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.

Subclinical myocardial dysfunction in patients with persistent dyspnea one year after COVID-19

Introduction: Coronavirus disease 2019 (COVID-19) rapidly spread across the globe,evolving into a global pandemic,with a crucial impact on healthcare systems. Several short-term follow-up studies emphasized the persistence of symptoms, referred as long COVID, in a significant number of discharged patients even without history of cardiopulmonary diseases, with dyspnea being one of the most frequent complaint [1-3]. Even though those reports on recovered COVID-19 patients did not describe major left ventricle (LV) function abnormalities, subtle cardiac changes may be present. Purpose(s): We aimed to investigate the presence of subclinical cardiac dysfunction, assessed by transthoracic echocardiography (TTE) in recovered COVID-19 patients, without previous cardiopulmonary disease at 1 year follow-up. Method(s): 310 COVID-19 consecutive hospitalized patients were prospectively included between March and April 2020. 66 patients out of 251 recovered patients had no previous history of coronary artery disease, arrhythmia, arterial hypertension, valvular heart disease, asthma, chronic obstructive pulmonary disease and obstructive sleep apnea, respectively and were included in the final analysis (Figure 1). The follow-up consisted in 2 parts, a 6-months visit including clinical and physical examination, chest computed tomography and spirometry and a 12-months visit including clinical and physical examination, spirometry and TTE. Result(s): 66 patients (mean age 51.39+/-11.15 years, 45 (68.2%) males) were included in the final analysis. 23 (34.8%) patients reported dyspnea at 1 year. TTE parameters were in the normal range, with a mean LV ejection fraction of 56.9+/-4.6%, mean global longitudinal strain (GLS) of -20.9+/-2.3%, global constructive work (GCW) of 2381.4+/-463.6 mmHg% and global work index (GWI) of 2132.5+/-419.2 mmHg%. Type 1 diastolic dysfunction was observed in 11 (16.7%) patients. One (1.5%) patient had type 2 diastolic dysfunction. A normal respiratory pattern was reported in 31 (47%) patients at 6 months spirometry, while 19 (28.8%) patients had a restriction pattern. No significant differences regarding clinical, laboratory or imaging findings at baseline were found between groups. The following TTE parameters were significantly different in patients with and without dyspnea at 1 year: GLS (-19.97+/-2.14 vs. -21.38+/-2.37, p=0.039), GCW (2183.72+/-487.93 vs. 2483.14+/-422.42, p=0.024) and GWI (1960.06+/-396.21 vs. 2221.17+/-407.99, p=0.030). Multivariable logistic regression showed that GCW and GWI were inversely and independently associated with persistent dyspnea, one year after COVID-19 (p=0.035, OR 0.998, 95% CI 0.997-1.000;p=0.040, OR 0.998, 95% CI 0.997-1.000) (Table 1). Conclusion(s): Persistent dyspnea one year after COVID-19 was present in more than a third of patients without known cardiovascular or pulmonary diseases. GCW and GWI were the only echocardiographic parameters independently associated with symptoms, suggesting a decrease in myocardial performance in this population and subclinical cardiac dysfunction.

Subclinical myocardial dysfunction in patients with persistent dyspnea 1 year after COVID-19

Background/Introduction: Long coronavirus disease 2019 (COVID-19) was described in a significant number of discharged patients, with dyspnea being one of the most frequent complaint. Even though COVID-19 follow-up studies did not describe major left ventricle (LV) function abnormalities, subtle cardiac changes may be present. Purpose(s): We investigated the presence of subclinical cardiac dysfunction, assessed by transthoracic echocardiography (TTE) in recovered COVID-19 patients, without previous cardiopulmonary diseases at 1 year follow-up. Method(s): 310 consecutive COVID-19 patients were prospectively included.66 patients out of 251 recovered patients without history of cardiopulmonary diseases underwent 1 year follow-up consisting of clinical examination, chest computed tomography, spirometry and TTE Results: 23 (34.8%)patients out of 66 patients (mean age 51.3 +/- 11.1 years, 45 (68.2%)males) reported dyspnea at 1 year. TTE parameters were in the normal range, with a mean LV ejection fraction of 56.9 +/- 4.6%, mean global longitudinal strain (GLS) of -20.9 +/- 2.3%, global constructive work (GCW) of 2381.4 +/- 463.6mmHg% and global work index(GWI) of 2132.5 +/- 419.2mmHg%. A normal respiratory pattern was reported in 31(47%) patients at 6 months spirometry, while 19(28.8%) patients had restriction pattern. No significant differences regarding clinical, laboratory or imaging findings at baseline were found between groups. The following parameters were significantly different in patients with and without dyspnea at 1 year: GLS (-19.9 +/- 2.1 vs.- 21.3 +/- 2.3, p=0.039), GCW (2183.7 +/- 487.9 vs.2483.1 +/- 422.4, p=0.024) and GWI(1960.0 +/- 396.2 vs. 2221.1 +/- 407.9, p=0.030). Multivariable logistic regression showed that GCW and GWI were inversely and independently associated with persistent dyspnea at 1 year (p=0.035, OR 0.998, 95% CI 0.997-1.000;p=0.040, OR 0.998, 95% CI 0.997-1.000). Conclusion(s): Persistent dyspnea 1 year after COVID-19 was present in more than a third of patients without known cardiopulmonary diseases. GCW and GWI were the only echocardiographic parameters independently associated with symptoms, suggesting a decrease in myocardial performance in this population and subclinical cardiac dysfunction.

