Feasibility, Prediction and Association of Right Ventricular Free Wall Longitudinal Strain with 30-Day Mortality in Severe COVID-19 Pneumonia: A Prospective Study

Introduction: Right ventricular (RV) systolic dysfunction (RVsD) is a common complication of coronavirus infection 2019 disease (COVID-19). The right ventricular free wall longitudinal strain parameter (RV-FWLS) is a powerful predictor of mortality. We explored the performance of RVsD parameters for predicting 30-day mortality and the association between RV-FWLS and 30-day mortality. Methods: COVID-19 patients hospitalized at Amiens University Hospital in the critical care unit with transthoracic echocardiography were included. We measured tricuspid annular plane systolic excursion (TAPSE), the RV S’ wave, RV fractional area change (RV-FAC), and RV-FWLS. The diagnostic performance of RVsD parameters as predictors for 30-day mortality was evaluated by the area under the receiver operating characteristic (ROC) curve (AUC). RVsD was defined by an RV-FWLS < 21% to explore the association between RVsD and 30-day mortality. Results: Of the 116 patients included, 20% (n = 23/116) died and 47 had a RVsD. ROC curve analysis showed that RV-FWLS failed to predict 30-day mortality, as did conventional RV parameters (all p > 0.05). TAPSE (21 (19−26) mm vs. 24 (21−27) mm; p = 0.024) and RV-FAC (40 (35−47)% vs. 47 (41−55)%; p = 0.006) were lowered in the RVsD group. In Cox analysis, RVsD was not associated with 30-day mortality (hazard ratio = 1.12, CI 95% (0.49−2.55), p = 0.78). Conclusion: In severe COVID-19 pneumonia, RV-FWLS was not associated with 30-day mortality.

Characteristics and outcomes of older patients undergoing out- versus inpatient surgery in Europe. A secondary analysis of the Peri-interventional Outcome Study in the Elderly (POSE)

BACKGROUND

The number of older patients undergoing surgical procedures with anaesthesia care is projected to rise. In order to cope with the increased demand, the expansion of outpatient surgery may play a decisive role. We aim to investigate the characteristics and outcomes of the older outpatient population.

PATIENTS AND METHODS

The Peri-interventional Outcome Study in the Elderly in Europe (POSE) was a prospective multicenter study investigating characteristics and outcomes in 9497 patients aged 80 years and older undergoing a procedure with anaesthesia care. This secondary analysis of the POSE data investigated characteristics, functional and cognitive outcomes, and mortality in the outpatient in comparison to the inpatient population. Functional status was assessed as independent, partially dependent, and totally dependent at baseline and 30 days postinterventional. Cognitive status was defined by the number of recalled words (0-3) in the Mini-Cog test and brief cognitive screening at baseline and follow-up.

RESULTS

Out of the 9497 older patients, 7562 were planned inpatients and 1935 planned outpatients. Older outpatients presented with fewer comorbidities and fewer medications than older inpatients and underwent minor procedures more often Their baseline functional status was more often independent, and they had a higher estimated probability of staying independent. Outpatients recalled three words at baseline and follow-up more often than inpatients. The estimated 30-day survival probabilities with 95% confidence intervals were 0.997 [0.994; 0.999] in the group with planned outpatient surgery and 0.948 [0.942; 0.953] with planned inpatient surgery.

CONCLUSION

Our results indicate that functional and cognitive status at baseline and follow-up were higher in planned outpatients than in planned inpatients. However, only short screening tools for the assessment of functional and cognitive status were used. Overall, outpatient interventions were associated with low mortality. Further research is recommended to develop scores that facilitate the identification of patients suitable for outpatient surgery.

EDITORIAL COMMENT

This secondary analysis of a prospectively collected cohort of elderly surgical cases in Europe describes case factors related to inpatient compared to outpatient surgical interventions. The findings show that inpatient or outpatient surgery selection is associated with different degrees of risk for important perioperative outcomes in this cohort.

Long-term survival comparison between the first and second waves among 265 critical COVID-19 patients admitted to the ICU: A retrospective cohort study

BACKGROUD

Management of severe COVID-19 patients admitted to ICU considerably evolved during the first months of the pandemic. It is unclear, however, whether these changes improved long-term survival of these critically ill patients.

METHODS

We conducted a retrospective cohort study in adults with COVID-19 pneumonia admitted to a French ICU between February 2020 and January 2021, a timeframe that covered the first two waves of the pandemic. Primary outcome was to compare long-term survival between the first and second waves. Survival predictor were identified using a Cox proportional-hazards model.

