|Year : 2020 | Volume
| Issue : 2 | Page : 193-195
Echocardiography Imaging as a Fast-track Tool to Identify High-risk Population in COVID-19 Pandemic Era
Kiran Multisuperspecialty Hospital and Research Centre, Surat, Gujarat, India
|Date of Submission||03-Apr-2020|
|Date of Decision||26-Apr-2020|
|Date of Acceptance||21-Jun-2020|
|Date of Web Publication||19-Aug-2020|
Dr. Keyur Vora
Kiran Multisuperspecialty Hospital and Research Center, Surat - 395 009, Gujarat
Source of Support: None, Conflict of Interest: None
Degenerative valvular changes are not uncommon findings in echocardiography studies of elderly population. Clinical significance becomes very important during noncardiac morbidities. Our case report identifies the importance of studying valvular changes in elderly population resulting in secondary pulmonary hypertension, in order to categorize them for appropriate preventive measures, to prevent escalation of low risk comorbid conditions to life-threatening clinical outcomes during ongoing coronavirus disease 2019 pandemic.
Keywords: Coronavirus disease 2019, degenerative valvular heart disease, pulmonary hypertension, pulmonary thromboembolism
|How to cite this article:|
Vora K. Echocardiography Imaging as a Fast-track Tool to Identify High-risk Population in COVID-19 Pandemic Era. J Indian Acad Echocardiogr Cardiovasc Imaging 2020;4:193-5
|How to cite this URL:|
Vora K. Echocardiography Imaging as a Fast-track Tool to Identify High-risk Population in COVID-19 Pandemic Era. J Indian Acad Echocardiogr Cardiovasc Imaging [serial online] 2020 [cited 2020 Sep 30];4:193-5. Available from: http://www.jiaecho.org/text.asp?2020/4/2/193/292620
| Introduction|| |
Cardiovascular complications of coronavirus disease 2019 (COVID-19) disease are gaining the attention of clinicians as we learn the disease course among critical ill patients during an ongoing pandemic. A large proportion of patients who died from COVID-19 have been found to have coagulopathy with high risk of myocarditis, pulmonary embolism, and stroke. Even though COVID-19 is a respiratory tract infection, vascular and cardiac complications are emerging as prime factors for mortality. Notably, the immediate need is to identify targeted therapeutics and vaccine development which are time-consuming scientific processes. In the current scenario, the early identification of risk factors is critical to prevent morbidity and mortality of vulnerable population. Echocardiography-based imaging data can play a vital role in segregation of high-risk population to ameliorate the community transmission rate and preserve the vital medical resources for critically ill patients.
| Case Report|| |
A 65-year-old male patient presented with dyspnea on exertion for 2 years which aggravated from the New York Heart Association Class I to class II for the past 1 month with recurrent upper respiratory tract infection treatments in the past 3 months. Electrocardiography reveals incomplete left bundle branch block pattern with left ventricular hypertrophy. Echocardiography reveals high-grade mitral regurgitation with eccentric jet [Figure 1]. The mitral valve (MV) morphology reveals increased thickness of leaflets >5 mm, asymmetric MV prolapse with posterior mitral leaflet prolapse [Figure 2], and severe pulmonary hypertension (PH) by TR jet [Figure 3]. Moreover, dilated tricuspid annulus (4.33 cm) reveals long duration of elevated right ventricular (RV) systolic pressure. RV systolic function was not impaired. Notably, the patient was never hospitalized or needed an emergency visit for any acute illness.
|Figure 1: Apical four-chamber view. Mitral regurgitation flow is displayed with color Doppler flow pattern during ventricular systole (Philips EPIQ 7, Amsterdam, Netherlands)|
Click here to view
|Figure 2: (a) In diastole, mitral leaflets are open. Anterior mitral leaflet and posterior mitral leaflet. (b) In systole, leaflets are closed. With posterior mitral leaflet prolapse. Note: Coaptation line of leaflets are at LA side of mitral annular plane|
Click here to view
|Figure 3: Pulmonary artery pressure measurement during inspiration by tricuspid regurgitant jet – tricuspid regurgitant velocity max method. Right atrial pressure is added to pulmonary pressure to calculate right ventricular pressure|
Click here to view
| Discussion|| |
Diseases of the MV are the second most frequent clinically significant form of valvular disease in adults. In particular, MV regurgitation occurs with increasing frequency as a part of degenerative changes in the aging process. Degenerative MV disease frequently has leaflet prolapse due to elongation, eversion, or rupture of the chordal apparatus, resulting in varying degrees of leaflet malcoaptation and regurgitation during ventricular systole phase. The systolic flow reversal into the left atrium leads to atrial dilatation/fibrillation, pulmonary venous dilatation, and secondary postcapillary PH. This pathophysiology creates a vulnerable microenvironment due to chronic elevation of plasma hydrostatic pressure in alveolar capillaries.
