Prognostic Utility of Right Ventricular Remodeling Over Conventional Risk Stratification in Patients With COVID-19

Abstract

Background Coronavirus disease 2019 (COVID-19) is a growing pandemic that confers augmented risk for right ventricular (RV) dysfunction and dilation; the prognostic utility of adverse RV remodeling in COVID-19 patients is uncertain. Objectives The purpose of this study was to test whether adverse RV remodeling (dysfunction/dilation) predicts COVID-19 prognosis independent of clinical and biomarker risk stratification. Methods Consecutive COVID-19 inpatients undergoing clinical transthoracic echocardiography at 3 New York City hospitals were studied; images were analyzed by a central core laboratory blinded to clinical and biomarker data. Results In total, 510 patients (age 64 ± 14 years, 66% men) were studied; RV dilation and dysfunction were present in 35% and 15%, respectively. RV dysfunction increased stepwise in relation to RV chamber size (p = 0.007). During inpatient follow-up (median 20 days), 77% of patients had a study-related endpoint (death 32%, discharge 45%). RV dysfunction (hazard ratio [HR]: 2.57; 95% confidence interval [CI]: 1.49 to 4.43; p = 0.001) and dilation (HR: 1.43; 95% CI: 1.05 to 1.96; p = 0.02) each independently conferred mortality risk. Patients without adverse RV remodeling were more likely to survive to hospital discharge (HR: 1.39; 95% CI: 1.01 to 1.90; p = 0.041). RV indices provided additional risk stratification beyond biomarker strata; risk for death was greatest among patients with adverse RV remodeling and positive biomarkers and was lesser among patients with isolated biomarker elevations (p ≤ 0.001). In multivariate analysis, adverse RV remodeling conferred a >2-fold increase in mortality risk, which remained significant (p < 0.01) when controlling for age and biomarker elevations; the predictive value of adverse RV remodeling was similar irrespective of whether analyses were performed using troponin, D-dimer, or ferritin. Conclusions Adverse RV remodeling predicts mortality in COVID-19 independent of standard clinical and biomarker-based assessment.

Persisting Adverse Ventricular Remodeling in COVID-19 Survivors: A Longitudinal Echocardiographic Study

“…Abnormalities in cardiac structure and function are common in patients hospitalized with severe COVID-19 pneumonia who have evidence of myocardial injury based on elevated high-sensitivity cardiac troponin (HScTn). 1 Studies performing transthoracic echocardiography (TTE) in an acute setting have consistently demonstrated a high prevalence of right ventricular (RV) dilation and dysfunction, a finding that is associated with early mortality independent of standard clinical and biomarker risk stratification. 1 , 2 These studies have, however, been limited by their cross-sectional design; to date, there have been no longitudinal studies aimed at determining whether adverse ventricular remodeling is transient or permanent.…”

“… 1 Studies performing transthoracic echocardiography (TTE) in an acute setting have consistently demonstrated a high prevalence of right ventricular (RV) dilation and dysfunction, a finding that is associated with early mortality independent of standard clinical and biomarker risk stratification. 1 , 2 These studies have, however, been limited by their cross-sectional design; to date, there have been no longitudinal studies aimed at determining whether adverse ventricular remodeling is transient or permanent. To address this, we elected to perform repeat echocardiographic assessment at 3 months in survivors following hospitalization for severe COVID-19 pneumonia.…”

The Right Ventricle

“…The current retrospective study in this issue of the Journal included 510 patients who underwent treatment for COVID-19 at 3 hospitals in the New York Presbyterian Hospital network who had clinically indicated transthoracic echocardiography ( 3 ). Indications included dyspnea and/or respiratory decompensation in 88%, hemodynamic instability in 62%, known and/or suspected myocardial infarction in 12%, and arrhythmia in 7%.…”

Multimodality Imaging for Cardiac Evaluation in Patients with COVID-19

“…In COVID-19, this most commonly results from pulmonary embolism or hypoxic respiratory failure with elevated airway pressures. Nonetheless, the finding of RV dysfunction or remodeling portends a poor overall prognosis in COVID-19 [ 46 , 49 , 50 ]. In addition, positive end-expiratory pressure, a common adjunctive support in COVID-19 lung disease, can acutely impair the RV, and such dysfunction that persists on repeat TTE has been shown to correlate with adverse outcomes [ 51 ].…”