RESULTS

We included 265 patients in the cohort: 140 (52.8 %) and 125 (47.2 %) belonging to the first and second waves, respectively. Baseline characteristics of the patients were similar between the two waves. During W2, use of early corticotherapy increased (86.4% vs. 17.8 %; p <0.001), as well as high-flow oxygen therapy use (68.5% vs. 37.4 %; p<0.001). Need for invasive mechanical ventilation decreased (49.6% vs. 72.9 %; p <0.001) and ICU length of stay was shorter (11 [6-22] vs 19 [8-32]days; p = 0.008). ICU mortality was 32.8 % without significant difference between waves. Survival analysis revealed that 3 variables were independently associated with a worse long-term prognosis: a higher SAPS II score (1.05 [1.04-1.06]; p<0.001), a higher age (1.05 [1.01-1.08]; p = 0.005) and admission during W2 (2.22 [1.15-4.28]; p = 0.017).

DISCUSSION

Despite substantial changes on management of severe COVID-19 patients, we observed a decreased long-term survival among patients admitted during the second wave. We also noted a shorter ICU length of stay.

Left atrial strain analysis and new-onset atrial fibrillation in patients with ST-segment elevation myocardial infarction: A prospective echocardiography study

BACKGROUND

New-onset atrial fibrillation (NOAF) is a well-known complication of ST-segment elevation myocardial infarction (STEMI), probably due to left atrial (LA) remodelling. LA strain (LAS) can predict NOAF in several cardiovascular diseases.

OBJECTIVE

To assess whether LAS predicts NOAF in sinus rhythm patients with STEMI during hospitalization.

METHODS

Adults with a STEMI and transthoracic echocardiography performed within 48hours of admission were included. LAS analysis, performed by automated software, recorded LAS during the reservoir phase (LASr), the conduit phase (LAScd) and the contraction phase (LASct).

RESULTS

From May 2021 to November 2022, 175 patients were included, 21 (12%) of whom developed NOAF. NOAF patients were older (median [Q1-Q3]: 67 [59-80] vs 59 [51-67]years; P=0.006) and had a higher Thrombolysis In Myocardial Infarction scores (4 [2-7] vs 3 [1-4]; P=0.005). All LAS parameters were significantly impaired in NOAF patients, especially LASr (13.0% [10.5-28.4] vs 36.6% [29.0-44.9]; P=0.001). An LASr cut-off of 27% had a sensitivity of 81% and a specificity of 80% to identify patients with NOAF. In a multivariable model, LASr was significantly associated with NOAF (odds ratio 1.18, 95% confidence interval 1.09-1.26; P=0.003). The cumulative risk of NOAF during hospital stay was 30% (18-43 with LASr<27% and 4% [1.5-8.5] with LASr≥27% [P<0.0001]).

CONCLUSION

NOAF is a frequent complication of STEMI. LASr seems helpful for identifying patients at high risk of NOAF during hospitalization.

Prognostic value of right ventricular dilatation on computed tomography pulmonary angiogram for predicting adverse clinical events in severe COVID-19 pneumonia

BACKGROUND

Right ventricle dilatation (RVD) is a common complication of non-intubated COVID-19 pneumonia caused by pro-thrombotic pneumonitis, intra-pulmonary shunting, and pulmonary vascular dysfunction. In several pulmonary diseases, RVD is routinely measured on computed tomography pulmonary angiogram (CTPA) by the right ventricle-to-left ventricle (LV) diameter ratio > 1 for predicting adverse events.

OBJECTIVE

The aim of the study was to evaluate the association between RVD and the occurrence of adverse events in a cohort of critically ill non-intubated COVID-19 patients.

METHODS

Between February 2020 and February 2022, non-intubated patients admitted to the Amiens University Hospital intensive care unit for COVID-19 pneumonia with CTPA performed within 48 h of admission were included. RVD was defined by an RV/LV diameter ratio greater than one measured on CTPA. The primary outcome was the occurrence of an adverse event (renal replacement therapy, extracorporeal membrane oxygenation, 30-day mortality after ICU admission).

RESULTS

Among 181 patients, 62% (n = 112/181) presented RVD. The RV/LV ratio was 1.10 [1.05-1.18] in the RVD group and 0.88 [0.84-0.96] in the non-RVD group (p = 0.001). Adverse clinical events were 30% and identical in the two groups (p = 0.73). In Receiving operative curves (ROC) analysis, the RV/LV ratio measurement failed to identify patients with adverse events. On multivariable Cox analysis, RVD was not associated with adverse events to the contrary to chest tomography severity score > 10 (hazards ratio = 1.70, 95% CI [1.03-2.94]; p = 0.04) and cardiovascular component (> 2) of the SOFA score (HR = 2.93, 95% CI [1.44-5.95], p = 0.003).

CONCLUSION

Right ventricle (RV) dilatation assessed by RV/LV ratio was a common CTPA finding in non-intubated critical patients with COVID-19 pneumonia and was not associated with the occurrence of clinical adverse events.