CRT-300.19 Trends and Disparities in Patients With Acute Pulmonary Embolism With and Without Cor Pulmonale Undergoing Percutaneous Mechanical Thrombectomy: A National Inpatient Sample Database Study

Background: Percutaneous mechanical thrombectomy is an increasingly utilized treatment modality for acute pulmonary embolism (PE), improving pulmonary flow with embolus/thrombus modification. We aimed to investigated national trends and outcomes in patients with acute pulmonary embolism with and without cor pulmonale undergoing mechanical thrombectomy. Method(s): We utilized the National Inpatient Sample (NIS) Database 2016-2020 to identify the cohort with principal diagnosis of acute pulmonary embolism, with or without cor pulmonale using ICD-10 codes. Patients who had COVID-19 infection during hospital stay were excluded from the 2020 database. Primary outcome analysis included adjusted inpatient mortality rate utilizing predictive margins, during each calendar year stratified by sex, age, race, and median household income (MHOI). Result(s): There were a total of 389,527 hospitalizations (367,205 without cor pulmonale;22,322 with cor pulmonale) with a principal diagnosis of acute PE from 2016-2020. Out of these hospitalizations, 3,168 (0.81%) underwent mechanical thrombectomy during hospital stay. Ratio of mechanical thrombectomy amongst all PEs increased significantly throughout the years (0.39% in 2016 vs 1.68% in 2020, p trend <0.001). There was a significant decline in mortality of patients without cor pulmonale undergoing mechanical thrombectomy (12.72% in 2016 vs. 8.30% in 2020, p-trend <0.001), however this trend was not observed in patients with cor pulmonale (12.11% in 2016 vs. 8.87% in 2020, p-trend = 0.45). Conclusion(s): Our findings suggest that, throughout the years of 2016-2020, there was a trend suggesting an increase in ratio of mechanical thrombectomy amongst patients admitted with pulmonary embolism and decrease in inpatient mortality in patients without cor pulmonale undergoing mechanical thrombectomy. [Formula presented]Copyright © 2023

Clinical Characteristics of COVID-19 between ICU and non-ICU patients

Introduction: During the peak of COVID-19 crisis between May and September 2021, Hospital UiTM Sg. Buloh was converted to a full COVID-19 hospital. We described our experience in managing active COVID-19 patients and subsequent follow-ups. Result(s): 215 COVID-19 patients were admitted to Hospital UiTM Sg Buloh between May and September 2021;81 patients (38%) required ICU admission, and 134 patients (62%) required only ward admission. Mean age was 53 years old, male 61%, mean day of illness at presentation was 9 days, and mean duration of hospital admission was 10 days. Fully vaccinated patients were less likely to be admitted to ICU, OR 0.2 (0.04 - 0.89). ICU patients were more likely to be female Adj OR 2.0 (1.11-3.56), diabetic Adj OR 1.9 (1.04-3.68), have more extended hospital stay (17 vs. 6 days), and higher mortality OR 5.50 (2.64-11.34). In terms of laboratory investigations 24 hours prior to oxygen requirement, those required ICU admissions have higher creatinine (167 vs. 107 mmol/L), CRP (115 vs. 69 ug/L), and ALT (80 vs. 53 mmol/L), as well as lower PF ratio (148 vs. 210). Cardiac arrhythmias and secondary infection were more likely in ICU patients, Adj OR 16.44 (1.56-172.81) and 12.05 (5.44-26.69), respectively. While pneumothorax, pneumomediastinum, subcutaneous emphysema, and acute cor-pulmonale were only observed in ICU patients. Mortality was recorded in 43 cases (20%). 83 patients out of 172 COVID-19 survivors (48%) attended a 3-month follow-up which revealed no difference in symptoms, 6-minute-walk-tests, and spirometry between ICU and non-ICU patients. Conclusion(s): ICU COVID-19 patients have poorer outcomes during hospital admission but similar recovery with nonICU patients at 3-month follow-up.

Contribution of Cardiovascular Disease to Adverse Hospital Outcomes in Covid-19 Hospitalizations: Results from National Inpatient Sample

Background It is a well-established fact that cardiovascular disease (CVD) adversely affects COVID-19 outcomes. However, the extend of the burden posed by CVD on hospitalized COVID-19 patients in the United States is unknown. In this study, using a national database, we estimated the effects CVD on COVID-19 hospitalizations in the United States. Methods This study is a retrospective analysis of National Inpatient Sample data, collected during 2020. Patients >=18 years of age, admitted with primary diagnosis of COVID-19 were included in the analysis. CVD was defined as presence of coronary artery disease, myocardial infarction, heart failure, sudden cardiac arrest, conduction disorders, cardiac dysrhythmias, cardiomyopathy, pulmonary heart disease, venous thromboembolic disorders, pericardial diseases, heart valve disorders, or peripheral arterial disease. The primary outcomes of the study were in-hospital mortality rate, prolonged hospital length of stay, mechanical ventilation, and disposition other than home. Multivariable logistic regression analysis was done to examine the association between presence of CVD and primary outcomes. Results During 2020 there were 1,050,040 COVID-19 hospitalizations in the United Sates. Of these 454650 (43.3%) had CVD. COVID-19 patients with CAD were older, males, and had higher comorbidity burden. The odds of in-hospital mortality (OR, 3.40;95% CI: 3.26-3.55), prolonged hospital length (OR, 1.71;95% CI: 1.67-1.76) and mechanical ventilation use (OR, 3.40;95% CI: 3.26-3.55), and disposition other than home (OR, 2.11;95% CI: 2.06-2.16) were significantly higher for COVID-19 hospitalizations with CAD. Mean hospitalization costs were also significantly higher among COVID-19 patients with CAD ($24,023 versus $15,320, P<0.001). The total cost of all COVID-19 hospitalizations during 2020 was $19.9 billion - $10.9 billion for those with CAD and $9.0 billion for those without CVD. Conclusion Cardiovascular disease was present in a substantial proportion of COVID-19 patients hospitalized in the United States and contributed to considerable adverse hospital outcomes and significantly higher hospitalization cost.Copyright © 2023 American College of Cardiology Foundation

Prognostic value of acute cor pulmonale in COVID-19-related pneumonia: A prospective study.

