Information regarding the use of lung ultrasound (LUS) in patients with Coronavirus disease 2019 (COVID-19) is quickly accumulating, but its use for risk stratification and outcome prediction has yet to be described. We performed the first systematic and comprehensive LUS evaluation of consecutive patients hospitalized with COVID-19 infection, in order to describe LUS findings and their association with clinical course and outcome. Methods: Between 21/03/2020 and 04/05/2020, 120 consecutive patients admitted to the Tel Aviv Medical Center due to COVID-19, underwent complete LUS within 24 h of admission. A second exam was performed in case of clinical deterioration. LUS score of 0 (best)-36 (worst) was assigned to each patient. LUS findings were compared with clinical data. Results: The median baseline total LUS score was 15, IQR [7-20]. Baseline LUS score was 0-18 in 80 (67%) patients, and 19-36 in 40 (33%) patients. The majority had patchy pleural thickening (n = 100; 83%), or patchy subpleural consolidations (n = 93; 78%) in at least one zone. The prevalence of pleural thickening, subpleural consolidations and the total LUS score were all correlated with severity of illness on admission. Clinical deterioration was associated with increased follow-up LUS scores (p = 0.0009), mostly due to loss of aeration in anterior lung segments. The optimal cutoff point for LUS score was 18 (sensitivity = 62%, specificity = 74%). Both mortality and need for invasive mechanical ventilation were increased with baseline LUS score > 18 compared to baseline LUS score 0-18. Unadjusted hazard ratio of death for LUS score was 1.08 per point [1.02-1.16], p = 0.008; Unadjusted hazard ratio of the composite endpoint (death or need for invasive mechanical ventilation) for LUS score was 1.12 per point [1.05-1.2], p = 0.0008. Conclusion: Hospitalized patients with COVID-19, at all clinical grades, present with pathological LUS findings. Baseline LUS score strongly correlates with the eventual need for invasive mechanical ventilation and is a strong predictor of mortality. Routine use of LUS may guide patients' management strategies, as well as resource allocation in case of surge capacity.

Background Large number of patients around the world are recovering from COVID-19; many of them report persistence of symptoms. Objectives We sought to test pulmonary, cardiovascular and peripheral responses to exercise in patients recovering from COVID-19. Methods We prospectively evaluated patients who recovered from COVID-19 using a combined anatomic/functional assessment. All patients underwent clinical examination, laboratory tests, and a combined stress echocardiography and cardiopulmonary exercise test. We measured left ventricular volumes, ejection fraction, stroke volume, heart rate, E/e' ratio, right ventricular function, VO 2 , lung volumes, Ventilatory efficiency, O 2 saturation and muscle O 2 extraction in all effort stages and compared them to historical controls. Results A total of 71 patients were assessed 90.6±26 days after onset of COVID-19 symptoms. Only 23 (33%) were asymptomatic. The most common symptoms were fatigue (34%), muscle weakness/pain (27%) and dyspnea (22%). VO 2 was lower among post-COVID-19 patients compared to controls (p=0.03, group by time interaction p=0.007). Reduction in peak VO 2 was due to a combination of chronotropic incompetence (75% of post-COVID-19 patients vs. 8% of controls, p<0.0001) and insufficient increase in stroke volume during exercise (p=0.0007, group by time interaction p=0.03). Stroke volume limitation was mostly explained by diminished increase in left ventricular end-diastolic volume (p=0.1, group by time interaction p=0.03) and insufficient increase in ejection fraction (p=0.01, group by time interaction p=0.01). Post-COVID-19 patients had higher peripheral O 2 extraction (p=0.004) and did not have significantly different respiratory and gas exchange parameters compared to controls. Conclusions Patients recovering from COVID-19 have symptoms associated with objective reduction in peak VO 2 . The mechanism of this reduction is complex and mainly involves a combination of attenuated heart rate and stroke volume reserve.

