|Year : 2021 | Volume
| Issue : 2 | Page : 144-149
Spectrum of Echocardiographic Findings in Coronavirus Disease-2019 Patients
Soumya Kanti Dutta1, Bidyut Roy1, Rakesh Das1, Sankar Chandra Mandal1, Sulagna Sahu2, Manimoy Bandopadhyay3, Kaushik Paul1, Sandipan Ghosh1
1 Department of Cardiology, IPGMER and SSKM Hospital, Kolkata, West Bengal, India
2 Department of Neuromedicine, BIN, IPGMER and SSKM, Kolkata, West Bengal, India
3 Department of Anatomy, IPGMER and SSKM, Kolkata, West Bengal, India
|Date of Submission||20-May-2021|
|Date of Acceptance||12-Jun-2021|
|Date of Web Publication||19-Aug-2021|
Dr. Rakesh Das
Room No 527, PGT Hostel, IPGMER and SSKM Hospital, Kolkata, West Bengal
Source of Support: None, Conflict of Interest: None
Background: Although coronavirus disease-2019 (COVID-19) is predominantly a respiratory disease, cardiac involvement occurs commonly, especially in those with more severe illness. Echocardiography is the preferred imaging modality for diagnosing cardiac involvement in COVID-19. However, there are currently no data to describe echocardiographic abnormalities in Indian patients with COVID-19. Methodology: A cross-sectional observational analysis was performed among adult patients admitted to a tertiary care center between May 2020 and August 2020. Patients were included if they underwent transthoracic echocardiography during the hospitalization after a positive reverse transcriptase–polymerase chain reaction diagnosis for COVID-19 pneumonia. Demographic and clinical data were obtained and analyzed along with echocardiographic data. Results: During the study period, consecutive 245 patients were evaluated with echocardiography, of whom 11 were excluded due to nondiagnostic images. The remaining 234 (mean age 57 ± 16 years, 71.7% of men) were included in this analysis. All patients were admitted to intensive care unit or high-dependency unit. Right ventricular (RV) dilatation and/or dysfunction (37%) was the most common finding, followed by left ventricular (LV) systolic and diastolic dysfunction (27.7% and 23.1%, respectively). Pericardial effusion was present in 12% of cases. A total of 49 (20.9%) patients had preexisting LV systolic dysfunction (LVSD). After excluding them, the LVSD and LV diastolic dysfunction were observed in 8.6% and 2.7% of patients, respectively. Conclusions: This study demonstrates that RV dilatation/dysfunction is the most common echocardiographic abnormality in hospitalized patients with severe COVID-19. Further, larger, multicentric studies with systematic data collection and comparison with non-COVID patients are needed to determine the true incidence of echocardiographic abnormalities in COVID-19.
Keywords: Coronavirus disease-2019, left ventricle, right ventricle, reverse transcriptase–polymerase chain reaction, transthoracic echocardiography
|How to cite this article:|
Dutta SK, Roy B, Das R, Mandal SC, Sahu S, Bandopadhyay M, Paul K, Ghosh S. Spectrum of Echocardiographic Findings in Coronavirus Disease-2019 Patients. J Indian Acad Echocardiogr Cardiovasc Imaging 2021;5:144-9
|How to cite this URL:|
Dutta SK, Roy B, Das R, Mandal SC, Sahu S, Bandopadhyay M, Paul K, Ghosh S. Spectrum of Echocardiographic Findings in Coronavirus Disease-2019 Patients. J Indian Acad Echocardiogr Cardiovasc Imaging [serial online] 2021 [cited 2021 Oct 24];5:144-9. Available from: https://www.jiaecho.org/text.asp?2021/5/2/144/324094
| Introduction|| |
The first case of coronavirus disease-2019 (COVID-19) was identified in Wuhan, China, in December 2019 and since then, it has become a global pandemic. The disease is caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). Pathogenetically, it has been shown that after virus entry in the pneumocytes via the angiotensin-converting enzyme-2 receptors, it triggers a systemic inflammatory response, creating an immune dysfunction with a hyperactivity of T-lymphocytes and release of pro-inflammatory cytokines. Hyperinflammation at the systemic level may lead to vascular injury, thrombosis, and cytokine toxicity phenomenon, resulting in multisystemic lesions., Although the clinical presentation of COVID-19 is mostly characterized by constitutional and respiratory tract symptoms, cardiovascular involvement is common, especially in patients with severe illness. Cardiovascular involvement in COVID-19 may occur in the form of pulmonary and systemic thromboembolism, myocarditis, myocardial infarction, and new-onset arrhythmia – mostly atrial fibrillation, sick sinus syndrome including tachy-brady syndrome, and occasional atrioventricular block. Echocardiography is the preferred imaging modality for diagnosing cardiac involvement in COVID-19. Several studies in the western populations have described echocardiographic findings in COVID-19.,, However, to the best of our knowledge, there is no such study currently available in Indian patients. Hence, we sought this study to characterize echocardiographic findings in severe COVID-19 cases in an Indian population.
