The Dual Role of Echocardiography in the Diagnosis of Acute Cardiac Complications and Treatment Monitoring for Coronavirus Disease 2019 (COVID-19)

Emergency Department Point-Of-Care Echocardiography and Lung Ultrasound in Predicting COVID-19 Severity

OBJECTIVES

We sought to determine if point-of-care ultrasound (POCUS) performed on patients with COVID-19 in the emergency department (ED) can help predict disease course, severity, or identify complications.

METHODS

This was a retrospective cohort study of adult ED patients who tested positive for COVID-19 at hospital admission or within 2 weeks of presentation and received heart or lung POCUS. Clips were reviewed for presence of decreased left ventricular ejection fraction (LVEF), right ventricular dilation, presence of B-lines, and pleural line abnormalities. Patients with worsening hypoxemic respiratory failure or shock requiring higher level of care and patients who expired were considered to have developed severe COVID-19. Regression analysis was performed to determine if there was a correlation between ED POCUS findings and development of severe COVID-19.

RESULTS

A total of 155 patients met study criteria; 148 patients had documented cardiac views and 116 patients had documented lung views (113 with both). Mean age was 66.5 years old (±18.6) and 53% of subjects were female. Subjects with decreased LVEF that was not previously documented had increased odds of having severe COVID during their hospitalization compared to those with old or no dysfunction (OR 5.66, 95% CI: 1.55-19.95, P = .08). The presence of pleural line abnormalities was also predictive for development of severe COVID (OR 2.68, 95% CI: 1.04-6.92, P = .04).

CONCLUSION

POCUS findings of previously unidentified decreased LVEF and pleural line abnormalities in patients with COVID-19 evaluated in the ED were correlated to a more severe clinical course and worse prognosis.

Screening for Myocardial Injury after Mild SARS-CoV-2 Infection with Advanced Transthoracic Echocardiography Modalities

Although the clinical manifestations of SARS-CoV-2 viral infection affect mainly the respiratory system, cardiac complications are common and are associated with increased morbidity and mortality. While echocardiographic alterations indicating myocardial involvement are widely reported in patients hospitalized for acute COVID-19 infection, much fewer data available in non-hospitalized, mildly symptomatic COVID-19 patients. In our work, we aimed to investigate subclinical cardiac alterations characterized by parameters provided by advanced echocardiographic techniques following mild SARS-CoV-2 viral infection. A total of 86 patients (30 males, age: 39.5 ± 13.0 yrs) were assessed 59 ± 33 days after mild SARS-CoV-2 viral infection (requiring no hospital or <5 days in-hospital treatment) by advanced echocardiographic examination including 2-dimensional (2D) speckle tracking echocardiography and non-invasive myocardial work analysis, and were compared to an age-and sex-matched control group. Altogether, variables from eleven echocardiographic categories representing morphological or functional echocardiographic parameters showed statistical difference between the post-COVID patient group and the control group. The magnitude of change was subtle or mild in the case of these parameters, ranging from 1−11.7% of relative change. Among the parameters, global longitudinal strain [−20.3 (−21.1−−19.0) vs. −19.1 (−20.4−−17.6) %; p = 0.0007], global myocardial work index [1975 (1789−2105) vs. 1829 (1656−2057) Hgmm%; p = 0.007] and right ventricular free wall strain values (−26.6 ± 3.80 vs. −23.8 ± 4.0%; p = 0.0003) showed the most significant differences between the two groups. Subclinical cardiac alterations are present following even mild SARS-CoV-2 viral infection. These more subtle alterations are difficult to detect by routine echocardiography. Extended protocols, involving speckle-tracking echocardiography, non-invasive measurement of cardiac hemodynamics, and possibly myocardial work are necessary for detection and adequate follow-up.

Echocardiographic 60-day mortality markers in patients hospitalized in intensive care for COVID-19

BACKGROUND

Coronavirus disease COVID-19 produces a predominantly pulmonary affection, being cardiac involvement an important component of the multiorganic dysfunction. At the moment there are few reports about the behavior of echocardiographic images in the patients who have the severe forms of the disease.

OBJECTIVE

Identify the echocardiographic prognostic markers for death within 60 days in patients hospitalized in intensive care.

METHODS

A single-center prospective cohort was made with patients hospitalized in intensive care for COVID-19 confirmed via polymerase chain reaction who got an echocardiogram between May and October 2020. A Cox multivariate model was plotted reporting the HR and confidence intervals with their respective p values for clinical and echocardiographic variables.

