Right ventricular-arterial uncoupling independently predicts survival in COVID-19 ARDS

Abstract

Aim: To investigate the prevalence and prognostic impact of right heart failure and right ventricular-arterial uncoupling in Corona Virus Infectious Disease 2019 (COVID-19) complicated by an Acute Respiratory Distress Syndrome (ARDS).

Methods: Ninety-four consecutive patients (mean age 64 years) admitted for acute respiratory failure on COVID-19 were enrolled. Coupling of right ventricular function to the pulmonary circulation was evaluated by a comprehensive trans-thoracic echocardiography with focus on the tricuspid annular plane systolic excursion (TAPSE) to systolic pulmonary artery pressure (PASP) ratio RESULTS: The majority of patients needed ventilatory support, which was noninvasive in 22 and invasive in 37. There were 25 deaths, all in the invasively ventilated patients. Survivors were younger (62 ± 13 vs. 68 ± 12 years, p = 0.033), less often overweight or usual smokers, had lower NT-proBNP and interleukin-6, and higher arterial partial pressure of oxygen (PaO₂)/fraction of inspired O₂ (FIO₂) ratio (270 ± 104 vs. 117 ± 57 mmHg, p < 0.001). In the non-survivors, PASP was increased (42 ± 12 vs. 30 ± 7 mmHg, p < 0.001), while TAPSE was decreased (19 ± 4 vs. 25 ± 4 mm, p < 0.001). Accordingly, the TAPSE/PASP ratio was lower than in the survivors (0.51 ± 0.22 vs. 0.89 ± 0.29 mm/mmHg, p < 0.001). At univariate/multivariable analysis, the TAPSE/PASP (HR: 0.026; 95%CI 0.01-0.579; p: 0.019) and PaO₂/FIO₂ (HR: 0.988; 95%CI 0.988-0.998; p: 0.018) ratios were the only independent predictors of mortality, with ROC-determined cutoff values of 159 mmHg and 0.635 mm/mmHg, respectively.

Conclusions: COVID-19 ARDS is associated with clinically relevant uncoupling of right ventricular function from the pulmonary circulation; bedside echocardiography of TAPSE/PASP adds to the prognostic relevance of PaO₂/FIO₂ in ARDS on COVID-19.

Keywords: ARDS; COVID-19; Echocardiography; Prognosis; Right ventricular-arterial uncoupling.

Fig. 1

Coupling of right ventricular function to the pulmonary circulation evaluated by the tricuspid annular plane systolic excursion (TAPSE) to systolic pulmonary artery pressure (PASP) ratio. a Normal echocardiographic phenotype with increased pulmonary artery systolic pressure (PASP), normal tricuspid annulus plane systolic excursion (TAPSE), and preserved TAPSE/PASP. b Typical right heart echocardiographic phenotype with increased PASP, reduced TAPSE, low TAPSE/PASP, and right/left ventricular basal diameter ratio > 1. IVC inferior vena cava

Fig. 2

Individual values for TAPSE/PASP and PaO₂/FIO₂ ratios. Individual values for the tricuspid annulus plane systolic excursion (TAPSE)/pulmonary artery systolic pressure (PASP) ratio (panel a), and arterial partial pressure of oxygen (PaO₂)/fraction of inspired O₂ (FIO₂) ratio (panel b). Means are indicated by horizontal bars. Both ratios were markedly decreased in non-survivors (p < 0.001)

Fig. 3

ROC curves to predict outcome of as a function of TAPSE/PASP and PaO₂/FIO₂. Both ratios predicted outcome with Youden indices (highest combination of sensitivity and specificity) of, respectively, 0.625 mm/mmHg and 159 mmHg. Abbreviations see Fig. 2

Fig. 4

Survival according to TAPSE/PASP and PaO₂/FIO₂. Kaplan–Meyer curves of % survival over time as a function of TAPSE/PASP and PaO₂/FIO₂ above or below the ROC-determined cutoff values of 0.625 mm/mmHg and 159 mmHg, alone (upper panels) or in combination (lower panel). Abbreviations see Fig. 2