The Utility of Handheld Cardiac and Lung Ultrasound in Predicting Outcomes of Hospitalised Patients With COVID-19

BACKGROUND

Strict isolation precautions limit formal echocardiography use in the setting of COVID-19 infection. Information on the importance of handheld focused ultrasound for cardiac evaluation in these patients is scarce. This study investigated the utility of a handheld echocardiography device in hospitalised patients with COVID-19 in diagnosing cardiac pathologies and predicting the composite end point of in-hospital death, mechanical ventilation, shock, and acute decompensated heart failure.

METHODS

From April 28 through July 27, 2020, consecutive patients diagnosed with COVID-19 underwent evaluation with the use of handheld ultrasound (Vscan Extend with Dual Probe; GE Healthcare) within 48 hours of admission. The patients were divided into 2 groups: "normal" and "abnormal" echocardiogram, as defined by biventricular systolic dysfunction/enlargement or moderate/severe valvular regurgitation/stenosis.

RESULTS

Among 102 patients, 26 (25.5%) had abnormal echocardiograms. They were older with more comorbidities and more severe presenting symptoms compared with the group with normal echocardiograms. The prevalences of the composite outcome among low- and high-risk patients (oxygen saturation < 94%) were 3.1% and 27.1%, respectively. Multivariate logistic regression analysis revealed that an abnormal echocardiogram at presentation was independently associated with the composite end point (odds ratio 6.19, 95% confidence interval 1.50-25.57; P = 0.012).

CONCLUSIONS

An abnormal echocardiogram in COVID-19 infection settings is associated with a higher burden of medical comorbidities and independently predicts major adverse end points. Handheld focused echocardiography can be used as an important "rule-out" tool among high-risk patients with COVID-19 and should be integrated into their routine admission evaluation. However, its routine use among low-risk patients is not recommended.

The quality, safety, feasibility, and interpretive accuracy of echocardiographic and lung ultrasound assessment of COVID-19 patients using a hand-held ultrasound

Background

The association between COVID‐19 infection and the cardiovascular system necessitates the use of an echocardiogram in this setting. Information on the utilization, safety, and quality of point‐of‐care cardiac and lung ultrasound using a hand‐held device in these patients is scarce.

Aims

To investigate the safety, technical aspects, quality indices, and interpretive accuracy of a hand‐held echocardiogram in patients with COVID‐19.

Methods

From April‐28 through July‐27, 2020, consecutive patients with COVID‐19 underwent hand‐held echocardiogram and lung ultrasound evaluation (Vscan Extend™; GE Healthcare) within 48‐h of admission. The operators recorded a series of technical parameters and graded individual experiences. The examinations were further analyzed by a blinded fellowship‐trained echocardiographer for general quality, proper acquisition, and right ventricular (RV) demonstration.

Results

Among 103 patients, 66 (64.1%) were male. Twenty‐nine (28.2%) patients could not turn on their left side and 23 (22.3%) could not maintain effective communication. The mean length of each echocardiogram study was 8.5 ± 2.9 min, battery usage was 14 ± 5%, and mean operator‐to‐patient proximity was 59 ± 11 cm. Ninety‐five (92.2%) examinations were graded as fair/good quality. A fair agreement was demonstrated between the operator and the echocardiographer for general ultrasound quality (Kappa = 0.329, p < 0.001). A fair‐good correlation (r = 0.679, p < 0.001) and substantial agreement (Kappa = 0.612, p < 0.001) were demonstrated between the operator and echocardiographer for left ventricular ejection fraction (LVEF), whereas a fair agreement was demonstrated for RV systolic function (Kappa = 0.308, p = 0.002). LVEF agreement was also assessed using the Bland‐Altman analysis revealing a mean bias of −0.96 (95% limits of agreement 9.43 to −11.35; p = 0.075).

Conclusions

Among patients with COVID‐19, echocardiography with a hand‐held ultrasound is a safe and reasonable alternative for a complete formal study (<10% poor‐quality indices). Echocardiogram assessment by the operators during the exam acquisition is reliable for LVEF, while RV systolic function should be subsequently offline reassessed.

Treatment with haemodiafiltration stabilises vascular stiffness (measured by aortic pulse wave velocity) compared to haemodialysis

BACKGROUND/AIMS

Cerebrovascular diseases such as stroke are increased in dialysis patients, and haemodiafiltration has been reported to reduce cerebrovascular mortality compared to haemodialysis. We wished to determine whether haemodiafiltration improves arterial stiffness.

