Positive End-Expiratory Pressure Deescalation in COVID-19–induced Acute Respiratory Distress Syndrome Unloads the Right Ventricle, Improving Hemodynamics and Oxygenation

Tsolaki, Vasiliki; Zakynthinos, George E.; Papanikolaou, John; Karavidas, Nikitas; Vazgiourakis, Vassilios; Papadonta, Maria Eirini; Zygoulis, Paris; Pantazopoulos, Ioannis; Makris, Demosthènes; Zakynthinos, Epaminondas

doi:10.1164/rccm.202301-0154le

Cited by 4 publications

(3 citation statements)

References 10 publications

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“…However, the MV settings and respiratory system mechanics are not reported, thus, one cannot conclude on the effects of MV on the observed results. RV involvement in COVID-19 ARDS seems to be related to the increased afterload due to COVID-19-induced microthrombosis, lung mechanics’ impairment and mechanical ventilator settings, which may have additional contribution, as we have recently shown [ 37 ]. Surprisingly, RV IVA, a load independent variable indicating RV systolic dysfunction, was normal during the two timepoints of measurements, supporting the role of increased RV afterload in RV dysfunction.…”

Section: Discussionmentioning

confidence: 90%

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Comprehensive temporal analysis of right ventricular function and pulmonary haemodynamics in mechanically ventilated COVID-19 ARDS patients

Tsolaki,

Zakynthinos,

Karavidas

et al. 2024

Ann. Intensive Care

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Background Cardiac injury is frequently reported in COVID-19 patients, the right ventricle (RV) is mostly affected. We systematically evaluated the cardiac function and longitudinal changes in severe COVID-19 acute respiratory distress syndrome (ARDS) admitted to the intensive care unit (ICU) and assessed the impact on survival. Methods We prospectively performed comprehensive echocardiographic analysis on mechanically ventilated COVID-19 ARDS patients, using 2D/3D echocardiography. We defined left ventricular (LV) systolic dysfunction as ejection fraction (EF) < 40%, or longitudinal strain (LS) > − 18% and right ventricular (RV) dysfunction if two indices among fractional area change (FAC) < 35%, tricuspid annulus systolic plane excursion (TAPSE) < 1.6 cm, RV EF < 44%, RV–LS > − 20% were present. RV afterload was assessed from pulmonary artery systolic pressure (PASP), PASP/Velocity Time Integral in the right ventricular outflow tract (VTIRVOT) and pulmonary acceleration time (PAcT). TAPSE/PASP assessed the right ventriculoarterial coupling (VACR). Results Among 176 patients included, RV dysfunction was common (69%) (RV–EF 41.1 ± 1.3%; RV–FAC 36.6 ± 0.9%, TAPSE 20.4 ± 0.4mm, RV–LS:− 14.4 ± 0.4%), usually accompanied by RV dilatation (RVEDA/LVEDA 0.82 ± 0.02). RV afterload was increased in most of the patients (PASP 33 ± 1.1 mmHg, PAcT 65.3 ± 1.5 ms, PASP/VTIRVOT, 2.29 ± 0.1 mmHg/cm). VACR was 0.8 ± 0.06 mm/mmHg. LV–EF < 40% was present in 21/176 (11.9%); mean LV–EF 57.8 ± 1.1%. LV–LS (− 13.3 ± 0.3%) revealed a silent LV impairment in 87.5%. A mild pericardial effusion was present in 70(38%) patients, more frequently in non-survivors (p < 0.05). Survivors presented significant improvements in respiratory physiology during the 10th ICU-day (PaO2/FiO2, 231.2 ± 11.9 vs 120.2 ± 6.7 mmHg; PaCO2, 43.1 ± 1.2 vs 53.9 ± 1.5 mmHg; respiratory system compliance—CRS, 42.6 ± 2.2 vs 27.8 ± 0.9 ml/cmH2O, all p < 0.0001). Moreover, survivors presented significant decreases in RV afterload (PASP: 36.1 ± 2.4 to 20.1 ± 3 mmHg, p < 0.0001, PASP/VTIRVOT: 2.5 ± 1.4 to 1.1 ± 0.7, p < 0.0001 PAcT: 61 ± 2.5 to 84.7 ± 2.4 ms, p < 0.0001), associated with RV systolic function improvement (RVEF: 36.5 ± 2.9% to 46.6 ± 2.1%, p = 0.001 and RV–LS: − 13.6 ± 0.7% to − 16.7 ± 0.8%, p = 0.001). In addition, RV dilation subsided in survivors (RVEDA/LVEDA: 0.8 ± 0.05 to 0.6 ± 0.03, p = 0.001). Day-10 CRS correlated with RV afterload (PASP/VTIRVOT, r: 0.535, p < 0.0001) and systolic function (RV–LS, 0.345, p = 0.001). LV–LS during the 10th ICU-day, while ΔRV–LS and ΔPASP/RVOTVTI were associated with survival. Conclusions COVID-19 improvements in RV function, RV afterload and RV–PA coupling at day 10 were associated with respiratory function and survival.

