key: cord-0693034-m84ozpze
authors: Argulian, Edgar; Sud, Karan; Vogel, Birgit; Bohra, Chandrashekar; Garg, Vaani P.; Talebi, Soheila; Lerakis, Stamatios; Narula, Jagat
title: Right Ventricular Dilation in Hospitalized Patients with COVID-19 Infection
date: 2020-05-15
journal: JACC Cardiovasc Imaging
DOI: 10.1016/j.jcmg.2020.05.010
sha: 6bcd9e5168b95b53789789afccb582a8552cbf22
doc_id: 693034
cord_uid: m84ozpze

nan

Hospitalized patients with COVID-19 infection are at a high risk of progressive respiratory failure, endotracheal intubation and mortality. The pathophysiology of COVID-19 infection has not been elucidated but cytokine storm, prothrombotic state and myocardial dysfunction have been implicated. (1) Echocardiography is an essential bedside tool, which allows non-invasive assessment of biventricular function in COVID-19 patients, and echocardiographic findings can significantly influence decision making in the appropriate clinical settings. (2) We aimed at studying the association of in-hospital mortality with right ventricular size measured by a focused, time-efficient echocardiography protocol. (2) In this retrospective study, we enrolled consecutive patients hospitalized to Mount Sinai Morningside Hospital, New York, NY due to COVID-19 infection who underwent clinically Univariate and multivariate regression analysis was used to explore the associations of clinical and echocardiographic variables with mortality. The study protocol was approved by Mount Sinai Institutional Review Board.

Echocardiograms of 110 consecutive patients were reviewed, 5 were excluded due to inadequate study quality. The mean age was 66 (standard deviation, 14.6) years, and 38 (36%) patients were female. Thirty one (30%) patients were intubated and mechanically ventilated at the time of the echocardiographic examination. Right ventricular dilation was present in 32 (31%) patients.

Patients with right ventricular dilation did not have significant differences in the prevalence of major co-morbidities (hypertension, diabetes, and known coronary artery disease), laboratory markers of inflammation (white blood cell count, C-reactive protein) or myocardial injury (troponin I), but were more likely to have renal dysfunction (creatinine >1.5 mg/dl, 72% vs 41%, p =0.01) compared to patients without right ventricular dilation. There were no differences between the groups in the use of therapeutic anticoagulation (38% vs 39%, p=0.83) at the time of the echocardiographic examination. Similarly, there were no differences in the measures of left ventricular size and function between the groups (mean left ventricular ejection fraction 54% vs 55%, p =0.61). Right ventricular hypokinesis (66% vs 5%, p = 0.01) and moderate or severe tricuspid regurgitation (21% vs 7%, p=0.05) were more prevalent in patients with right ventricular enlargement. Computed tomography angiography of the chest was obtained in 10 patients (31%) with right ventricular enlargement, and 5 patients had evidence of pulmonary embolism. At the end of the study period, 21 (20%) patients died: 13 (41%) deaths were observed in patients with right ventricular dilation and 8 (11%) in patients without right ventricular dilation (Figure 1 ). On univariate analysis, mechanical ventilation (p=0.003), vasoactive medication use (p=0.007) and right ventricular enlargement (p=0.001) were significantly associated with mortality. On multivariate analysis, right ventricular enlargement was the only variable significantly associated with mortality (odds ratio 4.5, 95% confidence internal 1.5-13.7, p = 0.005).

This is a small, retrospective, single center study from the epicenter city of COVID-19 infection.

None of the studies were performed in prone position.

In conclusion, right ventricular dilation was prevalent in the current study of hospitalized patients with COVID-19 infection using a focused, time-efficient echocardiography protocol. The mechanism of right ventricular dilation is likely multifactorial and includes thrombotic events, hypoxemic vasoconstriction, cytokine milieu, and direct viral damage. Right ventricular dilation was strongly associated with in-hospital mortality in these patients. 

COVID-19) and Cardiovascular Disease

ASE Statement on Protection of Patients and Echocardiography Service Providers During the 2019 Novel Coronavirus Outbreak