Right ventricular dysfunction in critically ill COVID-19 ARDS

Abstract

Aims: Comprehensive echocardiography assessment of right ventricular (RV) impairment has not been reported in critically ill patients with COVID-19. We detail the specific phenotype and clinical associations of RV impairment in COVID-19 acute respiratory distress syndrome (ARDS).

Methods: Transthoracic echocardiography (TTE) measures of RV function were collected in critically unwell patients for associations with clinical, ventilatory and laboratory data.

Results: Ninety patients (25.6% female), mean age 52.0 ± 10.8 years, veno-venous extracorporeal membrane oxygenation (VVECMO) (42.2%) were studied. A significantly higher proportion of patients were identified as having RV dysfunction by RV fractional area change (FAC) (72.0%,95% confidence interval (CI) 61.0-81.0) and RV velocity time integral (VTI) (86.4%, 95 CI 77.3-93.2) than by tricuspid annular plane systolic excursion (TAPSE) (23.8%, 95 CI 16.0-33.9), RVS' (11.9%, 95% CI 6.6-20.5) or RV free wall strain (FWS) (35.3%, 95% CI 23.6-49.0). RV VTI correlated strongly with RV FAC (p ≤ 0.01). Multivariate regression demonstrated independent associations of RV FAC with NTpro-BNP and PVR. RV-PA coupling correlated with PVR (univariate p < 0.01), as well as RVEDAi (p < 0.01), and RVESAi (p < 0.01), and was associated with P/F ratio (p 0.026), PEEP (p 0.025), and ALT (p 0.028).

Conclusions: Severe COVID-19 ARDS is associated with a specific phenotype of RV radial impairment with sparing of longitudinal function. Clinicians should avoid interpretation of RV health purely on long-axis parameters in these patients. RV-PA coupling potentially provides important additional information above standard measures of RV performance in this cohort.

Keywords: Acute respiratory distress syndrome; COVID-19; Critical care; Echocardiography; Right ventricle.

Fig. 1

Proportion of patients with COVID-19 admitted to critical care identified as having abnormal right ventricular function defined by different measures. The tricuspid annular plane systolic excursion (TAPSE) defined 23.8 (95 CI 16.0–33.9) % as having RV dysfunction and 76.2 (95% CI 66.1–84.0) % as having normal RV function. Right ventricular velocity time integral (RV VTI) defined 86.4 (95 CI 77.3–93.2) % as having RV dysfunction and 13.6 (95% CI 7.8–22.7)% as having normal RV function. Right ventricular systolic velocity (RVS’) defined 11.9 (95% CI 6.6–20.5) % as having RV dysfunction and 88.1 (95% CI 79.4–93.4)% as having normal RV function. Right ventricular fractional area change (RV FAC) defined 72.0 (95% CI 61.0–81.0) % as having RV dysfunction and 28.0 (95% CI 19.0–39.0)% as having normal RV function. Right ventricular free wall strain (RVFWS) defined 35.3 (95% CI 23.6–49.0) % as having RV dysfunction and 64.7 (95% CI 51.0–76.4) % as having normal RV function. Chi squared 164.7, df 4, p < 0.001.

Fig. 2

Significant correlations of measures of right ventricular function and right ventricular size in critically unwell patients with COVID-19. A) Right ventricular fractional area change (RV FAC) is plotted against right ventricular end diastolic area index (REVDAI) and B) against indexed right ventricular end systolic area (RVESAi). C) Right ventricular velocity time integral (RV VTI) is plotted against RVEDAi and D) against RVESAi. E) Tricuspid annular plane systolic excursion (TAPSE) is plotted against RVESAi.

Fig. 3

Significant correlations between right ventricular fractional area change (RV FAC) and other measures of right ventricular function in critically unwell COVID-19 patients. A) RV FAC plotted against right ventricular velocity time integral (RV VTI). B) RV FAC plotted against tricuspid annular plane systolic excursion (TAPSE). C) RV FAC plotted against right ventricular S velocity (RVS’).

Fig. 4

Significant correlations of right ventricular size and pulmonary vascular resistance with right ventricular-pulmonary artery coupling measured by right ventricular fractional area change (RV FAC) / Right ventricular systolic pressure (RVSP) in critically unwell patients with COVID-19. A) RV FAC/RVSP plotted against indexed right ventricular end diastolic area (RVEDAi). B) RV FAC/RVSP plotted against indexed right ventricular end systolic area (RVESAi). C) RV FAC/RVSP plotted against pulmonary vascular resistance (PVR).