Background: It is known that acute cor pulmonale (ACP) worsens the prognosis of non-coronavirus disease 2019 (COVID-19) acute respiratory distress syndrome (NC-ARDS). The ACP risk score evaluates the risk of ACP occurrence in mechanically ventilated patients with NC-ARDS. There is less data on the risk factors and prognosis of ACP induced by COVID-19-related pneumonia. Objective: The objective of this study was to evaluate the prognostic value of ACP, assessed by transthoracic echocardiography (TTE) and clinical factors associated with ACP in a cohort of patients with COVID-19-related pneumonia. Materials and methods: Between February 2020 and June 2021, patients admitted to intensive care unit (ICU) at Amiens University Hospital for COVID-19-related pneumonia were assessed by TTE within 48 h of admission. ACP was defined as a right ventricle/left ventricle area ratio of >0.6 associated with septal dyskinesia. The primary outcome was mortality at 30 days. Results: Among 146 patients included, 36% (n = 52/156) developed ACP of which 38% (n = 20/52) were non-intubated patients. The classical risk factors of ACP (found in NC-ARDS) such as PaCO2 >48 mmHg, driving pressure >18 mmHg, and PaO2/FiO2 < 150 mmHg were not associated with ACP (all P-values > 0.1). The primary outcome occurred in 32 (22%) patients. More patients died in the ACP group (n = 20/52 (38%) vs. n = 12/94 (13%), P = 0.001). ACP [hazards ratio (HR) = 3.35, 95%CI [1.56-7.18], P = 0.002] and age >65 years (HR = 2.92, 95%CI [1.50-5.66], P = 0.002) were independent risk factors of 30-day mortality. Conclusion: ACP was a frequent complication in ICU patients admitted for COVID-19-related pneumonia. The 30-day-mortality was 38% in these patients. In COVID-19-related pneumonia, the classical risk factors of ACP did not seem relevant. These results need confirmation in further studies.

Right Ventricular Function in Acute Respiratory Distress Syndrome: Impact on Outcome, Respiratory Strategy and Use of Veno-Venous Extracorporeal Membrane Oxygenation.

Acute respiratory distress syndrome (ARDS) is characterized by protein-rich alveolar edema, reduced lung compliance and severe hypoxemia. Despite some evidence of improvements in mortality over recent decades, ARDS remains a major public health problem with 30% 28-day mortality in recent cohorts. Pulmonary vascular dysfunction is one of the pivot points of the pathophysiology of ARDS, resulting in a certain degree of pulmonary hypertension, higher levels of which are associated with morbidity and mortality. Pulmonary hypertension develops as a result of endothelial dysfunction, pulmonary vascular occlusion, increased vascular tone, extrinsic vessel occlusion, and vascular remodeling. This increase in right ventricular (RV) afterload causes uncoupling between the pulmonary circulation and RV function. Without any contractile reserve, the right ventricle has no adaptive reserve mechanism other than dilatation, which is responsible for left ventricular compression, leading to circulatory failure and worsening of oxygen delivery. This state, also called severe acute cor pulmonale (ACP), is responsible for excess mortality. Strategies designed to protect the pulmonary circulation and the right ventricle in ARDS should be the cornerstones of the care and support of patients with the severest disease, in order to improve prognosis, pending stronger evidence. Acute cor pulmonale is associated with higher driving pressure (≥18 cmH2O), hypercapnia (PaCO2 ≥ 48 mmHg), and hypoxemia (PaO2/FiO2 < 150 mmHg). RV protection should focus on these three preventable factors identified in the last decade. Prone positioning, the setting of positive end-expiratory pressure, and inhaled nitric oxide (INO) can also unload the right ventricle, restore better coupling between the right ventricle and the pulmonary circulation, and correct circulatory failure. When all these strategies are insufficient, extracorporeal membrane oxygenation (ECMO), which improves decarboxylation and oxygenation and enables ultra-protective ventilation by decreasing driving pressure, should be discussed in seeking better control of RV afterload. This review reports the pathophysiology of pulmonary hypertension in ARDS, describes right heart function, and proposes an RV protective approach, ranging from ventilatory settings and prone positioning to INO and selection of patients potentially eligible for veno-venous extracorporeal membrane oxygenation (VV ECMO).

Cardiac function in critically ill patients with severe COVID: A prospective cross-sectional study in mechanically ventilated patients.

PURPOSE: To evaluate cardiac function in mechanically ventilated patients with COVID-19. MATERIALS AND METHODS: Prospective, cross-sectional multicenter study in four university-affiliated hospitals in Chile. All consecutive patients with COVID-19 ARDS requiring mechanical ventilation admitted between April and July 2020 were included. We performed systematic transthoracic echocardiography assessing right and left ventricular function within 24 h of intubation. RESULTS: 140 patients aged 57 ± 11, 29% female were included. Cardiac output was 5.1 L/min [IQR 4.5-6.2] and 86% of the patients required norepinephrine. ICU mortality was 29% (40 patients). Fifty-four patients (39%) exhibited right ventricle dilation out of whom 20 patients (14%) exhibited acute cor pulmonale (ACP). Eight out of the twenty patients with ACP exhibited pulmonary embolism (40%). Thirteen patients (9%) exhibited left ventricular systolic dysfunction (ejection fraction <45%). In the multivariate analysis acute cor pulmonale and PaO2/FiO2 ratio were independent predictors of ICU mortality. CONCLUSIONS: Right ventricular dilation is highly prevalent in mechanically ventilated patients with COVID-19 ARDS. Acute cor pulmonale was associated with reduced pulmonary function and, in only 40% of patients, with co-existing pulmonary embolism. Acute cor pulmonale is an independent risk factor for ICU mortality.

