Clinical, historical and diagnostic findings associated with right ventricular dysfunction in patients with central and non-massive pulmonary embolism

Rendina, Domenico; Bonis, Silvana De; Gallotta, Giovanni; Piedimonte, Vincenzo; Mossetti, Giuseppe; Filippo, Gianpaolo De; Farina, Francesca; Vargas, Giuseppe; Barbella, Maria Rosaria; Postiglione, Alfredo; Strazzullo, Pasquale

doi:10.1007/s11739-009-0330-8

Cited by 16 publications

(13 citation statements)

References 40 publications

(67 reference statements)

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“…Compensatory inotropic and chronotropic effects may not be sufficient to maintain a preserved RV function in a condition of increased RV myocardial oxygen demand and decreased coronary perfusion. The findings of Rendina et al [1] confirm and extend the significance of RVD in low-moderate risk patients with PE. They find that chronic obstructive pulmonary disease (COPD) and a history of type 2 diabetes mellitus are independently related to the occurrence of RVD.…”

supporting

confidence: 53%

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mentioning

confidence: 99%

“…The parameters used by Rendina et al [1] represent the current indices traditionally used in this clinical setting. However, the use of a novel technique in the sub-acute phase (i.e.…”

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confidence: 99%

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Right ventricular dysfunction in patients diagnosed with pulmonary embolism

Marra

Pengo

2010

Intern Emerg Med

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We read with interest the paper by Rendina and co-workers [1] dealing with the significance of right ventricular dysfunction (RVD) in patients with pulmonary embolism (PE) without hemodynamic impairment at presentation. It was recently recognized that RVD is a risk marker in patients with PE without shock or hypotension [2,3]. Accordingly, the authors report that RVD at presentation is a significant predictor of later instability occurring on average 72.8 ± 18.6 h after admission. The initial hemodynamic response to PE depends on the extension of vascular occlusion and coexistent cardiopulmonary diseases. A subsequent hemodynamic destabilization may occur within the first 24-48 h as a result of recurrent emboli and right ventricle (RV) failure. Compensatory inotropic and chronotropic effects may not be sufficient to maintain a preserved RV function in a condition of increased RV myocardial oxygen demand and decreased coronary perfusion. The findings of Rendina et al. [1] confirm and extend the significance of RVD in low-moderate risk patients with PE. They find that chronic obstructive pulmonary disease (COPD) and a history of type 2 diabetes mellitus are independently related to the occurrence of RVD. While it is well known that COPD may be associated with pulmonary hypertension and RVD, long lasting diabetes may induce RVD by a damage to cardiac microcirculation; this in turn determining a poor RV function. More attention should thus be paid to patients with PE and associated COPD or type 2 diabetes as RV function may already be compromised.The definition of RVD used by the authors [3], takes into account the most important indices reported in the literature. In fact, a universal definition of RVD on echocardiography has not yet been established. Most important features used in major studies are: RV hypokinesia and dilatation [4], paradoxical septal motion and tricuspid insufficiency. Dilatation of RV with a diastolic diameter [30 mm is an important prognostic index accounting for an early mortality rate as high as 4.6-13% [5]. In the same way, abnormal motion of the interventricular septum, has an important prognostic significance [5]. As these signs may be also related to concomitant cardiac or pulmonary diseases, extensive research has been carried out to find more specific echocardiographic signs with high prognostic value. In this context, the so called ''McConnell Sign'' seems to have an higher positive predictive value irrespective of pre-existing cardiorespiratory disease [2]. This is defined as the presence of normokinesia or hyperkinesia in the apical segment of free RV wall associated with hypokinesia or akinesia in the remaining parts of the RV; potential mechanisms responsible for this feature are the tethering of the RV apex, the lower wall stress in the RV apex associated with a hyperdynamic left ventricle, and the local ischemia of the RV free wall.The evaluation of RV function appears more complex compared to the left ventricle for the following reasons: (1) different longitudinal shortening fr...

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Right ventricular dysfunction in patients diagnosed with pulmonary embolism

Marra

Pengo

2010

Intern Emerg Med

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“…Nutrients which escape the digestion, due to host's limited capability of glycoside hydrolases to digest complex dietary plant polysaccharides, are fermented by gut microbes into monosaccharides and short-chain fatty acids (SCFAs), such as acetate, propionate, and butyrate [11, 48], representing an important energy source for the body. Normal colonic epithelia derive 60–70% of their energy supply from SCFAs, particularly butyrate [49, 50], while propionate is largely taken up by the liver for gluconeogenesis, liponeogenesis, and protein synthesis [51, 52]. …”

