key: cord-0733335-4cb5kmr8 authors: Lazzeri, Chiara; Bonizzoli, Manuela; Batacchi, Stefano; Socci, Filippo; Peris, Adriano title: The clinical and prognostic role of echocardiography in ‘SARS-CoV-2’ disease date: 2021-02-17 journal: Eur J Emerg Med DOI: 10.1097/mej.0000000000000795 sha: 133bb50c1a156c5ebed78f42e582cd71d86cd40e doc_id: 733335 cord_uid: 4cb5kmr8 nan shows the studies reporting echocardiographic findings in COVID patients according to disease severity. Only two studies included solely noncritical COVID patients [3, 4] . Rath et al. [3] observed that left ventricle ejection fraction (LVEF) was independently associated with mortality, while right ventricle (RV) stress (as indicated by RV failure and pulmonary arterial hypertension) resulted to be related to a poor prognosis in both studies [3, 4] in whom echocardiography was performed routinely (with no inclusion restriction). Three studies specifically addressed more severe COVID patients needing ICU admission [5] [6] [7] . Evrad et al. [5] compared echocardiographic findings in COVID patients (transesophageal echocardiography) with those observed in flu-related acute respiratory distress syndrome (ARDS). Patients with COVID-related ARDS showed a lower prevalence of LV and RV failure in respect to those with flu-related ARDS. These data are to be considered preliminary, because the small number of patients included (COVID: n. 18) and the lower mortality rate reported in ICU patients with COVID-ARDS (6%). When serial echocardiographic examinations were performed [6] , systolic pulmonary arterial pressures were found to be increased in all COVID patients on ICU admission (n. 28, mostly mechanically ventilated) but they significantly decreased during ICU stay. The increase in systolic pulmonary arterial pressures could be related to the hypoxic vasoconstriction in compliant lungs, factors which seems to characterize COVID-19-related ARDS, although mechanical ventilation itself might represent also a contributing factor (by increasing RV afterload). An interesting protocol, combining lung and cardiac ultrasound, was presented by García-Cruz et al. [7] and implemented in 82 COVID patients admitted to ICU. The most frequent ultrasonographic findings were elevated pulmonary artery systolic pressure (69.5%), LV diastolic dysfunction (indicated by E/e′ ratio > 14, 29.3%), and RV abnormalities (dilatation in 28% and dysfunction in 26.8%. Elevated pulmonary artery systolic pressure was associated with higher in-hospital mortality. Most studies [8] [9] [10] [11] [12] [13] were performed in a mixed population and common bias for inclusion characterized many of these studies in whom echocardiography was performed in 'selected patients', because most often the appropriateness of the examination was assessed on a case by case basis by the attending cardiologist [11] [12] [13] . In a retrospective analysis (749 patients) [13] , transthoracic echocardiography was performed only in 72 patients (9.6%, the majority on mechanical ventilation), mainly for a suspected major cardiovascular event and hemodynamically instability. Nevertheless, echocardiographic findings changed management in about one-fifth of patients (24.2%). In a retrospective analysis (112 patients), Deng et al. [12] focused on the incidence of myocardial injury, assessed by serial measurements of troponin values while echocardiography was performed only once. Troponin levels increased during hospitalization in 37.5% of patients, but, in the absence of typical signs of myocarditis on echocardiogram and ECG, the authors concluded that in COVID disease myocardial injury was more likely related to systemic consequences rather than direct damage by COVID. A direct relationship between troponin and C reactive protein was described in a small cohort of ICU patients [6] . Comparing nonsevere (n. 45) and In hemodynamically ventilated COVID-19 patients, a lower prevalence of LV and RV failure than in flu-related ARDS patients. Lazzeri et al. [6] Italy 28 COVID-related ARDS. On admission: on admission, acute core pulmonale was detected in two patients (2/28, 7 %). Increased systolic arterial pressure was detected in all patients. Observational single-center investigation. (1) increased Tn levels, although common, was not associated with echo wall motion abnormalities; (2) a significant direct relationship was detectable between Tn and C-reactive protein. (3) Observational study. Some information were collected from free-text fields. No data on outcome. In this global survey, cardiac abnormalities were observed in half of all COVID patients undergoing echocardiography. Imaging changed management in one-third of patients. Li et al. [10] China 157 hospitalized COVID patients RV dysfunction was found in 25.5%. Troponin elevation, mechanical ventilation, and