| Methodology|| |
This observational cohort study included adults 18 years of age or older with COVID-19 pneumonia who underwent transthoracic echocardiography (TTE) between May 2020 and August 2020 in a tertiary care hospital in Kolkata, West Bengal. All cases were confirmed through reverse transcriptase–polymerase chain reaction (RT-PCR) assays for SARS-CoV-2, performed on nasopharyngeal swabs. According to the “Diagnosis and Treatment Program of Pneumonia of New CoV Infection (Trial Fifth Edition),” recommended by China's National Health Commission on February 5, 2020, COVID-19 patients are classified as having minimal, common, severe, and critical illness. Minimal disease patients have subtle clinical symptoms and no lung opacities on chest imaging. These patients were not included in this study. Common cases have symptoms such as fever and respiratory tract symptoms, with chest imaging showing lung opacities. Severe cases should meet any of the following criteria: (1) respiratory distress, defined as respiratory rate >30 beats/min; (2) resting blood oxygen saturation <93%; or (3) ratio of partial pressure of arterial blood oxygen (PaO2) to oxygen concentration (FiO2) <300 mmHg. Critical patients need to meet one of the following conditions: (1) respiratory failure and need for mechanical ventilation; (2) shock; and (3) other organ failure needing intensive care unit monitoring and treatment. The patients with features of common, severe, or critical illness who were referred for TTE were included in this study. The referral for TTE was at the discretion of the clinician responsible for the patient's care.
For all the study patients, demographic and clinical data were collected. Echocardiographic protocol followed in our study is described in [Table 1]. Standard echocardiographic imaging was performed in accordance with the published recommendations to assess cardiac chamber size, function, valvular function, pulmonary hypertension, and pulmonary artery changes.,
|Table 1: Protocol used for transthoracic echocardiography evaluation in the study|
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All the data were managed in a Microsoft Excel worksheet. Standard descriptive analysis was performed to summarize various clinical characteristics and echocardiographic findings. Continuous variables were described using mean ± standard deviation, whereas categorical variables were described as counts and proportions.
| Results|| |
During the study period, 245 consecutive, hospitalized, RT-PCR-confirmed COVID-19 patients were evaluated by echocardiography at our center. Of these, 11 patients were excluded from the study as TTE evaluation was nondiagnostic in them. The remaining 234 patients were included in this analysis. All patients were admitted to the intensive care unit or high-dependency unit.
Baseline characteristics of the study population are described in [Table 2]. Mean age of the patients was 57 ± 16 years. There were 168 (71.7%) men and 66 (28.2%) women. Medical comorbidities included hypertension (58.5%), diabetes (47.8%), obesity (45.2%), and history of coronary artery disease (CAD, 28.9%). Forty-nine (20.9%) subjects had preexisting reduced left ventricular (LV) ejection fraction (LVEF). Presenting symptoms included shortness of breath (70.8%), cough (61.1%), fever (59.7%), diarrhea (18.1%), and chest pain (13.9%).
