key: cord-0990643-4fniuqro
authors: Vasudev, Rahul; Guragai, Nirmal; Habib, Habib; Hosein, Kevin; Virk, Hartaj; Goldfarb, Irvin; Bikkina, Mahesh; Shamoon, Fayez; Pullatt, Raja
title: The utility of bedside echocardiography in critically ill COVID‐19 patients: Early observational findings from three Northern New Jersey hospitals
date: 2020-08-13
journal: Echocardiography
DOI: 10.1111/echo.14825
sha: ec9622e7476bb0643a8c63be8380cec4da989e1b
doc_id: 990643
cord_uid: 4fniuqro

INTRODUCTION: Cardiovascular complications related to coronavirus disease 2019 (COVID‐19) have led to the need for echocardiographic services during the pandemic. The present study aimed to identify the echocardiographic findings in hospitalized COVID‐19 patients and their utility in disease management. METHODS: We included patients who were diagnosed with COVID‐19 using polymerase chain reaction and those who underwent echocardiographic examination during their hospitalization. RESULTS: Altogether, 45 patients were evaluated. The mean age was 61.4 ± 12.2 years. Hypertension (n = 29, 64%) and diabetes mellitus (n = 25, 55%) were the most common comorbidities followed by congestive heart failure (n = 11, 24%), coronary artery disease (n = 9, 20%), and valvular heart disease (n = 3, 7%). Eight patients (18%) showed evidence of myocardial injury, as suggested by elevated troponin levels. Brain natriuretic peptide was elevated in 14 patients (36%), and 14 patients had left ventricular dysfunction in the form of reduced ejection fraction (31%). Right ventricular (RV) dilatation was observed in six patients, and five patients had reduced RV ejection fraction. RV pressure and volume overload were observed in three patients. RV thrombus was observed in one patient. Pulmonary pressure was elevated in 10 patients (24%). CONCLUSION: Two‐dimensional echocardiography can be an important bedside tool for the assessment of cardiovascular abnormalities and hemodynamic status of COVID‐19 patients.

on the cardiovascular system include myocardial infarction, acute exacerbation of heart failure, arrhythmias, and procoagulant effects.

Cardiovascular abnormalities related to COVID-19 have led to the need for echocardiographic evaluation of these patients to help in the management and identification of cardiac complications. The present study aimed to identify the echocardiographic findings in COVID-19 patients and their utility in disease management.

The present study was conducted between March 15, 2020 and April 15, 2020 during the COVID-19 pandemic in three different hospitals in Northern New Jersey, USA, which is one of geographical hotspots of COVID-19 in the United States. We retrospectively reviewed the charts of patients who were diagnosed with COVID-19 using polymerase chain reaction and underwent echocardiographic examination during admission for COVID-19. All examinations were performed in the patient rooms on the medical floors or in the intensive care units to decrease the risk of infection, which may occur while moving patients from one location to another. The equipment was cleaned before and after the procedures according to the hospitals' infectious disease control guidelines. All requests for echocardiograms were screened by a cardiologist to limit the examinations to those that were truly needed and appropriate. All measurements and Doppler calculations were performed offline after acquisition of images to minimize patient contact time. Echocardiographic parameters were obtained according to the recommendations by the 

Altogether, 45 patients were included in the present study. The mean age of the included patients was 61.4 ± 12.2 years (range: 28-81 years). Males and females were equally represented in our data (males = 23, females = 22). The most common reason for requesting an echocardiogram was hypoxemic respiratory failure (n = 14), followed by shock (n = 11), acute coronary syndrome (n = 9), thromboembolic phenomenon (n = 6), and malignant arrhythmias (n = 5).

Hispanics constituted 47% of the study population (n = 21), followed by African Americans (27%, n = 12), Caucasians (20%, n = 9), and other races (6%, n = 3). Hypertension (n = 29, 64%) and diabetes mellitus (n = 25, 55%) were the most common comorbidities, followed by congestive heart failure (n = 11, 24%), coronary artery disease (n = 9, 20%), and valvular heart disease (n = 3, 7%). Eight patients (18%) had myocardial injury, as suggested by elevated troponin (n = 44). Brain natriuretic peptide (BNP) was elevated in 14 patients (35.8%) (n = 39). Among the inflammatory biomarkers, the majority (93%, n = 29) had an elevated lactate dehydrogenase (LDH) and ferritin level of 87.8% (n = 33). Elevated D-dimer levels were observed in 24 patients (88%) (n = 27), suggesting that they might be in a prothrombotic state. Table 1 . None of the patients from our study population underwent a transesophageal echocardiogram.

The unequal racial distribution in our study possibly reflects the demographics that our institution caters to. However, there have been reports that Hispanic and African American patients are disproportionately affected and have worse outcomes. 3 Hypertension and diabetes mellitus were the most common comorbidities associated with COVID-19 infection in our patients, which is consistent with most of the previously published literature. 4 Inflammatory biomarkers also play an important role in risk stratification of COVID-19 severity and prognostication. Elevated BNP and cardiac troponin have been associated with myocardial injury and poor outcomes. 2 The prevalence of elevated cardiac biomarkers in our study was higher than that observed by Lippi et al (8%-12%). 5 This difference was Our study population contained two patients with pulmonary embolism (PE) whose diagnosis was aided by echocardiography. There is a very high risk of thromboembolism including pulmonary embolism in patients with severe COVID-19 infection. Recently published data suggest that the incidence of thromboembolism was as high as 31% in critically ill patients and pulmonary embolism was the most frequent (81%) thromboembolic complication in these patients. 8 In our study, RV thrombus was observed in one patient, which was confirmed with CTA of the chest that showed extensive pulmonary embolism. The patient was treated with low-molecular-weight heparin. The most common and clinically significant echocardiography findings in these patients included decreased LVEF and echocardiographic signs of pulmonary embolism. Identification of these conditions assisted in patient management. We recommend using contrast agents in these patients, as they help in better estimation of LVEF and identification of thrombi. In patients with ischemic changes on electrocardiogram and elevated troponins, we found that the echocardiogram was very helpful in decision-making regarding cardiac catheterization versus conservative management. Similarly, in patients with hypoxemia and respiratory distress out of proportion to the radiographic findings, echocardiograms helped us identify RV dysfunction, elevated pulmonary pressures, and RV thrombus. Thus, we could order more definitive tests like CTA to guide further management. In their recently published case series, Zhang et al focused on cardiac ultrasound in COVID-19 patients. Similar to our findings, they reported its utility in the assessment of LV function, suggestion of pulmonary embolism, and identification of myocardial injury and thrombus. 13 We recommend following the ASE's "whom to image, where to image, and how to image" guideline at the institutional level as a guide for the utilization of echocardiographic evaluation to TA B L E 1 Echocardiographic and laboratory parameters provide high-quality care to patients. 14 Echocardiography laboratories throughout the world need to adapt to the changing practice of transthoracic echocardiography in the times of COVID-19 pandemic.

A strategy that enables screening of all requested echocardiograms by a physician and performing more focused echocardiograms will help minimize the risk of exposure to the sonographers and avoid inappropriate studies. 15 Our study has a few limitations. It was an observational retrospective study, and the number of patients was relatively small. As some of the patients in our study population were still hospitalized at the conclusion of our data collection, outcomes could not be assessed. We recommend larger prospective studies to identify the indications and utility of echocardiography in COVID-19 patients.

In conclusion, two-dimensional echocardiography can be an important bedside tool in the assessment of cardiovascular abnormalities and hemodynamic status of COVID-19 patients. When performed in an appropriate group of patients, the echocardiogram is an invaluable tool that can aid in navigating management options. 

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