Critical Care Transesophageal Echocardiography in Patients during the COVID-19 Pandemic

Cardiovascular Complications and Imaging in the Era of the COVID-19 Pandemic 2020 to Present

The COVID-19 pandemic has impacted the world that was not previously conceivable. In early 2020, hospitals on all continents were overwhelmed with patients afflicted with this novel virus, with unanticipated mortality worldwide. The virus has had a deleterious effect, particularly the respiratory and cardiovascular systems. Cardiovascular biomarkers demonstrated an array of cardiovascular insults from hypoxia to inflammatory and perfusion abnormalities of the myocardium to life-threatening arrhythmias and heart failure. Patients were at increased risk of a pro-thrombotic state early in the course of the disease. Cardiovascular imaging became a primary tool in diagnosing, prognosing and risk-stratifying patients. Transthoracic echocardiography became the initial imaging modality in management of cardiovascular implications. In addition to cardiac function, LV longitudinal strain (LVLS) and right ventricular free wall strain (RVFWS) were indicators of increased morbidly and mortality. Cardiac MRI has become the diagnostic cardiovascular imaging for myocardial injury and tissue evaluation in the age of COVID-19.

Hypotensive patient with superior vena cava obstruction diagnosed using resuscitative transesophageal echocardiography

BACKGROUND

Superior vena cava syndrome (SVCS) is a malignancy-related emergency. It is caused by obstruction of blood flow in the superior vena cava (SVC) secondary to intraluminal thrombosis, external compression, or direct invasion of tumor.

CASE SUMMARY

A 49-year-old male presented to the emergency department (ED) with acute hypoxemic respiratory failure. He was intubated and treated as pneumonia. Post-intubation, he became hypotensive, requiring fluid resuscitation and inotropic support. Resuscitative transesophageal echocardiography (TEE) showed external compression by a lung mass and an intraluminal thrombus causing SVC obstruction. Computed tomography (CT) angiography was performed, and it confirmed the TEE findings. A provisional diagnosis of lung carcinoma was made, and he underwent endovascular therapy for rapid symptomatic relief.

DISCUSSION

This case report highlights the role of resuscitative TEE in evaluating a hypotensive patient with clinical suspicion of SVCS at the emergency department. TEE performed at the bedside could help to diagnose and demonstrate the pathology causing SVCS in this case. TEE allowed high-quality image acquisition and was able to overcome the limitation of transthoracic echocardiography (TTE). TEE should be considered as an alternative ED imaging modality in the management of SVCS.

LEARNING POINTS

Ultrasound vector flow imaging during veno-arterial extracorporeal membrane oxygenation in a thoracic aorta model

In veno-arterial extracorporeal membrane oxygenation (VA-ECMO) treatment, the mixing zone is a key hemodynamic factor that determines the efficacy of the treatment. This study aimed to evaluate the applicability of a novel ultrasound technique called vector flow imaging (VFI) for visualizing complex flow patterns in an aorta phantom under VA-ECMO settings. VFI experiments were performed to image aortic hemodynamics under VA-ECMO treatment simulated in an anthropomorphic thoracic aorta phantom using a pulsatile pump (cardiac output: 2.7 L/min) and an ECMO pump with two different flow rates, 0.35 L/min and 1.0 L/min. The cardiac cycle of hemodynamics in the ascending aorta, aortic arch, and descending aorta was visualized, and the spatio-temporal dynamics of flow vectors were analyzed. VFI successfully visualized dynamic flow patterns in the aorta phantom. When the flow rate of the ECMO pump increased, ECMO flow was more dominant than cardiac output in the diastole phase, and the speed of cardiac output was suppressed in the systole phase. Vortex flow patterns were also detected in the ascending aorta and the arch under both ECMO flow rate conditions. The VFI technique may provide new insights into aortic hemodynamics and facilitates effective and safe VA-ECMO treatment.

Rescue Transesophageal Echocardiography: A Narrative Review of Current Knowledge and Practice

Perioperative transesophageal echocardiography (TEE) has been part of clinical activity for more than 40 years. During this period, TEE has evolved in terms of technology and clinical applications beyond the initial fields of cardiology and cardiac surgery. The benefits of TEE in the diagnosis and management of acute hemodynamic and respiratory collapse have been recognized in noncardiac surgery and by other specialties too. This natural progress led to the development of rescue TEE, a relatively recent clinical application that extends the use of TEE and makes it accessible to a large group of clinicians and patients requiring acute care. In this review, the authors appraise the current clinical applications and evidence base around this topic. The authors provide a thorough review of the various image acquisition protocols, clinical benefits, and compare it with the more frequently used transthoracic echocardiography. Furthermore, the authors have reviewed the current training and credentialing pathways. Overall, rescue TEE is a highly attractive and useful point-of-care examination, but the current evidence base is limited and the technical protocols, training, and credentialing processes are not standardized. There is a need for adequate guidelines and high-quality research to support its application as a bedside rescue tool.

