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Objective Preliminary data suggest that nonalcoholic fatty liver disease (NAFLD) is associated with early heart failure (HF). However, whether nonalcoholic steatophepatitis (NASH) is directly associated with echocardiographic changes in cardiac structure or function remains unknown. Methods We identified a retrospective cohort (N=65) without known heart disease, undergoing elective bariatric surgery with perioperative liver biopsy, and available recent transthoracic echocardiography (TTE). TTE measures were evaluated by NASH status using correlation coefficients, ANOVA and linear regression, accounting for cardiometabolic factors. Results Median age was 47 years; 22% (n=14) had NASH. NASH patients had increased median left atrial (LA) volume (28.6mL/m2 vs. 24.8mL/m2, p<0.0001) and LV mass (82.6 g/m2 vs. 78.6 g/m2, p<0.0001), indexed for height. NASH was inversely correlated with indices of diastolic function, including septal E′ (r= −0.90 [95% CI −1.21, −0.42], p=0.020) and E:A (r= −0.31 [95% CI −0.51, −0.09], p=0.037). In adjusted analyses, NASH remained associated with increased LV mass index (ß1 = 7.16 [SE 4.95], p=0.001), LA volume index (ß1= 0.19 [0.08], p=0.001), and reduced lateral and septal E′ (ß1 = −0.91, p=0.015; ß1 = −0.89, p=0.047, respectively). Conclusions In this bariatric cohort, NASH was associated with changes in myocardial structure and in loaddependent indices of LV diastolic function, suggestive of subclinical HF.

The COVID-19 pandemic caused by the SARS-CoV-2 virus presents new diagnostic challenges including differentiating COVID-19 infection from other diagnostic entities. Both COVID-19 infection and acute endocarditis may present with hypoxic respiratory failure, fever, and elevated inflammatory biomarkers. The task of distinguishing the two is complicated by the complexities of interpreting SARS-CoV-2 RT-PCR test results. The RT-PCR test may be negative early in the disease course 1-3 and may remain positive long after the initial infection due to viral clearance delay. 4,5 Here, we present two cases of left-sided endocarditis, which were both initially attributed to COVID-19 infection, and only correctly diagnosed after echocardiography was performed.

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