[Figure 1] depicts the salient echocardiographic findings in the 234 patients. Right ventricular (RV) dilatation with or without dysfunction was the most common abnormality, found in 87 (37%) patients [Figure 2] and [Table 3]. Of the 87 patients with RV dilatation, majority had mid-level RV diameter of 35–40 mm. RV dysfunction defined as tricuspid annular plane systolic excursion <17 mm was found in 79 (33.8%) patients. Notably, we observed five cases of RV free wall hypokinesia with apical sparing. One patient had RV dilatation with RV apical thrombus [Figure 3].
|Figure 1: Distribution of major echocardiographic abnormalities in the study population|
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|Figure 2: Modified apical four-chamber view demonstrating right ventricular dilatation in a patient with coronavirus disease-2019|
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|Table 3: Right ventricular size and systolic function in the study patients|
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|Figure 3: Echocardiography of a coronavirus disease-2019 patient with dilated right ventricle with right ventricular apical thrombus (arrow)|
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LV systolic dysfunction (LVSD) with or without regional wall motion abnormalities (RWMA) was found in 65 (27.7%) cases [Table 4]. Among the 65 cases of LVSD, 49 patients (20.8%) had preexisting LVSD, and 16 patients had new-onset LVSD. Nearly two-third (42 or 65) of those with LVSD had mild LVSD (LVEF 40%–49%), whereas 14 and 9 patients had moderate (LVEF 30%–39%) and severe (LVEF < 30%) LVSD, respectively. In 29 (44.6% of 65) patients, LVSD was global, whereas the remaining 36 (55.4%) had RWMA. After comparing with the previously available echocardiographic reports, we found that all patients with preexisting LVSD had deterioration of LV systolic function. We found three patients with severe LVSD with global hypokinesia; two of them did not have any previous LVSD, whereas one patient had moderate LVSD previously which now worsened to severe LVSD. In addition, there were seven patients who had new-onset RWMA with preserved wall thickness with electrocardiographic evidence of ST-elevation myocardial infarction.
LV diastolic dysfunction (LVDD) was found in 54 (23.1) patients, of whom 50 (21.3%) patients had grade 1 diastolic dysfunction, while four patients had grade 2 dysfunction [Table 4]. No patient had grade 3 or 4 LVDD. It was observed that all patients with preexisting LVSD also had LVDD. Only 5 patients (2.13%) had de novo LVDD and all of them had grade I diastolic dysfunction.
Majority of the patients (88%) did not have any pericardial effusion (PE). Only 29 (12.3%) patients had PE, which was circumferential in all. Among the 29 patients, 5 (2.13%) had moderate PE [Figure 4], while the rest had mild PE. None of our patients showed any features of cardiac tamponade physiology at the time of evaluation. Three patients had rheumatic heart disease with mitral and/or aortic valve regurgitation and in all of them, the valvular regurgitation worsened with COVID-19.
|Figure 4: Echocardiography of a coronavirus disease-2019 patient showing moderate pericardial effusion in the parasternal long-axis view|
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| Discussion|| |
To our best knowledge, this is the first study from India describing the echocardiographic findings in severe COVID-19 patients. A previous study described echocardiography findings in a very small subgroup of COVID-19 patients. However, the spectrum and incidence of echocardiographically detected cardiac involvement in COVID-19 has not been well elucidated. In this study, we describe the technical characteristics and cardiac findings of 234 transthoracic echocardiographic examinations performed on COVID-19 patients with severe illness.
In our study, we found a significant prevalence of RV dilatation/dysfunction and LVSD which must be interpreted within the clinical context of COVID-19. In our cohort, we found RV dilatation and/or dysfunction to be very common (37%) with severe COVID-19 infection. The etiology of this RV dysfunction is unclear but probably related to increased pulmonary resistance. RV dysfunction is a known complication of hypoxemic injury, including acute respiratory distress syndrome, pulmonary embolism, decreases in lung volume, excessive positive end-expiratory pressure, pneumonia, hypercarbia, elevated left atrial pressure, or a combination of all these factors.,,, The abnormalities in RV size and function in these critically ill patients raise concern for pulmonary thromboembolism, which is a prevalent complication of COVID-19. Unfortunately, in our study, computed tomographic pulmonary angiography was not performed in most of the patients due to logistic reasons. Moreover, the current guidelines and expert opinions recommend the performance of computed tomographic pulmonary angiography only in very selected patients when clinically really necessary.
