The overlooked chamber in coronavirus disease 2019

Abstract

Coronavirus disease 2019 (COVID-19) causes a pandemic around the globe. Debilitating and even deadly complications have occurred to the millions. A recent study reported 31% of right ventricular dilation in the hospitalized COVID-19 patients, which is significantly associated with the mortality. Therefore, we sought to search for the lines of evidence in the literature that COVID-19 may contribute to right heart dysfunction. The relevant literature and data from PubMed, Embase, Cochrane Library databases, and Web of Science were searched using the MeSH terms including 'COVID-19', 'SARS-CoV-2', 'novel coronavirus pneumonia', 'novel coronavirus', 'right heart failure', 'right heart dysfunction', 'pulmonary hypertension', 'pulmonary embolism', and various combinations. The collected literature and data were sorted and summarized. Literature reports that angiotensin-converting enzyme 2 (ACE2) is the host receptor mediating the cell entry of severe acute respiratory syndrome coronavirus 2. Clinical and experimental evidence shows that loss of function of ACE2 aggravates pulmonary hypertension and gain of function of ACE2 exerts protection on cardiopulmonary circulation. Moreover, the patients with COVID-19 are more susceptible to pulmonary embolism and severe pneumonia-induced acute respiratory distress syndrome. Therefore, COVID-19 may cause right heart dysfunction by inducing pulmonary hypertension, pulmonary embolism, and acute respiratory distress syndrome. Particular attention should be paid to the function of the right heart, the overlooked chamber in COVID-19. Blood gas analysis, laboratory test of cardiac injury markers, physical examination, and echocardiography should be performed to identify right heart failure as early as possible. Once the right heart failure is confirmed, the therapeutic modalities following the guidelines of European Society of Cardiology should be employed to reduce mortality.

Prevalence of right ventricular dysfunction and impact on all-cause death in hospitalized patients with COVID-19: a systematic review and meta-analysis

“…Moreover, a direct detrimental viral effect on pulmonary microcirculation up to a pattern of endothelium with endothelial dysfunction 46 and increased vascular inflammatory infiltrate was reported in autopsies from COVID-19 patients 3 . As a matter of fact, an interplay between COVID-19, angiotensin-converting enzyme 2, and pulmonary hypertension have been postulated 47 , 48 .…”

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

“… 2 , 3 , 4 Right ventricular (RV) dysfunction (RVD) seems to be particularly frequent (20-39%) in the COVID-19 patient group and often remains undiagnosed. 5 , 6 Right ventricular dysfunction is present when the functional and structural variables to quantify RV function are less than the lower value of the normal range: RV fractional area change (RVFAC) < 35%, RV ejection fraction < 45%, tricuspid annular plane systolic excursion (TAPSE) < 17 mm, and pulsed Doppler S wave < 9.5 cm/s. Right ventricular fractional area change has been used to classify the degree of RVD as mild (25%-35%), moderate (18%-25%), and severe (< 18%).…”

Cardiopulmonary disease as sequelae of long-term COVID-19: Current perspectives and challenges

“…Right ventricular dysfunction is a known cardiovascular complication of COVID-19 infection observed in 20-31% of cases and associated with increased mortality (23)(24)(25)(26)(27). Additionally, worse right ventricular function is associated with elevated troponin and worse clinical presentation (23) and (27,28).…”

“…Pulmonary fibrosis can be further complicated by pulmonary hypertension ( 25 ), which in turn has been noted to be a major determinant of higher mortality ( 26 ). The severity of pulmonary fibrosis is not correlated with the development of pulmonary hypertension, and numerous mechanisms involving dysregulation of molecular pathways resulting in vascular remodeling have been suggested ( 25 ).…”