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Correspondence |

2009 Influenza A(H1N1) Infection and Associated Myocardial Dysfunction FREE TO VIEW

Rashmi Ranjan Das, MD
Author and Funding Information

From the Department of Pediatrics, All India Institute of Medical Sciences (AIIMS).

Correspondence to: Rashmi Ranjan Das, MD, Department of Pediatrics, AIIMS, New Delhi-110029, India; e-mail: rrdas05@gmail.com


Financial/nonfinancial disclosures: The author has reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).


© 2011 American College of Chest Physicians


Chest. 2011;139(6):1545-1546. doi:10.1378/chest.10-3307
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Published online

To the Editor:

I read with great interest the article by Martin et al1 in a recent issue of CHEST (May 2010). The authors, in their description of echocardiography findings in six patients, concluded that potentially reversible cardiac dysfunction is a relatively common complication associated with hospitalized patients with 2009 influenza A(H1N1) (A[H1N1]).

In Table 1, the authors described the characteristics of patients with A(H1N1) and cardiac dysfunction. However, if we look carefully at the table, the following points merit attention. All the patients had some underlying comorbidity that directly or indirectly affects the cardiac function. The baseline ejection fraction of case 4 was 40%, which might decrease not only because of A(H1N1) infection per se but also because of associated bacterial pneumonia/sepsis (which was not clearly described in the article). Cases 5 and 6 were pregnant patients in their third trimester. There is a possibility that these two cases may represent peripartum cardiomyopathy (criteria for diagnosis: cardiac failure within last months of pregnancy or within 5 months postpartum, no determinable cause for failure, no previous heart diseases, left ventricular dysfunction with ejection fraction <45%) that improved with treatment.2 More importantly, the Pao2/Fio2 fraction in all except case 5 (Pao2/Fio2 >300) fulfilled the criteria for ARDS (Pao2/Fio2 ≤200).3 ARDS is a reasonably well-characterized cause of acute cor pulmonale. Whether A(H1N1) virus induces disproportionate pulmonary vascular disease is not known, although preliminary autopsy results may be compatible with this finding.4 The thin-walled right side of the heart is particularly susceptible to ischemia and failure in the face of acute increases in afterload. Right-sided heart dysfunction has direct effects on left ventricular diastolic and systolic function. Except in cases 3 and 5, the APACHE (Acute Physiology And Chronic Health Evaluation) II score in the other four cases varied from 20 to 28, indicating that these patients were severely ill.5 In severely ill patients, multiple factors contribute to myocardial dysfunction, including sepsis, pneumonia, ARDS, and associated other organ dysfunction (as described in case 1, the dose of oseltamivir was reduced because of associated severe renal impairment). The rapid downhill course of case 1 (being intubated within 24 h of hospitalization) and partial response to diuretics and inotropes suggests the above possibilities rather than reversible cardiac dysfunction alone.

Martin SS, Hollingsworth CL, Norfolk SG, Wolfe CR, Hollingsworth JW. Reversible cardiac dysfunction associated with pandemic 2009 influenza A(H1N1). Chest. 2010;1375:1195-1197. [CrossRef] [PubMed]
 
Pearson GD, Veille JC, Rahimtoola S, et al. Peripartum cardiomyopathy: National Heart, Lung, and Blood Institute and Office of Rare Diseases (National Institutes of Health) workshop recommendations and review. JAMA. 2000;2839:1183-1188. [CrossRef] [PubMed]
 
Bernard GR, Artigas A, Brigham KL, et al. The American-European Consensus Conference on ARDS. Definitions, mechanisms, relevant outcomes, and clinical trial coordination. Am J Respir Crit Care Med. 1994;1493 pt 1:818-824. [PubMed]
 
Centers for Disease Control and Prevention (CDC)Centers for Disease Control and Prevention (CDC) Intensive-care patients with severe novel influenza A (H1N1) virus infection - Michigan, June 2009. MMWR Morb Mortal Wkly Rep. 2009;5827:749-752. [PubMed]
 
Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: a severity of disease classification system. Crit Care Med. 1985;1310:818-829. [CrossRef] [PubMed]
 

Figures

Tables

References

Martin SS, Hollingsworth CL, Norfolk SG, Wolfe CR, Hollingsworth JW. Reversible cardiac dysfunction associated with pandemic 2009 influenza A(H1N1). Chest. 2010;1375:1195-1197. [CrossRef] [PubMed]
 
Pearson GD, Veille JC, Rahimtoola S, et al. Peripartum cardiomyopathy: National Heart, Lung, and Blood Institute and Office of Rare Diseases (National Institutes of Health) workshop recommendations and review. JAMA. 2000;2839:1183-1188. [CrossRef] [PubMed]
 
Bernard GR, Artigas A, Brigham KL, et al. The American-European Consensus Conference on ARDS. Definitions, mechanisms, relevant outcomes, and clinical trial coordination. Am J Respir Crit Care Med. 1994;1493 pt 1:818-824. [PubMed]
 
Centers for Disease Control and Prevention (CDC)Centers for Disease Control and Prevention (CDC) Intensive-care patients with severe novel influenza A (H1N1) virus infection - Michigan, June 2009. MMWR Morb Mortal Wkly Rep. 2009;5827:749-752. [PubMed]
 
Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: a severity of disease classification system. Crit Care Med. 1985;1310:818-829. [CrossRef] [PubMed]
 
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