Most of the previous studies in COVID-19 patients have demonstrated a similarly high prevalence of RV dilatation and/or dysfunction. Szekely et al. studied 100 patients with COVID-19 and found that 39% of them had RV dilatation and dysfunction with shortened acceleration time (AT, suggestive of higher pulmonary resistance). Patients with shorter AT were older, had more comorbidities, but, most importantly, had worse lung disease (based on both chest X-ray and lung ultrasound), lower oxygen saturation, higher LV filling pressure, and higher biomarker levels (D-dimer, brain natriuretic peptide, troponin-I, and C-reactive protein). These findings suggested that elevated pulmonary vascular resistance in COVID-19 infection was multifactorial and related to parenchymal lung disease, pulmonary vascular disease, and elevated left atrial pressure, all leading to cardiac injury. It is noteworthy that such high prevalence of RV dilatation/dysfunction in this study was observed despite the fact that 61% of patients had only mild illness.
In another large, multicentric international survey, Dweck et al. found that RV abnormalities were present in 33% of the patients. They also observed that RV abnormalities were more common in patients with more severe symptoms of COVID-19 and these were likely to reflect severe respiratory disease, including viral pneumonia itself, as well as both clinical and subclinical pulmonary thromboembolism.
Thus, our finding of high prevalence of RV dilatation/dysfunction in COVID-19 patients is consistent with the published literature and is related to the fact that our patients had severe illness and most of them were admitted to intensive care unit or high-dependency unit.
LV diastolic dysfunction, leading to heart failure with preserved ejection fraction, is much more common and develops earlier than LVSD. In an analysis by Li et al., patients with infection due to phylogenetically similar SARS CoV often had subclinical LV diastolic dysfunction without significant systolic impairment. Szekely et al. also showed in their study that 16% of their COVID-19 patients had LV diastolic dysfunction. We found a similar prevalence of LV diastolic dysfunction in our study.
Our 27.8% of cases had LVSD though 20.9% of cases had previous LVSD. Thus, we found new-onset LVSD in only 8.6% of patients. However, it was our observation that majority of the preexisting LVSD patients had clinical and echocardiographic deterioration of LV systolic function with COVID-19 infection, raising concern for potential direct viral-mediated cardiotoxicity and/or systemic inflammation leading to depression of myocardial function. In the study conducted by Szekely et al., 10% of patients had LVSD, whereas Dweck et al. reported LV abnormalities in 39% of patients. Although these studies as well as several case reports have raised concern about acute cardiac injury related to the infection or cytokine storm resulting in LVSD in patients with COVID-19 infection, our findings suggest that though LVSD occurs in patients with acute COVID-19 infection, it is much less common than RV dysfunction.
In all the studies describing echocardiography findings in COVID-19 patients, echocardiography was performed when the patients had presented with COVID-19.,, Therefore, it was not apparent what proportion of the echocardiographic abnormalities were preexisting. In fact, many of these studies have not even made any such distinction. Thus, it is apparent that the prevalence of various echocardiographic abnormalities reported in these studies represents overestimates. In the study by Dweck et al., LV and RV abnormalities were reported in 39% and 33% of patients, respectively, in the overall cohort. However, after excluding 315 patients with preexisting cardiac disease, LV and RV abnormalities were found in 27.7% and 30.1% of the remaining 901 patients. We too observed similar findings.
Our study had several limitations, and therefore, our findings should be interpreted within the context of these limitations. First, our study had a referral bias, as echocardiography was done on the basis of referral request by the treating physician, and thus, our cohort comprised only those patients in whom there was a suspicion of cardiac involvement. Second, being a cross-sectional observational cohort, our study had only single-point data evaluation without any follow-up during and/or after hospitalization. Third, considering the severity of the illness and to limit the spread of infection, echocardiographic evaluation was abbreviated; hence, more comprehensive imaging such as strain echocardiography was not performed. Fourth, as we performed echocardiography on referral requests from the treating physician, clinical correlation with echocardiography was not a part of our study, reflecting a major limitation. Fifth, our center is a tertiary referral institute and majority of our patients might be suffering from more advanced form of disease. Whether our findings can be reproduced in a larger multicenter study would be an area of further investigation and research.
| Conclusions|| |
This is the first Indian study describing various echocardiographic findings in hospitalized patients with severe COVID-19. RV dilatation/dysfunction was the most common echocardiographic abnormality noted in these patients, followed by LVSD and LV diastolic function. However, further, larger, multicentric studies with systematic data collection and comparison with non-COVID patients are needed to determine the true incidence of echocardiographic abnormalities in COVID-19. Nonetheless, the present study demonstrates the potential utility of echocardiography in guiding management in appropriately selected COVID-19 patients.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4]