Ultrasound during the COVID-19 Pandemic: A Global Approach

SARS-CoV-2 (severe acute respiratory syndrome Coronavirus-2) rapidly spread worldwide as COVID-19 (Coronavirus disease 2019), causing a costly and deadly pandemic. Different pulmonary manifestations represent this syndrome's most common clinical manifestations, together with the cardiovascular complications frequently observed in these patients. Ultrasound (US) evaluations of the lungs, heart, and lower limbs may be helpful in the diagnosis, follow-up, and prognosis of patients with COVID-19. Moreover, POCUS (point-of-care ultrasound) protocols are particularly useful for patients admitted to intensive care units. The present review aimed to highlight the clinical conditions during the SARS-CoV-2 pandemic in which the US represents a crucial diagnostic tool.

Transesophageal Echocardiography-Guided Extracorporeal Membrane Oxygenation Cannulation in COVID-19 Patients

OBJECTIVES

A paucity of data supports the use of transesophageal echocardiography (TEE) for bedside extracorporeal membrane oxygenation (ECMO) cannulation. Concerns have been raised about performing TEEs in patients with COVID-19. The authors describe the use and safety of TEE guidance for ECMO cannulation for COVID-19.

DESIGN

Single-center retrospective cohort study.

SETTING

The study took place in the intensive care unit of an academic tertiary center.

PARTICIPANTS

The authors included 107 patients with confirmed SARS-CoV-2 infection who underwent bedside venovenous ECMO (VV ECMO) cannulation under TEE guidance between May 2020 and June 2021.

INTERVENTIONS

TEE-guided bedside VV ECMO cannulation.

MEASUREMENTS

Patient characteristics, physiologic and ventilatory parameters, and echocardiographic findings were analyzed. The primary outcome was the number of successful TEE-guided bedside cannulations without complications. The secondary outcomes were cannulation complications, frequency of cannula repositioning, and TEE-related complications.

MAIN RESULTS

TEE-guided cannulation was successful in 99% of the patients. Initial cannula position was adequate in all but 1 patient. Fourteen patients (13%) required cannula repositioning during ECMO support. Forty-five patients (42%) had right ventricular systolic dysfunction, and 9 (8%) had left ventricular systolic dysfunction. Twelve patients (11%) had intracardiac thrombi. One superficial arterial injury and 1 pneumothorax occurred. No pericardial tamponade, hemothorax or intraabdominal bleeding occurred in the authors' cohort. No TEE-related complications or COVID-19 infection of healthcare providers were reported during this study.

CONCLUSIONS

Bedside TEE guidance for VV ECMO cannulation is safe in patients with severe respiratory failure due to COVID-19. No tamponade or hemothorax, nor TEE-related complications were observed in the authors' cohort.

Monitoring during extracorporeal membrane oxygenation

PURPOSE OF REVIEW

Extracorporeal membrane oxygenation (ECMO) offers advanced mechanical support to patients with severe acute respiratory and/or cardiac failure. Ensuring an adequate therapeutic approach as well as prevention of ECMO-associated complications, by means of timely liberation, forms an essential part of standard ECMO care and is only achievable through continuous monitoring and evaluation. This review focus on the cardiorespiratory monitoring tools that can be used to assess and titrate adequacy of ECMO therapy; as well as methods to assess readiness to wean and/or discontinue ECMO support.

RECENT FINDINGS

Surrogates of tissue perfusion and near infrared spectroscopy are not standards of care but may provide useful information in select patients. Echocardiography allows to determine cannulas position, evaluate cardiac structures, and function, and diagnose complications. Respiratory monitoring is mandatory to achieve lung protective ventilation and identify early lung recovery, surrogate measurements of respiratory effort and ECMO derived parameters are invaluable in optimally managing ECMO patients.

SUMMARY

Novel applications of existing monitoring modalities alongside evolving technological advances enable the advanced monitoring required for safe delivery of ECMO. Liberation trials are necessary to minimize time sensitive ECMO related complications; however, these have yet to be standardized.

