Vascular Thrombosis in Severe COVID-19 Requiring Extracorporeal Membrane Oxygenation: A Multicenter Study.

OBJECTIVES: Coronavirus disease 2019 has been reported to be a prothrombotic condition; however, multicenter data comparing this with other viral pneumonias in those requiring extracorporeal membrane oxygenation are lacking. We conducted a multicenter study using whole-body CT to examine the prevalence, severity, and nature of vascular complications in coronavirus disease 2019 in comparison with patients with other viral pneumonias. DESIGN: We analyzed whole-body CT scans for the presence of vascular thrombosis (defined as pulmonary artery thrombus, venous thrombus, systemic arterial thrombus, or end-organ infarct). The severity, distribution, and morphology of pulmonary artery thrombus were characterized. Competing risk cumulative incidence analysis was used to compare survival with discharge. SETTING: Three centers of the English national extracorporeal membrane oxygenation service. PATIENTS: Consecutive patients admitted with either coronavirus disease 2019 or noncoronavirus disease 2019 viral pneumonia admitted from January 2019. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: One-hundred thirty-six patients (45.2 ± 10.6 yr old, 39/146 [27%] female) requiring extracorporeal membrane oxygenation support underwent whole-body CT scans at admission. Of these, 86 had coronavirus disease 2019 pneumonia, and 50 had noncoronavirus disease 2019 viral pneumonia. Vascular thrombosis was seen more often in patients with coronavirus disease 2019 (odds ratio, 12.9 [95% CI 4.5-36.8]). In those with coronavirus disease 2019, 57 (73%) demonstrated pulmonary artery thrombus or pulmonary perfusion defects. Eighty-two percent of thrombus exhibited emboli-like morphology. The location of pulmonary artery thrombus and parenchymal perfusion defects was only concordant in 30% of cases. The risk of mortality was higher in those with coronavirus disease 2019 compared with noncoronavirus disease 2019 pneumonia (χ2 = 3.94; p = 0.047). Mortality was no different in coronavirus disease 2019 patients with or without vascular thrombosis (χ2 = 0.44; p = 0.51). CONCLUSIONS: In patients who received extracorporeal membrane oxygenation, coronavirus disease 2019 is associated with a higher prevalence of vascular thrombosis compared with noncoronavirus disease viral pneumonias. The pattern of pulmonary vascular changes suggests concurrent embolic disease and small vessel disease. Despite this, vascular thrombosis was not linked to poorer short-term prognosis in those with coronavirus disease 2019.

A head-to-head comparison of the intra- and interobserver agreement of COVID-RADS and CO-RADS grading systems in a population with high estimated prevalence of COVID-19.

OBJECTIVE: To evaluate the inter- and intraobserver agreement of COVID-RADS and CO-RADS reporting systems among differently experienced radiologists in a population with high estimated prevalence of COVID-19. METHODS AND MATERIALS: Chest CT scans of patients with clinically-epidemiologically diagnosed COVID-19 were retrieved from an open-source MosMedData data set, randomised, and independently assigned COVID-RADS and CO-RADS grades by an abdominal radiology fellow, thoracic imaging fellow and a consultant cardiothoracic radiologist. The inter- and intraobserver agreement of the two systems were assessed using the Fleiss' and Cohen's κ coefficients, respectively. RESULTS: A total of 200 studies were included in the analysis. Both systems demonstrated moderate interobserver agreement, with κ values of 0.51 [95% confidence interval (CI): 0.46-0.56] and 0.55 (95% CI: 0.50-0.59) for COVID-RADS and CO-RADS, respectively. When COVID-RADS and CO-RADS grades were dichotomised at cut-off values of 2B and 4 to evaluate the agreement between grades representing different levels of clinical suspicion for COVID-19, the interobserver agreement became substantial with κ values of 0.74 (95% CI: 0.66-0.82) for COVID-RADS and 0.73 (95% CI: 0.65-0.81) for CO-RADS. The median intraobserver agreement was considerably higher for CO-RADS reaching 0.81 (95% CI: 0.43-0.76) compared with 0.60 (95% CI: 0.43-0.76) of COVID-RADS. CONCLUSIONS: COVID-RADS and CO-RADS showed comparable interobserver agreement, which was moderate when grades were compared head-to-head and substantial when grades were dichotomised to better reflect the underlying levels of suspicion for COVID-19. The median intraobserver agreement of CO-RADS was, however, considerably higher compared with COVID-RADS. ADVANCES IN KNOWLEDGE: This paper provides a comprehensive review of the newly introduced COVID-19 chest CT reporting systems, which will help radiologists of all sub-specialties and experience levels make an informed decision on which system to use in their own practice.

Paravalvular leakage in transcatheter mitral valve replacement: Bringing simulation theory one step closer to reality.

Transcatheter mitral valve replacement (TMVR) has emerged as a promising technique for the treatment of these patients with severe mitral valve disease and high or prohibitive surgical risk. Early experience with TMVR has shown a high rate of technical success and promising reductions in the severity of mitral regurgitation sustained out to 1 year post procedure. Despite this, procedural complications remain high, with the most common and significant of these being valve embolization, left ventricualr outflow tract (LVOT) obstruction and paravalvular leakage (PVL). It is this currently unanswered question that Morris et al. start to address in this issue of the Journal. They use the same annular segmentation and valve simulation as already proposed to predict LVOT obstruction, but use it to focus instead on examining the residual gap left between the base of the simulated transcatheter valve and the mitral leaflets or surgical prosthesis.