Echocardiographic characteristics of patients with SARS-CoV-2 infection

Abstract

Background: Myocardial involvement induced by SARS-CoV-2 infection might be important for long-term prognosis. The aim of this observational study was to characterize the myocardial effects during SARS-CoV-2 infections by echocardiography.

Results and methods: An extended echocardiographic image acquisition protocol was performed in 18 patients with SARS-CoV-2 infection assessing LV longitudinal, radial, and circumferential deformation including rotation, twist, and untwisting. Furthermore, LV deformation was analyzed in an age-matched control group of healthy individuals (n = 20). The most prevalent finding was a reduced longitudinal strain observed predominantly in more than one basal LV segment (n = 10/14 patients, 71%). This pattern reminded of a "reverse tako-tsubo" morphology that is not typical for other viral myocarditis. Additional findings included a biphasic pattern with maximum post-systolic or negative regional radial strain predominantly basal (n = 5/14 patients, 36%); the absence or dispersion of basal LV rotation (n = 6/14 patients, 43%); a reduced or positive regional circumferential strain in more than one segment (n = 7/14 patients, 50%); a net rotation showing late post-systolic twist or biphasic pattern (n = 8/14 patients, 57%); a net rotation showing polyphasic pattern and/or higher maximum net values during diastole (n = 8/14 patients, 57%).

Conclusion: Myocardial involvement due to SARS-CoV-2-infection was highly prevalent in the present cohort-even in patients with mild symptoms. It appears to be characterized by specific speckle tracking deformation abnormalities in the basal LV segments. These data set the stage to prospectively test whether these parameters are helpful for risk stratification and for the long-term follow-up of these patients.

Keywords: COVID-19; Deformation imaging; Myocardial strain; Myocarditis; Rotation; SARS-CoV-2.

Fig. 1

Longitudinal deformation pattern of a SARS-CoV-2-infected patient with severe symptoms: regional peak systolic longitudinal strain values are presented in the apical long axis (a aLAX), 2- (b 2ChV) and 4-chamber view (c 4ChV). Below regional left-ventricular (LV) longitudinal strain (rLS) curves of subepimyocardial (d, g, j), full myocardial (e, h, k) and subendomyocardial tracking (f, i, l) of the aLAX (d–f), 2- (g–i) and 4-ChV (j–l) show reduced basal rLS values. Subepimyocardial (m), full myocardial (n), and subendomyocardial (o) LS bull’s eye patterns and corresponding LS values (p–r) are shown with predominantly reduced rLS inferolateral, anterolateral, and anterior

Fig. 2

Rotational deformation pattern of the same SARS-CoV-2-infected patient with COVID-19 pulmonary disease as in Fig. 1: normal radial strain patterns are documented in apical (a) and basal (b) left-ventricular (LV) segments. Apical rotation was also normal (c), whereas basal rotation showed a regional dispersion with almost no rotation septal and anterior (d, white arrow). Below parasternal short-axis views with segmental subendomyocardial (e, g) and subepimyocardial (f, h) circumferential strain values, strain curves, and color-M-Modes are shown. Abnormal deformation is documented in basal anterior, anterolateral, and inferolateral (g, h white arrows). Line graphs of apical (blue) and basal rotation (magenta) as well as net rotation (twist) (white) (i) and corresponding line graphs of rotation rate (j) document abnormal twist (biphasic apical rotation, i white arrows) and normal untwisting (j)

Fig. 3

Rotational deformation pattern in another SARS-CoV-2-infected patient with severe symptoms: normal radial strain patterns are documented in apical (a), whereas abnormal patterns are shown in basal (b) left-ventricular (LV) segments. Apical rotation was also normal (c), whereas basal rotation showed a regional dispersion with inverse rotation in various LV segments (d, white arrows). Below parasternal short-axis views with segmental subendomyocardial (e, g) and subepimyocardial (f, h ) circumferential strain values, strain curves, and color-M-Modes are shown. Abnormal deformation is documented basal inferior, inferolateral, and anterolateral (g, h white arrows). Line graphs of apical (blue) and basal rotation (magenta) as well as net rotation (twist) (white) (i) and corresponding line graphs of rotation rate (j) document abnormal basal rotation with compensated twist by pronounced apical rotation (i white arrows) and a “chaotic” pattern of net-rotation rate during diastole (j)

Fig. 4

Scheme of longitudinal and radial (a, b) and apical (c, d) and basal (e, f) circumferential and rotational left-ventricular (LV) deformation under normal conditions (a, c, e) and in patients with SARS-CoV-2-infection (b, d, f). Normal changes of longitudinal strain (LS) are documented by longitudinal LV shortening (↑) and normal changes of radial strain (RS) by LV wall thickening (↔) (a). In patients with SARS-CoV-2-infection, regional LS and RS are reduced (b). In comparison to normal conditions (e), basal circumferential strain (CS—black arrows) and clockwise rotation (colored arrows) are severely reduced in patients with SARS-CoV-2 infection (f). In addition, especially basal rRS is reduced (↔) in patients with SARS-CoV-2 infection (f)

Fig. 5

Overview of typical echocardiographic examples of abnormal deformation criteria in SARS-CoV-2-infected patients (left column) including representative schemes (mid column) and description (right column): reduced regional longitudinal strain predominantly in basal LV segments (a), reduced radial strain predominantly in basal LV segments (b), absence or dispersion of basal rotation (c), regional positive circumferential strain predominantly mid/basal lateral and anterior (d), biphasic net rotation (e), and polyphasic curves during systole, higher maximum, and “chaotic” curves of net-rotation rate during diastole (f)

Fig. 6

CMR findings of the same SARS-CoV-2-infected patient with COVID-19 pulmonary disease as in Fig. 1: BTFE images of long-axis view (LAX—a, d), two-chamber view (2-ChV—b, e) and four-chamber view (4ChV—c, f) during diastole (a–c) and systole (d–f). T2STIR sequences of apical (g), mid (h), and basal (i) short-axis views (SAX). Edema is pronounced mid/basal septal-anterior (white arrows). Representative images of T1- (j), T2-mapping (k), and T1-mapping after contrast (l); PSIR sequences of mid/basal SAX views (m–o) documenting regional patchy late enhancement predominantly lateral (white arrows). Scar-T1TFE images of LAX (p), 2-ChV (q), and 4-ChV (r) document late enhancement mid/basal inferolateral (p), inferior (q), and anterolateral (r). Tagging images (s–v) of apical (s, t) and basal SAX (u, v) document abnormal basal rotation

Fig. 7

Rotational deformation pattern of a healthy individual: radial strain patterns in apical (a) and basal (b) left-ventricular (LV) segments as well as apical (c) and basal rotation (d) are documented. Below parasternal short-axis views with apical (e, f) and basal (g, h) segmental subendomyocardial (e, g) and subepimyocardial (f, h) circumferential strain values, strain curves, and color-M-Modes are shown. Line graphs of apical (blue) and basal rotation (magenta) as well as net rotation (twist) (white) (i) and corresponding line graphs of rotation rate (j) document normal findings