Section: Mechanisms Involved In Fat Storagementioning

confidence: 99%

Obesity as a Consequence of Gut Bacteria and Diet Interactions

Kotzampassi

Giamarellos‐Bourboulis

Stavrou

2014

ISRN Obesity

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Obesity is a major public health concern, caused by a combination of increased consumption of energy-dense foods and reduced physical activity, with contributions from host genetics, environment, and adipose tissue inflammation. In recent years, the gut microbiome has also been found to be implicated and augmented research in mice and humans have attributed to it both the manifestation and/or exacerbation of this major epidemic and vice versa. At the experimental level, analysis of fecal samples revealed a potential link between obesity and alterations in the gut flora (drop in Bacteroidetes and increase in Firmicutes), the specific gut microbiome being associated with the obese phenotype. Conventionally raised mice were found to have over 40% more total body fat compared with those raised under germ-free conditions, while conventionalization of germ-free mice resulted in a significant increase in total body fat. Similarly, the sparse data in humans supports the fact that fat storage is favoured by the presence of the gut microbiota, through a multifaceted mechanism. Efforts to identify new therapeutic strategies to modulate gut microbiota would be of high priority for public health, and to date, probiotics and/or prebiotics seem to be the most effective tools.

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“…Rendina et al [5] recently report on a case-control study aimed at evaluating the clinical, historical and diagnostic findings associated with RVD in hemodynamically stable patients with pulmonary embolism. In this study, RVD at echocardiography is defined as the presence of any of the following: (1) abnormal motion of the interventricular septum, (2) dilatation of the right ventricle (diastolic diameter [30 mm), (3) hypokinesis of the right ventricle, (4) tricuspid valve regurgitation/jet velocity [2.5 m/s).…”

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confidence: 99%

Right ventricle dysfunction in patients with pulmonary embolism

2010

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Prognostic stratification is currently used to frame clinical management in terms of diagnostic strategies, hospitalization in intensive care or general ward, and acute treatment in patients with acute pulmonary embolism. In these patients, risk stratification is based on the evaluation of clinical features at presentation, markers of myocardial dysfunction and markers of myocardial injury [1].Echocardiography is currently the mainstay for the assessment of right ventricle dysfunction (RVD) in patients with acute pulmonary embolism. According to recent studies, the proportion of patients with acute pulmonary embolism presenting with RVD at echocardiography varies between 25 and 55% [2]. Criteria used for the diagnosis of RVD at echocardiography are different across studies [3, 4] ( Table 1). Right ventricle free-wall hypokinesia (mild, moderate or severe) or paradoxical septal wall motion are the most used qualitative echocardiographic signs, while right ventricular absolute dimension, or right-to-left ventricle dimension ratio and estimated pulmonary arterial pressure are the quantitative echocardiographic criteria for RVD. Several combinations of these criteria, or, sometimes, a single criterion have been used to diagnose RVD in different studies. However, it is unknown which of these criteria are the most sensitive indicator of pulmonary embolism-induced RVD, and which, if any, best correlates with the patient's prognosis. Thus, only a completely normal result at echocardiography should be considered to define and identify low-risk pulmonary embolism.In a recent meta-analysis of studies including patients with acute pulmonary embolism, the presence of RVD at echocardiography is associated with a more than twofold increase in the risk of in-hospital mortality (risk ratio 2.5, 95% CI 1.2-5.5) [4]. In an observational study, RVD at echocardiography is shown to be associated with a 5% in-hospital mortality rate in patients with a normal blood pressure at admission. On the other hand, none of the patients without RVD at echocardiography died during the hospital stay.The prognostic value of echocardiography in hemodynamically stable patients with acute pulmonary embolism is confirmed in a post-hoc analysis of the ICOPER registry. Among the 1,035 patients who were hemodynamically stable at the time of diagnosis of pulmonary embolism, right ventricle hypokinesis is an independent predictor of the 30-day mortality (hazard ratio 1.94, 95% CI 1.23-3.06) (Fig. 1).However, in order to optimize the accuracy of echocardiography assessments, the use of quantitative parameters have to be preferred than the qualitative ones. The right-to-left ventricle ratio assessed at echocardiography is easy to measure, and less dependent on imaging quality or physician experience. In a study of 950 patients with pulmonary embolism, a right-to-left ventricle ratio major or equal to 0.9 is an independent predictor of in-hospital mortality (odds ratio 2.7, 95% CI 1.7-6.0) after adjustment for a history of left-heart failure, systolic blood pre...

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Clinical, historical and diagnostic findings associated with right ventricular dysfunction in patients with central and non-massive pulmonary embolism

Cited by 16 publications

References 40 publications

Right ventricular dysfunction in patients diagnosed with pulmonary embolism

Right ventricular dysfunction in patients diagnosed with pulmonary embolism

Obesity as a Consequence of Gut Bacteria and Diet Interactions

Right ventricle dysfunction in patients with pulmonary embolism

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