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Prone position ventilation (PPV) is resource-intensive, yet the optimal strategy for PPV in intubated patients with COVID-19 is unclear.Does a prolonged (24 or more hours) PPV strategy improve mortality in intubated COVID-19 patients compared to intermittent (∼16 hours with daily supination) PPV?Multicenter, retrospective cohort study of consecutively admitted intubated COVID-19 patients treated with PPV between March 11 - May 31, 2020. The primary outcome was 30-day all-cause mortality. Secondary outcomes included 90-day all-cause mortality and prone-related complications. Inverse probability treatment weights (IPTW) were used to control for potential treatment selection bias.Of the COVID-19 patients who received PPV, 157 underwent prolonged and 110 underwent intermittent PPV. Patients undergoing prolonged PPV had reduced 30-day (adjusted hazard ratio [aHR] 0.475, 95% CI 0.336-0.670, P value0.001) and 90-day (aHR 0.638, 95% CI 0.461-0.883, P value = 0.006) mortality compared to intermittent PPV. In patients with PAmong intubated COVID-19 patients who received PPV, prolonged PPV was associated with reduced mortality. Prolonged PPV was associated with fewer pronation and supination events and a small increase in rates of facial edema. These findings suggest that prolonged PPV is a safe, effective strategy for mortality reduction in intubated COVID-19 patients.

INTRODUCTION: Pulmonary embolism is a common cause of cardiopulmonary mortality and morbidity worldwide. Survivors of acute pulmonary embolism may experience dyspnea, report reduced exercise capacity, or develop overt pulmonary hypertension. Clinicians must be alert for these phenomena and appreciate the modalities and investigations available for evaluation.AREAS COVERED: In this review, the current understanding of available contemporary imaging and physiologic modalities is discussed, based on available literature and professional society guidelines. The purpose of the review is to provide clinicians with an overview of these modalities, their strengths and disadvantages, and how and when these investigations can support the clinical work-up of patients post-pulmonary embolism.EXPERT OPINION: Echocardiography is a first test in symptomatic patients post-pulmonary embolism, with ventilation/perfusion scanning vital to determination of whether there is chronic residual emboli. The role of computed tomography and magnetic resonance in assessing the pulmonary arterial tree in post-pulmonary embolism patients is evolving. Functional testing, in particular cardiopulmonary exercise testing, is emerging as an important modality to quantify and determine cause of functional limitation. It is possible that future investigations of the post-pulmonary embolism recovery period will better inform treatment decisions for acute pulmonary embolism patients.

The American Thoracic Society Core Curriculum updates clinicians annually in adult and pediatric pulmonary disease, medical critical care, and sleep medicine in a 3- to 4-year recurring cycle of topics. The topics of the 2020 Pulmonary Core Curriculum include pulmonary vascular disease (submassive pulmonary embolism, chronic thromboembolic pulmonary hypertension, and pulmonary hypertension) and pulmonary infections (community-acquired pneumonia, pulmonary nontuberculous mycobacteria, opportunistic infections in immunocompromised hosts, and coronavirus disease [COVID-19]).

Purpose Evaluate the association between chronic right ventricle (RV) dysfunction by transthoracic echocardiogram (TTE) and outcomes in patients with acute pulmonary embolism (PE). Methods This was a retrospective analysis of TTE findings in acute PEs. TTEs were used to classify the presence of chronic right ventricular pressure overload (RPVO), defined as RV hypertrophy or RV systolic pressure (RVSP) >50 mmHg, acute RVPO, defined as RV dysfunction not meeting the chronic RVPO definition, or no RV dysfunction. The primary outcome was a composite of death or need for advanced PE therapies at 7 days. Results Of 466 patients, 288 had evidence of RV dysfunction. Thirty percent (140) had evidence of chronic RVPO and 148 patients had evidence of acute RVPO. Chronic RVPO patients were older (P = .004), more likely to have COPD, and had lower heart rates and troponin-t values. The acute RVPO patients included more women and were less likely to have a prior PE. There was no difference in outcomes between the acute and chronic RVPO cohorts. Conclusions Chronic RVPO patients had lower heart rates and troponin-t values. Despite these differences there were no differences in need for advanced therapeutic interventions or 7 day mortality.

