key: cord-0815436-at8ad5mo
authors: Zhang, Li; Wang, Bin; Zhou, Jianhua; Kirkpatrick, James; Xie, Mingxing; Johri, Amer M.
title: Bedside Focused Cardiac Ultrasound in COVID-19 Infection From the Wuhan Epicenter: The Role of Cardiac Point of Care Ultrasound (POCUS), Limited Transthoracic Echocardiography and Critical Care Echocardiography
date: 2020-04-09
journal: J Am Soc Echocardiogr
DOI: 10.1016/j.echo.2020.04.004
sha: 5f65b64dfb4af07e82c59e2792ffb49568031ef5
doc_id: 815436
cord_uid: at8ad5mo

Abstract Three cases of the application of focused cardiac ultrasound in patients with COVID-19 infection are presented. Cardiac point-of-care ultrasound (POCUS), limited transthoracic echocardiography (TTE), and critical care echocardiography (CCE) were applied in cases of heart failure, pulmonary embolism, and myocarditis with thrombus respectively. The impact upon patient management and the global context of each presentation are discussed.

The Wuhan Union Hospital is a large hospital system of 3 

A 73 year-old male presented with 12 days of fever. Following hospital admission on February 6 th , 2020, he was diagnosed with novel coronavirus pneumonia (RNA nucleic acid testing, NAT). The patient did not have records of a past medical history available, however he reported a history of heart failure. There was no history of coronary artery disease, diabetes, hypertension, cerebral infarction, acute coronary syndrome, tumour, kidney, or liver disease. There was no history of angiotensin converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) therapy. Physical examination revealed a blood pressure of 128/74 mmHg, heart rate of 72 bpm, a temperature of 38°C and normal oxygen saturation (97%). Upon lung auscultation, decreased breath sounds and crackles were noted. Course in hospital: The patient continued to be febrile and to experience dyspnea but did not require ventilation. Given the CT, BNP, and symptoms, a cardiac ultrasound was conducted on February 14 th , 2020 to rapidly assess left ventricular function, in a bedside, targeted assessment to help guide further management and testing. Right ventricular size and function were normal. The aortic valve appeared structurally normal, however significant aortic regurgitation was noted by color Doppler. The aortic regurgitation was thought to be severe by visual assessment but not fully quantified given the limits of the 'quick-look' cardiac ultrasound scan Management: Heart failure treatment was initiated with beta-blockers and diuretics. Over the course of the next 4 days the patient's symptoms improved and BNP levels decreased markedly.

The cardiac ultrasound at the point-of-care demonstrated the value of a rapid, bedside, binary assessment of the left ventricle, especially in the setting where the cause of dyspnea is difficult to discern from the underlying respiratory condition. In some settings, such as in North America, such a bedside, quick-look scan would be described as a cardiac POCUS. Cardiac POCUS to provide binary information, can be achieved with limited training, often conducted with highly portable (hand held or mobile) devices and can be performed by non-cardiologists. In this case, full chamber and valvular function was not quantified by POCUS and was not required immediately, thereby limiting operator and/or sonographer exposure while impacting management. Comprehensive TTE evaluation of the degree of aortic regurgitation, if clinically warranted, could be attained at a later date, or in a targeted manner if the clinical status changes.

Teaching Point 2-Patient Impact: Cardiac ultrasound played an important role in guiding heart failure management. The decision to conduct cardiac ultrasound was based upon the finding of symptoms and an elevated BNP value, known to be generally associated with an unfavourable course in heart failure and pneumonia. However, not all patients with an elevation in BNP may require evaluation or treatment for heart failure. In this case, the patient continued to be symptomatic and the cardiac POCUS affected management by suggesting the need for heart failure therapies. It is likely that the aortic regurgitation and dilated cardiomyopathy were underlying conditions, however etiology could not be confirmed by this technique. Due to the severe shortage of medical resources during the pandemic, only one cardiac ultrasound was conducted during the hospital stay to answer a targeted clinical question. Thus the aetiology of the aortic regurgitation was not fully determined but deferred for examination by comprehensive TTE at a later time following resolution of the pandemic.

COVID-19 infection is correlated with dilated cardiomyopathy and further study is required confirm this association. COVID-19 infection, like many other acute illnesses, may play a role in unmasking or exacerbating underlying chronic cardiovascular conditions. Thus it has been suggested that excessive cytokine release syndromes might be occurring with the infection and this syndrome contributing to cardiac injury and cardiovascular events. 4, 5

A 69 year-old man presented to the hospital following 10 days of fever and 2 days of chest pain. The patient had been bed-bound for more than 3 days.