RV dysfunction were independent predictors of higher mortality. The prevalence of RV dysfunction was higher than that of LV dysfunction in patients with COVID. Szekely et al. [11] Israel 100 patients The most common cardiac pathology was RV dilatation and dysfunction (observed in 39% of patients), followed by LV diastolic dysfunction (16%) and LV systolic dysfunction (10%). Only hospitalized (for at least 24 h) patients with COVID infection. The fact that only ≈7% of patients diagnosed with COVID infection in Israel are admitted to the hospital probably led to an overestimation of the severity of echocardiographic pathology in COVID infection. LV systolic function is preserved in the majority of patients, but LV diastolic function and RV function are impaired. Rath et al. [3] Germany 123 patients at hospital admission. LV and RV as well as tricuspid regurgitation >grade 1 were significantly associated with higher mortality. Not reported Cardiac failure is associated with poor prognosis in patients COVID infection. Deng et al. [12] China 112 patients LV < 50% (5.4%). Pulmonary hypertension (13.4%). Echocardiography was performed on demand. Myocardial injury is related to systemic consequences in absence of echocardiographic signs of myocarditis. Jain et al. [13] USA severe (n. 67) patients [12] , no difference was found in the incidence of LV failure (<50%) and RV failure (tricuspid annular plane excursion < 16 mm), while severe patients exhibited a higher incidence of systolic pulmonary hypertension (20.9 vs. 2.2%). In the first systematic echocardiographic assessment [11] , a normal echocardiogram was present in about one-third of patients (32%) and RV dilatation and dysfunction was the most common alteration (39%) being associated with more severe lung disease and higher levels of biomarkers related with adverse prognosis. The baseline echocardiographic parameters associated with mortality were low LVEF, LV diastolic dysfunction (indicated by elevated E/e′ ratio), and RV dilatation (RV end-diastolic area). The relationship between echocardiographic findings and COVID disease severity was assessed by Zeng et al. [8] (single-center, 416 patients). Comparing ICU (n. 35) and non-ICU (n. 381), they observed a higher incidence of myocardial injury marker elevation (troponin), ventricular wall thickening, pulmonary artery hypertension, and cardiac complications including acute myocardial injury, arrhythmia, and acute heart failure in ICU patients. In a prospective survey [14] (1272 COVID patients), a normal echocardiogram was described in half of the entire population (45%) but in one-third of patients who underwent echocardiography on clinical indication, imaging was reported to result in an immediate change in patient management. The main finding of this survey is that echocardiographic alterations were detectable in one in seven patients across the entire population and in one in eight patients without pre-existing cardiac disease. This proportion rose to one in five when the indication for imaging included increased cardiac biomarkers. Overall, data on mixed COVID population (non-ICU and ICU) point out those cardiac alterations are quite common, being RV dysfunction and pulmonary hypertension more prevalent, and associated with prognosis. Moreover, echocardiographic findings are related to disease severity being RV dilatation/dysfunction, systolic pulmonary hypertension, and myocardial injury more common in severe disease. European Society for Emergency Medicine position paper on emergency medical systems' response to COVID-19 Recommendations for echocardiography laboratories participating in cardiac point of care cardiac ultrasound (POCUS) and critical care echocardiography training: report from the American Society of Echocardiography Impaired cardiac function is associated with mortality in patients with acute COVID-19 infection Pulmonary hypertension and right ventricular involvement in hospitalised patients with COVID-19 Cardiovascular phenotypes in ventilated patients with COVID-19 acute respiratory distress syndrome Cardiac involvement in COVID-19-related acute respiratory distress syndrome Critical care ultrasonography during COVID-19 pandemic: the ORACLE protocol Cardiac manifestations of COVID-19 in Shenzhen Echocardiographic findings in patients with COVID-19 pneumonia The prevalence, risk factors and outcome of cardiac dysfunction in hospitalized patients with COVID-19 Spectrum of cardiac manifestations in COVID-19: a systematic echocardiographic study Suspected myocardial injury in patients with COVID-19: evidence from front-line clinical observation in Wuhan, China Indications for and findings on transthoracic echocardiography in COVID-19 Global evaluation of echocardiography in patients with COVID-19 There are no conflicts of interest.