POINT-OF-CARE ULTRASOUND FOR DIAGNOSIS AND EFFECT ON CLINICAL DECISION-MAKING DURING EVALUATION OF RESPIRATORY SYMPTOMS IN AN AMBULATORY PULMONARY CLINIC

SESSION TITLE: Technological Innovations in Imaging SESSION TYPE: Original Investigations PRESENTED ON: 10/17/22 1:30 PM - 2:30 PM PURPOSE: Point-of-Care Ultrasound (POCUS) has become an indispensable tool for clinicians evaluating patients with acute illness in hospital settings. Trained clinicians can rapidly detect cardiopulmonary disease with high sensitivity, guiding diagnosis and therapeutic management based on real-time findings. Despite this revolution to bedside care, POCUS has rarely been employed in the ambulatory setting. We aimed to evaluate the role of POCUS in the diagnosis and effect on clinical-decision-making in patients presenting to a pulmonary clinic with respiratory complaints. METHODS: This is a prospective case series of adult patients presenting to a pulmonary clinic in an urban medical center between January and February 2022. POCUS was performed by trained pulmonary faculty and triggered at the discretion of the clinician. Studies triggered by POCUS were followed-up, and a diagnosis if made was recorded. RESULTS: Between January-February 2022, the clinic saw N=53 patients for whom POCUS was triggered for N=10. Reasons included: no prior imaging on record (N=4), physical exam findings (N=5) and/or unclear clinical picture (N=4) after review of history, exam, and the medical record. Average age was 59.5±12.7 years. The chief complaint was dyspnea for all patients. In 4 patients, POCUS revealed diffuse B-lines with irregular pleural line suggestive of ILD. The work-up eventually diagnosed UIP-pattern ILD related to rheumatoid arthritis (N=1), non-specific interstitial pneumonitis (N=1), and sarcoidosis (N=1). Work-up remains pending for 1 patient. POCUS revealed new left ventricular dysfunction in 2 patients: one subclinical post-viral cardiomyopathy following COVID-19 and one ischemic cardiomyopathy from coronary artery disease. POCUS revealed new biventricular failure in one patient, for whom cardiac sarcoidosis is currently being worked-up given a history of anterior uveitis. In 1 patient, POCUS revealed a massive echogenic mass within the right hemithorax, prompting urgent chest x-ray and referral to ER. With a personal history of leiomyosarcoma, this mass was eventually diagnosed as recurrence of cancer. In 1 patient, POCUS diagnosed new pleural effusion, prompting referral for thoracentesis revealing an exudate of unclear etiology. One patient presented with COPD exacerbation, for whom POCUS found a basilar consolidation suggestive of pneumonia, prompting antibiotic therapy. CONCLUSIONS: POCUS can detect in real-time cardiopulmonary disease, and thus may serve as a powerful tool in the diagnosis and clinical-decision-making by trained clinicians encountering patients with respiratory complaints in an ambulatory setting. CLINICAL IMPLICATIONS: Our case series demonstrates the potential utility of POCUS, when triggered appropriately, can allow additional diagnostic studies to be considered earlier, and potentially narrow the time interval between patient presentation and a made diagnosis. DISCLOSURES: No relevant relationships by Gerardo Eman No relevant relationships by Marjan Islam No relevant relationships by Rahul Nair No relevant relationships by Abhishek Sharma No relevant relationships by Shwe Synn No relevant relationships by Tito Zerpa

