Clinical case analysis of novel coronavirus pneumonia complicated with pulmonary hypertension.

Objective: To report the clinical features of pulmonary hypertension diagnosed by echocardiography in 5 patients with novel coronavirus pneumonia (COVID-19) in order to understand the special clinical manifestations of COVID-19 and explore the possible mechanism. Method(s): The echocardiographic data and clinical characteristics of COVID-19 patients complicated with pulmonary hypertension diagnosed by echocardiography in Beijing Ditan Hospital, Capital Medical University were analyzed descriptively from February 5 to March 31, 2020. Result(s): A total of 15 patients with severe and critical COVID-19 patients underwent echocardiography. Of them, 7 patients were diagnosed with pulmonary hypertension, 5 of which were confirmed as complications of COVID-19. Among the 5 patients, 4 were female and 1 was male, aged 62-78 years;4 were with hypertension, 3 were with diabetes, and 1 was with coronary atherosclerotic heart disease. All 5 critically ill patients with COVID-19 were given ventilator-assisted breathing, 2 of which were given extracorporeal membrane oxygenation at the same time. According to echocardiography, the systolic pressure of pulmonary artery in 5 patients was 43-65 mmHg, with an average of 54 mmHg. The severity of pulmonary hypertension was graded as mild in 1 patient and moderate in 4 patients. During the follow-up, pulmonary artery systolic pressure gradually decreased to normal in 4 patients, and then ventilator and ECMO were withdrawn;1 patient died due to respiratory failure and persistent pulmonary hypertension. Conclusion(s): Patients with COVID-19 may be complicated by pulmonary hypertension, which is often found in the critical patients. Echocardiography is an important imagingdiagnostic method for pulmonary hypertension in patients with COVID-19.Copyright © 2020 by the Chinese Medical Association.

Short term impact of COVID19 pneumonia on cardiovascular profile

Introduction: COVID19 pneumonias have significantly contributed to short and long-term patient morbidity. Their impact on patients' cardiovascular profile following hospital discharge remains unclear. Aim(s): To investigate the short-term impact of COVID19 pneumonias on patients' atheromatic index (AI), Pulmonary Artery Systolic Pressure (PASP) and lipid profile at 4 weeks following hospital discharge. Material(s) and Method(s): We prospectively reviewed patients in our postCOVID19 outpatient clinic at 4 weeks following hospital discharge. All patients were previously admitted due to COVID19 pneumonia. Thoroughly review of all medical records and the local registry followed. Result(s): 237 patients attended their first outpatient appointment at 4 weeks post discharge (11.2020-12.2021) (103 males, 134 females, mean age 54 years). We reviewed 3 cardiovascular parameters: AI (chol/HDL), PASP and lipid profile. Increased PASP (30> mmHg) was reported in 7.17% (17/237) who were previously PASP naive and increased AI (>3.5) was reported in 37.7% (61/237 patients) who were also previously AI naive. Only 62% patients were compliant in undergoing a lipid profile investigation and 64% of them presented with increased levels of cholesterol (>200mg/dl), triglycerides (>150mg/dl), LDL (>150mg/dl). Conclusion(s): COVID19 pneumonia leaves a cardiovascular footprint at 4 weeks post hospital discharge in cardiovascular naive patients. Overall, these patients seem to be at an increased risk for cardiovascular diseases that increases with age. Our study is prospectively continued to investigate the impact at 3 and 6 months post hospital discharge.

Pulmonary hypertension at admission predicts ICU mortality in elderly critically ill with severe COVID-19 pneumonia: retrospective cohort study.