A 19-year-old, previously healthy man presented with 3 days of cough, high-grade fevers (40 °C), and dyspnea. Apart from a resolved history of seizures not requiring medications, he had no medical or surgical history. He had no known drug allergies. He took montelukast for allergies and trimethoprim-sulfamethoxazole (TMP-SMX) for 2 weeks before admission for acne, but no other medications, including over-the-counter medications and supplements. He had animal exposures to a new puppy and a friend’s bird. He had no history of smoking, vaping, or recreational drug use. His paternal grandmother had rheumatoid arthritis.

PURPOSE OF REVIEW Acute pulmonary embolism is a life-threatening condition that can lead to both acute and long-term morbidity and mortality. Patients with acute pulmonary embolism are at risk for significant complications including the development of chronic pulmonary embolism and chronic thromboembolic pulmonary hypertension. This review will describe the rationale for and structure of pulmonary embolism response teams, with a focus on the recognition and treatment of patients with persistent morbidity following pulmonary embolism. RECENT FINDINGS For patients with intermediate and high-risk pulmonary embolism, a myriad of treatment options exist, ranging from anticoagulation alone to surgical embolectomy and hemodynamic support with extracorporeal membrane oxygenation. Optimizing treatment for these patients requires rapid assessment and multidisciplinary cooperation. Over the last five years, the pulmonary embolism response team has emerged as a mechanism to facilitate this care. SUMMARY Pulmonary embolism response teams can streamline and expedite care for patients with intermediate and high-risk pulmonary embolism. However, the care for patients with acute pulmonary embolism does not end at hospital discharge. It is essential to ensure adequate follow-up and identify patients with persistent symptoms and impaired quality of life, particularly those who may have symptomatic chronic pulmonary embolism or chronic thromboembolic pulmonary hypertension.

INTRODUCTION: Hepatic involvement in hereditary hemorrhagic telangiectasia (HHT) is common and can be associated with severe clinical consequences, including portal hypertension, cardiac failure, and encephalopathy. However, there are no reliable clinical predictors of hepatic involvement and its associated complications, limiting appropriate identification of these patients. In this work, we define the utility of serum ammonia and liver biochemical tests (LFTs) in predicting hepatic HHT involvement and its complications. METHODS: We performed a retrospective study examining a well-characterized cohort of patients with HHT. Clinical characteristics, laboratory tests, liver imaging, transthoracic echocardiography assessment of right ventricular systolic pressure (RVSP), and history of other HHT-related outcomes were assessed. Patients were followed for the development of encephalopathy. RESULTS: Of 45 patients with definite HHT, 18 (40%) had elevated ammonia levels. An elevated ammonia associated with the presence of hepatic arteriovenous malformations (AVMs) on imaging (P < 0.03) and when combined with elevated liver tests increased the sensitivity for hepatic AVMs by 18% (55% for LFTs vs 73% for LFTs plus ammonia). Furthermore, an elevated serum ammonia in patients with HHT associated with an elevated RVSP (>35 mm Hg), providing an 80% sensitivity and 71% specificity for predicting the presence of pulmonary hypertension. In contrast, there was no association with an elevated serum ammonia and encephalopathy over a total of 859 months of follow-up. DISCUSSION: Elevated ammonia in a cohort of patients with HHT was associated with the presence of hepatic AVMs and elevated RVSP, but no other complications of HHT, including encephalopathy.

