Trans-Thoracic Echocardiography in Prone Position during COVID-19 Pandemics

Introduction. During SARS-CoV-2 pandemic there was a surge in number of patients requiring ICU admission, monitoring devices, mechanical ventilation and prone positioning. In such conditions, proper hemodynamic assessment resulted challenging, whilst the need to evaluate right ventricle (RV) performance and pulmonary resistances in prone position ventilation was impellent. Aim. We explored the feasibility of a novel approach to assess both hemodynamics and cardiac function by trans-thoracic echocardiography (TTE) during mechanical ventilation before and after prone positioning. Materials and Methods. TTE was performed in eight patients before and 1 hour after prone positioning (TTEp), alongside standard hemodynamic monitoring. In order to obtain enough physical space to position the TTE-probe, we deflated the lower-thoracic section of the air-mattress, and placed the probe between the mattress surface and the thorax of the patient. Both apical-4-chambers and apical-5-chambers views were obtained. Results. We observed an overall improvement in the RV function parameters after pronation, although not statistically significant. In one case, prone position showed a reduction in TAPSE by 43% and an increase in PAPs by 9%, compared to the supine values. The same case showed a negative outcome. Conclusions. Despite trans-esophageal echocardiography remains the gold standard in patients in prone position, limited availability and the need for skilled sonographers limit its feasibility during pandemics. Though, TTEp guarantees resource-saving and time-effectiveness since multiple information can be drawn even on a single view.

Aging- and gender-related modulation of RAAS: potential implications in COVID-19 disease.

Coronavirus disease 2019 (COVID-19) is a new infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). COVID-19 is frequently characterized by a marked inflammatory response with severe pneumonia and respiratory failure associated with multiorgan involvement. Some risk factors predispose patients to develop a more severe infection and to an increased mortality; among them, advanced age and male gender have been identified as major and independent risk factors for COVID-19 poor outcome. The renin-angiotensin-aldosterone system (RAAS) is strictly involved in COVID-19 because angiotensin converting enzyme 2 (ACE2) is the host receptor for SARS-CoV-2 and also converts pro-inflammatory angiotensin (Ang) II into anti-inflammatory Ang(1-7). In this review, we have addressed the effect of aging and gender on RAAS with emphasis on ACE2, pro-inflammatory Ang II/Ang II receptor 1 axis and anti-inflammatory Ang(1-7)/Mas receptor axis.