Aims Cardiovascular involvement is common in COVID-19. We sought to describe the haemodynamic profiles of hospitalized COVID-19 patients and determine their association with mortality. Methods and results Consecutive hospitalized patients diagnosed with COVID-19 infection underwent clinical evaluation using the Modified Early Warning Score (MEWS) and a full non-invasive echocardiographic haemodynamic evaluation, irrespective of clinical indication, as part of a prospective predefined protocol. Patients were stratified based on filling pressure and output into four groups. Multivariable Cox-Hazard analyses determined the association between haemodynamic parameters with mortality. Among 531 consecutive patients, 44% of patients had normal left ventricular (LV) and right ventricular (RV) haemodynamic status. In contrast to LV haemodynamic parameters, RV parameters worsened with higher MEWS stage. While RV parameters did not have incremental risk prediction value above MEWS, LV stroke volume index, E/e′ ratio, and LV stroke work index were all independent predictors of outcome, particularly in severe disease. Patients with LV or RV with high filling pressure and low output had the worse outcome, and patients with normal haemodynamics had the best (P &lt; 0.0001). Conclusion In hospitalized patients with COVID-19, almost half have normal left and right haemodynamics at presentation. RV but not LV haemodynamics are related to easily obtainable clinical parameters. LV but not RV haemodynamics are independent predictors of mortality, mostly in patients with severe disease.

No abstract

Background and Objectives We aimed to evaluate sonographic features that may aid in risk stratification and propose a focused cardiac and lung ultrasound (LUS) algorithm in patients with COVID-19 Methods Two hundred consecutive hospitalized patients with COVID-19 underwent comprehensive clinical and echocardiographic examination, as well as LUS, irrespective of clinical indication, within 24 hours of admission as part of a prospective predefined protocol. Assessment included calculation of the Modified Early Warning Score (MEWS), left ventricular (LV) systolic and diastolic function, hemodynamic and right ventricular (RV) assessment and a calculated LUS score. We performed outcome analysis to identify echocardiographic and LUS predictors of mortality or the composite event of mortality or need for invasive mechanical ventilation, and to assess their adjunctive value on top of clinical parameters and MEWS. Results A simplified echocardiographic risk score comprised of LV ejection fraction< 50% combined with TAPSE< 18 mm, was associated with mortality (p=0.0002) and with the composite event (p=0.0001). Stepwise analyses evaluating echocardiographic and LUS parameters on top of existing clinical risk scores showed that addition of TAPSE and SVI improved prediction of mortality when added to clinical variables but not when added to MEWS. Once echocardiography was added, and patients re-categorized as high risk only if having both high risk MEWS, and high-risk cardiac features, the specificity increased from 63% to 87%, positive predictive value from 28% to 48% and accuracy improved from 66% to 85%. Although LUS was not associated with incremental risk prediction for mortality above clinical and echocardiographic criteria, it improved prediction of need for invasive mechanical ventilation. Conclusions In hospitalized patients with COVID-19, a very limited echocardiographic exam is sufficient for outcome prediction. The addition of echocardiography in patients with high risk MEWS score decreases the rate of falsely identifying patients as high risk to die, and may improve resource allocation in case of high patient load.background

BACKGROUND The list of medications linked to drug-induced long QT syndrome (LQTS) is diverse. It is possible that food products too have QT-prolonging potential.OBJECTIVE We tested the effects of grapefruit juice on the QT interval with the methodology used by the pharmaceutical industry to test new drugs. METHODSThis was an open-label, randomized, crossover study with blinded outcome evaluation, a thorough QT study of grapefruit juice performed according to the Guidelines for the Clinical Evaluation of QT/QTc for Non-antiarrhythmic Drugs. Thirty healthy volunteers and 10 patients with congenital LQTS were studied. Healthy volunteers drank 2 L of grapefruit juice (in divided doses), or received 400 mg oral moxifloxacin, in a randomized crossover study. Patients with LQTS were tested with only grapefruit. Repeated baseline, off-drug, and on-drug (grapefruit or moxifloxacin) electrocardiograms were scanned and coded. QT measurements were done with electronic calipers. RESULTSIn comparison to off-drug electrocardiograms, grapefruit juice led to significant rate-corrected QT (QTc) prolongation. The absolute net QTc prolongation from grapefruit was 14.0 ms (95% confidence interval 6.2-21.7 ms; P , .001). The QT-prolonging effects of grapefruit in healthy volunteers were comparable with those of moxifloxacin. The QT-prolonging effects of grapefruit juice were greater in female patients and particularly marked in patients with LQTS (net QTc prolongation 21.8 ms; 95% confidence interval 3.4-35.3 ms; P 5 .034).CONCLUSION Grapefruit juice, at doses tested, prolongs the QT interval. The effect is significant in healthy volunteers, greater in female patients, and more so in patients with LQTS.

