key: cord-0048587-zx21oztb authors: Kapur, Rohan; Garg, Naveen; Kapur, K. K.; Kapoor, Pranav; Kapoor, Poonam Malhotra title: Cardiac Echocardiography in COVID-19 Infection date: 2020-07-24 journal: nan DOI: 10.1055/s-0040-1714150 sha: 2b97699cd92ea75c12cb63a0712a33617dbad7ad doc_id: 48587 cord_uid: zx21oztb The novel COVID-19 disease mainly affects respiratory organs; however, involvement of cardiovascular system is also not uncommon. Cardiac involvement can manifest as myocarditis, heart failure, myocardial infarction, pulmonary embolism, or arrhythmias in COVID-19 patients. This novel Coronavirus enters into the cells of the human body by binding to ACE-2 receptors which are predominantly present on pneumocytes and cardiomyocytes. The damage to myocardium is manifested by the increase in cardiac enzymes such as troponin-I, CK-MB, and NT pro-BNP. Although echocardiogram is an important tool in the cardiac evaluation of COVID-19 patients, its indiscriminate use is discouraged, owing to the risk of transmission to echocardiography service providers, as well as possible risk of contaminating echocardiography equipment. In this article, we discuss the different mechanisms and cardiac manifestations of COVID-19. We also review the current guidelines for echocardiography evaluation of COVID-19 patients as well as current recommendations on safety of echocardiography personnel and equipment against contamination. We also include our experience of two cases in which COVID-19 affliction of heart was strongly suspected, and echocardiography clinched the diagnosis. The Coronavirus pandemic, which started in late 2019 and is still ongoing, has severely stretched and overwhelmed the healthcare infrastructure all over the world. The SARS CoV-2 is transmitted by droplets, which enter the mucous membranes of the patients' eyes, nose, and mouth. ACE-2 receptors, predominantly present in the lungs, facilitate the entry of the virus into the cells. 1 Cardiac involvement in the coronavirus infection is relatively uncommon in low-risk, younger, asymptomatic patients (< 40 yrs). In middle age/elderly patients, the cardiac involvement progressively increases, and in patients requiring intensive care facilities, with or without ventilator therapy, the prevalence of heart involvement rises steeply and could be in the range of 50 to 60%. [1] [2] [3] [4] Cardiac Involvement due to Coronavirus Infection can Occur in (►Table 1): 1) Patients with preexisting heart disease-coronary artery disease, well-compensated congenital heart disease, valvular heart disease, as well as those in whom there is involvement of the heart in comorbid conditions such as hypertension, diabetes and chronic kidney disease. These patients can undergo worsening and decompensation due to acute stress. 2) Direct/indirect involvement of myocardium (myocarditis) is as follows: • Direct involvement of the myocardium occurs because of the viral RNA affecting the endothelium of the myocardial vessels, leading to release of troponins (troponin-T and I), causing varying degrees of myocardial dysfunction. J Card Crit Care:2020;4:56-60 • Indirect involvement of the myocardium can occur as a result of a severe systemic inflammation, causing release of cytokines/chemokines. These proinflammatory cytokines like tumor necrosis factor (TNF), interleukin (IL)-6, ferritin, C-reactive protein (CRP), and IL-1β are overproduced in response to tissue injury. This phenomenon is called cytokine storm which leads to vascular hyperpermeability, plaque ruptures, and eventually multiorgan failure. This is mediated by activation of monocytes and macrophages. • The presence of myocardial injury is an independent risk factor associated with increased mortality in COVID patients. [5] [6] [7] [8] 3) Rupture of atherosclerotic plaque on a preexisting critical/noncritical coronary artery disease, causing acute myocardial infarction (MI), usually ST elevated myocardial infarction (STEMI). • The management of patients with MI could either be using thrombolytic therapy (provided no C/I exist) or be directly referred to a percutaneous coronary intervention (PCI) center. The thrombolytic therapy regimen has the advantage of being cost-effective, immediately available, and more importantly avoiding transmission of infections to the interventional team. However, the advantage of PCI approach avoids unnecessary delays arising from changes in the appearance of classical findings of ECG in STEMI. [5] [6] [7] [8] 4) Myocardial ischemia precipitated by myocardial supply/demand mismatch due to tachycardia, hypoxia, pyrexia, and systemic inflammation which could lead to severe left ventricle (LV) dysfunction. 