BACKGROUND: Point-of-care ultrasound (POCUS) is a useful diagnostic tool for non-invasive assessment of critically ill patients. Mortality of elderly patients with COVID-19 pneumonia is high and there is still scarcity of definitive predictors. Aim of our study was to assess the prediction value of combined lung and heart POCUS data on mortality of elderly critically ill patients with severe COVID-19 pneumonia. METHODS: This was a retrospective observational study. Data of patients older than 70 years, with severe COVID-19 pneumonia admitted to mixed 25-bed, level 3, intensive care unit (ICU) was analyzed retrospectively. POCUS was performed at admission; our parameters of interest were pulmonary artery systolic pressure (PASP) and presence of diffuse B-line pattern (B-pattern) on lung ultrasound. RESULTS: Between October 2020 and March 2021, 117 patients aged 70 years or more (average age 77 ± 5 years) were included. Average length of ICU stay was 10.7 ± 8.9 days. High-flow oxygenation, non-invasive ventilation and invasive mechanical ventilation were at some point used to support 36/117 (31%), 39/117 (33%) and 75/117 (64%) patients respectively. ICU mortality was 50.9%. ICU stay was shorter in survivors (8.8 ± 8.3 vs 12.6 ± 9.3 days, p = 0.02). PASP was lower in ICU survivors (32.5 ± 9.8 vs. 40.4 ± 14.3 mmHg, p = 0.024). B-pattern was more often detected in non-survivors (35/59 (59%) vs. 19/58 (33%), p = 0.005). PASP and B-pattern at admission, and also mechanical ventilation and development of VAP, were univariate predictors of mortality. PASP at admission was an independent predictor of ICU (OR 1.061, 95%CI 1.003-1.124, p = 0.039) and hospital (OR 1.073, 95%CI 1.003-1.146, p = 0.039) mortality. CONCLUSIONS: Pulmonary artery systolic pressure at admission is an independent predictor of ICU and hospital mortality of elderly patients with severe COVID-19 pneumonia.

A MULTIMODALITY IMAGING DIAGNOSIS OF A CHALLENGING CASE OF CONCOMITANT GROUP 1 PULMONARY HYPERTENSION AND PARADOXICALLY LOW- FLOW, LOW-GRADIENTAORTIC STENOSIS

A 76 year old woman was admitted to our hospital for self-limiting dyspnoea (NYHA class III) in oxygen dependence and frequent lipothymia following Valsalva manoeuvres. She was previously admitted to a Spoke Centre for heart failure (HF) with preserved ejection fraction (EF) and a new diagnosis of “pre-capillary pulmonary hypertension (PH)”. Despite a diagnosis of PH of unclear aetiology, she was started on macitentan without being reassessed for functional capacity due to Covid emergency;because of worsening symptoms, she was admitted to our Hub Centre. Resting ECG showed right axis deviation, right ventricle (RV) hypertrophy, first-degree atrioventricular block and right bundle branch block. Transthoracic echocardiography (TTE) showed reduced left ventricular (LV) volume with preserved EF (diastolic volume= 37 ml, EF=88%), severe right atrial and RV dilation with flattening of the interventricular septum, estimated pulmonary artery systolic pressure (PASP) of 124 mmHg, and moderate calcific aortic stenosis (peak aortic velocity 3.3 m/s, mean gradient 25 mmHg, valve area 1.1 cm2). Right and left heart catheterization showed severe pre-capillary PH (mean pulmonary pressure 60 mmHg, mean wedge 11 mmHg, pulmonary vascular resistance 14.41 WU), a severe aortic valve stenosis (aortic valve area 0.68 cmq and peak-to-peak gradient 25 mmHg, slight reduction of cardiac index 2.04 l/min/mq) and no significant coronary artery disease. The degree of aortic stenosis was considered as moderate-severe by integrating data of transesophageal echocardiography (planimetric area 1cm2) and assessment of calcium score (1615 Agatson units). Pneumological causes, chronic thromboembolic PH, rheumatologic diseases, HIV infection, paraneoplastic origin and veno-occlusive disease were all ruled out as potential PH causes and a diagnosis of Idiopathic pulmonary arterial hypertension (IPAH) was finally made. The Heart Team established the best therapeutic option was a transcatheter aortic valve replacement (TAVI) allowing better haemodynamic tolerability of PH therapy. The patient underwent TAVI and was started on PH therapy;a complete atrio-ventricular block developed after the procedure, requiring permanent pacemaker (PM) implantation. Unfortunately, few days later, the patient died following pacemaker's lead dislocation. Conclusion: PH has a diverse aetiology, and prognosis is generally poor, especially in patients with severe comorbidities. (Figure Presented).

