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1.
J Am Heart Assoc ; 11(4): e023220, 2022 02 15.
Article in English | MEDLINE | ID: covidwho-1685779

ABSTRACT

Background The COVID-19-related pulmonary effects may negatively impact pulmonary hemodynamics and right ventricular function. We examined the prognostic relevance of right ventricular function and right ventricular-to-pulmonary circulation coupling assessed by bedside echocardiography in patients hospitalized with COVID-19 pneumonia and a large spectrum of disease independently of indices of pneumonia severity and left ventricular function. Methods and Results Consecutive COVID-19 subjects who underwent full cardiac echocardiographic evaluation along with gas analyses and computed tomography scans were included in the study. Measurements were performed offline, and quantitative analyses were obtained by an operator blinded to the clinical data. We analyzed 133 patients (mean age 69±12 years, 57% men). During a mean hospital stay of 26±16 days, 35 patients (26%) died. The mean tricuspid annular plane systolic excursion/pulmonary artery systolic pressure (TAPSE/PASP) ratio was 0.48±0.18 mm/Hg in nonsurvivors and 0.72±0.32 mm/Hg in survivors (P=0.002). For each 0.1 mm/mm Hg increase in TAPSE/PASP, there was a 27% lower risk of in-hospital death (hazard ratio [HR], 0.73 [95% CI, 0.59-0.89]; P=0.003). At multivariable analysis, TAPSE/PASP ratio remained a predictor of in-hospital death after adjustments for age, oxygen partial pressure at arterial gas analysis/fraction of inspired oxygen, left ventricular ejection fraction, and computed tomography lung score. Receiver operating characteristic analysis was used to identify the cutoff value of the TAPSE/PASP ratio, which best specified high-risk from lower-risk patients. The best cutoff for predicting in-hospital mortality was TAPSE/PASP <0.57 mm/mm Hg (75% sensitivity and 70% specificity) and was associated with a >4-fold increased risk of in-hospital death (HR, 4.8 [95% CI, 1.7-13.1]; P=0.007). Conclusions In patients hospitalized with COVID-19 pneumonia, the assessment of right ventricular to pulmonary circulation coupling appears central to disease evolution and prediction of events. TAPSE/PASP ratio plays a mainstay role as prognostic determinant beyond markers of lung injury.


Subject(s)
COVID-19 , Pulmonary Circulation , Ventricular Dysfunction, Right , Aged , Aged, 80 and over , COVID-19/diagnostic imaging , COVID-19/mortality , COVID-19/physiopathology , COVID-19/therapy , Echocardiography, Doppler , Female , Hospital Mortality , Humans , Male , Middle Aged , Prognosis , Pulmonary Circulation/physiology , Ventricular Dysfunction, Right/diagnostic imaging , Ventricular Dysfunction, Right/mortality , Ventricular Dysfunction, Right/physiopathology
2.
Crit Care Med ; 49(10): 1757-1768, 2021 10 01.
Article in English | MEDLINE | ID: covidwho-1334267

ABSTRACT

OBJECTIVES: To assess whether right ventricular dilation or systolic impairment is associated with mortality and/or disease severity in invasively ventilated patients with coronavirus disease 2019 acute respiratory distress syndrome. DESIGN: Retrospective cohort study. SETTING: Single-center U.K. ICU. PATIENTS: Patients with coronavirus disease 2019 acute respiratory distress syndrome undergoing invasive mechanical ventilation that received a transthoracic echocardiogram between March and December 2020. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: Right ventricular dilation was defined as right ventricular:left ventricular end-diastolic area greater than 0.6, right ventricular systolic impairment as fractional area change less than 35%, or tricuspid annular plane systolic excursion less than 17 mm. One hundred seventy-two patients were included, 59 years old (interquartile range, 49-67), with mostly moderate acute respiratory distress syndrome (n = 101; 59%). Ninety-day mortality was 41% (n = 70): 49% in patients with right ventricular dilation, 53% in right ventricular systolic impairment, and 72% in right ventricular dilation with systolic impairment. The right ventricular dilation with systolic impairment phenotype was independently associated with mortality (odds ratio, 3.11 [95% CI, 1.15-7.60]), but either disease state alone was not. Right ventricular fractional area change correlated with Pao2:Fio2 ratio, Paco2, chest radiograph opacification, and dynamic compliance, whereas right ventricular:left ventricle end-diastolic area correlated negatively with urine output. CONCLUSIONS: Right ventricular systolic impairment correlated with pulmonary pathophysiology, whereas right ventricular dilation correlated with renal dysfunction. Right ventricular dilation with systolic impairment was the only right ventricular phenotype that was independently associated with mortality.