COVID-19 CHRONIC IMPAIRMENT WITH PULMONARY SYMPTOMS

SESSION TITLE: Long COVID: It Can Take Your Breath Away SESSION TYPE: Original Investigations PRESENTED ON: 10/16/2022 10:30 am - 11:30 am PURPOSE: As the novel coronavirus SARS-CoV-2 swept the globe causing COVID-19 infection, a syndrome now known as “long COVID” has been well described in 10-30% of those who have experienced COVID-19. This study hoped to characterize changes in anatomical structure and physiology that may explain the ongoing dyspnea experienced by some individuals affected by the COVID-19 pandemic. METHODS: Patients with a history of symptomatic COVID-19 confirmed by positive PCR or antibody testing, between the age of 18-65, without pre-existing significant cardiopulmonary disease, and currently experiencing ongoing exertional or respiratory symptoms at least 3 months after onset of initial COVID symptoms were enrolled into this study. Each participant underwent standardized testing for underlying cardiopulmonary pathology by performance of a high-resolution chest CT, transthoracic echocardiography, electrocardiogram, full pulmonary function testing with lung volumes and diffusing capacity, impulse oscillometry, and a six minute walk test. RESULTS: To date, 63 patients have enrolled in the study with ongoing completion of study procedures. Of the current patients enrolled, 29 have had a high resolution chest CT completed;16 or 55% had radiographic evidence of pulmonary pathology. Most common were a nodular pattern (38%), mosaic attenuation (34%), residual ground glass opacities (28%), septal thickening (14%). Thirty-six participants performed the six minute walk test with an average walk distance of 1338.9 feet ± 520.4 feet with no participants desaturating below 90%. Pulmonary function testing has been completed in 36 participants with normal mean values. Impulse oscillometry testing performed on 30 individuals revealed mixed results with resistance at 5 Hz (R5) showing no substantive change to bronchodilator with a -14% ± 5%, however the area of reactance showed a potentially significant bronchodilator response with bronchodilator change of -43% ± 41%. CONCLUSIONS: In this interim analysis, we evaluated the radiographic and physiologic changes seen in a group of patients at least three months after symptomatic infection with COVID-19. There were radiographic changes in 50% of patients with a reticulonodular pattern as the most often reported finding. However, this finding did not correlate with PFT or exercise findings in the cohort;few showed significant PFT changes and the 6MWT did not show desaturations or limitation in walking distance. Pulmonary function testing and impulse oscillometry showed no statistically substantive physiologic derangements that might explain the ongoing symptoms of the group evaluated. CLINICAL IMPLICATIONS: Other than radiographic findings, there were no unified findings that could shed further light on the effects of COVID-19 that would predispose an individual to ongoing symptoms. DISCLOSURES: No relevant relationships by Brian Agan no disclosure on file for Timothy Burgess;no disclosure on file for Anuradha Ganesan;No relevant relationships by Stephen Goertzen No relevant relationships by Travis Harrell no disclosure on file for Nikhil Huprikar;No relevant relationships by David Lindholm No relevant relationships by Katrin Mende Speaker/Speaker's Bureau relationship with Janssen Please note: $1001 - $5000 by Michael Morris, value=Honoraria Speaker/Speaker's Bureau relationship with GSK Please note: $1001 - $5000 by Michael Morris, value=Honoraria Removed 03/29/2022 by Michael Morris no disclosure on file for Simon Pollett;no disclosure on file for Julia Rozman;No relevant relationships by Mark Simons No relevant relationships by David Tribble No relevant relationships by Robert Walter

Outcome of cancer patients affected by COVID-19 in different settings

Background: The mortality rate of cancer patients diagnosed with COVID-19 infection has reached 25%. The time from symptom onset to admission to the intensive care unit (ICU) was on average 10 days, with approximately 26% of patients requiring ICU admission. A higher mortality attributed to COVID-19 was seen in older patients, patients with certain cancer types, and patients with a higher Charslon comorbidity score. Moreover, male sex and leukopenia at diagnosis were associated with an increased risk of worse clinical outcomes. Furthermore, a study done at Memorial Sloan Kettering showed that patients with hematological malignancies had a worse prognosis than those with solid tumors. Our aim is to identify the predictive factors for ICU admission in the setting of positive COVID-19 infection in cancer patients. Differences in prognosis were compared between cancer and non-cancer patients admitted to the ICU due to COVID-19 infection. We also compared the overall outcome between patients with solid cancers and hematologic malignancies. Methods: This is a single institution retrospective study based on chart review analysis conducted at the American University of Beirut Medical Center (AUBMC). 248 patients were diagnosed with COVID-19 from 1 January 2020 to 31 December 2021. The patient groups were (1) all cancer patients admitted to the COVID unit, (2) all cancer patients admitted to ICU, and (3) all other patients without cancer admitted to the ICU. The main outcomes were ICU admission and mortality. Results: 173 cancer patients were admitted to our institution for the management of COVID-19 with a mean age of 63 years. 52 patients (30%) required ICU admission and 50 patients (29%) died during hospital stay or 1 month following discharge. The time from symptom onset to ICU admission and death were 12.8 and 35 days, respectively. Patients admitted to the ICU were more likely to have anemia (Hb < 8 g/dL) and thrombocytopenia (< 50,000/ mm3) on admission (p = 0.001). Age, male sex and history of smoking, diabetes or cardiopulmonary diseases were not associated with greater risk of ICU admission or death. Among cancer patients, those with uncontrolled disease at the onset of COVID-19 had greater risk of death from COVID-19 (p = 0.001). Cancer type, number of lines of treatment, history of radiation to the chest, recent cytotoxic therapy, and neutropenia were not associated with ICU admission or death from COVID-19. There was no statistical significance in mortality or disease progression between patients with solid or hematologic malignancies. Conclusions: Our data reaffirms previously reported findings of high mortality in cancer patients who contract COVID-19. In particular, patients with anemia, thrombocytopenia, and uncontrolled disease at diagnosis had unfavorable outcomes. Contrary to the literature, age, male sex, cancer type, and neutropenia were not predictive factors for mortality in cancer patients in the setting of COVID-19 infections.

The peripheral proinflammatory responses in COVID-19: Clinical spectrum and outcome in patients with and without cancer