Comparative analysis of echocardiographic and electrocardiographic data of survivors and deceased patients with COVID-19 (sub-analysis of the international register “Dynamics analysis of comorbidities in SARS-CoV-2 survivors”)

Aim. To carry out comparative analysis of echocardiographic and electrocardiographic (ECG) data of survivors and deceased patients with COVID-19 (sub-analysis of the international register “Dynamics analysis of comorbidities in SARS-CoV-2 survivors”). Material and methods. The study presents the results of a sub-analysis of the international AKTIV registry, which was called AKTIV CARDIO. Data were collected from 9 medical centers in the Russian Federation. AKTIV CARDIO included 973 hospitalized patients, of which 50 patients died during hospitalization. Results. Comparative analysis of echocardiographic parameters revealed that 4 parameters differed in deceased patients compared to survivors: left ventricular ejection fraction (LVEF), right ventricular end diastolic dimension (RV EDD), right atrial (RA) short axis diameter and pulmonary artery systolic pressure (PASP). RA short axis diameter was higher in deceased patients compared with survivors (38,0 [36,0;39,0] versus 35,0 [33,0;38,0] mm, p=0,011). RV EDD was higher in deceased patients than in survivors (3,0 [29,0;33,0] vs 28,0 [27,0;32,0] mm, p=0,019). LVEF was lower in deceased patients compared with survivors (55 [52;55] vs 60 [56;65]%, p<0,001). PASP was higher in deceased patients compared with survivors (25 [21;35] vs 20 [19;25] mm Hg, p=0,006). Correlation analysis found that the largest number of correlations with markers of the infection severity was observed for RA short axis diameter and RV EDD. A comparative analysis of ECG data revealed that in deceased patients, compared with survivors, atrial fibrillation (AF) (21,4% vs 6,06%, p=0,001) and supraventricular premature beats (14,3% vs 3,36%, р=0,004) occurred more often. In addition, deceased patients had longer QTc interval (440 [416;450] vs 400 [380;430] ms, p<0,001). Conclusion. Comparative analysis of echocardiographic data showed that deceased patients have more pronounced right heart remodeling, higher PASP and lower LVEF. Patient survival was related to RV and RA sizes. Right heart enlargement was associated with markers of infection severity. Echocardiographic parameters characterizing the right heart side can probably be independent prognostic factors in the acute COVID-19 period.

Right ventricular strain in in COVID-19 patients: a single-center experience

BACKGROUND: Assessment of right ventricular systolic function using strain imaging analysis from two-dimensional echocardiography has been identified to have powerful predictive value. Utilization of right ventricular strain may provide additional information in the management of COVID-19 patients. OBJECTIVE: To determine and analyze the right ventricular systolic function using longitudinal strain imaging among COVID-19 patients. METHOD: This is a prospective cohort study of the right ventricular function using speckle tracking echocardiography among COVID-19 patients. The study included two dimensional (2D) echocardiographic studies among 137 adult patients with laboratory-confirmed COVID-19 from September to November 2020. Analysis of Variance (ANOVA) was used to compare more than two groups with numerical data. Pearson Correlation was utilized to determine correlation between numerical variables. RESULTS: The results showed a total of 35 patients (25.54%) to have abnormal right ventricular free wall strain. The results showed that there was a significant direct correlation between right ventricular free wall strain and the echocardiographic parameters of tricuspid annular plane systolic excursion (TAPSE) (r = 0.277;p = 0.001), S' (r = 0.166;p = 0.050), right ventricular fractional area change (r = 0.298;p < 0.0001) and left ventricular ejection fraction (LVEF) (r = 0.176;p = 0.040). There was a significant inverse correlation noted between right ventricular free wall strain and the echocardiographic parameters of the tricuspid regurgitation (r=-0.284;p = 0.001), pulmonary arterial systolic pressure (r=-0.209;p = 0.014) and left atrial size (r=-0.209;p = 0.014). There was a significant difference in the right ventricular free wall strain according to the severity of COVID-19 infection (p = 0.032). Moreover, a significant difference was also noted between right ventricular free wall strain and mortality (p = 0.0001). The mean right ventricular free wall strain of patients who died was significantly lower than those who were discharged with a mean of 18.92% and 23.59% respectively. CONCLUSION: Right ventricular free wall strain using speckle tracking echocardiography, can be used for risk stratification for patients with COVID-19. It also showed that it is has significant correlation with the severity of the disease and mortality. These findings together with other conventional echocardiographic parameters, may provide clinicians additional information in the management of these patients.