Subject(s)
COVID-19/complications , Respiratory Distress Syndrome/mortality , Ventricular Dysfunction, Right/complications , Aged , COVID-19/mortality , Echocardiography/methods , Female , Humans , Intensive Care Units/organization & administration , Intensive Care Units/statistics & numerical data , Male , Middle Aged , Mortality/trends , Respiratory Distress Syndrome/etiology , Retrospective Studies , United Kingdom , Ventricular Dysfunction, Right/mortality
3.
J Surg Res ; 264: 81-89, 2021 08.
Article in English | MEDLINE | ID: covidwho-1164149

ABSTRACT

BACKGROUND: Right ventricular failure is an underrecognized consequence of COVID-19 pneumonia. Those with severe disease are treated with extracorporeal membrane oxygenation (ECMO) but with poor outcomes. Concomitant right ventricular assist device (RVAD) may be beneficial. METHODS: A retrospective analysis of intensive care unit patients admitted with COVID-19 ARDS (Acute Respiratory Distress Syndrome) was performed. Nonintubated patients, those with acute kidney injury, and age > 75 were excluded. Patients who underwent RVAD/ECMO support were compared with those managed via invasive mechanical ventilation (IMV) alone. The primary outcome was in-hospital mortality. Secondary outcomes included 30-d mortality, acute kidney injury, length of ICU stay, and duration of mechanical ventilation. RESULTS: A total of 145 patients were admitted to the ICU with COVID-19. Thirty-nine patients met inclusion criteria. Of these, 21 received IMV, and 18 received RVAD/ECMO. In-hospital (52.4 versus 11.1%, P = 0.008) and 30-d mortality (42.9 versus 5.6%, P= 0.011) were significantly lower in patients treated with RVAD/ECMO. Acute kidney injury occurred in 15 (71.4%) patients in the IMV group and zero RVAD/ECMO patients (P< 0.001). ICU (11.5 versus 21 d, P= 0.067) and hospital (14 versus 25.5 d, P = 0.054) length of stay were not significantly different. There were no RVAD/ECMO device complications. The duration of mechanical ventilation was not significantly different (10 versus 5 d, P = 0.44). CONCLUSIONS: RVAD support at the time of ECMO initiation resulted in the no secondary end-organ damage and higher in-hospital and 30-d survival versus IMV in specially selected patients with severe COVID-19 ARDS. Management of severe COVID-19 ARDS should prioritize right ventricular support.


Subject(s)
COVID-19/complications , Extracorporeal Membrane Oxygenation/methods , Heart Failure/therapy , Heart-Assist Devices , Respiratory Distress Syndrome/therapy , Ventricular Dysfunction, Right/therapy , Adult , COVID-19/diagnosis , COVID-19/therapy , Combined Modality Therapy , Critical Care/methods , Critical Care/statistics & numerical data , Extracorporeal Membrane Oxygenation/statistics & numerical data , Female , Heart Failure/diagnosis , Heart Failure/etiology , Heart Failure/mortality , Hospital Mortality , Humans , Intensive Care Units/statistics & numerical data , Male , Middle Aged , Respiration, Artificial/statistics & numerical data , Respiratory Distress Syndrome/diagnosis , Respiratory Distress Syndrome/etiology , Respiratory Distress Syndrome/mortality , Retrospective Studies , Severity of Illness Index , Treatment Outcome , Ventricular Dysfunction, Right/diagnosis , Ventricular Dysfunction, Right/etiology , Ventricular Dysfunction, Right/mortality
4.
Int J Infect Dis ; 105: 351-356, 2021 Apr.
Article in English | MEDLINE | ID: covidwho-1077931

