key: cord-0877996-3i53risl authors: Argulian, Edgar; Sud, Karan; Bohra, Chandrashekar; Vogel, Birgit; Garg, Vaani; Talebi, Soheila; Lerakis, Stamatios; Narula, Jagat title: Safety of Ultrasonic Enhancing Agents in Patients with COVID-19 date: 2020-04-23 journal: J Am Soc Echocardiogr DOI: 10.1016/j.echo.2020.04.022 sha: 21b1203b71849494899a1b23628230518bdcf8e6 doc_id: 877996 cord_uid: 3i53risl nan To the Editor: Patients admitted with coronavirus disease 2019 (COVID-19) due to infection with severe acute respiratory syndrome coronavirus-2 present with a variety of respiratory and chest symptoms. Distinct and severe cardiovascular manifestations of COVID-19 have been reported. 1 Echocardiography is the mainstay of noninvasive cardiac assessment in these patients because of its immediate bedside availability, as the feasibility and safety of other diagnostic modalities may be limited. Prior studies have indicated that up to 30% of unenhanced echocardiographic examinations may have limited diagnostic utility in critical care settings. 2 This number is possibly higher in critically ill patients with COVID-19 because of respiratory distress syndrome and a high positive end-expiratory pressure requirement. Prior studies have consistently shown that the use of ultrasonic enhancing agents can significantly improve the diagnostic yield of echocardiographic studies and influence decision-making, but safety has not been established in patients with COVID-19. 3, 4 We aimed to study the immediate safety of ultrasonic enhancing agents in patients with COVID-19, including critically ill patients. In this retrospective study, we enrolled consecutive patients hospitalized at Mount Sinai Morningside Hospital (New York, NY) with COVID-19 who underwent clinically indicated echocardiographic examinations. Echocardiograms were obtained using portable ultrasound machines (CX50 [Philips Medical Systems, Bothell, WA] and Vivid S70 [GE Medical Systems, Milwaukee, WI]) and followed a focused, time-efficient protocol with appropriate use of personal protective equipment and limited viral exposure time. The ultrasonic enhancing agent was prepared in advance and was immediately available for the sonographer if needed. Contrast-enhanced images were obtained using contrast-specific, low-mechanical index settings after the administration of an ultrasonic enhancing agent, either Definity (perflutren lipid microsphere; Lantheus Medical Imaging, North Billerica, MA) or Optison (perflutren protein type-A microspheres; GE Healthcare, Little Chalfont, United Kingdom). The following were recorded as adverse events if they occurred in close temporal proximity (within 1 hour) to ultrasonic enhancing agent administration: sustained arrhythmic event, deterioration of respiratory status including endotracheal intubation, cardiac arrest, and death. A total of 33 patients underwent contrast-enhanced echocardiography for clinical indications, including 14 patients on mechanical ventilation and 19 patients who did not require mechanical ventila- 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 tion at the time of echocardiographic evaluation. The mean age was 66 years, with a male predominance (58%). Twelve patients (36%) had body mass index > 30 kg/m 2 . Ten patients (30%) had decreased left ventricular ejection fractions, and 13 patients (39%) had evidence of right ventricular enlargement. On unenhanced examinations, 27 studies (82%) were classified as technically difficult, defined as more than two myocardial segments not visualized from any acoustic window, and six studies (18%) were deemed uninterpretable, defined as poor left ventricular visualization without the ability to report the ejection fraction. In 32 of 33 studies (97%), adequate left ventricular opacification was achieved after the administration of an ultrasonic enhancing agent (Figure 1 ). Right ventricular assessment was feasible in 30 patients (91%), with contrast opacification aiding the visualization of the right ventricular contours (Figure 1) . The patients' charts were reviewed for adverse events in close temporal proximity to ultrasonic enhancing agent administration. None of the patients experienced adverse events within the specified time frame. This was a small, retrospective, single-center study of the immediate safety of ultrasonic enhancing agents from New York, the epicenter city of COVID-19. None of the studies were performed in a prone position. In conclusion, a focused, time-efficient protocol incorporating the use of ultrasonic enhancing agents increases the diagnostic yield of bedside echocardiography, as seen in the present study. In addition, the study provides the first evidence of the immediate safety of ultrasonic enhancing agents in patients with confirmed COVID-19, including critically ill patients. 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 155 156 157 158 159 160 161 162 163 164 165 166 167 168 169 170 171 172 173 174 175 176 177 178 179 180 181 182 183 184 185 186 187 188 189 190 191 192 193 194 195 196 197 198 199 200 201 202 203 204 205 206 207 208 209 210 211 212 213 214 215 216 217 218 219 220 221 222 223 224 225 226 227 228 229 230 231 232 233 234 235 236 237 238 239 240 241 242 243 244 245 246 247 248 249 250 251 252 253 254 255 256 257 258 259 260 261 262 263 264 265 266 267 Coronavirus disease 2019 (COVID-19) and cardiovascular disease. Circulation Impact of contrast echocardiography on evaluation of ventricular function and clinical management in a large prospective cohort Safety with echocardiographic contrast agents ASE statement on protection of patients and echocardiography service providers during the 2019 novel coronavirus outbreak