Background: A meta-analysis of COVID-19 shows that the pooled prevalence of cancer is 1.4%. Febrile illness during COVID-19 is caused by cytokine release syndrome energized by innate inflammatory immune cells, neutrophils, monocytes, and macrophages. Cancer has a worse clinical outcome with COVID-19 due to a potential contribution of the disordered inflammatory microenvironment and immune system. This study aimed to determine the impact of peripheral inflammatory responses on clinical outcome and severity of COVID-19 patients with and without cancer and compare their clinical spectra. Methodology: This IRB-approved, retrospective chart review performed at PNOC included patients 18 years or older with PCR-confirmed COVID-19 from April 2020 to April 2021. Histopathology-confirmed cases identified excluded cranial metastases, pregnancy, or ICU-ineligible due to advanced malignancy or missing data. We collected the first clinical encounter data following a positive COVID-19 test, including CDC-defined COVID-19 symptoms, co-morbidities, cancer status, and treatment' clinical outcomes and death from any cause within30 days of COVID-19 diagnosis. We determined peripheral blood inflammatory cells of neutrophils, lymphocytes, monocytes, platelets and the ratios between lymphocytes and the other three. According to INH guidelines, we ranked clinical severity as presymptomatic, mild, moderate, severe, or critical. Results: Of 3745 people with PCR-confirmed COVID-19, 65 (1.7%) had cancer. We randomly selected 130 non-cancer subjects, homogeneously distributed across each month. The median age was 59 years. Of all, 52.3% were women, 43% were diabetic, 45% were hypertensive, and 35% had the cardiopulmonary disease. Dyspnea occurs in 30.8% of those with cancer but in 59.2% of those without cancer (P < .001). High neutrophil was significantly associated with severity (P = .038), but there was no significant difference between cancer and non-cancer groups. High lymphocytes, MPV, and Neutrophil/Lymphocyte ratio were associated with symptoms but not outcome or severity. Death from any cause was more in the group with cancer 23.1% vs. 6.9%, P= .001. Only 2% of study participants with cancer continued chemotherapy after the diagnosis of COVID-19 was confirmed. Conclusion: Mortality significantly remains higher when cancer is comorbid with COVID-19, as seen in international groups. Further studies are needed to confirm whether cancer immunomodulation is a factor. Peripheral inflammatory response modestly predicts a worse outcome, particularly with elevated neutrophils, known for its proinflammatory rule by polarization and neutrophil extracellular trap (NET) formation with platelet activation. There was a modest increase in symptoms severity in non-cancer COVID19 but more mortality in cancer comorbid COVID-19.

Rare Form of Congenital Cystic Bronchiectasis in a Filipino Adult

Background: Tuberculosis remains to be the most common lung infection in the Philippines. Compliance to medication leads to significant improvement. A portion of the population however remains untreated leading to complication such as bronchiectasis. In the approach to treatment, etiologies such as a possible genetic abnormality must be considered aside from a post inciting event. Case: This is a case of D.A. 20 year old, female who came in due to difficulty of breathing. She grew up having recurrent upper and lower respiratory tract infection. She was previously treated with pulmonary tuberculosis for 6 months last 2011. She was initially admitted at the COVID wards during the surge because any patient with pulmonary complains with bilateral infiltrates will be tagged as COVID suspect until a negative RT PCR result becomes available. She was admitted with complains of difficulty of breathing with desaturation. Her body mass index is 12.8 which is underweight. Pertinent physical examination shows bilateral coarse crackles with clubbing which suggest a chronic disease. Complete work up was done. Echocardiography which revealed an ejection fraction of 74%, severe pulmonary hypertension with dilated right atrium and right ventricle. Chest radiography revealed bronchiectatic changes with infiltrates while a confirmatory chest computed tomography scan revealed post infection pulmonary fibrosis with cystic bronchiectasis both lung fields. Spirometry revealed a severe obstructive ventilatory defect with no response to bronchodilator and a probable restrictive ventilatory defect which explains why the patient had higher frequency of admissions. Paranasal sinus xray to rule out Kartagener's syndrome was done which revealed normal results. Microbiologic studies such as sputum TB culture and sputum gene xpert was negative. The sputum culture revealed Stenotrophomonas maltophilia which was treated with intravenous antibiotics. To rule out other possible differentials for the cystic bronchiectasis, karyotyping was facilitated which revealed a normal female karyotype (46 XX). She was managed as a case of cor pulmonale, post tuberculous bronchiectasis, bacterial pneumonia, with considerations of mucociliary defects such as cystic fibrosis. It was unfortunate that a sweat chloride test was not done as it was not available in the country. Conclusion: In a country with endemic infectious pulmonary diseases such as tuberculosis, there is an anticipated sequelae of post infection bronchiectasis and fibrosis. Even if resources are scare and diagnostic tests are limited, repeated lung infection in a young patient warrants further investigation as congenital causes of structural lung diseases may initially present as an infectious process. (Figure Presented).

Prolonged ECMO Support of an Adult with SARS-CoV-2 ARDS and Right Heart Failure in a Children's Hospital