Identification of COVID-19-associated myocarditis by speckle-tracking transesophageal echocardiography in critical care

A 68-year-old male presented with flu-like symptoms, fatigue, history of obesity, hypertension, type 2 diabetes and chronic smoking. Chest radiography revealed right basal opacity consisting of infiltrate. With respiratory failure, orotracheal intubation and mechanical ventilation were performed. Patient presented gas exchange alteration. Real-time PCR detected SARS-CoV-2. Treatment with liponavir/ritonavir and hydroxychloroquine was started. Because of poor acoustic window, speckle-tracking transoesophageal echocardiography (TEE) was performed, detecting deterioration in global longitudinal strain. Acute COVID 19 infection led us to suspect myocarditis, with no other signs or symptoms other than elevated troponin and altered strain. On day 15, the patient suffered bacteraemic sepsis at endovascular focus with Serratia marcescens and multiorgan failure. TEE-guided haemodynamic monitoring was repeated showing global longitudinal strain improvement. Acute COVID 19 infection led us to suspect myocarditis, with no other signs or symptoms beyond elevated troponin and altered strain.

Is There a Role for Transesophageal Echocardiography in the Perioperative Trauma Patient?

Purpose of Review

This review article summarizes the advantages and potential uses of focused transesophageal echocardiography (TEE) in the perioperative period for trauma patients. We suggest a locally developed TEE protocol for trauma and provide strategies to achieve widespread use of TEE in the anesthesia care of trauma patients.

Recent Findings

In recent years, TEE has gained interest as an additional modality as point-of-care ultrasound (POCUS) for the resuscitation of acutely ill patients in whom transthoracic echocardiography is not feasible or non-diagnostic. Nevertheless, its use among non-cardiac anesthesiologists is still limited compared to the more traditional POCUS applications.

Summary

A goal-directed, focused TEE can be performed at the bedside in different locations and mechanically ventilated patients. TEE provides relevant diagnostic information to guide the resuscitation of acutely injured patients, particularly to identify life-threatening hidden thoracic injuries in the scenario of patients with multi-system trauma.

Focused Transesophageal Echocardiography in Critical Care: The COVID-19 Pandemic

Background

The use of transesophageal echocardiography (TEE) is controversial in patients with COVID-19. The aim of this case series was to demonstrate the usefulness of transesophageal echocardiography in acute cardiovascular care settings in patients with COVID-19 infection.

Materials and Methods

We enrolled 13 patients with confirmed SARS-CoV-2 infection admitted to the critical care unit of our center from April 1, 2020, to July 30, 2020, in which transesophageal echocardiography was performed. TOE was performed by three cardiologists with training in echocardiography.

Results

The main indication was suspected infective endocarditis in four cases, venovenous extracorporeal membrane oxygenation cannulation in four cases, suspected prosthetic mitral valve dysfunction in two patients, suspected pulmonary embolism in two patients, and acute right ventricular dysfunction and prone position ventilation in one patient. The final diagnosis was confirmed in 11 patients and discarded in 2 patients. None of the operators result infected.

Conclusions

TOE is safe in the context of COVID-19 infection; it must be performed in well-selected cases and in a targeted manner.

Echocardiography in the intensive care unit: An essential tool for diagnosis, monitoring and guiding clinical decision-making

In the last years, new trends on patient diagnosis for admission in cardiac intensive care unit (CICU) have been observed, shifting from acute myocardial infarction or acute heart failure to non-cardiac diseases such as sepsis, acute respiratory failure or acute kidney injury. Moreover, thanks to the advances in scientific knowledge and higher availability, there has been increasing use of positive pressure mechanical ventilation which has its implications on the heart. Therefore, there is a growing need for Cardiac intensivists to quickly, noninvasively and repeatedly evaluate various hemodynamic conditions and the response to therapy. Transthoracic critical care echocardiography (CCE) currently represents an essential tool in CICU, as it is used to evaluate biventricular function and complications following acute coronary syndromes, identify the mechanisms of circulatory failure, acute valvular pathologies, tailoring and titrating intravenous treatment or mechanical circulatory support. This could be completed with trans-esophageal echocardiography (TOE), advanced echocardiography and lung ultrasound to provide a thorough evaluation and monitoring of CICU patients. However, CCE could sometimes be challenging as the acquisition of good-quality images is limited by mechanical ventilation, suboptimal patient position or recent surgery with drains on the chest. Moreover, there are some technical caveats that one should bear in mind while performing CCE in order to optimize its use and avoid misleading findings. The aim of this review is to highlight the key role of CCE, providing an updated overview of its main applications and possible pitfalls in order to facilitate its use in CICU for clinical decision-making.

