Functional outcomes in post Covid-19 patients with persistent dyspnea: multidisciplinary approach.

BACKGROUND: Post-acute sequelae of SARS-CoV-2 (PASC) have emerged as a major health issue in patients who have previously been infected with Covid-19 virus. PURPOSE: we aimed at the assessment of functional outcomes in post Covid-19 patients with persistent dyspnea using a multidisciplinary approach including clinical assessment, laboratory investigations, exercise ECG, and different echo-Doppler modalities, including left atrial functions. METHODS: The current observational randomized controlled study conducted on 60- patients one month after recovery from Covid-19 infection presented with persistent dyspnea compared to 30 healthy volunteers. All participants were subjected to evaluation of dyspnea by different scores, laboratory investigations, stress ECG, and echo-Doppler examination to measure LV dimensions, volumes, systolic and diastolic functions by M-mode, 2D, and tissue Doppler imaging in addition to 2-D speckle tacking LA strain. RESULTS: Post Covid-19 patients had persistent elevation of inflammatory markers, low functional capacity (evidenced by a higher NYHA class, m MRC score, PCFS scale) and decreased METs by stress ECG compared to control group. Post Covid-19 patients showed LV diastolic dysfunction and impairment of 2D-STE LA functions compared to control group. We found negative correlations between LA strain with NYHA class, mMRC scale, LAVI, ESR and CRP; meanwhile, there were significant positive correlations between LA strain with exercise duration and METs. CONCLUSION: post Covid patients presented with persistent dyspnea demonstrated low functional capacity evidenced by different scores and stress ECG. Moreover, patients with post Covid syndrome showed elevated inflammatory biomarkers, LV diastolic dysfunction in addition to impaired LA strain functions. Impairment of LA strain was closely correlated to different functional scores, inflammatory biomarkers, exercise duration, and METs suggesting that these could to be the possible etiologies for the persistence of post Covid symptoms.

Implantable devices for heart failure monitoring.

Heart failure (HF) is associated with considerable morbidity and mortality. The increasing prevalence of HF and inpatient HF hospitalization has a considerable burden on healthcare cost and utilization. The recognition that hemodynamic changes in pulmonary artery pressure (PAP) and left atrial pressure precede the signs and symptoms of HF has led to interest in hemodynamic guided HF therapy as an approach to allow earlier intervention during a heart failure decompensation. Remote patient monitoring (RPM) utilizing telecommunication, cardiac implantable electronic device parameters and implantable hemodynamic monitors (IHM) have largely failed to demonstrate favorable outcomes in multicenter trials. However, one positive randomized clinical trial testing the CardioMEMS device (followed by Food and Drug Administration approval) has generated renewed interest in PAP monitoring in the HF population to decrease hospitalization and improve quality of life. The COVID-19 pandemic has also stirred a resurgence in the utilization of telehealth to which RPM using IHM may be complementary. The cost effectiveness of these monitors continues to be a matter of debate. Future iterations of devices aim to be smaller, less burdensome for the patient, less dependent on patient compliance, and less cumbersome for health care providers with the integration of artificial intelligence coupled with sophisticated data management and interpretation tools. Currently, use of IHM may be considered in advanced heart failure patients with the support of structured programs.

Skewed Cytokine Responses Rather Than the Magnitude of the Cytokine Storm May Drive Cardiac Dysfunction in Multisystem Inflammatory Syndrome in Children.

Background Cardiac dysfunction is a prominent feature of multisystem inflammatory syndrome in children (MIS-C), yet the etiology is poorly understood. We determined whether dysfunction is global or regional, and whether it is associated with the cytokine milieu, microangiopathy, or severity of shock. Methods and Results We analyzed echocardiographic parameters of myocardial deformation and compared global and segmental left ventricular strain between 43 cases with MIS-C ≤18 years old and 40 controls. Primary outcomes included left ventricular global longitudinal strain, right ventricular free wall strain), and left atrial strain. We evaluated relationships between strain and profiles of 10 proinflammatory cytokines, microangiopathic features (soluble C5b9), and vasoactive-inotropic requirements. Compared with controls, cases with MIS-C had significant impairments in all parameters of systolic and diastolic function. 65% of cases with MIS-C had abnormal left ventricular function (|global longitudinal strain|<17%), although elevations of cytokines were modest. All left ventricular segments were involved, without apical or basal dominance to suggest acute stress cardiomyopathy. Worse global longitudinal strain correlated with higher ratios of interleukin-6 (ρ -0.43) and interleukin-8 (ρ -0.43) to total hypercytokinemia, but not absolute levels of interleukin-6 or interleukin-8, or total hypercytokinemia. Similarly, worse right ventricular free wall strain correlated with higher relative interleukin-8 expression (ρ -0.59). There were no significant associations between function and microangiopathy or vasoactive-inotropic requirements. Conclusions Myocardial function is globally decreased in MIS-C and not explained by acute stress cardiomyopathy. Cardiac dysfunction may be driven by the relative skew of the immune response toward interleukin-6 and interleukin-8 pathways, more so than degree of hyperinflammation, refining the current paradigm of myocardial involvement in MIS-C.