9,10 5) Cardiac arrhythmias varying from benign atrial/ventricular ectopics to life-threatening ventricular arrhythmias like Torsades de pointes, which could occur as a result of the following: Myocardial inflammation; use of cardiotoxic medications like chloroquine, hydroxychloroquine, azithromycin antiviral drugs; congenital disorders such as Brugada syndrome and long QT; electrolyte imbalance 11,12 (►Table 2). 6) Involvement of pericardium, including myopericarditis, and large pericardial effusions like cardiac tamponade are less frequent manifestations of COVID involvement of the heart. 7) Stress cardiomyopathy is again an uncommon reflection of COVID involvement of the heart, leading to either a classical Tako-Tsubo cardiomyopathy, a more rarer, reverse Tako-Tsubo cardiomyopathy, and nonischemic cardiomyopathy. 13, 14 8) Cardiac involvement due to pulmonary embolism. • Acute vascular thrombosis including deep vein thrombosis (DVT) is more likely to occur in patients with severe COVID infection. • Pulmonary embolism has a greater propensity to occur in patients with COVID pneumonias than other viral infections like influenza. • The prevalence of pulmonary embolism is likely to be in the range of 20 to 30% in patients with COVID pneumonias. • Significant elevation of D-dimer levels is likely to indicate a high-probability acute pulmonary embolism in a patient with COVID pneumonia and hypoxemia. • Acute cor pulmonale causing right ventricular (RV) enlargement can occur as a result of pulmonary embolization or severe hypoxemia due to COVID pneumonia itself. 15 Echocardiography is the most widely used cardiac imaging modality as it is noninvasive, portable and extremely cost-effective with accurate and immediate results. However, the use of echocardiographic technique exposes 2) Patient with decompensated cardiac failure. 3) Heart murmur. 4) Evaluation of patients with known preexisting cardiac disease. 21, 22 • However elaborate precautions should be undertaken with regard to protection of the personnel with adequate personal protection equipment (PPE) as well as protection of echocardiographic equipment from contamination. The detailed process of protection of the equipment can be divided into: A) Before the echocardiographic procedure: 1) Echocardiographic machine is carefully and thoroughly cleaned with sodium hypochlorite solution, including transducers, knobs, touch screen panel, and the monitor of the machine. 2) After drying, the knobs' board, touch screen panel, monitor, and transducer, are then completely covered with transparent polythene, as shown in ►Fig. 1. 3) The main body of the echocardiography machine, the transducer connecting cords, connectors, as well as the electrical wires, are draped in an outer polythene covering, as shown in ►Fig. 1. B) During echocardiographic procedure on a COVID patient, the outer draping of the body is removed, while the transducers, touch panel, monitor and knobs remain covered with transparent polythene. C) After the echocardiographic procedure, the echo machine is wheeled back to the echo room, and all the polythene coverings are removed. The entire echocardiographic machine is again cleaned meticulously with sodium hypochlorite solution, and the entire process is then repeated for another examination on COVID/suspected COVID patient. • High-quality PPE should be provided (as shown in ►Fig. 1), including complete covering of the face, eye-protection glasses, and headgear. Case 2-A 65-year-old diabetic male, with h/o high fever along with breathing difficulty, was admitted with hemodynamic instability for further management. X-Ray revealed large B/L consolidation. His HR-120/min, BP-80/60 mm Hg, and SPO2-88% at room air. Emergency echocardiography was done with a strong suspicion of myocarditis (►Fig. 3). Hematological investigations revealed leucocytosis and lymphopenia. COVID test was positive. Echocardiography ruled out any direct or indirect involvement of heart in this patient. Later troponin and NT-proBNP levels were also found to be normal. Although COVID involvement of the heart is uncommon in young, asymptomatic individuals; it is likely to be a challenging situation in the middle age/elderly population, especially with comorbid conditions. Appropriate management of decompensated, unstable, cardiac is usually sufficient to provide the required hemodynamics ►Table 5. • Echocardiographic personnel have a high-probability of getting infected when a transesophageal (TEE) procedure is performed on a COVID patient. Therefore, as far as possible, TEE should be avoided. One of the most common indication is to detect LA appendage clot in patients with atrial