Bedside cannulation for veno-venous extracorporeal membrane oxygenation using portable X-ray system in a coronavirus disease patient

Transportation of patients with coronavirus disease (COVID)-19 outside isolation rooms should be avoided to prevent further spread of the disease. Here, we report a safe and accurate bedside cannulation method for veno-venous extracorporeal membrane oxygenation (VV-ECMO) in a COVID-19 patient in the intensive care unit. A 71-year-old man was admitted to our hospital and diagnosed as having COVID-19 pneumonia. We decided to initiate VV-ECMO therapy because maintaining blood oxygen saturation was difficult despite the mechanical ventilation. We placed two flat-panel detectors behind the patient's chest and the right inguinal area. We repeatedly imaged and monitored insertion of wires and cannulas using a portable X-ray system. Cannulas were successfully inserted in the appropriate position, and VV-ECMO was initiated without any complications.

<Learning objective: Transportation of patients with coronavirus disease outside isolation rooms carries the risk of further spread of the disease. By repeatedly acquiring images using a portable X-ray system, safe and accurate cannulation for veno-venous extracorporeal membrane oxygenation cannulation can be performed at the bedside in the intensive care unit.>

Absent right superior vena cava with persistent left superior vena cava in a patient with COVID-19

Vascular injury associated with cannulation during extracorporeal membrane oxygenation (ECMO) induction is a rare but life-threatening complication. The presence of abnormal vascular anatomy increases the risk of vascular injury and should be recognized before cannulation. We report the case of a patient with coronavirus disease (COVID-19) who was expected to undergo ECMO. By performing computed tomography (CT), we identified the absence of right superior vena cava (RSVC) with a persistent left superior vena cava (PLSVC) that could have caused serious complications associated with ECMO cannulation. PLSVC is observed in less than 0.5% of the general population; however, the combination of PLSVC and an absent RSVC in visceroatrial situs solitus is extremely rare. Attempting cannulation for Veno-venous (VV)-ECMO from the right (or left) internal jugular vein to the right atrium may cause serious complications. Cannulation may fail or lead to complications even in patients with inferior vena cava malformations. Although these vascular abnormalities are rare, it is possible to avoid iatrogenic vascular injury by identifying their presence in advance. Since anatomical variations in the vessels from the deep chest and abdominal cavity cannot be visualized using chest radiography and ultrasonography, we recommend CT, if possible, for patients with severe respiratory failure, including those with COVID-19, who may be considered for VV-ECMO induction.

Echocardiography, lung ultrasound, and cardiac magnetic resonance findings in COVID-19: A systematic review

BACKGROUND

The manifestations of COVID-19 as outlined by imaging modalities such as echocardiography, lung ultrasound (LUS), and cardiac magnetic resonance (CMR) imaging are not fully described.

METHODS

We conducted a systematic review of the current literature and included studies that described cardiovascular manifestations of COVID-19 using echocardiography, CMR, and pulmonary manifestations using LUS. We queried PubMed, EMBASE, and Web of Science for relevant articles. Original studies and case series were included.

RESULTS

This review describes the most common abnormalities encountered on echocardiography, LUS, and CMR in patients infected with COVID-19.

Imaging Evaluation of Pulmonary and Non-Ischaemic Cardiovascular Manifestations of COVID-19

Coronavirus Disease 2019 (COVID-19) has been a pandemic challenge for the last year. Cardiovascular disease is the most described comorbidity in COVID-19 patients, and it is related to the disease severity and progression. COVID-19 induces direct damage on cardiovascular system, leading to arrhythmias and myocarditis, and indirect damage due to endothelial dysfunction and systemic inflammation with a high inflammatory burden. Indirect damage leads to myocarditis, coagulation abnormalities and venous thromboembolism, Takotsubo cardiomyopathy, Kawasaki-like disease and multisystem inflammatory syndrome in children. Imaging can support the management, assessment and prognostic evaluation of these patients. Ultrasound is the most reliable and easy to use in emergency setting and in the ICU as a first approach. The focused approach is useful in management of these patients due its ability to obtain quick and focused results. This tool is useful to evaluate cardiovascular disease and its interplay with lungs. However, a detailed echocardiography evaluation is necessary in a complete assessment of cardiovascular involvement. Computerized tomography is highly sensitive, but it might not always be available. Cardiovascular magnetic resonance and nuclear imaging may be helpful to evaluate COVID-19-related myocardial injury, but further studies are needed. This review deals with different modalities of imaging evaluation in the management of cardiovascular non-ischaemic manifestations of COVID-19, comparing their use in emergency and in intensive care.

