Echocardiography and Multimodality Cardiac Imaging in COVID-19 Patients

Abstract

The pandemic caused by the new SARS-CoV-2, named coronavirus disease 2019 (COVID-19) disease, has challenged the health-care systems and raised new diagnostic pathways and safety issues for cardiac imagers. Myocardial injury may complicate COVID-19 infection in more than a quarter of patients and due to the wide a range of possible insults, cardiac imaging plays a crucial diagnostic and prognostic role. There is still little evidence regarding the best-imaging pathway and the echocardiographic findings. Most of the data derive from the single centers experiences and case-reports; therefore, our review reflects the recommendations mainly based on expert opinion. Moreover, knowledge is constantly evolving. The health-care system and physicians are called to reorganize the diagnostic pathways to minimize the possibility of spreading the infection. Thus a rapid, bedside, ultrasound assessment of the heart, chest, and leg veins by point-of-care ultrasound seems to be the first-line tool of the fight against the SARS-CoV-2. A second Level of cardiac imaging is appropriate when the result may guide decision-making or may be life-saving. Dedicated scanners should be used and special pathways should be reserved for these patients. The current knowledge on cardiac imaging COVID-19 patients is reviewed.

Keywords: COVID-19; SARS-CoV-2; echocardiography; imaging; multimodality; pandemic.

Figure 1

Case of cardiogenic shock in a 45 yo COVID-19 man and high hs-troponin levels suggesting possible “fulminant myocarditis”. (a): Three-fascicular block in ECG. (b) hemodynamic parameters show low arterial pressure and cardiac index, high systemic vascular resistance index, low global end diastolic index and increased extravascular lung water index. (c and d) Echocardiographic five and three-chamber views showing concentric hypertrophy or “pseudo”-hypertrophy due to myocardial edema with reduced left ventricular volume and systolic function (frame from Video 3)

Figure 2

Ultrasound diagnosis of pulmonary embolism treated with thrombolysis in a COVID-19 patient who underwent a cardiac arrest due to pulseless electrical activity. (a) Venous Ultrasound showing a deep femoral vein thrombosis. (b) Echocardiographic long-axis view showing a right ventricle enlargement and dysfunction. (C) Echocardiographic sub-xifoideal view showing a right ventricle enlargement and dysfunction (frame of Video 2). (d) After thrombolysis the echocardiographic long-axis view shows a right ventricle enlargement and dysfunction recovery which is confirmed by the sub-xifoideal approach (e)

Figure 3

Ecocardiographic posterior views in COVID-19 patient. (a) Chest X-ray with multiple, bilateral and diffuse peripheral opacities. (b) CT scan with bilateral, subpleural opacities, septal thickening, air space consolidations and pleural effusion. (c-e) Ecocardiographic left posterior views showing, through pleural and pericardial effusion and parenchimal consolidation, left ventricle in short axis (diastolic frame of Video 1). (e) Systolic frame of same video. (d) Left posterior view in another case of large pleural effusion. (f) Right posterior view showing inferior vena cava collapsibility

Figure 4

Computed tomography scan showing a right (a) and Left (b) appendage thrombosis