fibrillation (AF), or those having a history of embolic stroke. The use of MRI/CT could be extremely useful in this respect, owing to a much lesser probability of transmission of the virus to the MRI/CT personnel, as they are at a considerable distance from the patient. However, protection of the CT/MRI equipment from contamination is extremely important and due diligence should be followed. • Echocardiographic procedure could be obviated if: 1) Troponin and NT pro-BNP levels are normal 2) If an LV angiogram is performed during PCI in a COVID patient with MI. 3) Similarly, if CT angiogram is done for suspected pulmonary embolism, CT angiographic imaging of the heart and the coronaries can provide adequate information and prevent unnecessary echocardiographic procedure. • If patient is critically ill and CT angiography cannot be performed, then echocardiography could be performed to make a direct/indirect diagnosis of a probable pulmonary embolism (occasionally direct imaging of pulmonary artery [PA] clot but more commonly RV dysfunction and low-flow states in PA). CASE 1-A 61-year-old hypertensive male with no previous history of chronic obstructive (COPD) and diabetes; COVID-19 positive with pulmonary pneumonia was under treatment in ICU. His heart rate (HR)-120/min, blood pressure (BP)-100/60 mm Hg, respiratory rate (RR) 32/min, and SPO2 92% at room air ( ►Fig. 2 a, b) . patients in the COVID ICU is extremely demanding and requires expert management. A judicious use of echocardiography is advised. Hemodynamically, unstable patients may require echocardiography, but in patients with normal troponin levels, its use may be obviated. For performing an additional LV angiogram in patients undergoing coronary angiography or cardiac evaluation by CT scan in patients undergoing CT of the chest for pulmonary embolism, the need of echocardiography can be deferred. However, where patients cannot be transported, bedside echocardiography is an important tool. Provision of high-quality PPE, disinfecting, and draping of the echocardiographic equipment is essential. In the two patients described above, the use of echocardiography was crucial to diagnosis. COVID-19 and the cardiovascular system: implications for risk assessment, diagnosis, and treatment options SARS-CoV2: should inhibitors of the renin-angiotensin system be withdrawn in patients with COVID-19? Cardiac Manifestations of Coronavirus (COVID-19) A service of the National Library of Medicine COVID-19 and the cardiovascular system Management of acute myocardial infarction during the COVID-19 pandemic Management of acute myocardial infarction during the COVID-19 pandemic: A Consensus Statement from the Society for Cardiovascular Angiography and Interventions (SCAI), the American College of Cardiology (ACC), and the American College of Emergency Physicians (ACEP) Acute myocardial infarction after laboratory-confirmed influenza infection Risk of myocardial infarction and stroke after acute infection or vaccination Association of cardiac injury with mortality in hospitalized patients with COVID-19 in Wuhan, China Cardiovascular implications of fatal outcomes of patients with coronavirus disease 2019 (COVID-19) Coronavirus Disease (COVID-19): Arrhythmias and Conduction System Disease Guidance for Cardiac Electrophysiology During the Coronavirus (COVID-19) Pandemic from the Heart Rhythm Society COVID-19 Task Force. Guidance for Cardiac Electrophysiology During the Coronavirus (COVID-19) Pandemic from the Heart Rhythm Society COVID-19 Task Force; Electrophysiology Section of the American College of Cardiology; and the Electrocardiography and Arrhythmias Committee of the Council on Clinical Cardiology Takotsubo syndrome associated with ST elevation myocardial infarction Takotsubo Syndrome Associated with COVID-19 Abnormal coagulation parameters are associated with poor prognosis in patients with novel coronavirus pneumonia Acute pulmonary embolism and COVID-19 pneumonia: a random association? Remdesivir in adults with severe COVID-19: a randomised, double-blind, placebo-controlled, multicentre trial Randomised controlled trial begins for Ebola therapeutics Hydroxychloroquine, a less toxic derivative of chloroquine, is effective in inhibiting SARS-CoV-2 infection in vitro Treatment options in myocarditis and inflammatory cardiomyopathy: focus on i. v. immunoglobulins Cardiac complications attributed to chloroquine and hydroxychloroquine: a systematic review of the literature ASE Statement on Protection of Patients and Echocardiography Service Providers During the 2019 Novel Coronavirus Outbreak Using echocardiography to guide the treatment of novel coronavirus pneumonia None.