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Section: Discussionmentioning

confidence: 90%

“…Moreover, we cannot conclude whether the lack of RV improvement in non-survivors might also present a marker of septic cardiomyopathy presenting upon the 10th ICUday, as sepsis was more frequent in this subset of patients. RV dysfunction is a common finding in early sepsis [ 37 ].…”

Section: Discussionmentioning

confidence: 99%

Comprehensive temporal analysis of right ventricular function and pulmonary haemodynamics in mechanically ventilated COVID-19 ARDS patients

Tsolaki,

Zakynthinos,

Karavidas

et al. 2024

Ann. Intensive Care

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“…This phenomenon is likely exacerbated in COVID-19 ARDS, where there is an increased occurrence of dead space formation and relatively preserved compliance of the respiratory system [70,71]. Recent findings indicate that in COVID-19 ARDS patients with mostly preserved respiratory system mechanics, PEEP impairs RV function and has an amplified effect on RV afterload by inducing non-zone three conditions [72].…”

Section: Pathophysiological Mechanisms Assumed To Be Involved In the ...mentioning

confidence: 99%

New-Onset Atrial Fibrillation in the Critically Ill COVID-19 Patients Hospitalized in the Intensive Care Unit

Zakynthinos,

Tsolaki,

Oikonomou

et al. 2023

JCM

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New-onset atrial fibrillation (NOAF) is the most frequently encountered cardiac arrhythmia observed in patients with COVID-19 infection, particularly in Intensive Care Unit (ICU) patients. The purpose of the present review is to delve into the occurrence of NOAF in COVID-19 and thoroughly review recent, pertinent data. However, the causality behind this connection has yet to be thoroughly explored. The proposed mechanisms that could contribute to the development of AF in these patients include myocardial damage resulting from direct virus-induced cardiac injury, potentially leading to perimyocarditis; a cytokine crisis and heightened inflammatory response; hypoxemia due to acute respiratory distress; disturbances in acid-base and electrolyte levels; as well as the frequent use of adrenergic drugs in critically ill patients. Additionally, secondary bacterial sepsis and septic shock have been suggested as primary causes of NOAF in ICU patients. This notion gains strength from the observation of a similar prevalence of NOAF in septic non-COVID ICU patients with ARDS. It is plausible that both myocardial involvement from SARS-CoV-2 and secondary sepsis play pivotal roles in the onset of arrhythmia in ICU patients. Nonetheless, there exists a significant variation in the prevalence of NOAF among studies focused on severe COVID-19 cases with ARDS. This discrepancy could be attributed to the inclusion of mixed populations with varying degrees of illness severity, encompassing not only patients in general wards but also those admitted to the ICU, whether intubated or not. Furthermore, the occurrence of NOAF is linked to increased morbidity and mortality. However, it remains to be determined whether NOAF independently influences outcomes in critically ill COVID-19 ICU patients or if it merely reflects the disease’s severity. Lastly, the management of NOAF in these patients has not been extensively studied. Nevertheless, the current guidelines for NOAF in non-COVID ICU patients appear to be effective, while accounting for the specific drugs used in COVID-19 treatment that may prolong the QT interval (although drugs like lopinavir/ritonavir, hydrochlorothiazide, and azithromycin have been discontinued) or induce bradycardia (e.g., remdesivir).

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High PEEP/low FiO2 ventilation is associated with lower mortality in COVID–19

Goossen,

van Vliet,

Bos

et al. 2024

Journal of Critical Care

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Positive End-Expiratory Pressure Deescalation in COVID-19–induced Acute Respiratory Distress Syndrome Unloads the Right Ventricle, Improving Hemodynamics and Oxygenation

Cited by 4 publications

References 10 publications

Comprehensive temporal analysis of right ventricular function and pulmonary haemodynamics in mechanically ventilated COVID-19 ARDS patients

Comprehensive temporal analysis of right ventricular function and pulmonary haemodynamics in mechanically ventilated COVID-19 ARDS patients

New-Onset Atrial Fibrillation in the Critically Ill COVID-19 Patients Hospitalized in the Intensive Care Unit

High PEEP/low FiO2 ventilation is associated with lower mortality in COVID–19

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