Echocardiographic assessment of right ventricular function and pulmonary pressures in hospitalized patients with COVID-19

ABSTRACT

Aims: Pulmonary involvement in Coronavirus 19 disease (COVID-19) may affect right ventricular (RV) function and pulmonary pressures resulting in further deterioration of patient clinical status. However, the prognostic value of echocardiographic parameters including tricuspid annular plane systolic excursion (TAPSE), systolic pulmonary artery pressure (PASP), and TAPSE/PASP ratio has been poorly investigated in this clinical setting. Methods and results: This is a multicentre Italian study including patients admitted for severe COVID-19 in seven Italian Hospitals. Transthoracic echocardiography (TTE) was performed within 48 h from admission in all cases. In-hospital mortality and pulmonary embolism (PE) were identified as the primary and secondary outcome measures, respectively. Of 1401 patients with severe COVID-19, 227 (16.1%) subjects underwent TTE within 48 h from admission and were included in this study. The mean age was 68±13 years and 62.6% of patients were male. Intensive care unit (ICU) admission was reported in 73 patients (32.2%);ICU patients showed lower left ventricular ejection fraction (LVEF), lower TAPSE, and higher LV end systolic volume and PASP values than non-ICU patients. Also, ICU patients showed higher incidence of acute respiratory distress syndrome (82.2% vs. 30.5%;P<0.001), acute cardiac injury (46.6% vs. 22.7%;P<0.001), acute heart failure (34.2% vs. 9.1%;P<0.001), and death (63.9% vs. 14.3%;P<0.001) compared with non-ICU patients. By stratifying the study population into tertiles according to TAPSE, PASP, and TAPSE/PASP values, patients in the lower TAPSE and TAPSE/PASP ratio tertiles, and those in the higher PASP tertile, showed a significantly higher incidence of death during the hospitalization. At univariable logistic regression analysis, TAPSE, PASP, and TAPSE/PASP were significantly associated with a higher risk of death and PE, both in patients admitted or not to ICU. After propensity score weighting adjustment for multiple baseline potential confounders and further multivariable adjustment for LVEF value, the regression analysis showed that TAPSE, PASP and TAPSE/PASP were independently associated with risk of death (TAPSE OR 0.85, CI 0.74-0.97, P=0.017;PASP OR 1.08, CI 1.03-1.13, P=0.002;TAPSE/PASP OR 0.02, CI 0.02 × 10-1-0.20, P<0.001) and with the risk of PE (TAPSE OR 0.70, CI 0.60-0.82, P<0.001;PASP OR 1.10, CI 1.05-1.14, P<0.001;TAPSE/PASP OR 0.02 × 10-1, CI 0.01 × 10-2- 0.04, P<0.001) during the hospitalization. The risk death according to TAPSE, PASP, and TAPSE/PASP ratio tertiles was estimated considering discharge alive as competing risk (Figure). The lowest TAPSE and TAPSE/PASP tertiles, and the highest PASP tertile, were significantly associated with poorer survival during the hosptialization (P<0.001). Conclusions: Echocardiographic evidence of RV systolic dysfunction, increased PASP and a poor RV-arterial coupling assessed by TAPSE/PAPS ratio may help to identify COVID-19 patients at higher risk of mortality and PE during the hospitalization.