Evaluation of ventricular strain values in patients after coronavirus 2019 infection

Background: During the first months of coronavirus disease 2019 (COVID 19) pandemic there were several reports of myocardial involvement in recovered patients despite of symptoms presented during acute phase of the infection. That information led to a rising number of recomendations of screening for myocardial damage with different methods like electrocardiogram, echocardiography, cardiac magnetic resonance and biomarkers in the pursuit of a cardiac event free return to normal activities. Because of this and knowing the capability of strain imaging to detect subclinical myocardial damage we decided to evaluate values of left ventricular global longitudinal strain (GLS) and right ventricular free wall strain (RVFWS) in patients that were derived for echocardiographic evaluation after COVID 19 infection and their evolution. Methods: We enrolled prospectively patients derived to our laboratory for evaluation of Doppler echocardiography after confirmed COVID 19 infection if they were in the month after clinical discharge and did not have previous known structural cardiac alterations. We obtained demographic, symptoms and echocardiographic data and calculated GLS and RVFWS. Six months after the index examination we did phone calls to asess symptoms and events. Data is presented with mean and standard deviation and percentages. Results: of 68 patients included 38 (55,88%) were male, mean age was 42 years (+- 12,5) and half of them were sedentary. 52 had mild symptoms during infection, 15 moderate and 1 severe that required mechanical ventilation. At the time of examination 58 were asymptomatic (85,29%) and the other complaint of dyspnea (3), weakness (8) and palpitations (6). Regarding echocardiographic data, mean eyection fraction estimated by Simpson?s biplane method was 65,6% (+- 4,33) and left atrial indexed volume 25 ml/m2 (+- 5,98). 44 patients had normal left ventricular diastolic function, 21 grade 1 dysfunction and 2 had grade 2, with mean E/e? relation 8,52 (+-2,03). Mean pulmonary artery systolic pressure estimated was 27,4 mmHg (+- 4,1) and tricuspid anular plane systolic excursion was 23,81 mm (+-3,12). Mean GLS was - 21,52% (+- 1,91) and RVFWS was - 29,15% (+- 5,4), in 2 patients we could not measure RVFWS due to bad quality of images. Only 2 patients had GLS above - 18%, thta were the patient with severe symptoms and 1 with moderate symptoms;and 10 had RVFWS above - 23%, all of them with moderate symptoms. We could contact 60 patients (88,23%) after 6 months and none of them had cardiac events or persistence of symptoms. Conclusions: Calculation of GLS and RVFWS in this patients was feasible. We observed abnormalities in patients with severe and moderate symptoms at the time of infection, more frequently in RVFWS, but without relation to cardiac events or symptoms on follow up.

Right heart function in patients with viral pneumonia of varying severity caused by SARS-n-COV-2