Pulmonary thromboembolism in conjunction with intracavitary thrombus caused by severe acute respiratory syndrome coronavirus-2 infection in a patient living with human immunodeficiency virus

Approximately one-third of patients with coronavirus disease 2019 (COVID-19) present with coagulation disorders and hematological changes. However, the clinical manifestations of COVID-19 and prognoses of people living with human immunodeficiency virus (HIV) remain controversial. This study reports the case of a 27-year-old HIV-infected man who regularly used antiretroviral medications, had no other comorbidities and was admitted for acute respiratory distress syndrome caused by COVID-19. Complementary examinations during hospitalization revealed a diagnosis of pulmonary thromboembolism in association with an intracavitary thrombus.

Heart-lung interactions in COVID-19: prognostic impact and usefulness of bedside echocardiography for monitoring of the right ventricle involvement

Due to the SARS-CoV-2 infection–related severe pulmonary tissue damages associated with a relative specific widespread thrombotic microangiopathy, the pathophysiologic role of heart–lung interactions becomes crucial for the development and progression of right ventricular (RV) dysfunction. The high resistance in the pulmonary circulation, as a result of small vessel thrombosis and hypoxemia, is the major cause of right heart failure associated with a particularly high mortality in severe COVID-19. Timely identification of patients at high risk for RV failure, optimization of mechanical ventilation to limit its adverse effects on RV preload and afterload, avoidance of medication-related increase in the pulmonary vascular resistance, and the use of extracorporeal membrane oxygenation in refractory respiratory failure with hemodynamic instability, before RV failure develops, can improve patient survival. Since it was confirmed that the right-sided heart is particularly involved in the clinical deterioration of patients with COVID-19 and pressure overload-induced RV dysfunction plays a key role for patient outcome, transthoracic echocardiography (TTE) received increasing attention. Limited TTE focused on the right heart appears highly useful in hospitalized COVID-19 patients and particularly beneficial for monitoring of critically ill patients. In addition to detection of right-sided heart dilation and RV dysfunction, it enables assessment of RV-pulmonary arterial coupling and evaluation of RV adaptability to pressure loading which facilitate useful prognostic statements to be made. The increased use of bedside TTE focused on the right heart could facilitate more personalized management and treatment of hospitalized patients and can contribute towards reducing the high mortality associated with SARS-CoV-2 infection.

COVID-19 cardiac arrest management: A review for emergency clinicians

INTRODUCTION

A great deal of literature has recently discussed the evaluation and management of the coronavirus disease of 2019 (COVID-19) patient in the emergency department (ED) setting, but there remains a dearth of literature providing guidance on cardiac arrest management in this population.

OBJECTIVE

This narrative review outlines the underlying pathophysiology of patients with COVID-19 and discusses approaches to cardiac arrest management in the ED based on the current literature as well as extrapolations from experience with other pathogens.

DISCUSSION

Patients with COVID-19 may experience cardiovascular manifestations that place them at risk for acute myocardial injury, arrhythmias, and cardiac arrest. The mortality for these critically ill patients is high and increases with age and comorbidities. While providing resuscitative interventions and performing procedures on these patients, healthcare providers must adhere to strict infection control measures and prioritize their own safety through the appropriate use of personal protective equipment. A novel approach must be implemented in combination with national guidelines. The changes in these guidelines emphasize early placement of an advanced airway to limit nosocomial viral transmission and encourage healthcare providers to determine the effectiveness of their efforts prior to placing staff at risk for exposure.

CONCLUSIONS

While treatment priorities and goals are identical to pre-pandemic approaches, the management of COVID-19 patients in cardiac arrest has distinct differences from cardiac arrest patients without COVID-19. We provide a review of the current literature on the changes in cardiac arrest management as well as details outlining team composition.

A Severe COVID-19 Case Complicated by Right Atrium Thrombus

Patient: Male, 73-year-old

Final Diagnosis: Severe COVID-19 pneumonia complicated by right atrium thrombus

Symptoms: Fever • dyspnea • cough

Medication:—

Clinical Procedure: —

Specialty: Critical Care Medicine