key: cord-0942755-eedq0lj5 authors: Truong, Vien T.; Palmer, Cassady; Chung, Eugene S.; Mazur, Wojciech title: It’s a marathon not a sprint: the need for long-term monitoring of myocardial dysfunction in COVID-19 date: 2022-01-27 journal: Int J Cardiovasc Imaging DOI: 10.1007/s10554-022-02527-w sha: ed37a1529f93848fbb24128d1ba1a31dda1e11d0 doc_id: 942755 cord_uid: eedq0lj5 nan impairment, and whether there may be a myocardial culprit responsible for prolonged shortness of breath, chest pain, and fatigue following recovery from COVID-19. In this issue of the Journal, Tryfou et al. [9] report their findings from a prospective cohort study of 100 recovered COVID-19 patients (mean age of 47.2 ± 9.1 years) with preserved LVEF. These patients were divided into two groups: The first group consisted of 67 patients who were hospitalized, and the second group included 33 patients with the milder disease who were treated as outpatients. In addition, a control group was constructed for comparison. A comprehensive evaluation of echocardiography with 2D-STE was performed after a minimum of 30 days from the initial diagnosis for the outpatients and 10 days after their discharge for the hospitalized patients. The mean time of performed echocardiography was 33.28 ± 9.4 days after the diagnosis of COVID-19. Compared to controls, cardiovascular risk factors including hypertension, hyperlipidemia, and diabetes mellitus were less prevalent in the COVID-19 cohort. Other baseline clinical characteristics did not differ significantly between the two groups. Of note, LV chamber dimensions, volumes, and ejection fraction (59.22 ± 3.72% vs. 60.14 ± 3.19%, p = 0.187) were comparable between the COVID group and controls. However, left ventricular global longitudinal strain (LVGLS) was significantly reduced compared to the control group (− 18.47 ± − 2.4% vs − 21.07 ± − 1.76%, p < 0.0001). The reduced LVGLS occurred in both cohorts (outpatients and hospitalized) but to a greater degree in the latter. Furthermore, regional strain analysis revealed posterior and lateral longitudinal strain values were markedly impaired in both hospitalized and nonhospitalized patients. Regarding right ventricular impairment in COVID-19, the authors report that right ventricular global longitudinal strain (RVGLS) was significantly lower in the hospitalized group when compared to the control group (− 18.17 ± − 3.32 vs. − 26.03 ± − 4.55, p < 0.0001). No significant correlation of LVGLS and RVGLS with high sensitivity cardiac troponin I and D-dimer were found. The main finding of this study was that despite demonstration of preserved LVEF, subclinical biventricular dysfunction persisted following COVID-19. Tangen et al. also reported LVGLS to be reduced in 15% of patients measured 3 months after hospitalization [10] . Interestingly, in agreement with previous data, the current study did not find a statistically significant association between reduced myocardial function and elevated high sensitivity cardiac troponin levels [10] . Similarly, a multicenter, prospective cohort study showed that there was evidence of persistent adverse ventricular remodeling in nearly one-third of the patients [11] . Cardiovascular magnetic resonance imaging known for its high accuracy for functional assessment further reinforces evidence of myocardial impairment in patients recently recovered from COVID-19 [12] . Importantly, the current study is one of the first to highlight regional subclinical dysfunction in patients recovering from COVID-19. The authors add to the current medical knowledge of LV strain in COVID-19 by highlighting the unique features of regional dysfunction involving the posterior and lateral segments. The regional wall motion abnormalities in posterior and lateral segments are similar to that of viral myocarditis in general [13] , perhaps supporting the possibility of direct viral injury to the myocardium in COVID-19. Additionally, it is important to emphasize that a recently published paper showed in a community-based cohort, subclinical myocardial dysfunction was associated with an increased incidence of heart failure later in life [14] . This novel finding raises concerns for patients recovering from COVID-19 with a subclinical myocardial dysfunction who may develop heart failure over time. This study has several limitations worth noting. First, this is a single-center study with a relatively small sample size. Second, an association of residual myocardial impairment with clinical outcomes is not reported in this study. Nonetheless, the current study by Tryfou et al. [9] has potential clinical implications regarding the importance of myocardial functional assessment in patients who have recovered from COVID-19. A comprehensive LV and RV functional assessment following COVID-19 using 2D-STE is warranted and should be tested in a larger cohort, and therapies tailored for myocardial dysfunction will need to be determined. COVID-19 cardiac injury: implications for long-term surveillance and outcomes in survivors H (2020) Endothelial cell infection and endotheliitis in COVID-19 Pathological findings of COVID-19 associated with acute respiratory distress syndrome Pathological features of COVID-19-associated myocardial injury: a multicentre cardiovascular pathology study The science underlying COVID-19: implications for the cardiovascular system Myocardial strain imaging: how useful is it in clinical decision making? Widespread myocardial dysfunction in COVID-19 patients detected by myocardial strain imaging using 2-D speckle-tracking echocardiography Short-term and long-term rates of postacute sequelae of SARS-CoV-2 infection: a systematic review Biventricular myocardial function in Covid-19 recovered patients assessed by speckle tracking echocardiography: a prospective cohort echocardiography study Reduced cardiac function by echocardiography in a minority of COVID-19 patients 3 months after hospitalization Steeds RP (2021) Persisting adverse ventricular remodeling in COVID-19 survivors: a longitudinal echocardiographic study Outcomes of cardiovascular magnetic resonance imaging in patients recently recovered from coronavirus disease 2019 (COVID-19) Subclinical left ventricular dysfunction and correlation with regional strain analysis in myocarditis with normal ejection fraction. A new diagnostic criterion Association of left ventricular systolic function with incident heart failure in late life The authors have no conflicts of interest to declare.