RESULTS

Out of the 326 patients included, 153 patients got an echocardiogram performed on average 6.8 days after admission. The average age was 60.7, 47 patients (30.7%) were females and 67 (44.7%) registered positive troponin. 91 patients (59.5%) died. The univariate analysis identified TAPSE, LVEF, pulmonary artery systolic pressure, acute cor pulmonale, right ventricle diastolic dysfunction, and right ventricular dilatation as variables associated with mortality. The multivariate model identified that the acute cor pulmonale with HR= 4.05 (CI 95% 1.09 - 15.02, p 0.037), the right ventricular dilatation with HR= 3.33 (CI 95% 1.29 - 8.61, p 0.013), and LVEF with HR= 0.94 (CI 95% 0.89 - 0.99, p 0.020) were associated with mortality within 60 days.

CONCLUSIONS

In patients hospitalized in the intensive care unit for COVID-19, the LVEF, acute cor pulmonale and right ventricular dilatation are prognostic echocardiographic markers associated with death within 60 days.

Factors Influencing the Evolution of Pulmonary Hypertension in Previously Healthy Subjects Recovering from a SARS-CoV-2 Infection

(1) Background: While the COVID-19 pandemic has been persisting for almost 2 years, more and more people are diagnosed with residual complications such as pulmonary hypertension (PH) and right ventricular dysfunction (RVD). This study aims to evaluate the course of PH and borderline PH (BPH) at 3 and 6 months after the acute COVID-19 infection and investigate if there are differences regarding its evolution between the patients from the first three waves of this disease. (2) Methods: We analyzed, by transthoracic echocardiography (TTE), the 3 and 6 months' evolution of the echocardiographically estimated systolic pulmonary artery pressures (esPAP) in 116 patients already diagnosed with PH or BPH due to COVID-19 during the first three subsequent waves of COVID-19. (3) Results: We documented a gradual, statistically significant reduction in esPAP values, but also an improvement of the parameters characterizing RVD after 3 and 6 months (p < 0.001). This evolution was somewhat different between subjects infected with different viral strains and was related to the initial severity of the pulmonary injury and PH (adjusted R² = 0.722, p < 0.001). (4) Conclusions: PH and RVD alleviate gradually during the recovery after COVID-19, but in some cases, they persist, suggesting the activation of pathophysiological mechanisms responsible for the self-propagation of PH.

Cardiovascular Abnormalities and Mental Health Difficulties Result in a Reduced Quality of Life in the Post-Acute COVID-19 Syndrome

(1) Background: Post-acute COVID-19 syndrome, characterized by persisting symptoms up to 12 weeks after the acute illness, impairs numerous people’s physical and mental health. (2) Methods: 64 inpatients and 79 outpatients, aged under 55 years, with post-acute COVID-19, were evaluated by a transthoracic echocardiography (TTE), mental health examination, Quality of Life (QoL) questionnaire, post-COVID-19 functional status scale (PCFS) and Hospital Anxiety and Depression Scale (HADS). (3) Results: all inpatients had mild/moderate pulmonary injury during acute COVID-19, in contrast to 37.97% of outpatients. Inpatients who reported an average of 5 persisting symptoms, had, predominantly, level 3 PCFS and a median QoL of 62, compared to outpatients, who reported an average of 3 symptoms, level 1 PCFS and a median QoL score of 70. Increased pulmonary artery pressure was detected in 28.11% of inpatients, compared to 17.72% of outpatients, while diastolic dysfunction was diagnosed in 28.12% of inpatients, in comparison with 20.25% of outpatients (p = 0.02). Abnormal systolic function was assessed in 9.37% of inpatients, and 7.58% of outpatients. According to the HADS depression subscale, 46.87% of inpatients and 27.84% of outpatients had clinical depression. Concomitantly, anxiety was detected in 34.37% of inpatients and 40.5% of outpatients (4) Conclusions: cardiovascular and mental health difficulties were frequently detected in patients with post-acute symptoms of COVID-19, which correlated with the number and intensity of persisting symptoms and reduced QoL scores.

Imaging in the COVID-19 era: Lessons learned during a pandemic

The first year of the coronavirus disease 2019 (COVID-19) pandemic has been a year of unprecedented changes, scientific breakthroughs, and controversies. The radiology community has not been spared from the challenges imposed on global healthcare systems. Radiology has played a crucial part in tackling this pandemic, either by demonstrating the manifestations of the virus and guiding patient management, or by safely handling the patients and mitigating transmission within the hospital. Major modifications involving all aspects of daily radiology practice have occurred as a result of the pandemic, including workflow alterations, volume reductions, and strict infection control strategies. Despite the ongoing challenges, considerable knowledge has been gained that will guide future innovations. The aim of this review is to provide the latest evidence on the role of imaging in the diagnosis of the multifaceted manifestations of COVID-19, and to discuss the implications of the pandemic on radiology departments globally, including infection control strategies and delays in cancer screening. Lastly, the promising contribution of artificial intelligence in the COVID-19 pandemic is explored.