Purpose: the purpose of this study was to estimate condition of right heart in patients with COVID-19 and viral pneumonia. Material and methods: 87 patients were included (age 53 ± 13, 58% male) with established diagnosis of COVID-19 via PCR and viral pneumonia on CT scans. Patient's clinical condition was assessed by SHOCS-COVID and NEWS scales. Transthoracic echocardiography was performed on 12 ± 4.6 day from the first symptoms of disease. Levels of high-sense Troponin I and NT-proBNP were measured in blood samples. Results: Patients were divided into 3 groups according to pattern of viral pneumonia severity on CT scans. Group I with CT 1 grade (involvement of the pulmonary parenchyma 0-25%) - 11(12.6%) patients;mid age- 48.9 ± 17 years;NEWS score - 1.4 ± 0.9;SHOCS-COVID score - 7.5 ± 3.7. Group II with CT 2 grade (involvement of the pulmonary parenchyma 25-50%). 48 (55.2%) patients;mid age- 51.6 ± 13.1 years;NEWS score - 2 ± 1;SHOCS-COVID score - 9 ± 2.1. Group III with CT 3 grade (involvement of the pulmonary parenchyma 50%-75%). 28 (32.2%) patients;mid age- 57.1 ± 10.3 years;NEWS score - 3.2 ± 1.5;SHOCS-COVID score - 12.4 ± 2. Groups didn't differ in age (p-value >0.05). Highest NEWS and SHOCS-COVID scores were observed in group III (p < 0.0001 and p = 0.01, accordingly). All patients had preserved LV ejection fraction (62 ± 4.2%). Range of right heart echocardiography parameters was higher in patients with more severe grade of viral pneumonia: - pulmonary artery systolic pressure in group I - 26,3 ± 4 mmHg, in II - 28.7 ± 4 mmHg, in III - 29.1 ± 13.2 mmHg (pI-III= 0.002), r = 0.4, p < 0.0001;- myocardial systolic velocity (s') of free tricuspid annulus site by TDI in group I-11 ± 0.5 cm/s, in II-13 ± 2 cm/s, in III -14 ± 2 cm/s (pI-III= 0.02), r = 0.4. p < 0.0001;- GLS of right ventricle (RV) in group I -18.6 ± 3%, in II - 21.6 ± 3.9%, in III - 21 ± 3.9% (pI-III = 0.038), r = 0.4, p = 0.005;- RV mid diameter in apical position in group I- 27 ± 2.8 mm, in II - 31 ± 5.1 mm, in III - 29 ± 4.2 mm (pI-III = 0.03), r = 0.3, p = 0.002. TAPSE and right heart areas didn't differ between groups (p > 0.05). Levels of high-sense Troponin I were under 0.2 ng/ml in all groups (p > 0.05). NT-proBNP level were elevated only in group III - 172 [97,7;330] ng/l (pI-III = 0,03) and correlated with SHOCS-COVID scores (r = 0.4, p = 0.04), CT grade (r = 0.3, p = 0.01) and RV Tei index from pulse-wave Doppler (r = 0.3, p = 0.02). Conclusion: perhaps, RV hyperfunction is compensatory reaction in response to increased afterload of right heart in patients with severe viral pneumonia caused by SARS-n-COV-2. Increased level of NT-proBNP indirectly confirms presence of myocardial stress in patients with severe viral pneumonia caused by SARS-n-COV-2.

Pulmonary artery systolic pressure at admission predicts ICU mortality in elderly critically ill with severe COVID-19 pneumonia

Introduction: Point-of-care ultrasound (POCUS) is a useful diagnostic tool in noninvasive assessment of critically ill patients. Mortality of especially elderly patients with COVID-19 pneumonia is high and there is still scarcity of definitive predictors. Aim of our study was to assess the prediction value of combined lung and heart POCUS data on mortality of elderly critically ill patients with severe COVID-19 pneumonia. Methods: Data of patients older than 70 years, with severe COVID-19 pneumonia admitted to 22-bed mixed ICU, level 3, was analysed retrospectively. POCUS was performed on all admitted patients;our parameters of interest were pulmonary artery systolic pressure (PAPs) and diffuse B-line lung pattern (B-pattern). Results: A total of 116 patients (average age 77 ± 5 years) were included. Average length of ICU stay was 10.7 ± 8.9 days. High-flow oxygenation, non-invasive ventilation and invasive mechanical ventilation were at some point used to support 36/116, 39/116 and 75/116 patients respectively. ICU mortality was 59/116 (50.9%). ICU stay was shorter in survivors (8.8 ± 8.3 vs 12.6 ± 9.3 days, p = 0.02). PAPs was lower in ICU survivors (32.5 ± 9.8 vs. 40.4 ± 14.3 mmHg, p = 0.024) (Table 1). B-pattern was more often detected in non-survivals (35/24 (59%) vs. 19/38 (33%), p = 0.005). PAPs and B-pattern were both univariate predictors of mortality. PAPs was an independent predictor of ICU mortality (OR 1.0683, 95%CI: 1.0108-1.1291, p = 0.02). Conclusions: PAPs at admission is an independent predictor of ICU mortality of elderly patients with severe COVID-19 pneumonia. (Table Presented).

SUCCESSFUL DIAGNOSIS AND SURGICAL RESECTION OF A PULMONIC SARCOMATOID CARCINOMA LACKING PET AVIDITY OR MALIGNANT APPEARING CMR TISSUE CHARACTERISTICS