METHODS

We audited aortic pulse wave velocity (PWV) measurements 6 months apart in 3 cohorts of patients: 69 treated with haemodialysis, 78 who converted from haemodialysis to haemodiafiltration and 142 treated with haemodiafiltration.

RESULTS

Cohorts were well matched for age (means ± SD: haemodialysis 64 ± 15 years vs. haemodialysis to haemodiafiltration 64 ± 17 years vs. haemodiafiltration 67 ± 16 years), sex (male 65 vs. 59 vs. 63%), diabetes (45 vs. 56.4 vs. 44%) and body mass index (26 ± 6 vs. 26 ± 5 vs. 26 ± 5), respectively. Systolic blood pressure did not differ over time (haemodialysis 143 ± 25 vs. 146 ± 27 mm Hg, haemodialysis to haemodiafiltration 153 ± 26 vs. 154 ± 25 mm Hg, haemodiafiltration 149 ± 31 vs. 148 ± 30 mm Hg) or between groups. Aortic PWV significantly increased in the haemodialysis group (9.5 ± 1.9 vs. 10.2 ± 2.2 m/s, p < 0.01) and haemodialysis to haemodiafiltration group (9.4 ± 1.9 vs. 10.1 ± 2.2 m/s, p < 0.01), but did not change with haemodiafiltration (9.9 ± 2.1 vs. 10.1 ± 2.2 m/s).

CONCLUSIONS

Aortic PWV, a measure of vascular stiffness, stabilised with haemodiafiltration. Our preliminary findings require further investigation to determine how haemodiafiltration may potentially improve vascular stiffness.

The role of the computerized tomography scanner in the cross-transmission of carbapenem-resistant Acinetobacter baumannii between hospitalized patients

OBJECTIVE

To assess the role of the computerized tomography (CT) scanner in cross-transmission of carbapenem-resistant Acinetobacter baumannii between hospitalized patients undergoing CT scan.

METHODS

A single-centre retrospective observational analysis of inpatients undergoing CT scans. Patient-unique CT scans were defined as 'index cases' (patients undergoing CT scan with carbapenem-resistant Acinetobacter baumannii (CRAB) colonization documented during the previous 60 days), 'incident cases' (patients found colonized with CRAB within 14 days following CT scan), and 'negative cases' (negative for CRAB before and after CT scan). CRAB acquisition was analysed by time interval between CT scan and CT scan of the prior index-case patient.

RESULTS

Amongst 73 047 CT scans performed over 5 years, 4834 scans were performed within 12 hours of an index case. CRAB acquisition was detected in 20 patients (incident cases), including 16/2725 (5.8/1000 scans) who underwent CT scan within 6 hours of an index-case CT scan and 4/2109 (1.9/1000 scans) who had their CT scan 7-12 hours after the CT scan of an index-case patient (p 0.033, risk ratio 3.1, 95%CI 1.03-9.25). Patient characteristics for the two time periods were similar. While not the only significant predictor of CRAB acquisition (others included age and length of hospital stay prior to the CT scan), the time elapsed from an index case remained a significant predictor for CRAB acquisition on multivariate analysis (OR 0.84, 95%CI 0.74-0.95, p 0.007).

CONCLUSIONS

Performing a CT scan within 6 hours of a CT scan performed in a CRAB-positive patient was an independent predictor of CRAB acquisition, approximately tripling the risk. This probably reflects poor infection control practice in the CT suite.

Association between cardiac pathology and outcomes of patients with COVID-19 using a hand-held ultrasound

Background

The association between COVID-19 infection and the cardiovascular system has been well described. Strict precautions limit the use of formal echocardiography in this setting. Information on the importance of the utilization of a hand-held point-of-care cardiac ultrasound (POCCUS) for cardiac evaluation in these patients is scarce.

Objective

To investigate the utilization of hand-held echocardiography in COVID-19 hospitalized patients and the association between cardiac pathologies and outcomes.

Methods

Consecutive patients diagnosed with COVID-19 underwent POCCUS evaluation using a hand-held ultrasound within 24 hours of admission at our institute, throughout March-May 2020. According to the POCCUS results, the patients were divided into two groups: 'Normal' and 'Abnormal' (including left or right ventricular dysfunction or enlargement, or moderate/severe valvular regurgitation/stenosis).

