key: cord-0774782-r3jwo73m
authors: Wehit, Jeanette M; Sosa, Fernando A; Merlo, Pablo; Roberti, Javier; Osatnik, Javier
title: Identification of COVID-19-associated Myocarditis by Speckle-Tracking Transesophageal Echocardiography in Critical Care
date: 2020-11-24
journal: nan
DOI: 10.1016/j.acci.2020.11.008
sha: d15db6581039e1b80b336b8c52523b70337690a7
doc_id: 774782
cord_uid: r3jwo73m

A 68-year-old male presented with flu-like symptoms, fatigue, history of obesity, hypertension, type 2 diabetes and chronic smoking. Chest radiography revealed right basal opacity consisting of infiltrate. With respiratory failure, orotracheal intubation and mechanical ventilation were performed. Patient presented gas exchange alteration. Real-time PCR detected SARS-CoV-2. Treatment with liponavir/ritonavir and hydroxychloroquine was started. Because of poor acoustic window, speckle-tracking transoesophageal echocardiography (TEE) was performed, detecting deterioration in global longitudinal strain. Acute COVID 19 infection led us to suspect myocarditis, with no other signs or symptoms other than elevated troponin and altered strain. On day 15, the patient suffered bacteraemic sepsis at endovascular focus with Serratia marcescens and multiorgan failure. TEE-guided haemodynamic monitoring was repeated showing global longitudinal strain improvement. Acute COVID 19 infection led us to suspect myocarditis, with no other signs or symptoms beyond elevated troponin and altered strain.

Because of poor acoustic window, speckle-tracking transoesophageal echocardiography (TEE) was performed, detecting deterioration in global longitudinal strain. Acute COVID 19 infection led us to suspect myocarditis, with no other signs or symptoms other than elevated troponin and altered strain. On day 15, the patient suffered bacteraemic sepsis at endovascular focus with Serratia marcescens and multiorgan failure. TEE-guided haemodynamic monitoring was repeated showing global longitudinal strain improvement.

Acute COVID 19 infection led us to suspect myocarditis, with no other signs or symptoms beyond elevated troponin and altered strain.

Keywords: myocarditis; speckle-tracking transoesophageal echocardiography; COVID-19; SARS-CoV-2.

Un hombre de 68 años presentó síntomas similares a los de la gripe, fatiga, antecedentes de obesidad, hipertensión, diabetes de tipo 2 y tabaquismo crónico. La radiografía de tórax reveló una opacidad basal derecha consistente con infiltración. Se realizó una intubación orotraqueal y ventilación mecánica. El paciente presentó alteración del intercambio gaseoso. La PCR en tiempo real detectó SARS-CoV-2. Se inició el tratamiento con liponavir/ritonavir e hidroxicloroquina. Debido a la deficiente ventana acústica, se realizó una ecocardiografía transoesofágica (ETE) de speckle-tracking, que detectó el deterioro de la tensión longitudinal global. La infección aguda por COVID 19 nos llevó a sospechar de miocarditis, sin más signos o síntomas que la elevación de la troponina y la alteración de la cepa. El día 15, el paciente sufrió una sepsis bacteriana en el foco endovascular con Serratia marcescens y fallo multiorgánico. Se repitió la monitorización hemodinámica guiada por ETE que mostró una mejora en la tensión longitudinal global. The novel coronavirus disease (COVID-19) has been spreading exponentially in most countries around the world. Its clinical course is characterized by respiratory tract symptoms. 1 However, COVID-19 also affects multiple organs and acute myocarditis has been described as an associated complication. 2 Haemodynamic monitoring is important in the recovery process. Bedside transthoracic echocardiography (TTE) may be insufficient due to deficient acoustic window or suboptimal views when using positive end-expiratory pressure in mechanically ventilated patients. [3] [4] [5] [6] Strain imaging using speckle-tracking TEE could play a crucial role because of its greater sensitivity for the early diagnosis of myocarditis associated to COVID-19 in critically ill patients. We present a patient with J o u r n a l P r e -p r o o f COVID-19 whose myocardial deformation was detected using myocardial strain speckle-tracking by TEE.

A 68-year-old male presented to the emergency department with a complaint of flu-like symptoms for the previous ten days and fatigue that had worsen in the previous hours. The patient had a history QTc interval, treatment with antimalarials was discontinued. Due to persistent gas exchange alteration (PaO2/FiO2 <150 mmHg), the prone position was performed five times with subsequent improvement of PaO2/FiO2 ratio, keeping lung mechanics.

As a result of poor acoustic window, guided monitoring by TEE was performed on day 5, using an CX50

Philips Ultrasound (X7-2t) fitted with a multiplane 2-7 MHz TEE transducer, following a standard procedure (Figure 2 ), detecting deterioration in global longitudinal strain. Table 1 infection, increased high-sensitivity troponin T and strain alteration. Although cardiac magnetic J o u r n a l P r e -p r o o f resonance imaging (CMRi) and endomyocardial biopsy are the gold standards for the diagnosis of myocarditis, the evidence shows a good correlation between echocardiographic strain and CMRi. 9 We routinely screen ventilated patients with echocardiograms, especially in the case of COVID-19

infection, which can affect the cardiovascular system. Because of the impossibility of a good acoustic window by speckle-tracking TEE, the presence of altered strain in the first TEE and the patient´s clinical deterioration with significant haemodynamic instability 10 days after the first ultrasound study, the speckle-tracking TEE was repeated. Of note, in the context of COVID-19 and with severe hypoxemia requiring placing the patient in the prone position, TEE could be performed nonetheless. 10 A notable improvement was seen in the global longitudinal strain values without significant changes in cardiac troponin.

In this patient, myocarditis appears to have been a subclinical event; however, myocardial injury cannot be ruled out. Myocarditis was suspected because of acute COVID-19 although the patient only presented increased troponin and an altered strain. Moreover, in the context of acute COVID-19 myocardial assessment in ventilated patients with sedation and analgesia seems to be important due to the prevalence of myocardial dysfunction.

Strain imaging using speckle-tracking TEE is a relatively new tool in ICUs -although not widely available -and evidence suggests that it has better sensitivity than the ejection fraction in assessing myocardial function. Although speckle tracking alterations in this scenario cannot confirm the diagnosis of myocarditis, the literature supports the use of this technique in critical transthoracic echocardiography; in the context of transesophageal echocardiography, results still need to be validated. The need for a good quality image by common two-dimensional ultrasound imagining was met by speckle-tracking TEE. Speckle-tracking echocardiography works as a "digital biopsy" and it could become an essential diagnostic tool for myocarditis and septic cardiomyopathy. 11 Understanding atypical presentations and imaging findings could contribute to prompt diagnosis of COVID-19 induced myocarditis.

Clinical course and mortality risk of severe COVID-19. The Lancet

COVID-19 and the cardiovascular system: implications for risk assessment, diagnosis, and treatment options

Detection of Myocardial Dysfunction in Septic Shock: A Speckle-Tracking Echocardiography Study

Strain echocardiography identifies impaired longitudinal systolic function in patients with septic shock and preserved ejection fraction

Left ventricular systolic function evaluated by strain echocardiography and relationship with mortality in patients with severe sepsis or septic shock: a systematic review and meta-analysis

Transthoracic Speckle Tracking Echocardiography for the Quantitative Assessment of Left Ventricular Myocardial Deformation

The feasibility of speckle tracking for intraoperative assessment of regional myocardial function by transesophageal echocardiography

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Critical Care Transesophageal Echocardiography in Patients during the COVID-19 Pandemic

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