ABSTRACT

BACKGROUND: In this systematic review and meta-analysis, we assessed the association between tricuspid annular plane systolic excursion (TAPSE) measured by echocardiography and mortality in coronavirus disease 2019 (COVID-19). METHODS: We performed a systematic literature search using PubMed, Embase, and Scopus databases with the keywords "COVID-19" OR "SARS-CoV-2" OR "2019-nCoV" AND "Tricuspid annular plane systolic excursion" OR "TAPSE" until January 20, 2021. The main outcome was mortality. The effect estimate was reported as the hazard ratio (HR), which was pooled from the unadjusted and adjusted effect estimates retrieved from the studies included. Mean differences in TAPSE (in mm) between non-survivors and survivors were pooled. RESULTS: In total, 641 patients from seven studies were included in this systematic review and meta-analysis. TAPSE was lower in non-survivors compared with survivors (mean difference = -3.74 [-5.22, -2.26], p < 0.001; I2: 85.5%, p < 0.001). Each 1 mm decrease in TAPSE was associated with increased mortality (HR = 1.24 [1.18, 1.31], p < 0.001; I2: 0.0%, p = 0.491). In the pooled adjusted model, each 1 mm decrease in TAPSE was associated with increased mortality (HR = 1.21 [1.11, 1.33], p < 0.001; I2: 45.1%, p = 0.156). Meta-regression indicated that the difference in TAPSE between non-survivors and survivors was affected by chronic obstructive pulmonary disease (-0.183, p < 0.001) and pulmonary artery systolic pressure (-0.344, p = 0.039), but not by age (p = 0.668), male gender (p = 0.821), hypertension (p = 0.101), diabetes (p = 0.603), coronary artery disease (p = 0.564), smoking (p = 0.140), and left ventricular ejection fraction (p = 0.452). CONCLUSION: Every 1 mm decrease in TAPSE was associated with an increase in mortality of approximately 20%. PROSPERO ID: CRD42021232194.


Subject(s)
COVID-19/mortality , Echocardiography/methods , Tricuspid Valve/diagnostic imaging , Ventricular Dysfunction, Right/diagnostic imaging , Aged , Blood Pressure , Female , Humans , Male , Middle Aged , Proportional Hazards Models , SARS-CoV-2 , Stroke Volume , Tricuspid Valve/physiopathology , Ventricular Dysfunction, Right/mortality , Ventricular Dysfunction, Right/physiopathology , Ventricular Function, Left , Ventricular Function, Right
5.
Crit Care ; 24(1): 670, 2020 11 30.
Article in English | MEDLINE | ID: covidwho-949110

ABSTRACT

AIM: To investigate the prevalence and prognostic impact of right heart failure and right ventricular-arterial uncoupling in Corona Virus Infectious Disease 2019 (COVID-19) complicated by an Acute Respiratory Distress Syndrome (ARDS). METHODS: Ninety-four consecutive patients (mean age 64 years) admitted for acute respiratory failure on COVID-19 were enrolled. Coupling of right ventricular function to the pulmonary circulation was evaluated by a comprehensive trans-thoracic echocardiography with focus on the tricuspid annular plane systolic excursion (TAPSE) to systolic pulmonary artery pressure (PASP) ratio RESULTS: The majority of patients needed ventilatory support, which was noninvasive in 22 and invasive in 37. There were 25 deaths, all in the invasively ventilated patients. Survivors were younger (62 ± 13 vs. 68 ± 12 years, p = 0.033), less often overweight or usual smokers, had lower NT-proBNP and interleukin-6, and higher arterial partial pressure of oxygen (PaO2)/fraction of inspired O2 (FIO2) ratio (270 ± 104 vs. 117 ± 57 mmHg, p < 0.001). In the non-survivors, PASP was increased (42 ± 12 vs. 30 ± 7 mmHg, p < 0.001), while TAPSE was decreased (19 ± 4 vs. 25 ± 4 mm, p < 0.001). Accordingly, the TAPSE/PASP ratio was lower than in the survivors (0.51 ± 0.22 vs. 0.89 ± 0.29 mm/mmHg, p < 0.001). At univariate/multivariable analysis, the TAPSE/PASP (HR: 0.026; 95%CI 0.01-0.579; p: 0.019) and PaO2/FIO2 (HR: 0.988; 95%CI 0.988-0.998; p: 0.018) ratios were the only independent predictors of mortality, with ROC-determined cutoff values of 159 mmHg and 0.635 mm/mmHg, respectively. CONCLUSIONS: COVID-19 ARDS is associated with clinically relevant uncoupling of right ventricular function from the pulmonary circulation; bedside echocardiography of TAPSE/PASP adds to the prognostic relevance of PaO2/FIO2 in ARDS on COVID-19.