Background: In 2017 a middle-aged woman with a hypercoagulable state on warfarin was found to have pulmonary emboli and a left upper lung mass on computed tomography (CT). A mass on the pulmonic valve was also identified on echocardiography. Patient History: Thorascopic biopsy of lung mass confirmed spindle cell carcinoma with sarcomatoid features. No metastatic disease was suggested by Positron emission tomography (PET) imaging showing no avidity. Left pneumonectomy was planned. Nuclear stress testing was low risk. Cardiac magnetic resonance (CMR), transthoracic echo (TTE) and transesophageal echo identified a 11 x 6 mm mobile mass on the right pulmonic valve cusp, with mild tricuspid regurgitation (TR) and moderate pulmonic insufficiency (PI). The mass characteristics by CMR suggested a fibroelastoma and not metastasis, thrombus or vegetation. The working diagnosis was a fibroelastoma requiring observation and medical therapy for PI/TR. At pneumonectomy, 3 of 19 N1 nodes were involved and all N2 nodes were clear. She received 4 cycles of adjuvant cispaltin and docetaxel for T2N1M0/stage II spindle cell carcinoma, followed by surveillance. Exams and Imaging: In 2019, she complained of new dyspnea;a CMR was recommended. Chest CT was negative for recurrence. The patient deferred follow up during COVID-19 pandemic until April 2021, when CMR revealed known pulmonary mass was now enlarging, 19 x 14 mm, extending into the outflow tract, with moderate PI and severe TR. The pulmonary artery and right ventricle were dilated. By TTE, pulmonary systolic pressure was estimated at 71 mmHg. The LVEF was preserved. Treatment Plan: After a multidisciplinary discussion, cardiac surgery was recommended. Due to mediastinal shift post lung resection, anterolateral clamshell approach was utilized for enbloc resection with placement of Cryolife 29 mm pulmonary homograft and 31 mm Mosaic porcine tricuspid valve. The pulmonic mass pathology revealed intimal pleomorphic sarcomatoid neoplasm, clonally related but molecularly distinct from her prior tumor. Patient Outcomes: The patient recovered well and dyspnea resolved;the current treatment strategy is surveillance without chemotherapy or radiation. Clinical Implications: This case illustrates that sarcomatoid masses frequently lack PET avidity and lack suspicious features by CMR. A high index of suspicion must be considered even in the setting of benign appearing images.

Prognostic Value of Right Ventricular Longitudinal Strain in Patients With COVID-19.

Objectives: The aim of this study was to investigate whether right ventricular longitudinal strain (RVLS) was independently predictive of higher mortality in patients with coronavirus disease-2019 (COVID-19). Background: RVLS obtained from 2-dimensional speckle-tracking echocardiography has been recently demonstrated to be a more accurate and sensitive tool to estimate right ventricular (RV) function. The prognostic value of RVLS in patients with COVID-19 remains unknown. Methods: One hundred twenty consecutive patients with COVID-19 who underwent echocardiographic examinations were enrolled in our study. Conventional RV functional parameters, including RV fractional area change, tricuspid annular plane systolic excursion, and tricuspid tissue Doppler annular velocity, were obtained. RVLS was determined using 2-dimensional speckle-tracking echocardiography. RV function was categorized in tertiles of RVLS. Results: Compared with patients in the highest RVLS tertile, those in the lowest tertile were more likely to have higher heart rate; elevated levels of D-dimer and C-reactive protein; more high-flow oxygen and invasive mechanical ventilation therapy; higher incidence of acute heart injury, acute respiratory distress syndrome, and deep vein thrombosis; and higher mortality. After a median follow-up period of 51 days, 18 patients died. Compared with survivors, nonsurvivors displayed enlarged right heart chambers, diminished RV function, and elevated pulmonary artery systolic pressure. Male sex, acute respiratory distress syndrome, RVLS, RV fractional area change, and tricuspid annular plane systolic excursion were significant univariate predictors of higher risk for mortality (p < 0.05 for all). A Cox model using RVLS (hazard ratio: 1.33; 95% confidence interval [CI]: 1.15 to 1.53; p < 0.001; Akaike information criterion = 129; C-index = 0.89) was found to predict higher mortality more accurately than a model with RV fractional area change (Akaike information criterion = 142, C-index = 0.84) and tricuspid annular plane systolic excursion (Akaike information criterion = 144, C-index = 0.83). The best cutoff value of RVLS for prediction of outcome was -23% (AUC: 0.87; p < 0.001; sensitivity, 94.4%; specificity, 64.7%). Conclusions: RVLS is a powerful predictor of higher mortality in patients with COVID-19. These results support the application of RVLS to identify higher risk patients with COVID-19.