Under such primed condition, any respiratory viral infection can result in alveolar edema by direct viral toxicity, recruitment of inflammatory cells, and impairment of alveolar fluid clearance. As reported previously, PH detected by echocardiography during respiratory syncytial virus infection was associated with increased morbidity and mortality. Also, it is well-established sex dimorphism in patients with increased frequency of PH in females and more severe disease with poor survival prognosis in males.
While most patients having COVID-19 pneumonia have a mild disease course, some patients develop severe respiratory distress, sepsis, and septic shock. Coagulopathy commonly occurs in sepsis and may predict outcomes in severe forms of COVID-19. Han et al. reported disturbed coagulation function in patients infected with COVID-19 as compared to healthy controls, including elevated D-dimer, fibrinogen levels, and fibrin/fibrinogen degradation products. In addition, two different studies by Zhou et al. and Tang et al. recently reported a positive correlation between elevated D-dimer levels on admission and in-hospital COVID-19 mortality, raising questions regarding potentially unknown pulmonary embolism.
Among recently reported cases, computed tomography (CT) scans reveal extensive ground-glass opacities along with bilateral pulmonary embolism in elderly patients. This identifies an interesting phenomenon that even in the absence of major predisposing factors, diffuse bilateral COVID-19 pneumonia seems to confirm the role of severe form of disease as a precipitating factor for acute pulmonary thromboembolism and the causal relationship. This novel information about COVID-19 infection course emphasizes the importance of echocardiography in the emergency room for baseline parameter collection, e.g., right-sided chamber sizes, pulmonary trunk size, and RV systolic pressure by tricuspid regurgitation jet if detectable. This baseline information can be a vital source of information if in-patient COVID-19 patients develop aggravating dyspnea and elevated D-dimer levels. The majority of tertiary care centers do not have isolated dedicated CT scan facilities for COVID-19 patients. Echocardiography offers safe, reproducible, and dynamic measurements of pulmonary artery pressure, RV function, and right atrial pressure status. Furthermore, there is no need for contrast in echocardiography imaging which can be a limitation for CT contrast imaging in many of the severely ill COVID-19 patients with deteriorating renal function. In summary, echocardiography is a versatile tool to identify high-risk patient populations both in outpatient clinics, emergency rooms, and in-patient intensive care units for PH and acute embolism.
| Conclusion|| |
This article highlights a potential diagnostic pitfall in screening for secondary PH for identification of high-risk individuals. Echocardiography is an excellent widely available noninvasive approach to identify high risk individuals, provide detailed consultations, and implement targeted population measures to reduce prevalence of cross-infections and community-acquired infections. In the case of elevated D-dimer levels on admission or sudden clinical worsening, echocardiography should be considered as first-line diagnostic tool as pulmonary embolism is a life-threatening but potentially treatable condition. Nevertheless, further research may be instrumental to elucidate the pathogenesis of infection-prone pulmonary systems among degenerative valvular heart disease patients. In the era of annular influenza endemics and the very recent COVID-19 pandemic, echocardiography should be promoted as a gold-standard cardiac screening imaging method to identify vulnerable populations and high-risk hospitalized patients.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Perlowski A, St Goar F, Glower DG, Feldman T. Percutanenous therapies for mitral regurgitation. Curr Probl Cardiol 2012;37:42-68.
Alegria-Barrero E, Franzen OW. Mitral regurgitation A multidisciplinary challenge. Europ Cardiol 2014:9:49-53.
Brauer R, Chen P. Influenza leaves a TRAIL to pulmonary edema. J Clin Investigation 2016:126:1245-7.
Kimura D, McNamara I, Wang J, Fowke J, West A, Philip R. Pulmonary hypertension during respiratory syncytial virus bronchiolitis: A risk factor for severity of illness. Cardiol Young 2019:29:615-9.
Rafikova O, James J, Eccles CA, Kurdyukov S, Niihori M, Varghese MV, et al
. Early progression of pulmonary hypertension in the monocrotaline model in males is associated with increased lung permeability. Biol Sex Differ 2020;11:11.
Guan WJ, Ni ZY, Hu Y, Liang WH, Ou CQ, He JX. China medical treatment expert group for COVID-19. Clinical characteristics of coronavirus disease 2019 in China. N
Engl J Med 2020;382:1708-20.
Han H, Yang L, Liu R, Liu F, Wu KL, Li J, et al
. Prominent changes in blood coagulation of patients with SARS-CoV-2 infection. Clin Chem Lab Med 2020;58:1116-20.
Zhou F, Yu T, Du R. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: A retrospective cohort study. Lancet 2020. pii: S0140-6736 (20) 30566-3.
Tang N, Li D, Wang X, Sun Z. Abnormal coagulation parameters are associated with poor prognosis in patients with novel coronavirus pneumonia. J Thromb Haemost 2020;18:844-7.
Danzi GB, Loffi M, Galeazzi G, Gherbesi E. Acute pulmonary embolism and COVID-19 pneumonia: A random association? Europ Heart J 2020;41:1858.
[Figure 1], [Figure 2], [Figure 3]