Cardiac Involvment in COVID-19–Related Acute Respiratory Distress Syndrome

Abstract

The cardiac involvement in Coronavirus disease (COVID-19) is still under evaluation, especially in severe COVID-19-related Acute Respiratory Distress Syndrome (ARDS). The cardiac involvement was assessed by serial troponin levels and echocardiograms in 28 consecutive patients with COVID-19 ARDS consecutively admitted to our Intensive Care Unit from March 1 to March 31. Twenty-eight COVID-19 patients (aged 61.7 ± 10 years, males 79%). The majority was mechanically ventilated (86%) and 4 patients (14%) required veno-venous extracorporeal membrane oxygenation. As of March 31, the Intensive Care Unit mortality rate was 7%, whereas 7 patients were discharged (25%) with a length of stay of 8.2 ±5 days. At echocardiographic assessment on admission, acute core pulmonale was detected in 2 patients who required extracorporeal membrane oxygenation support. Increased systolic arterial pressure was detected in all patients. Increased Troponin T levels were detectable in 11 patients (39%) on admission. At linear regression analysis, troponin T showed a direct relationship with C-reactive Protein (R square: 0.082, F: 5.95, p = 0.017). In conclusions, in COVID-19-related ARDS, increased in Tn levels was common but not associated with alterations in wall motion kinesis, thus suggesting that troponin T elevation is likely to be multifactorial, mainly linked to disease severely (as inferred by the relation between Tn and C-reactive Protein). The increase in systolic pulmonary arterial pressures observed in all patients may be related to hypoxic vasoconstriction. Further studies are needed to confirm our findings in larger cohorts.

Echocardiographic assessment of the right ventricle in COVID -related acute respiratory syndrome

“…According to available evidence [13,[15][16][17], echocardiography should be part of the clinical evaluation of patients with COVID-19 infection, especially those with moderateto-severe disease. Indeed, RV dimension and function and systolic pulmonary arterial pressure are sensitive indicators of RV afterload, an indirect marker of lung disease severity in COVID-19 infection.…”

“…In a retrospective study included in 112 COVID-19 patients, Deng et al [15] reported an incidence of pulmonary hypertension of 13% but their series was constituted mainly by patients with mild COVID-19 disease. In a series of 28 patients with COVID-19 disease requiring intensive care unit (ICU) admission, by means of serial echocardiograms, we observed that systolic pulmonary arterial pressures were increased in all patients on ICU admission but significantly decreased during ICU stay [16]. In a cohort of 200 patients with mild disease, those with pulmonary hypertension had signs of more severe COVID-19-related lung disease [16] and Szekely et al [13] observed that patients with worse clinical grade had shorter pulmonary accelerating times suggesting increased RV afterload.…”

“…In a series of 28 patients with COVID-19 disease requiring intensive care unit (ICU) admission, by means of serial echocardiograms, we observed that systolic pulmonary arterial pressures were increased in all patients on ICU admission but significantly decreased during ICU stay [16]. In a cohort of 200 patients with mild disease, those with pulmonary hypertension had signs of more severe COVID-19-related lung disease [16] and Szekely et al [13] observed that patients with worse clinical grade had shorter pulmonary accelerating times suggesting increased RV afterload. In COVID-19-related ARDS, the development of increased systolic arterial pressures may be multi-factorial.…”

“…This is particularly true taking into account the high incidence of pulmonary embolism in COVID-19 patients [22] due to COVID-19-related alteration in the haemostatic system [23]. In a series of 28 patients with COVID-19-related ARDS, ACP was detected in two patients (7%), who required ECMO support [16].…”

Integrated clinical role of echocardiography in patients with COVID-19 disease

“…Investigations combining echocardiographic assessment and troponin measurements reported that serial echocardiograms (and electrocardiograms) failed to detect signs of myocarditis in patients with elevated troponin both in mild 2 and severe COVID-19 disease. 3 Ruling out coronary ischaemia, cardiologists should interpret troponin elevation in COVID-19 disease as multifactorial, 4 related to right ventricle (RV) increased intraventricular pressures (due to lung disease/RV dysfunction). A direct relationship was reported between troponin and C reactive protein.…”