Background The scope of pericardial involvement in COVID‐19 infection is unknown. We aimed to evaluate the prevalence, associates, and clinical impact of pericardial involvement in hospitalized patients with COVID‐19. Methods and Results Consecutive patients with COVID‐19 underwent clinical and echocardiographic examination, irrespective of clinical indication, within 48 hours as part of a prospective predefined protocol. Protocol included clinical symptoms and signs suggestive of pericarditis, calculation of modified early warning score, ECG and echocardiographic assessment for pericardial effusion, left and right ventricular systolic and diastolic function, and hemodynamics. We identified predictors of mortality and assessed the adjunctive value of pericardial effusion on top of clinical and echocardiographic parameters. The study included 530 patients. Pericardial effusion was found in 75 (14%), but only 17 patients (3.2%) fulfilled the criteria for acute pericarditis. Pericardial effusion was independently associated with modified early warning score, brain natriuretic peptide, and right ventricular function. It was associated with excess mortality (hazard ratio [HR], 2.44; P =0.0005) in nonadjusted analysis. In multivariate analysis adjusted for modified early warning score and echocardiographic and hemodynamic parameters, it was marginally associated with mortality (HR, 1.86; P =0.06) and improvement in the model fit ( P =0.07). Combined assessment for pericardial effusion with modified early warning score, left ventricular ejection fraction, and tricuspid annular plane systolic excursion was an independent predictor of outcome (HR, 1.86; P =0.02) and improved model fit ( P =0.02). Conclusions In hospitalized patients with COVID‐19, pericardial effusion is prevalent, but rarely attributable to acute pericarditis. It is associated with myocardial dysfunction and mortality. A limited echocardiographic examination, including left ventricular ejection fraction, tricuspid annular plane systolic excursion, and assessment for pericardial effusion, can contribute to outcome prediction.

Aims Most patients with significant (defined as ≥ moderate) tricuspid regurgitation (TR) are treated conservatively. Individual mortality rates are markedly variable. We developed a risk score based on comprehensive clinical and echocardiographic evaluation, predicting mortality on an individual patient level. Methods and results The cohort included 1,701 consecutive patients with significant TR, half with isolated TR, admitted to a single hospital, treated conservatively. We derived a scoring system predicting one-year mortality and validated it using k-fold cross validation and with external validation on another cohort of 5,141 patients. Score utility was compared to matched patients without significant TR. One-year mortality rate was 31.3%. The risk score ranged 0-17 points and included 11 parameters: age (0-3), body-mass-index ≤ 25 (0-1), history of liver disease (0-2), history of chronic lung disease (0-2), estimated-glomerular-filtration-rate (0-5), hemoglobin (0-2), left-ventricular-ejection-fraction (0-1), right-ventricular dysfunction (0-1), right-atrial-pressure (0-2), stroke-volume-index (SVI) (0-1) and left ventricular end-diastolic-diameter (0-1). One-year mortality rates increased from 0% to 100%, as the score increased up to ≥16. Areas under the receiver operating curves were 0.78, 0.70 and 0.73, for the original, external validation and external validation with SVI measured cohorts. The score remained valid in subpopulations of patients with quantified RV function, quantified TR and isolated TR. Significant TR compared to no TR, affected one-year mortality stronger with higher scores, with a significantly positive interaction term. Conclusion We suggest a robust risk score for inpatients with significant TR, assisting risk stratification and decision making. Our findings underscore the burden of TR providing benchmarks for clinical trial design.