Prognostic Value of Right Ventricular Longitudinal Strain in Patients With COVID-19

Abstract

The aim of this study was to investigate whether right ventricular longitudinal strain (RVLS) was independently predictive of higher mortality in patients with coronavirus disease-2019 .BACKGROUND RVLS obtained from 2-dimensional speckle-tracking echocardiography has been recently demonstrated to be a more accurate and sensitive tool to estimate right ventricular (RV) function. The prognostic value of RVLS in patients with COVID-19 remains unknown.METHODS One hundred twenty consecutive patients with COVID-19 who underwent echocardiographic examinations were enrolled in our study. Conventional RV functional parameters, including RV fractional area change, tricuspid annular plane systolic excursion, and tricuspid tissue Doppler annular velocity, were obtained. RVLS was determined using 2-dimensional speckle-tracking echocardiography. RV function was categorized in tertiles of RVLS.RESULTS Compared with patients in the highest RVLS tertile, those in the lowest tertile were more likely to have higher heart rate; elevated levels of D-dimer and C-reactive protein; more high-flow oxygen and invasive mechanical ventilation therapy; higher incidence of acute heart injury, acute respiratory distress syndrome, and deep vein thrombosis; and higher mortality. After a median follow-up period of 51 days, 18 patients died. Compared with survivors, nonsurvivors displayed enlarged right heart chambers, diminished RV function, and elevated pulmonary artery systolic pressure. Male sex, acute respiratory distress syndrome, RVLS, RV fractional area change, and tricuspid annular plane systolic excursion were significant univariate predictors of higher risk for mortality (p < 0.05 for all). A Cox model using RVLS (hazard ratio: 1.33; 95% confidence interval [CI]: 1.15 to 1.53; p < 0.001; Akaike information criterion ¼ 129; C-index ¼ 0.89) was found to predict higher mortality more accurately than a model with RV fractional area change (Akaike information criterion ¼ 142, Cindex ¼ 0.84) and tricuspid annular plane systolic excursion (Akaike information criterion ¼ 144, C-index ¼ 0.83). The best cutoff value of RVLS for prediction of outcome was À23% (AUC: 0.87; p < 0.001; sensitivity, 94.4%; specificity, 64.7%).CONCLUSIONS RVLS is a powerful predictor of higher mortality in patients with COVID-19. These results support the application of RVLS to identify higher risk patients with COVID-19.

Observations on echocardiographic findings in patients with COVID-19

“…Our data also showed that elevated PASP on echocardiogram was an independent predictor of death. Our study corroborates with other literature which suggests that elevated PASP was related to morbidity (32). A case series also noted elevated PASP in their patients, which could be explained by pulmonary hypertension or recurrent pulmonary-embolic disease (37,40).…”

“…The commonest echocardiogram abnormality noted in our study was TR, similar to ndings from another study (31), and under one third of our patients demonstrated RV dysfunction. The latter could be secondary to the acute respiratory distress syndrome seen in critically ill COVID-19 patients, which results in RV systolic dysfunction (8,32,33). Despite not being overly sensitive for a pulmonary embolism (PE), echocardiographic features of right heart strain and right heart dysfunction can indicate the presence of a pulmonary embolus (PE) or Pulmonary Intravascular Coagulation (PIC) which has been hypothesised to be one of the causative mechanisms leading to respiratory distress in COVID-19 patients (34).…”

“…Although RV dysfunction relates to poor outcomes, RV longitudinal strain is more highly predictive of mortality in COVID-19 patients (32,35,36). Despite the advantages of RV longitudinal strain, time constraints and increased risk of exposure to the SARS-CoV-2 virus for the sonographer limits its usage in the COVID-19 positive patients.…”

Different cardiac perfoemance in patients with COVID-19 in ICU and general ward by standard and strain echocardiography

“…Previous study also demonstrated that compared with survivors, nonsurvivors displayed enlarged right heart chambers, diminished RV function, and elevated pulmonary artery systolic pressure. 14…”

Usefulness of echocardiography to detect cardiac involvement in COVID‐19 patients

“…A comprehensive evaluation of these patients, including clinical, basic, and advanced ultrasonographic parameters, could be useful for an accurate prognostic assessment: In fact, it has been demonstrated that, in patients with acute HF, underlying pathologies, changes in renal function and TTE findings are associated with mortality 42 . Moreover, a recent study by Li et al investigating inhospital mortality in 120 patients with COVID‐19 has shown RV dilation and dysfunction in nonsurvivors and found global right ventricular longitudinal strain (RVLS) < 23% to be an independent predictor of mortality with multivariate analysis (AUC = 0.87, P < .001) 43 …”