key: cord-1010869-btmmjen2
authors: Rameshwar, R.; Meenakshi, K.; Hanumanram, Gowtham; Kannan, R.; Magesh Kumar, S.; Damodaran, J.; Nandhini, S.
title: Post COVID assesment of right and left ventricular global longitudinal strain
date: 2022-02-22
journal: Indian Heart J
DOI: 10.1016/j.ihj.2022.02.007
sha: 54b933d4c4d08394226716c72b47ba0c35833391
doc_id: 1010869
cord_uid: btmmjen2

nan

Cardiac dysfunction has been reported in SARS-CoV2 infection (1) . Most studies of ventricular function in covid patients were during the acute infection and there are very few studies during post covid convalescence (2) . Two Dimensional echocardiography (2D ECHO) is mandatory in all dyspnoeic post covid patients to look for persistent or new onset overt cardiac dysfunction as evidenced by reduced ejection fraction(EF) or a subtle cardiac dysfunction as determined by global longitudinal strain(GLS), even after they have turned covid negative. GLS has been proven to be a sensitive determinant of myocardial dysfunction and antedates the reduction of ejection fraction(EF).

Aim-To assess if subclinical myocardial dysfunction indicating a smouldering myocarditis, could be identified by GLS in post COVID19 patients who have become covid negative.

Study cohort -100 patients Inclusion criteria -Covid 19 patients admitted with breathlessness.

Exclusion criteria -Patients with poor ECHO window All patients underwent at admission, routine 2D ECHO to detect ventricular dysfunction, Inflammatory markers like C reactive protein(CRP), serum Ferritin, D Dimer, Neutrophil lymphocyte ratio(NLR), serum albumin and CT chest, in addition to routine tests.

Interleukin(IL)6 and troponin I were assayed when indicated.

Two weeks later, after they had become covid negative, they underwent another 2D ECHO along with determination of left ventricular(LV) and right ventricular(RV) GLS to detect subtle cardiac dysfunction.

ECHO was done with Vivid T8 Echo machine and 3.5Mhz transducer. EF <50% was taken as overt LV systolic dysfunction. Tricuspid annular plane systolic excursion(TAPSE) <15mm was taken as overt RV dysfunction. The GLS was determined by speckle tracking and normal LVGLS was taken as -18% and above and normal RV GLS as -24% and above.

Initial ECHO in these patients revealed overt LV systolic dysfunction in 4%, LV diastolic dysfunction in 57% and overt RV dysfunction in 2%. 2D ECHO, 2 weeks later revealed that 51% had reduced GLS viz; 18%, 21% and 12% had reduced LV GLS, reduced RV GLS and J o u r n a l P r e -p r o o f reduced biventricular GLS respectively. 36% had pulmonary hypertension of varying severity. 100 % with normal GLS were admitted within 5 days of symptoms onset in contrast to 73.3% with reduced GLS who were admitted 5 days after symptoms onset. ) Table6) 77.6% with normal LV and RV GLS and 61.9% with reduced RV GLS were <50 yrs. 72.2% with reduced LV GLS and 66.7% with biventricular GLS were >50 yrs. 51.2% of males and 50% of females had reduced GLS.

Subclinical LV dysfunction in ECHO has been observed in 30% -80% of COVID 19 patients. (2) . Our study shows that 51%, 2 weeks after diagnosis of covid had reduction of LV or RV or biventricular GLS.

Zhou et al reported higher troponin levels in covid non survivors (1). All our patients with ECG changes or EF <50% had elevated serum troponin I levels.

J o u r n a l P r e -p r o o f A retrospective study of COVID19 patients indicated that CRP is an independent predictor of severe infection. (3) . In our study, 81.3% with reduced GLS had CRP > 100.

A meta-analysis of 9 studies reported mean IL-6 values 3 times higher in complicated Covid. (4) . IL6 >25 pg/ml occurred in 80.1% with reduced GLS.

Significantly higher D-Dimer levels were reported as a prognostic marker in severe covid (5) . 82.2% of our patients with reduced GLS had D Dimer >2000.

Literature reports elevated serum ferritin as an independent indicator of severed covid (6) . In our study 85% with reduced GLS had serum Ferritin values >500pg/ml. CT severity score semi quantitatively estimates lung involvement with a total score from 0 to 25(7). 84% with reduced GLS in our study had CT score >15/25. Lymphopenia in COVID19 is an independent prognostic marker. NLR >10 was seen in 83.3% of our patients with reduced GLS. (8) Hypo albuminemia occurs in severe covid (9) . 83% of our patients with reduced GLS had Serum albumin <2.9g/dl.

Older age, male sex and co morbidities have been reported as risk factors for cardiac involvement in covid(10). We did not find any clear difference however.

Literature indicates higher morbidity in patients seeking medical help late (11). Most of our patients with reduced GLS had sought treatment 5 days or more after onset of symptoms.

The 12% with reduced biventricular GLS, had a stormy course with a 5-9 day ICU stay.

Biventricular strain imaging has been sparsely studied in covid. One study in acute covid reported reduced biventricular strain as predictive of higher mortality(12).

Overt cardiac manifestations seen in covid 19 represent the tip of the iceberg. Incipient cardiac dysfunction, which could have long term cardiac repercussions are more prevalent than known and can be detected by assessment of GLS, even 2 weeks after admission and after the patient became covid negative. The GLS reduction post covid, mandates the need to seek medical help early, even before the reduction of the EF and to follow up adequately, to see if it improves, remains as such or progresses and to prevent acute episodes of overt cardiac dysfunction. J o u r n a l P r e -p r o o f 

Albumin(Normal) Albumin 3 -3.5 g/dl Albumin <2.9 g/dl

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