Echocardiographic findings in critically Ill patients with COVID-19 treated with and without extracorporeal membrane oxygenation

Objectives: There is a paucity of data on echocardiographic findings in patients with COVID-19 supported with Venovenous Extracorporeal Membrane Oxygenation (VV ECMO). This study aimed to compare baseline echocardiographic characteristics of mechanically ventilated patients for acute respiratory distress syndrome (ARDS) due to COVID-19 infection with and without VV ECMO support and to describe the incidence of new echocardiographic abnormalities in these patients. Method(s): Single-center, retrospective cohort study of patients admitted from March 2020 to June 2021 with COVID-19 infection, that required mechanical ventilation, and had an available echocardiogram within 72 hours of admission. Follow-up echocardiograms during ICU stay were reviewed. Result(s): A total of 242 patients were included in the study. One-hundred and forty-five (60%) patients were supported with VV ECMO. Median (IQR) PaO2/ FiO2 was 76 (65-95) and 98 (85-140) in the VV ECMO and non-ECMO patients, respectively (P = < 0.001). On the admission echocardiograms, the prevalence of left ventricular (LV) systolic dysfunction (10% vs 15%, P= 0.31) and right ventricular (RV) systolic dysfunction (38% vs. 27%, P = 0.27) was not significantly different in the ECMO and non-ECMO groups. However, there was a higher proportion of acute cor pulmonale (41% vs. 26 %, P = 0.02) in the ECMO group. During their ICU stay, echocardiographic RV systolic function worsened in 44 (36%) patients in the ECMO group compared with six (10%) patients in the non-ECMO group (P< 0.001). The overall odds ratio for death for patients with worsening RV systolic function was 1.8 (95% confidence interval 0.95-3.37). Conclusion(s): Echocardiographic findings suggested that the presence of RV systolic dysfunction in COVIDECMO patients was comparable to the non-ECMO group on admission. However, a higher percentage of patients on ECMO developed worsening RV systolic function during follow-up.

Transesophageal echocardiography guidance for bedside extracorporeal membrane oxygenation cannulation in COVID-19 patients

Objective: To describe the use and safety of transesophageal echocardiography guidance for bedside ECMO cannulation in a large academic center. Methods: In this retrospective cohort study, we studied all patients who underwent bedside (in the intensive care unit) venovenous ECMO (VV-ECMO) cannulation under TEE guidance between May 4 to November 4, 2020, in a tertiary care center. Patient characteristics, physiological, and ventilatory parameters, as well as echocardiographic findings, were recorded and analyzed. Results: During the study period, 35 patients were placed on VV-ECMO. Nineteen patients (54%) were cannulated under TEE guidance of which sixteen (84%) had a confirmed COVID SARS-COV-2 pneumonia;two patients (11%) had mild to moderate right ventricular systolic dysfunction, and one (5%) had biventricular dysfunction. Cannula position was adequate in 18 cases (95%). No significant complications, such as post-cannulation complications, nosocomial COVID transmission or TEE related complications, were reported during this study. Conclusions: We report the safe utilization of bedside TEE-guidance for VV-ECMO cannulation in patients with severe respiratory failure, including in COVID patients. No TEE related complications, nor nosocomial transmission occurred in our cohort. Besides one superficial vascular injury, we did not encounter significant ECMO related complications.

Clinical Course and Cardiac Complications of Hospitalized COVID-19 Patients

Purpose We describe the hospitalization course, cardiac complications and echocardiographic findings in a subset of acutely ill hospitalized patients with COVID-19. Methods Patients admitted to a large academic hospital in Ontario, Canada from March-June 2020 with COVID-19 and who had an echocardiogram within 4-weeks of their diagnosis were included in this study. Their demographics, hospitalization details and echocardiographic findings were analyzed. Results 76 patients are included in our study, 83% of whom required ICU. Mean age was 58.9 years (+/-15.7 years). Cardiovascular comorbidities were common: diabetes (35.5%), hypertension (50%), CKD (11.8%), prior CAD (13.2%) or stroke (11.8%). Median length of admission was 25.5 days (IQR 22days). Overall, in-hospital mortality was high at 35.5%, with increased mortality in the ICU vs. non-ICU group (32.9% vs. 15.4%). A large number of patients required invasive support: intubation (77.6%), Extracorporeal life support (23.7%), or renal replacement therapy (19.7%). Cardiac complications included new AF (13.2%), hemodynamically significant VT (3.9%), moderate or more pericardial effusion (2.6%) and acute stroke (9.2%). Echocardiographic analysis demonstrated that 7.9% of patients developed moderate or more LV dysfunction on visual assessment. RV dysfunction was more common (27.6%) with 11.8% being visually classified as moderate or greater in severity. High sensitivity troponin was elevated in 59.2% of patients and was statistically higher in patients experiencing cardiac complications (Chi-Square 0.005). Although not achieving significance, there was a trend towards elevated troponin and development of moderate or greater LV/RV dysfunction (Chi-square 0.30). Conclusion In acute patients hospitalized with COVID-19, there was a high prevalence of cardiovascular co-morbidities. Troponin elevations was common and associated with a significantly increased risk of cardiovascular events and a trend towards moderate or greater ventricular dysfunction.