Right ventricular-arterial uncoupling independently predicts survival in COVID-19 ARDS

Abstract

Aim To investigate the prevalence and prognostic impact of right heart failure and right ventricular-arterial uncoupling in Corona Virus Infectious Disease 2019 (COVID-19) complicated by an Acute Respiratory Distress Syndrome (ARDS). Methods Ninety-four consecutive patients (mean age 64 years) admitted for acute respiratory failure on COVID-19 were enrolled. Coupling of right ventricular function to the pulmonary circulation was evaluated by a comprehensive trans-thoracic echocardiography with focus on the tricuspid annular plane systolic excursion (TAPSE) to systolic pulmonary artery pressure (PASP) ratio Results The majority of patients needed ventilatory support, which was noninvasive in 22 and invasive in 37. There were 25 deaths, all in the invasively ventilated patients. Survivors were younger (62 ± 13 vs. 68 ± 12 years, p = 0.033), less often overweight or usual smokers, had lower NT-proBNP and interleukin-6, and higher arterial partial pressure of oxygen (PaO2)/fraction of inspired O2 (FIO2) ratio (270 ± 104 vs. 117 ± 57 mmHg, p < 0.001). In the non-survivors, PASP was increased (42 ± 12 vs. 30 ± 7 mmHg, p < 0.001), while TAPSE was decreased (19 ± 4 vs. 25 ± 4 mm, p < 0.001). Accordingly, the TAPSE/PASP ratio was lower than in the survivors (0.51 ± 0.22 vs. 0.89 ± 0.29 mm/mmHg, p < 0.001). At univariate/multivariable analysis, the TAPSE/PASP (HR: 0.026; 95%CI 0.01–0.579; p: 0.019) and PaO2/FIO2 (HR: 0.988; 95%CI 0.988–0.998; p: 0.018) ratios were the only independent predictors of mortality, with ROC-determined cutoff values of 159 mmHg and 0.635 mm/mmHg, respectively. Conclusions COVID-19 ARDS is associated with clinically relevant uncoupling of right ventricular function from the pulmonary circulation; bedside echocardiography of TAPSE/PASP adds to the prognostic relevance of PaO2/FIO2 in ARDS on COVID-19.

Tricuspid annular plane systolic excursion (TAPSE) measured by echocardiography and mortality in COVID-19: A systematic review and meta-analysis

“…(Stockenhuber et al, 2020;Wibowo et al, 2021) Multiple studies has found that RV strain and TAPSE were associated with higher severity and mortality. (Bursi et al, 2020;D'Alto et al, 2020;Lassen et al, 2020;Li et al, 2020;Liu et al, 2020;Sattarzadeh Badkoubeh et al, 2021;Stockenhuber et al, 2020) LV function is usually preserved or hyperdynamic in COVID-19 patients. (Moody et al, 2020) If affected, this may be secondary to RV volume and excess pressure due to ventricular interdependence.…”

“…(Raymond Pranata et al, 2020a) COVID-19 itself is associated with myocardial injury and impaired right ventricle (RV) strain, which are independent predictors of poor prognosis. (D'Alto et al, 2020;Wibowo et al, 2021) Meanwhile, left ventricle (LV) function is usually relatively unaffected in the majority of COVID-19 patients. (Moody et al, 2020) Acute cor pulmonale or right heart failure (RHF) is a J o u r n a l P r e -p r o o f long-established complication of ARDS, in relation to disease severity and ventilatory strategies associated with permissive hypercapnia and pulmonary hyperinflation.…”

“…There were 641 patients from 7 studies included in this systematic review and meta-analysis [ Figure 1, Table 1]. (Bursi et al, 2020;D'Alto et al, 2020;Lassen et al, 2020;Li et al, 2020;Liu et al, 2020;Sattarzadeh Badkoubeh et al, 2021;Stockenhuber et al, 2020) The baseline characteristics of the included studies and the risk of bias assessment using the NOS is displayed in Table 1.…”

The Right Ventricle in COVID-19 Lung Injury: Proposed Mechanisms, Management, and Research Gaps

“… 21 It remains however unclear whether RVD in the presence of myocardial complications without micro- or macrovascular pulmonary thrombosis is caused by RV ischemia, RV-PA uncoupling or severe inflammation. 23 …”

“…Hypoxemia and/or hypercapnia with or without acidemia in COVID-19 patients with severe acute respiratory failure may cause or exacerbate pulmonary vasoconstriction resulting in increased (even modest) RV afterload, RV-PA uncoupling and RVD with potential for reduced cardiovascular performance. 23 , 29 , 30 …”