key: cord-0711767-9gqiumqy
authors: González-Del-Hoyo, Maribel; Servato, Luz; Ródenas, Eduardo; Bañeras, Jordi; Ferreira-González, Ignacio; Rodríguez-Palomares, Jose
title: Echocardiography in the acute phase of COVID-19 infection: impact on management and prognosis
date: 2021-12-14
journal: Rev Esp Cardiol (Engl Ed)
DOI: 10.1016/j.rec.2021.11.012
sha: 360751428b824a31b1d7b6cf77ccb7a30783c7a8
doc_id: 711767
cord_uid: 9gqiumqy

nan

understand whether myocardial injury is a bystander phenomenon or a contributor to severe damage.

Thus, this study aimed to define abnormalities on advanced TTE analysis in acute COVID-19 infection and to determine their implications in management and prognosis.

We performed a prospective cohort study including 200 patients admitted with and undergoing a TTE at the discretion of the clinician between March 1 and May 25, 2020. Due to the lack of familiarity with COVID-19, imaging was limited to patients who were expected to derive a benefit from its findings. 3 Exclusion criteria were as follows: absence of confirmed SARS-CoV-2, age < 18 years, handheld echocardiograms, and lack of quality. Each patient's chart was reviewed following TTE assessment to evaluate changes in management: treatment changes (antibiotics, diuretics, anticoagulation), hemodynamic support titration, facilitating decisions regarding patient care level, and no changes. Echocardiographic assessment, 2D-strain imaging, and myocardial work analysis was performed. Approval for the study was obtained from the center's Institutional Review Board. All patients included in the study signed the consent form prior to inclusion.

Sixty-six studies were included in the final analysis after exclusion of 134 patients (handheld echocardiograms, not following quality protocols). No differences regarding demographics and clinical characteristics were found between patients included and excluded in the analysis (P > .05 conditions concern (endocarditis, pulmonary embolism), 30.3% hemodynamic assessment (shock, heart failure), 19.7% cardiac conditions (elevated biomarkers, chest pain). Patients with an abnormal TTE were older and presented more cardiovascular risk factors compared with patients with a normal TTE. Overall, 36 patients (54.5%) had an abnormal TTE study (table 2). The most frequent abnormality was diastolic dysfunction (defined according to the 2016 ASE/EACVI guidelines) (33.3%), followed by RV dysfunction (12.1%), LV dysfunction (6.1%), and severe valvular heart disease or endocarditis (3%).

2-dimensional strain imaging and myocardial work analysis were performed only in 33 and 16 patients, respectively, due to the required high-resolution image quality. LV global longitudinal strain (GLS) was J o u r n a l P r e -p r o o f 4 in our data, myocardial work analysis was also significantly associated with hs-cTnI levels. Therefore, the most prevalent findings were subclinical changes, reinforcing evidence from other cohort studies, that cardiac involvement is high but mainly subclinical 4,5 (reduced GLS and persistent myocardial inflammation on cardiovascular magnetic resonance). In our cohort, strain and myocardial work analysis were not considered as surrogate markers of LV dysfunction in COVID-19 patients with a normal echocardiogram and did not influence the decision-making process. It remains unknown whether clinical decisions based on these parameters result in a better outcome. Further multimodality imaging and large-scale biomarker studies are necessary to understand the pathophysiology. In previous reports, a major cardiovascular event was the main factors indicating TTE 2 ; however, in our study, the most frequent indicator was a systemic condition, because myocardial injury was carefully interpreted with integration of symptoms, electrocardiographic changes, and the likelihood of coronary disease. Based on our results and in agreement with previous publications, 6 an echocardiographic study should be limited to patients with a primary concern about a systemic condition, to rule out long-term intensive care unit complications, or to evaluate causes of hemodynamic instability and facilitate the decision-making process regarding patient care level and de-escalation of medical treatments.

This study has the limitations of selection bias, as echocardiography and biomarker testing were left to the physician's decision. Second, the single site and small sample size may have led to type II errors. However, the study was performed in a tertiary center representative of a large suburban area admitting 2025 patients with COVID-19 during the first wave of the pandemic. Third, it is unknown whether imaging abnormalities (diastolic dysfunction) were previously present and were thus unrelated to the infection. Finally, our results should be interpreted in light of the low mortality of our population and the absence of a short-term impact does not allow conclusions to be drawn on the absence of long-term consequences. In-hospital mortality 7 (10.6) 2 (6.7) 5 (13.9) . 

Association of Cardiac Injury With Mortality in Hospitalized Patients With COVID-19 in Wuhan, China

Indications for and Findings on Transthoracic Echocardiography in COVID-19

COVID-19 pandemic and cardiac imaging: EACVI