Bedside echocardiography to predict mortality of COVID-19 patients beyond clinical data: Data from the PROVAR-COVID study

Abstract

INTRODUCTION: Cardiac involvement seems to impact prognosis of COVID-19, being more frequent in critically ill patients. We aimed to assess the prognostic value of right ventricular (RV) and left ventricular (LV) dysfunction, evaluated by bedside echocardiography (echo), in patients hospitalized with COVID-19. METHODS: Patients admitted in 2 reference hospitals in Brazil from Jul to Sept/2020 with confirmed COVID-19 and moderate/severe presentations underwent clinical and laboratory evaluation, and focused bedside echo (GE Vivid-IQ), at the earliest convenience, with remote interpretation. The association between demographics, clinical comorbidities and echo variables with all-cause hospital mortality was assessed, and factors significant at p<0.10 were put into multivariable models. RESULTS: Total 163 patients were enrolled, 59% were men, mean age 64±16 years, and 107 (66%) were admitted to intensive care. Comorbidities were present in 144 (88%) patients: hypertension 115 (71%), diabetes 61 (37%) and heart failure 22 (14%). In-hospital mortality was 34% (N=56). In univariate analysis, echo variables significantly associated with death were: LV ejection fraction (LVEF, OR=0.94), RV fractional area change (OR=0.96), tricuspid annular plane systolic excursion (TAPSE, OR=0.83) and RV dysfunction (OR=5.3). In multivariate analysis, after adjustment for clinical and demographic variables, independent predictors of mortality were age≥63 years (OR=5.53, 95%CI 1.52-20.17), LVEF<64% (OR=7.37, 95%CI 2.10-25.94) and TAPSE<18.5 mm (OR=9.43, 95% CI 2.57-35.03), and the final model had good discrimination, with C-statistic=0.83 (95%CI 0.75-0.91). CONCLUSION: Markers of RV and LV dysfunction assessed by bedside echo are independent predictors of mortality in hospitalized COVID-19 patients, after adjustment for clinical variables.

Influence of right ventricular structure and function on hospital outcomes in COVID-19 patients

“…For the purposes of this discussion, we have selected and tabulated ( Table 5 ) prior relevant reports where there was sufficient data for between-study comparisons, including RV dysfunction, need for mechanical ventilation, and mortality rates. 2 , 11 , 12 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 To simplify the comparison between our study and the previously published reports, prior studies were sorted by the reported hospital mortality. Accounting for differences in study populations and reported endpoints, our findings agree with prior reports.…”

“… In the studies with available data endpoints, including current one (star), visual assessment reveals strong positive correlation between RV dilatation and mortality (Panel A), RV dilatation and positive pressure ventilation (Panel B), and positive pressure ventilation and mortality (Panel C). 2 , 11 , 12 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 …”

Cardiac involvement in COVID-19: cause or consequence of severe manifestations?

“…Even when the LV is spared, variables such as TAPSE, RV ejection fraction, RV strain and pulmonary artery pressure are associated with lab markers (D-dimer, troponin) and clinical outcomes. 9 Although this may result from pulmonary vascular and parenchymal involvement and ventilatory support, the exact mechanisms are yet to be elucidated. Importantly, given the hyperdynamic state of patients with COVID-19 (especially in severe forms with exposure to vasopressors), LV and RV variables must be cautiously interpreted, as they may predict unfavourable outcomes even within a 'normal' range for other populations.…”

“…Importantly, given the hyperdynamic state of patients with COVID-19 (especially in severe forms with exposure to vasopressors), LV and RV variables must be cautiously interpreted, as they may predict unfavourable outcomes even within a 'normal' range for other populations. 9 Thus, MRI may add to prognostic scores, given its high sensitivity for subtle abnormalities.…”

Response Letter: Are atypical lymphocytes a new predictive factor in the development of coronavirus disease 2019?

“…Bruno Ramos Nascimento [1]  [1]. Universidade Federal de Minas Gerais, Hospital das Clínicas, Belo Horizonte, MG, Brasil.…”