ECMO has become a widely recognized support modality for patients with severe cardiac or respiratory failure, and has been increasingly utilized in the ongoing severe acute respiratory syndrome due to coronavirus-2 (SARS-CoV-2) pandemic. Long-term support on ECMO for acute respiratory distress syndrome (ARDS) is also becoming more commonplace with eventual lung recovery, obviating the need for lung transplantation. However, long-term ECMO support has not been well studied for SARS-CoV-2 ARDS patients. We report the case of a 39-year-old female with severe SARS-CoV-2-induced ARDS successfully supported on venovenous ECMO (V-V ECMO) for 5,208 hours (217 days) in a high ECMO-volume, quaternary care children's hospital in 2021. At the time of this writing, this is the longest reported patient successfully supported on ECMO for SARS-CoV-2 ARDS. Our patient was initially cannulated at our children's hospital with dual-site V-V ECMO, via the right internal jugular vein (RIJ) and right common femoral vein. Bedside tracheostomy was performed on ECMO day 40, for early mobility, oral feeding, interaction, and pulmonary rehabilitation planning. Unfortunately, during her course she suffered multiple complications including bacterial co-infections, bleeding requiring anticoagulant changes from unfractionated heparin (UFH) to bivalirudin, multiple ECMO circuit changes due to blood product consumption and coagulopathy, and pneumothoraces requiring thoracostomy tube placements. Approximately 1.5 months into her ECMO course, she suffered acute hypoxemia and echocardiography revealed indirect evidence of pulmonary hypertension with right heart failure. Initial right heart catheterization while on V-V ECMO revealed elevated right ventricular end-diastolic pressure (RVEDP=15-20 mmHg) and severe systemic desaturation with main pulmonary artery (MPA) pressure of 30 mmHg. Pulmonary hypertension and right heart support was initiated in the form of inhaled nitric oxide (iNO), inotropes, phosphodiesterase inhibitors, nitrates, angiotensin-converting enzyme inhibitors, and diuresis. Ultimately, due to necessity of right-heart decompression and support, on ECMO day 86 she was transitioned to single-site V-V ECMO utilizing a 31 Fr dual-lumen venovenous cannula (ProtekDuo (LivaNova, UK)) placed via her RIJ through her right atrium (RA) into the MPA in the cardiac catheterization laboratory. Subsequent heart catheterization more than 2 months later revealed severe right ventricular (RV) diastolic dysfunction (RVEDP=35 mmHg) and moderate left ventricular (LV) diastolic dysfunction (pulmonary capillary wedge pressure (PCWP=24 mmHg)). During her course, multiple trials off ECMO were attempted with varying lengths of time off ECMO support, but ultimately required ongoing ECMO support. She developed evidence of end-organ dysfunction from her cor pulmonale, including oliguric renal failure requiring renal replacement therapy (RRT), hepatic injury with elevated transaminases and hyperammonemia leading to depressed mental state, feeding intolerance, and coagulopathy. Additionally, due to long-term nasogastric enteral tube placement for caloric supplementation and enteral medication administration, she developed concerns for invasive sinusitis with erosion into ethmoid and maxillary sinuses. As she was an adult patient being cared for in a free-standing academic children's hospital, multiple adult medicine consultants were involved in her care. Specifically, adult nephrology, cardiology, cardiothoracic surgery (for ProtekDuo cannula placement), and gastroenterology/ hepatology were integral into her care, along with our pediatric critical care medicine and ECMO teams. Notably, this was the first patient supported on ECMO to receive tracheostomy, RA-MPA dual-lumen VV cannula, and full autonomous mobility outside of the ICU at our well-established ECMO program, which has served as the index patient leading to future advances in the care of our ECMO patients. Over time and with multiple therapies to alleviate her cor pulmonale, the patient's echocardiograms evealed improved, half-systemic right-sided cardiac pressures. She was ultimately decannulated from ECMO at our center before being transferred back to the referring adult facility, and discharged to home 8 months after her initial presentation with acute respiratory failure.

An interesting case of systemic amyloidosis with lung involvement - A case report

Introduction: Systemic amyloidosis is a rare disease with estimated incidence of 10 cases per million personyears. Amyloidosis is caused by misfolding of autologous protein and its extra- cellular deposition resulting in organ dysfunction and death. Case Report: A 63 year old male presented with complaints of breathlessness for past 3 months, bilateral swelling of legs & scrotum and abdominal distension for past 2weeks. He was diagnosed as a case of Amyloidosis (AL type)/ IgG lambda monoclonal gammapathy 2 months back. Renal biopsy s/o Amyloidosis (AL type) & Immuno-electrophoresis revealed IgG lambda monoclonal gammapathy, started on Bortezomib, Lenalidomide and dexamethasone regimen weekly. CT chest reported as interstitial lung disease. Swab for Covid19 negative. ECHO: mildly dilated right chambers, intact septae, corpulmonale. Urine for albumin: ++. 24 hour total urine volume and protein elevated. Bone marrow biopsy: plasma cells in clusters. IHC: CD138:10 to 15%. Sputum for AFB: negative, Mantoux: 0mm, Sputum for gram stain: gram positive cocci in pairs and short chains. Derm(o)- diffuse altered hyper and hypopigmentation (Macules of varying size) present over b/l upper and lower limb. Poikilodermic changes present. Multidisciplinary discussion done. He was treated with oxygen, albumin infusion, chemotherapy and supportive drugs. Conclusion: Pulmonary amyloidosis can be localized or part of systemic amyloidosis. It can present as diffuse alveolar-septal amyloidosis, nodular amyloidosis, tracheobronchial amyloidosis. Pulmonary interstitial involvement along with cardiac amyloidosis can result in cardiopulmonary failure and death.

Acute cor pulmonale and mortality in mechanically ventilated patients with COVID-19 acute respiratory distress syndrome

Introduction: Although COVID-19 affects primarily the respiratory system, several studies have shown evidence of cardiovascular alterations and right ventricular dysfunction. Our aim was to evaluated cardiac function and its association with lung function, hemodynamic compromise and mortality. Methods: Prospective, cross-sectional multicenter study in four university-affiliated hospitals in Chile. All consecutive patients with COVID-19 ARDS on mechanical ventilation admitted between April and July 2020 were included. Transthoracic echocardiography was performed within the first 24 h of intubation. Results: Consecutive 140 patients on mechanical ventilation with COVID-19 ARDS were included in the study, the mean age was 57 ± 11 years, PaO2/FiO2 ratio was 155 [IQR 107-177], cardiac output was 5.1 L/min [IQR 4.5-6.2] and 86% of the patients required norepinephrine. ICU mortality was 29% (40 patients). Fifty-four patients (39%) exhibited right ventricle dilation and 20 of them (37%) exhibited acute cor pulmonale (ACP). Eight of twenty (40%) patients with ACP exhibited pulmonary embolism. Patients with ACP had higher norepinephrine requirement, lower stroke volume, tachycardia, prolonged capillary refill time and higher lactate levels. In addition, acute cor pulmonale patients presented lower compliance, higher driving pressure and the presence of respiratory acidosis. Left ventricular systolic function was normal or hyperkinetic in most cases and only thirteen patients (9%) exhibited left ventricular systolic dysfunction (ejection fraction < 45%). In the multivariate analysis acute core pulmonale, PaO2/FiO2 ratio and pH were independent predictors of mortality (Table 1). Conclusions: Right ventricular dilation is highly prevalent in mechanically ventilated patients with COVID-19 ARDS. The presence of acute cor pulmonale is associated with poorer lung function, but only in 40% of patients it was associated to pulmonary embolism. Acute cor pulmonale is an independent risk factor for mortality in the ICU. (Table Presented).