Subject(s)
COVID-19/complications , COVID-19/mortality , Heart Failure/mortality , Heart Failure/virology , Respiratory Distress Syndrome/mortality , Respiratory Distress Syndrome/virology , Ventricular Dysfunction, Right/etiology , Ventricular Dysfunction, Right/mortality , Aged , COVID-19/epidemiology , Echocardiography , Female , Heart Failure/diagnostic imaging , Heart Failure/physiopathology , Humans , Italy/epidemiology , Male , Middle Aged , Prevalence , Prognosis , Prospective Studies , Pulmonary Artery/diagnostic imaging , Pulmonary Artery/physiopathology , Respiratory Distress Syndrome/diagnostic imaging , Respiratory Distress Syndrome/physiopathology , SARS-CoV-2 , Ventricular Dysfunction, Right/diagnostic imaging , Ventricular Dysfunction, Right/physiopathology
7.
Clin Res Cardiol ; 109(12): 1491-1499, 2020 Dec.
Article in English | MEDLINE | ID: covidwho-597440

ABSTRACT

BACKGROUND: COVID-19 infection may cause severe respiratory distress and is associated with increased morbidity and mortality. Impaired cardiac function and/or pre-existing cardiovascular disease may be associated with poor prognosis. In the present study, we report a comprehensive cardiovascular characterization in the first consecutive collective of patients that was admitted and treated at the University Hospital of Tübingen, Germany. METHODS: 123 consecutive patients with COVID-19 were included. Routine blood sampling, transthoracic echocardiography and electrocardiography were performed at hospital admission. RESULTS: We found that impaired left-ventricular and right-ventricular function as well as tricuspid regurgitation > grade 1 were significantly associated with higher mortality. Furthermore, elevated levels of myocardial distress markers (troponin-I and NT pro-BNP) were associated with poor prognosis in this patient collective. CONCLUSION: Impaired cardiac function is associated with poor prognosis in COVID-19 positive patients. Consequently, treatment of these patients should include careful guideline-conform cardiovascular evaluation and treatment. Thus, formation of a competent Cardio-COVID-19 team may represent a major clinical measure to optimize therapy of cardiovascular patients during this pandemic.


Subject(s)
COVID-19/mortality , Tricuspid Valve Insufficiency/mortality , Ventricular Dysfunction, Left/mortality , Ventricular Dysfunction, Right/mortality , Ventricular Function, Left , Ventricular Function, Right , Aged , Aged, 80 and over , COVID-19/diagnosis , COVID-19/physiopathology , COVID-19/therapy , Female , Germany , Hospital Mortality , Hospitalization , Humans , Male , Middle Aged , Prognosis , Prospective Studies , Risk Assessment , Risk Factors , Time Factors , Tricuspid Valve Insufficiency/diagnosis , Tricuspid Valve Insufficiency/physiopathology , Tricuspid Valve Insufficiency/therapy , Ventricular Dysfunction, Left/diagnosis , Ventricular Dysfunction, Left/physiopathology , Ventricular Dysfunction, Left/therapy , Ventricular Dysfunction, Right/diagnosis , Ventricular Dysfunction, Right/physiopathology , Ventricular Dysfunction, Right/therapy
8.
JACC Cardiovasc Imaging ; 13(11): 2287-2299, 2020 11.
Article in English | MEDLINE | ID: covidwho-133405

ABSTRACT

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.


Subject(s)
Coronavirus Infections/complications , Echocardiography, Doppler , Pneumonia, Viral/complications , Ventricular Dysfunction, Right/diagnostic imaging , Ventricular Function, Right , Adult , Aged , COVID-19 , Coronavirus Infections/diagnosis , Coronavirus Infections/mortality , Female , Humans , Male , Middle Aged , Pandemics , Pneumonia, Viral/diagnosis , Pneumonia, Viral/mortality , Predictive Value of Tests , Prognosis , Risk Assessment , Risk Factors , Ventricular Dysfunction, Right/etiology , Ventricular Dysfunction, Right/mortality , Ventricular Dysfunction, Right/physiopathology
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