A Multidisciplinary Approach to Evaluate the Presence of Hepatic and Cardiac Abnormalities in Patients with Post-Acute COVID-19 Syndrome-A Pilot Study

(1) Background: Patients suffering from the novel coronavirus 2019 (COVID-19) disease could experience several extra-pulmonary involvements, including cardiovascular complications and liver injury. This study aims to evaluate the presence of cardiac and liver alterations in patients with post-acute COVID-19 syndrome using transthoracic echocardiography (TTE) and liver elastography (LE). (2) Methods: A total of 97 subjects recovering from COVID-19, attending the hospital's specialized outpatient clinic for persisting symptoms at 3 to 11 weeks after the acute illness, were included in this study. They all had a basal COVID-19 assessment, and subsequently, a clinical evaluation, laboratory tests, TTE, and LE. (3) Results: considering the presence of pulmonary injury during COVID-19, patients were divided into two groups. Although none of them had altered systolic function, we evidenced pulmonary hypertension, diastolic dysfunction, increased liver stiffness, viscosity, and steatosis in around one-third of the patients, with significantly higher values in subjects with pulmonary injury compared to those without. (4) Conclusion: persisting symptoms characterizing the post-acute COVID-19 syndrome could be explained by residual cardiac and hepatic lesions, which were worse in more severe COVID-19 forms. These patients may be at risk of developing liver fibrosis and cardiac alterations and should be investigated in the first 12 weeks after the onset of the infection.

Sports Activity and Arrhythmic Risk in Cardiomyopathies and Channelopathies: A Critical Review of European Guidelines on Sports Cardiology in Patients with Cardiovascular Diseases

The prediction and prevention of sudden cardiac death is the philosopher’s stone of clinical cardiac electrophysiology. Sports can act as triggers of fatal arrhythmias and therefore it is essential to promptly frame the athlete at risk and to carefully evaluate the suitability for both competitive and recreational sports activity. A history of syncope or palpitations, the presence of premature ventricular complexes or more complex arrhythmias, a reduced left ventricular systolic function, or the presence of known or familiar heart disease should prompt a thorough evaluation with second level examinations. In this regard, cardiac magnetic resonance and electrophysiological study play important roles in the diagnostic work-up. The role of genetics is increasing both in cardiomyopathies and in channelopathies, and a careful evaluation must be focused on genotype positive/phenotype negative subjects. In addition to being a trigger for fatal arrhythmias in certain cardiomyopathies, sports also play a role in the progression of the disease itself, especially in the case arrhythmogenic right ventricular cardiomyopathy. In this paper, we review the latest European guidelines on sport cardiology in patients with cardiovascular diseases, focusing on arrhythmic risk stratification and the management of cardiomyopathies and channelopathies.

Alterations of Left Ventricular Function Persisting during Post-Acute COVID-19 in Subjects without Previously Diagnosed Cardiovascular Pathology

(1) Background: Coronavirus infection (Covid-19) has emerged as a severe medical condition, associated with high pulmonary morbidity and often with cardiovascular (CV) complications. This study aims to evidence the persistence of left ventricular (LV) systolic function (LV-SF) alterations and diastolic dysfunction (DD) in COVID-19 patients without history of cardiovascular (CV) diseases by transthoracic echocardiography (TTE). (2) Methods: 125 patients, aged under 55 years, hospitalized during the first outbreak of Covid-19 for moderate pneumonia, underwent a comprehensive cardiologic examination and TTE at 6-10 weeks after discharge. Their initial in-hospital laboratory data and thorax computer tomography (TCT) were accessed from the electronic database of the hospital. (3) Results: with TTE, we documented alterations of LV-SF and DD in 8.8% of patients and in 16.8% only patterns of DD, statistically correlated with the initial levels of creatin-kinase (CK-MB) and inflammatory factors. Multivariate regression analysis evidenced that CK-MB levels, age, and body mass index (BMI) are responsible for 65% of LV-SF decrease. (4) Conclusions: Alterations of LV-SF and DD are frequent in post-acute COVID-19 infection and are responsible for the persistence of symptoms. Elevated myocardial necrosis markers during the acute phase seem to predict subsequent alteration of cardiac performance.