To describe the frequency with which pulmonary capillary wedge pressure measurements, obtained during right heart catheterization, are falsely elevated and to educate operators on techniques to improve accuracy of pulmonary capillary wedge pressure reporting. Failure to completely occlude pulmonary artery branch vessels during balloon inflation can lead to falsely elevated, “incomplete” pulmonary capillary wedge pressures. Balloon deflation prior to catheter retraction may result in catheter advancement into smaller branch vessels, yielding an inadvertent but more accurate alternative pulmonary capillary wedge pressure. We hypothesized that this phenomenon can be identified on retrospective review of right heart catheterization tracings, which occurs commonly and goes unrecognized by operators. We conducted a retrospective study of patients undergoing right heart catheterization or right heart catheterization and left heart catheterization with computer-generated pulmonary capillary wedge pressure ≥20 from January 2015 to June 2017. Alternative pulmonary capillary wedge pressures were defined as a pulmonary capillary wedge pressure trace during balloon deflation ≥3 mmHg lower than the reported pulmonary capillary wedge pressure. Inter-rater reliability of tracing reviewers was also evaluated. Results showed that, of the 182 tracings reviewed, an alternative pulmonary capillary wedge pressure was identified in 26 or 14.3% of cases. Eleven of these alternative pulmonary capillary wedge pressures were ≤15 mmHg with a calculated pulmonary vascular resistance ≥3 Wood units in 10 patients, re-classifying the etiology of pulmonary hypertension from post-capillary to pre-capillary in 38.5% of cases. For the eight patients for whom left heart catheterization data were available, left ventricular end-diastolic pressure aligned with the alternative pulmonary capillary wedge pressure. In conclusion, inadvertently obtained, but likely more accurate, alternative pulmonary capillary wedge pressures were identified in almost 15% of procedures reviewed from a busy academic institution. As wedge pressures often drive diagnosis and treatment decisions for patients with cardiac and pulmonary pathology, operators should be attuned to balloon deflation as a time when alternative pulmonary capillary wedge pressures may be identified as they are likely more reflective of left ventricular end-diastolic pressure. Additional tools to ensure accuracy of pulmonary capillary wedge pressure reporting are reviewed.

A case of apparent chronic thromboembolic pulmonary hypertension that surprisingly exhibited metastatic squamous cell carcinoma embedded in the organized thrombus endarterectomized from the proximal pulmonary vessels.

A Woman with Venous Thromboembolism and Pulmonary Artery Aneurysm A 48-year-old woman with a history of venous thromboembolism presented with cough and decreased exercise tolerance. Magnetic resonance imaging of the chest revealed a 2.4-cm aneurysm of the segmental pulmonary artery in the left lower lobe. A diagnosis was made.

Pulmonary arterial hypertension is characterized by progressive vasculopathy in the pulmonary arterial bed leading to right ventricular dysfunction and failure. Despite significant advances in medical therapy over the last several decades, lung transplantation remains a necessary treatment option for patients with severe and refractory disease. This chapter discusses the role of lung transplantation in the management of pulmonary hypertension as well as transplant-specific considerations, including the use of single versus dual lung transplant and the diminishing role of combined heart and lung transplantation.

Pulmonary embolism is a common and often life-threatening event. Treatment options include anticoagulation alone, catheter-directed therapies, and surgical thromboembolectomy. While guidelines exist, there is often controversy over which treatment is most appropriate, particularly for intermediate-risk patients. The traditional care model, in which the primary team is responsible for consulting the appropriate specialists, may be inadequate and inefficient for emergent situations, as ensuring coordination and communication between various consulting services can be a time consuming and confusing process. The Pulmonary Embolism Response Team (PERT) model was developed to improve the quality and efficiency of care for patient with intermediate- and high-risk pulmonary embolism. Activation of the PERT allows for rapid, multidisciplinary discussion among dedicated specialists, which typically includes members of the cardiology, emergency medicine, hematology, pulmonary/critical care, and surgical services. While the majority of patients are still treated with anticoagulation alone, in the event that a more invasive approach is deemed necessary, the team expedites this process. Over the last several years, the PERT model has been adopted at more than 75 health care institutions and may represent a new standard of care.

The original version of the article unfortunately contained an error in conflict of interest. This erratum is published with the correct conflict of interest.

Chronic thromboembolic pulmonary hypertension (CTEPH) occurs when a pulmonary embolism fails to undergo complete thrombolysis leading to vascular occlusion and pulmonary hypertension. Despite the fact that CTEPH is a potential consequence of pulmonary embolism, diagnosis requires a high degree of vigilance as many patients will not have a history of thromboembolic disease. The ventilation perfusion scan is used to evaluate for the possibility of CTEPH although right heart catheterization and pulmonary artery angiogram are needed to confirm the diagnosis. Pulmonary thromboendarterectomy is the first-line treatment for patients who are surgical candidates. Recently, riociguat has been approved for patients with nonsurgical disease or residual pulmonary hypertension despite surgical intervention. This review describes the pathophysiology, risk factors, diagnosis, and management of CTEPH.