key: cord-0905023-wiywrmmh authors: Zuin, Marco; Rigatelli, Gianluca; Roncon, Loris; Zuliani, Giovanni title: Relationship between echocardiographic tricuspid annular plane systolic excursion and mortality in COVID‐19 patients: A Meta‐analysis date: 2021-08-06 journal: Echocardiography DOI: 10.1111/echo.15175 sha: 7bc2fa04098f43671d84cbdc66f27df045ad8ceb doc_id: 905023 cord_uid: wiywrmmh BACKGROUND: The evaluation of the tricuspid annular plane systolic excursion (TAPSE) is recommended to assess the right ventricular (RV) systolic function. We performed an updated meta‐analysis of the association between TAPSE and short‐term mortality in COVID‐19 patients. METHODS: MEDLINE and Scopus databases were searched to locate all the articles published up to May 1, 2021, reporting data on TAPSE among COVID‐19 survivors and non‐survivors. The difference of TAPSE between the two groups was expressed as mean difference (MD) with the corresponding 95% confidence interval (CI) using the Mantel‐Haenszel random effects model. Both Q value and I(2) statistics were used to assess heterogeneity across studies. Sensitivity analysis, meta‐regression, and evaluation of bias were performed. RESULTS: Twelve studies, enrolling 1272 COVID‐19 patients (778 males, mean age 69.3 years), met the inclusion criteria and were included in the final analysis. Non‐survivors had a lower TAPSE compared to survivors (MD = −3.089 mm, 95% CI = −4.087 to −2.091, p < 0.0001, I(2 )= 79.0%). Both the visual inspection of the funnel plot and the Egger's tests (t = 1.195, p = 0.259) revealed no evidence of publication bias. Sensitivity analysis confirmed yielded results. Meta‐regression analysis evidenced that the difference in TAPSE between the two groups was only influenced by pre‐existing chronic obstructive pulmonary disease (COPD, p = 0.02). CONCLUSION: COVID‐19 non‐survivors have a lower TAPSE when compared to survivors, especially in COPD subjects. Current data suggest that the TAPSE assessment may provide useful information regarding the short‐term prognosis of COVID‐19 patients during the infection. Right ventricular function represents an important prognostic predictor for several cardiovascular disease. [1] [2] [3] [4] However, its accurate estimation, in both normal and pathological conditions, remains difficult due to the peculiar geometry of the right ventricle (RV). 3, 4 The American Society of Echocardiography recommend to routinely use the tricuspid annular phase systolic excursion (TAPSE) to evaluate the RV systolic function. 5 In this regard, recent analyses have demonstrated that the echocardiographic assessment of RV function represents a useful parameter for the prognostication of COVID-19 patients. [6] [7] [8] Indeed, both RV size and function play a pivotal role in the pathogenesis of cardiovascular complications in COVID-19 patients. 9 However, EIR assessment in these subjects, is not routinely performed in daily clinical practice. Aim of the present manuscript is to perform an updated analysis on the association between TAPSE and short-term mortality in COVID-19 patients. The study was performed in accordance with the Preferred Report Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. 10 Data were independently extracted by two reviewers (C.B.; L.R.) using a standardized protocol. Disagreements were resolved through dis-cussion. For this meta-analysis, the following data elements were extracted: sample size, mean age, gender, number of NS and major comorbidities, such as arterial hypertension, diabetes mellitus, preexisting coronary artery disease and chronic obstructive pulmonary disease (COPD). Moreover, due the potential heart-lung interactions during respiratory support, also the number of patients requiring non-invasive (NIV) and invasive (IMV) mechanical ventilation were retrieved from the revised manuscripts. The quality of the included studies was graded using the Newcastle-Ottawa quality assessment scale (NOS). 11 The mortality risk related to TAPSE in COVID-19 patients was chosen as the primary outcome of the study. Continuous variables were expressed as mean ± standard deviation (SD) or as median with corresponding inter-quartile range while categorical variables as counts and percentages. The difference of TAPSE between non-survivors and survivors was expressed as mean difference (MD) with the corresponding 95% confidence interval (CI) using a random-effect model. Q value and I 2 statistics were used to assess heterogeneity across studies Specifically, a I 2 = 0 was considered to indicate no heterogeneity while values of I 2 as < 25%, 25-75% and above 75% to indicate low, moderate, and high degrees of heterogeneity, respectively. 12 A predefined sensitivity analysis (leave-oneout analysis) was performed removing one study at the time. To evaluate the presence of publication bias both funnel plot and Egger's test were computed. To further appraise the impact of potential baseline confounders, a meta-regression analysis using the patient's clinical characteristics, comorbidities and type of respiratory support (if any) were used as moderator variables. All meta-analyses were conducted using Comprehensive Meta-Analysis software, version 3 (Biostat, USA). A total of 421 articles were identified using our search strategy. After removing duplicates, 126 studies were excluded based on their title and/or abstract. Then, screening of the full texts of the remaining 106 articles identified 12 investigations 13-24 that met all the eligibility criteria, as showed in Figure 1 . One-by-one exclusion of the studies from the analysis slightly changed the combined MD, which remained statistically significant across a Meta-regression analysis evidenced that the difference in TAPSE between non-survivors and survivors was influenced by pre-existing COPD (p = 0.02). Conversely, no interactions were observed using age (Table 3) . Our results suggested that COVID-19 non-survivors have a lower TAPSE when compared to survivors. Therefore, this echocardiographic parameter should be considered as an additional prognostic tool for subjects with SARS-CoV-2 infection. It has already been demonstrated that echocardiography as non-invasive, portable imaging tool, can provide valuable information regarding the hemodynamic function and prognosis in several disease. 25 Furthermore, TAPSE can be easily evaluated at bedside and thanks to its low inter-observer variability, represents a well-established method for the assessment of RV function. 26 Our findings, which represent an update on the prognostic role Right ventricular dysfunction and risk of heart failure and mortality after myocardial infarction National heart, lung, and blood institute working group on cellular and molecular mechanisms of right heart failure. right ventricular function and failure: report of a national heart, lung, and blood institute working group on cellular and molecular mechanisms of right heart failure Evaluation of right ventricular function The echocardiographic assessment of the right ventricle: what to do in 2010? 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Response Rev Esp Cardiol Abnormal left ventricular global longitudinal strain by speckle tracking echocardiography in COVID-19 patients Additional supporting information may be found online in the Supporting Information section at the end of the article.