Exploring insights of hydroxychloroquine, a controversial drug in Covid-19: An update

The review summarizes chloroquine (CQ) and its safer derivative hydroxychloroquine (HCQ) and its utility in Covid-19. Recently this well-established drug made its way back to the headlines during the SARS-CoV-2 pandemic. This led to an upsurge in the scientific arena with multiple research and review articles along with expert opinions and commentaries. The HCQ has received mixed judgements so far about its efficacy to be used in Covid-19 patients in a limited trial conducted all across the Globe. The purpose of our article is to put forth the history, pharmacodynamics, and pharmacokinetics, along with the existing studies favouring and disapproving the role of HCQ in the treatment of Covid-19. We grouped HCQ use at three stages, this includes HCQ for i. prophylactic use by asymptomatic health workers or peoples at higher risk; ii. patients having mild symptoms; iii. patients with extreme symptoms. The review critically discusses the underlying plausible reasons and mechanisms exploring HCQ in prophylactic management or treatment of SARS-CoV-2. Furthermore, we have critically analysed the reported pharmacokinetic parameters and compiled the proponent, opponent, or neutral opinions on the use of HCQ in Covid-19. Authors discretion is to conduct more studies considering the optimal dosing regimen and pharmacokinetics assessment.

Evidence of Pulmonary Hypertension after SARS-CoV-2 Infection in Subjects without Previous Significant Cardiovascular Pathology

BACKGROUND

Coronavirus (Covid-19) infection represents a serious medical condition, often associated with cardiovascular complications, pulmonary hypertension (PH), and right ventricle dysfunction (RVD). The aim of this study is to show, by means of transthoracic echocardiography (TTE), the presence of an increased estimated systolic pressure in the pulmonary artery (esPAP) and altered right ventricular global longitudinal strain (RV-GLS) in patients without history of PH.

METHODS

In a group of 91 patients, aged under 55 years, hospitalized for a moderate Covid-19 infection, a thorough cardiologic and TTE examination were performed two months after discharge. Their initial thorax computer-tomography (TCT) images and laboratory data were accessed from the electronic data base of the hospital.

RESULTS

We observed an increased prevalence of PH (7.69%) and RVD (10.28%), significantly correlated with the initial levels of the TCT score and inflammatory factors (p ˂ 0.001), but borderline changes were observed in more patients. Multivariate regression analysis showed that these factors and RV-GLS explain 89.5% of elevated esPAP.

CONCLUSIONS

In COVID-19 infection, PH and RVD are common complications, being encountered after the recovery even in moderate cases. It appears to be a connection between their severity and the extent of the initial pulmonary injury and of the inflammatory response.

COVID-19: Intensivmedizinische Aspekte und Langzeitfolgen

Etwa 14% der COVID-19-Patienten weisen einen schwereren und ca. 5% einen kritischen Krankheitsverlauf auf. Besonders gefährdet sind ältere Personen, männliches Geschlecht, Raucher und stark adipöse Menschen. Wird der Patient invasiv oder nichtinvasiv beatmet, so steigt die Mortalität auf 53% respektive 50% an. In der Regel beträgt die Dauer vom Beginn der Symptome bis zur Aufnahme auf die Intensivstation 10 Tage. Die mittlere Verweildauer auf der Intensivstation beträgt 9 Tage. Für die Priorisierung sind die klinische Erfolgsaussicht einer intensivmedizinischen Behandlung sowie der Wunsch des Patienten maßgebend. Zentrale Kriterien für die Aufnahme auf die Intensivstation sind eine Hypoxämie (SpO2 < 90% unter 2 – 4 Liter Sauerstoff/min bei nicht vorbestehender Therapie), Dyspnoe, eine erhöhte Atemfrequenz (> 25 – 30/min) und ein systolischer Blutdruck ≤ 100 mmHg. Der Schutz des Personals genießt bei allen Maßnahmen Vorrang. Alle aerosolgenerierenden Prozeduren sollten nur mit großer Vorsicht erfolgen. Wird unter High Flow keine adäquate Oxygenierung erreicht (SpO2 ≥ 90% oder ein paO2 > 55 mmHg), sollte über eine Eskalation nachgedacht werden (NIV, invasive Beatmung). Die Patienten sollten lungenprotektiv beatmet werden. Die Intubation sollte als Rapid Sequence Induction erfolgen. Eine ECMO kann erwogen werden. Thrombembolische Komplikationen sind sehr häufig. Antibiotika sollten nicht routinemäßig gegeben werden. Die aktuell beste Datenlage liegt für Dexamethason vor. Remdesivir kann die Rekonvaleszenz beschleunigen. Langzeitfolgen nach COVID-19 sind sehr häufig. Kardiale, pulmonale und neurologische Probleme stehen dabei im Vordergrund.