratory distress syndrome: Prevalence, predictors, and clinical impact.
,16- Zeiton T
- Elsayed HM
- Hassan O
- et al.
Clinical risk score for the diagnosis of acute cor pulmonale in acute respiratory distress syndrome.
and central venous pressure higher than pulmonary capillary wedge pressure (three studies).
4- Monchi M
- Bellenfant F
- Cariou A
- et al.
Early predictive factors of survival in the acute respiratory distress syndrome. A multivariate analysis.
,6- Osman D
- Monnet X
- Castelain V
- et al.
Incidence and prognostic value of right ventricular failure in acute respiratory distress syndrome.
,7- Bull TM
- Clark B
- McFann K
- et al.
Pulmonary vascular dysfunction is associated with poor outcomes in patients with acute lung injury.
The most frequently used definition was the composite of size ratio and elevated pressure and/or septal dyskinesia (six studies).
9- Lheritier G
- Legras A
- Caille A
- et al.
Prevalence and prognostic value of acute cor pulmonale and patent foramen ovale in ventilated patients with early acute respiratory distress syndrome: A multicenter study.
, 10- Boissier F
- Katsahian S
- Razazi K
- et al.
Prevalence and prognosis of cor pulmonale during protective ventilation for acute respiratory distress syndrome.
, 11- Legras A
- Caille A
- Begot E
- et al.
Acute respiratory distress syndrome (ARDS)-associated acute cor pulmonale and patent foramen ovale: A multicenter noninvasive hemodynamic study.
,13- Mekontso Dessap A
- Boissier F
- Charron C
- et al.
Acute cor pulmonale during protective ventilation for acute respiratory distress syndrome: Prevalence, predictors, and clinical impact.
,16- Zeiton T
- Elsayed HM
- Hassan O
- et al.
Clinical risk score for the diagnosis of acute cor pulmonale in acute respiratory distress syndrome.
Three studies used pulmonary artery catheters,
4- Monchi M
- Bellenfant F
- Cariou A
- et al.
Early predictive factors of survival in the acute respiratory distress syndrome. A multivariate analysis.
,6- Osman D
- Monnet X
- Castelain V
- et al.
Incidence and prognostic value of right ventricular failure in acute respiratory distress syndrome.
,7- Bull TM
- Clark B
- McFann K
- et al.
Pulmonary vascular dysfunction is associated with poor outcomes in patients with acute lung injury.
four studies used TEE,
5- Vieillard-Baron A
- Schmitt JM
- Augarde R
- et al.
Acute cor pulmonale in acute respiratory distress syndrome submitted to protective ventilation: Incidence, clinical implications, and prognosis.
,9- Lheritier G
- Legras A
- Caille A
- et al.
Prevalence and prognostic value of acute cor pulmonale and patent foramen ovale in ventilated patients with early acute respiratory distress syndrome: A multicenter study.
,10- Boissier F
- Katsahian S
- Razazi K
- et al.
Prevalence and prognosis of cor pulmonale during protective ventilation for acute respiratory distress syndrome.
,13- Mekontso Dessap A
- Boissier F
- Charron C
- et al.
Acute cor pulmonale during protective ventilation for acute respiratory distress syndrome: Prevalence, predictors, and clinical impact.
and another four studies used TTE,
8- Fichet J
- Moreau L
- Genee O
- et al.
Feasibility of right ventricular longitudinal systolic function evaluation with transthoracic echocardiographic indices derived from tricuspid annular motion: A preliminary study in acute respiratory distress syndrome.
,14- See KC
- Ng J
- Siow WT
- et al.
Frequency and prognostic impact of basic critical care echocardiography abnormalities in patients with acute respiratory distress syndrome.
, 15- Bonizzoli M
- Cipani S
- Lazzeri C
- et al.
Speckle tracking echocardiography and right ventricle dysfunction in acute respiratory distress syndrome a pilot study.
, 16- Zeiton T
- Elsayed HM
- Hassan O
- et al.
