Prognostic Value of Right Ventricular Ejection Fraction Assessed by 3D Echocardiography in COVID-19 Patients

Abstract

Background: RVEF (right ventricular ejection fraction) measured by three-dimensional echocardiography (3DE) has been used in evaluating right ventricular (RV) function and can provide useful prognostic information in other various cardiovascular diseases. However, the prognostic value of 3D-RVEF in coronavirus disease 2019 (COVID-19) remains unknown. We aimed to investigate whether 3D-RVEF can predict the mortality of COVID-19 patients.Methods: A cohort of 128 COVID-19-confirmed patients who had undergone echocardiography were studied. Thirty-one healthy volunteers were also enrolled as controls. COVID-19 patients were divided into three subgroups (general, severe, and critical) according to COVID-19 severity-of-illness. Conventional RV structure and function parameters, RV free wall longitudinal strain (FWLS) and 3D-RVEF were acquired. RVFWLS was measured by two-dimensional speckle tracking echocardiography. RVEF was acquired by 3DE.Results: Compared with controls, 2D-RVFWLS and 3D-RVEF were both significantly decreased in COVID-19 patients (−27.2 ± 4.4% vs. −22.9 ± 4.8%, P < 0.001; 53.7 ± 4.5% vs. 48.5 ± 5.8%, P < 0.001). Critical patients were more likely to have a higher incidence of acute cardiac injury and acute respiratory distress syndrome (ARDS), and worse prognosis than general and severe patients. The critical patients exhibited larger right-heart chambers, worse RV fractional area change (RVFAC), 2D-RVFWLS, and 3D-RVEF and higher proportion of pulmonary hypertension than general and severe patients. Eighteen patients died during a median follow-up of 91 days. The multivariate Cox regression analysis revealed the acute cardiac injury, ARDS, RVFAC, RVFWLS, and 3D-RVEF were independent predictors of death. 3D-RVEF (chi-square to improve 18.3; P < 0.001), RVFAC (chi-square to improve 4.5; P = 0.034) and 2D-RVFWLS (chi-square to improve 5.1; P = 0.024) all provided additional prognostic value of higher mortality over clinical risk factors. Moreover, the incremental predictive value of 3D-RVEF was significantly (P < 0.05) higher than RVFAC and RVFWLS.Conclusion: 3D-RVEF was the most robust independent predictor of mortality in COVID-19 patients and provided a higher predictive value over conventional RV function parameters and RVFWLS, which may be helpful to identify COVID-19 patients at a higher risk of death.

Echocardiography, lung ultrasound, and cardiac magnetic resonance findings in COVID‐19: A systematic review

“…71 In another study of 128 COVID-19 patients with more than 50% of patients considered critical, low RVFAC, RV strain pattern, and 3D RV ejection fraction (EF) were independent predictors of mortality in their respective order with low 3D RVEF having the highest predictive value. 70 However, in other studies among COVID-19 patients RVFAC was not significantly different between survivors compared with non-survivors. 47,55,56 Finally, a study by D'Alto et al demonstrated that right ventriculararterial uncoupling expressed as TAPSE/PASP is an independent predictor of mortality in COVID-19 patients.…”

“…44,46,57 Further, E/e′ ratio was not significantly altered in the severe forms of COVID-19 compared with mild form or between survivors and non survivors. 44,53,55,57,70,71 Of note, in a study of COVID-19 patients that included 90% of patients on mechanical ventilation and 50% in prone position showed that E/e′ ratio was significantly higher in non-survivors, and it was a predictor of mortality on univariate but not on multivariate analysis. 52 However, two reports demonstrated that E/e′ ratio may be significantly higher in critically ill patients compared with healthy volunteers and milder forms of the disease.…”

Relationship between echocardiographic tricuspid annular plane systolic excursion and mortality in COVID‐19 patients: A Meta‐analysis

“…After removing duplicates, 126 studies were excluded based on their title and/or abstract. Then, screening of the full texts of the remaining 106 articles identified 12 investigations [13][14][15][16][17][18][19][20][21][22][23][24] that met all the eligibility criteria, as showed in Figure 1.…”

The Right Ventricle in COVID-19

“…In the third one, Zhang et al combined 2D-STE strain evaluation with the determination of 3D-RV ejection fraction, which comprehensively evaluates all parts of the RV, including inflow, apical, and outflow portions, in 128 ICU patients. These two indices were both independent predictors of mortality, with 3D-RVEF being the most robust, indicating that this parameter could provide incremental prognostic value over conventional echocardiography in COVID-19 patients [36].…”