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.

Same Day Discharge for Robotic-assisted Radical Prostatectomy: Recommendations from a Referral Center

Introduction & Objective: Due to the COVID-19 global pandemic, in July 2020 we developed a same day discharge (SDD) protocol for robotic assisted laparoscopic prostatectomy (RALP) that balanced safety concerns with benefits of early discharge. In this study we present our experience and protocol. Methods: We performed a prospective analysis of patients undergoing RALP who were selected for SDD in a high-volume prostate cancer referral center. The criteria for discharge included uncomplicated surgery, stable postoperative hemoglobin, ambulation, tolerance of clear liquids without nausea or vomiting, pain control with oral medication, and patient/family comfort with SDD. We excluded patients older than 70 years, having concomitant general surgery operations, significant comorbidities (e.g. cardiopulmonary disease), and challenging procedures (e.g. salvage procedure, large prostates). We analyzed patient demographics, clinicopathologic factors, and operative outcomes and evaluated rates of SDD and factors associated with SDD failure (SDF). Results: From July 13, 2020 to January 1, 2021, 101 patients undergoing RALP were selected for SDD. Eighty patients (79%) met criteria , 73 (72%) were successful SDD, and 28 (28%) were SDF. All the SDF were discharged on postoperative day 1. Preoperative demographics were similar between the two groups with a median age of 63 (57-67) years and median BMI of 27 (25-30) kg/m2. Intraoperative characteristics were not statistically different with a median operative time of 92 (81-107) vs 103 (91-111) minutes for SDD and SDF respectively (P = 0.51). The readmission in the SDD group was due to dizziness from hematoma and ileus from urine leak in the SDF cohort (P = 0.69). Of the 28 SDF patients, the most common reasons for staying were anesthesia-related factors of nausea (35%) and drowsiness (7%), followed by patient/caregiver preference (25%), pain (14%), labile blood pressure (7%), arrhythmia (7%), and dizziness (7%). Conclusions: SDD for patients undergoing RALP can be safely incorporated into a clinical care pathway without increasing readmission rates. Coordinated care with anesthesia and nursing teams is an integral part of developing a SDD program, as is preoperative counseling to manage expectations. Future aims will be to investigate anesthesia factors leading to nausea and to expand selection to more patients.

Echocardiographic markers of mortality at 60 days in patients with COVID-19 in the intensive care unit

Introduction: Coronavirus disease (COVID)-19 predominantly produces its effects through lung damage, but an important component of multi-organ dysfunction is cardiac involvement. We have few reports that inform about the behavior of echocardiographic images of patients with the most severe forms of the disease. Purpose: The present work aims to identify prognostic markers for 60-day mortality in patients hospitalized in intensive care based on echocardiographic findings. Methodology: A single-center retrospective cohort was conducted. Hospitalized patients were included in one of the nine intensive care units for COVID-19 confirmed by RT-PCR from May to October 2020. Patients with previous conditions that determined a limitation of the therapeutic effort, those who died before 24 hours and pregnant women were excluded. Portable echocardiograms were performed by two expert cardiologists following the recommendations for isolation and personal protection. The time to death was evaluated as outcome. A Cox proportional hazards model was constructed, HR and 95% confidence intervals with their p values. The study was approved by the institutional ethics committee. Results: Of 326 patients included, 153 patients had an echocardiogram. The mean age was 60.7 years, 47 (30.7%) were female and 67 (44.7%) had positive troponin. 91 patients (59.5%) not survive, the mean long of stay was 8.4 (SD: 4.2) days. 111 (72.5%) had shock, 128 (83.7%) severe ARDS (PaO2 / FiO2 <100 mmHg), 142 (92.8%) required invasive ventilatory support, and 86 (56.2%) acute kidney injury. 27 (17.6%) patients had acute pulmonary embolism, 16 (10.4%) acute myocardial infarction and 9 (5.9%) myocarditis. The mean right ventricular ejection fraction was 37%, TAPSE was decreased in 16 cases (10.4%). 41 cases (26.8%) had right diastolic dysfunction. 34/48 (71%) cases had pulmonary hypertension. The average LVEF was 59.3% and 74 (48.4%) had some left ventricular diastolic dysfunction. 12 (7.8%) had left ventricular segmental wall motion abnormality and 16 (10.4%) had pericardial effusion. Univariate analysis identified TAPSE, PSAP, acute cor pulmonale and right ventricular dilatation as variables related to the outcome of mortality. The multivariate Cox model (Table 2) documented that acute cor pulmonale with a HR of 12.8 (95% CI 3.51 - 46.63, p<0.001) and right ventricular dilation with a HR of 4, 87 (95% CI 1.36-17.46, P 0.016) were associated with mortality. Conclusions: In patients hospitalized in the intensive care unit for COVID- 19, acute cor pulmonale and right ventricular dilatation behaved as independent predictors of in-hospital death. (Figure Presented).