Clinical risk score for the diagnosis of acute cor pulmonale in acute respiratory distress syndrome.
while the other two studies used both TTE and TEE.
11- Legras A
- Caille A
- Begot E
- et al.
Acute respiratory distress syndrome (ARDS)-associated acute cor pulmonale and patent foramen ovale: A multicenter noninvasive hemodynamic study.
,12- Lazzeri C
- Cianchi G
- Bonizzoli M
- et al.
Right ventricle dilation as a prognostic factor in refractory acute respiratory distress syndrome requiring veno-venous extracorporeal membrane oxygenation.
The incidence of RV dysfunction varied from 9.6%-to-89.3%.
This systematic review highlighted that RV dysfunction in ARDS has been defined in 13 eligible studies by nine different definitions using three different modalities. RV-to-LV end-diastolic area ratio with or without septal dyskinesia was the most widely used definition. A conjunctive definition “AND” increases specificity at the expense of reduced sensitivity, which may fail to detect early or borderline cases. Lazzeri et al found that 47.6% of patients with severe ARDS had RV dysfunction with reduced TAPSE, but only 9.5% would meet the RV-to-LV end-diastolic area ratio criteria.
17- Lazzeri C
- Cianchi G
- Bonizzoli M
- et al.
Pulmonary vascular dysfunction in refractory acute respiratory distress syndrome before veno-venous extracorporeal membrane oxygenation.
An RV assessment in patients with ARDS should be sensitive to the earliest sign of RV dysfunction. The current definition assesses the presence of RV strain pattern or systolic dysfunction, which is an advanced stage of RV dysfunction. Tavazzi et al
18- Tavazzi G
- Bergsland N
- Alcada J
- et al.
Early signs of right ventricular systolic and diastolic dysfunction in acute severe respiratory failure: The importance of diastolic restrictive pattern.
showed an RV diastolic restrictive pattern to be present in 64% of patients compared to 33.6% with systolic dysfunction. Similarly, in COVID-19 ARDS, a higher proportion of patients were identified based on reduced RV fractional area change (72%) compared to TAPSE (23.8%). Right ventricle-pulmonary artery uncoupling may be an earlier indicator of RV dysfunction.
19- Bleakley C
- Singh S
- Garfield B
- et al.
Right ventricular dysfunction in critically ill COVID-19 ARDS.
The current definition also is binary, with RV dysfunction being either “present” or “absent” and does not account for any grading of severity of RV dysfunction in a meaningful way. Diagnostic criteria to grade the severity of RV in ARDS, including (1) “at risk for RV dysfunction,” (2) “early RV dysfunction,” and (3) “RV failure,” should be developed and validated as suggested by experts.
20- Vieillard-Baron A
- Naeije R
- Haddad F
- et al.
Diagnostic workup, etiologies and management of acute right ventricle failure: A state-of-the-art paper.
Conflict of Interest
None.
Acknowledgments
The authors thank Mary Schleicher, RN, BSN, MLIS, for assisting with the literature search.
Appendix. Supplementary materials
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The impact of right ventricular injury on the mortality in patients with acute respiratory distress syndrome: A systematic review and meta-analysis.
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Right ventricle in sepsis: Clinical and research priority.
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Early predictive factors of survival in the acute respiratory distress syndrome. A multivariate analysis.
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Acute cor pulmonale in acute respiratory distress syndrome submitted to protective ventilation: Incidence, clinical implications, and prognosis.
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Pulmonary vascular dysfunction is associated with poor outcomes in patients with acute lung injury.
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Feasibility of right ventricular longitudinal systolic function evaluation with transthoracic echocardiographic indices derived from tricuspid annular motion: A preliminary study in acute respiratory distress syndrome.
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Frequency and prognostic impact of basic critical care echocardiography abnormalities in patients with acute respiratory distress syndrome.
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Speckle tracking echocardiography and right ventricle dysfunction in acute respiratory distress syndrome a pilot study.
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Article info
Publication history
Published online: September 07, 2021
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© 2021 Elsevier Inc. All rights reserved.