There was no history of hypertension, coronary artery disease, diabetes, hypertension, cerebral infarction, acute coronary syndrome, tumour, kidney, or liver disease. Upon admission, February 2 nd , 2020, the patient was found to be positive for the novel coronavirus by NAT, and was diagnosed with viral pneumonia. Physical examination revealed a blood pressure of 115/74 mmHg, an elevated heart rate of 133 bpm, temperature of 37°C, and decreased oxygen saturation (85%) requiring invasive ventilation Cardiac examination was noncontributory, however mild lower leg edema was noted.

Initial Evaluation: The patient's Geneva Score was 3 and the Wells score was 2 suggesting high risk of deep vein thrombosis and pulmonary embolism.

Laboratory tests revealed an elevated white blood cell (WBC) count of 10.5 x pg/L). The patient required non-invasive ventilation. Given the presence of the chest discomfort, tachycardia, D-dimer elevation, and leg edema, cardiac and lower leg ultrasound was recommended to assess for possible pulmonary embolism. The patient underwent a bedside, limited TTE on February 17 th , 2020. There was an apical aneurysm with a mural thrombus. LVEF was significantly reduced and visually estimated at 45%. There were no significant valvular abnormalities (Figure 3 , Supplemental Videos 3A, 3B, 3C, 3D). Management: Given the diagnosis of acute myocardial injury, an acute coronary syndrome protocol with heparinization was administered. Beta-blockade for myocardial protection was begun. Critical care echocardiogram was repeated 14 days later. The segmental wall motion abnormality was still present, and the mural thrombus appeared to be larger. Anticoagulation therapy was continued.

After resolution of her pneumonia, the patient was discharge under stable condition. 

The mechanisms of myocardial injury in COVID-19 infection are not well understood, but thought to be due to direct myocardial tissue damage rather than coronary obstruction, similar to other acute and viral respiratory illnesses. In the case presented, left ventricular dysfunction was segmental. Thus in addition to fulminant myocarditis, acute myocardial infarction triggered by the infection may have been a possible underlying mechanism -either due to plaque rupture, or segmental injury from supplydemand mismatch. It has recently been proposed that Stage III or the extrapulmonary stage of COVID-19 infection represents a host inflammatory response during which multi-organ dysfunction may ensue. 6 Typically this stage may be characterized ARDS, shock, and cardiac failure. This stage is associated with elevation of inflammatory markers, troponin, and BNP. Further investigation is required to delineate the mechanisms of disease at this stage. Personnel and Equipment: All scans were conducted by trained individuals who were either caring for the patient or, who then provided their findings immediately to the treating physician directly in the COVID-19 isolation unit. Simultaneously, images were stored in the ultrasound machine. At the end of the day, following inspection and cleaning, images were copied to hard disk and saved in DICOM or JPG for later viewing. A variety of hand-held, portable, and full-service machines were used. All devices were dedicated to the COVID-19 unit and did not leave that unit. After each scan, device probes were cleaned with hydrogen peroxide disposable wipes. After each day of scanning, the entire device/machine was stored in a dedicated room for UV disinfection and air disinfection. Once a machine entered the COVID-19 ward, it remained in that ward and was not shared with any other parts of the hospital.

The goal of this case series was to illustrate the variety of applications for focused cardiac ultrasound during the COVID-19 pandemic.

All 

Cardiovascular Point-of-Care Imaging for the Medical Student and Novice User

Guidelines for Performing a Comprehensive Transthoracic Echocardiographic Examination in Adults: Recommendations from the American Society of Echocardiography

Recommendations for Echocardiography Laboratories Participating in Cardiac Point of Care Cardiac Ultrasound (POCUS) and Critical Care Echocardiography Training: Report from the American Society of Echocardiography

COVID-19: consider cytokine storm syndromes and immunosuppression

Cardiovascular Events Among Adults Treated With Chimeric Antigen Receptor T-Cells

COVID-19 Illness in Native and Immunosuppressed States: A Clinical-Therapeutic Staging Proposal

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

We would like to acknowledge the assistance of the Cardiovascular Imaging Network Queen's University (www.CINQLab.com) and for preparation of this manuscript and the assistance of Julia Herr for Figure and Video preparation.