Prognostic value of right ventricular dilatation on computed tomography pulmonary angiogram for predicting adverse clinical events in severe COVID-19 pneumonia

Abstract

BackgroundRight ventricle dilatation (RVD) is a common complication of non-intubated COVID-19 pneumonia caused by pro-thrombotic pneumonitis, intra-pulmonary shunting, and pulmonary vascular dysfunction. In several pulmonary diseases, RVD is routinely measured on computed tomography pulmonary angiogram (CTPA) by the right ventricle-to-left ventricle (LV) diameter ratio > 1 for predicting adverse events.ObjectiveThe aim of the study was to evaluate the association between RVD and the occurrence of adverse events in a cohort of critically ill non-intubated COVID-19 patients.MethodsBetween February 2020 and February 2022, non-intubated patients admitted to the Amiens University Hospital intensive care unit for COVID-19 pneumonia with CTPA performed within 48 h of admission were included. RVD was defined by an RV/LV diameter ratio greater than one measured on CTPA. The primary outcome was the occurrence of an adverse event (renal replacement therapy, extracorporeal membrane oxygenation, 30-day mortality after ICU admission).ResultsAmong 181 patients, 62% (n = 112/181) presented RVD. The RV/LV ratio was 1.10 [1.05–1.18] in the RVD group and 0.88 [0.84–0.96] in the non-RVD group (p = 0.001). Adverse clinical events were 30% and identical in the two groups (p = 0.73). In Receiving operative curves (ROC) analysis, the RV/LV ratio measurement failed to identify patients with adverse events. On multivariable Cox analysis, RVD was not associated with adverse events to the contrary to chest tomography severity score > 10 (hazards ratio = 1.70, 95% CI [1.03–2.94]; p = 0.04) and cardiovascular component (> 2) of the SOFA score (HR = 2.93, 95% CI [1.44–5.95], p = 0.003).ConclusionRight ventricle (RV) dilatation assessed by RV/LV ratio was a common CTPA finding in non-intubated critical patients with COVID-19 pneumonia and was not associated with the occurrence of clinical adverse events.

Commentary: Impact of COVID-19 pneumonia on pulmonary vascular volume

“…The considerable increase in pulmonary vascular volume (a 3.7 mean ratio of proportion of vascular volume between COVID-19 and non-COVID-19 affected areas) observed by the authors may support our data on right ventricular features in COVID-19 (11). We found a significant increase in right ventricular volume without any right ventricular dysfunction in non-intubated COVID-19 patients (without pulmonary embolism) (11). This suggests an adaptation of the right ventricle to an excess in volume load without increase in ventricular afterload as shown by Caravita et al who found an increased cardiac output with decreased pulmonary vascular resistance (12).…”

“…Indeed, the intrapulmonary shunt characterizing AVDS seems related to lung vascular enlargements, aberrant angiogenesis with numerous arteriovenous anastomoses ( 10 ), and thus to the increased lung vascular volume. The considerable increase in pulmonary vascular volume (a 3.7 mean ratio of proportion of vascular volume between COVID-19 and non-COVID-19 affected areas) observed by the authors may support our data on right ventricular features in COVID-19 ( 11 ). We found a significant increase in right ventricular volume without any right ventricular dysfunction in non-intubated COVID-19 patients (without pulmonary embolism) ( 11 ).…”