Results

Among 102 patients, 26 (25.5%) had an abnormal POCCUS study. They were older, with more co-morbidities, cardiovascular disease history, chronic medical therapy, and more severe presenting symptoms, as compared to the group with a normal echocardiography exam. Individual and composite endpoints (advanced ventilatory support, acute decompensated heart failure, shock, or death) are presented in Table 1. Multivariate logistic regression analysis adjusting for pertinent variables revealed that abnormal echocardiography at presentation was independently associated with the composite endpoint OR=4.63 (95% CI 1.51–14.15, p=0.007).

Conclusions

Abnormal echocardiography results in COVID-19 infection settings are associated with a higher burden of medical comorbidities and independently predict major adverse endpoints. Hand-held POCCUS at presentation can be utilized as an important tool for risk stratification for hospitalized COVID-19 patients.

Funding Acknowledgement

Type of funding sources: Private hospital(s). Main funding source(s): SZMC Scientific

Use of artificial intelligence for point-of-care echocardiographic assessment of left ventricular ejection fraction among COVID-19 patients

Background

The association between COVID-19 infection and the cardiovascular system has been well described. Isolation precautions limit the use of formal echocardiography in this setting. Artificial intelligence (AI) utilization using a hand-held device in these patients can be a reliable tool for left ventricular ejection fraction (LVEF) assessment.

Aims

To prospectively investigate the accuracy of AI-base tool for LVEF assessment using a hand-held echocardiogram in patients with COVID-19.

Methods

From April-28 through July-26, 2020, consecutive patients with COVID-19 underwent a real-time LVEF assessment within 48-h of admission using a hand-held echocardiogram evaluation (Vscan Extend) equipped with LVivoEF, an AI-based tool that automatically evaluates LVEF. The examinations were further analyzed off-line by a blinded fellowship-trained echocardiographer for LVEF as a gold standard.

Results

Among 42 patients, 21 (50%) were male (aged 53.3±17.8 years, mean BMI 27.6±5.1 kg/m²). Seven (16.7%) patients couldn't turn on their left side and three (7.1%) couldn't maintain effective communication. The mean length of each echocardiogram study was 6.8±2.2 minutes, battery usage was 13.4±4.9%, and mean operator-to-patient proximity was 64.5±9.3 cm.

A fair to good correlation was demonstrated between the AI and the echocardiographer LVEF assessment (Pearson's correlation of 0.691, p<0.001). An almost perfect agreement was demonstrated between the AI and the echocardiographer for LVEF using a threshold of 45% (kappa=0.806, p<0.001).

The sensitivity of focused echocardiogram for 45% LVEF threshold is 85.7%, specificity is 97.1% with a PPV of 85.7% and NPV of 97.1%.

Conclusions

An AI-based algorithm incorporated into an existing hand-held echocardiogram device can be reliably utilized as a decision support tool for automatic real-time LVEF assessment among COVID-19 patients.

Funding Acknowledgement

Type of funding sources: None.

Artificial Intelligence-Powered Left Ventricular Ejection Fraction Analysis Using the LVivoEF Tool for COVID-19 Patients

We sought to prospectively investigate the accuracy of an artificial intelligence (AI)-based tool for left ventricular ejection fraction (LVEF) assessment using a hand-held ultrasound device (HUD) in COVID-19 patients and to examine whether reduced LVEF predicts the composite endpoint of in-hospital death, advanced ventilatory support, shock, myocardial injury, and acute decompensated heart failure. COVID-19 patients were evaluated with a real-time LVEF assessment using an HUD equipped with an AI-based tool vs. assessment by a blinded fellowship-trained echocardiographer. Among 42 patients, those with LVEF < 50% were older with more comorbidities and unfavorable exam characteristics. An excellent correlation was demonstrated between the AI and the echocardiographer LVEF assessment (0.774, p < 0.001). Substantial agreement was demonstrated between the two assessments (kappa = 0.797, p < 0.001). The sensitivity, specificity, PPV, and NPV of the HUD for this threshold were 72.7% 100%, 100%, and 91.2%, respectively. AI-based LVEF < 50% was associated with worse composite endpoints; unadjusted OR = 11.11 (95% CI 2.25-54.94), p = 0.003; adjusted OR = 6.40 (95% CI 1.07-38.09, p = 0.041). An AI-based algorithm incorporated into an HUD can be utilized reliably as a decision support tool for automatic real-time LVEF assessment among COVID-19 patients and may identify patients at risk for unfavorable outcomes. Future larger cohorts should verify the association with outcomes.