Ventricular Changes in Patients with Acute COVID-19 Infection: Follow-up of the World Alliance Societies of Echocardiography (WASE-COVID) Study

Abstract

Background: COVID-19 infection is known to cause a wide array of clinical chronic sequelae, but little is known regarding the long-term cardiac complications. We aim to report echocardiographic follow-up findings and describe the changes in left (LV) and right ventricular (RV) function that occur following acute infection.

Methods: Patients enrolled in the World Alliance Societies of Echocardiography-COVID study with acute COVID-19 infection were asked to return for a follow-up transthoracic echocardiogram. Overall, 198 returned at a mean of 129 days of follow-up, of which 153 had paired baseline and follow-up images that were analyzable, including LV volumes, ejection fraction (LVEF), and longitudinal strain (LVLS). Right-sided echocardiographic parameters included RV global longitudinal strain, RV free wall strain, and RV basal diameter. Paired echocardiographic parameters at baseline and follow-up were compared for the entire cohort and for subgroups based on the baseline LV and RV function.

Results: For the entire cohort, echocardiographic markers of LV and RV function at follow-up were not significantly different from baseline (all P > .05). Patients with hyperdynamic LVEF at baseline (>70%), had a significant reduction of LVEF at follow-up (74.3% ± 3.1% vs 64.4% ± 8.1%, P < .001), while patients with reduced LVEF at baseline (<50%) had a significant increase (42.5% ± 5.9% vs 49.3% ± 13.4%, P = .02), and those with normal LVEF had no change. Patients with normal LVLS (<-18%) at baseline had a significant reduction of LVLS at follow-up (-21.6% ± 2.6% vs -20.3% ± 4.0%, P = .006), while patients with impaired LVLS at baseline had a significant improvement at follow-up (-14.5% ± 2.9% vs -16.7% ± 5.2%, P < .001). Patients with abnormal RV global longitudinal strain (>-20%) at baseline had significant improvement at follow-up (-15.2% ± 3.4% vs -17.4% ± 4.9%, P = .004). Patients with abnormal RV basal diameter (>4.5 cm) at baseline had significant improvement at follow-up (4.9 ± 0.7 cm vs 4.6 ± 0.6 cm, P = .019).

Conclusions: Overall, there were no significant changes over time in the LV and RV function of patients recovering from COVID-19 infection. However, differences were observed according to baseline LV and RV function, which may reflect recovery from the acute myocardial injury occurring in the acutely ill. Left ventricular and RV function tends to improve in those with impaired baseline function, while it tends to decrease in those with hyperdynamic LV or normal RV function.

Keywords: COVID-19; Echocardiography; Left ventricular function; Right ventricular function; WASE.

Figure 1

Study flow chart. After excluding patients without analyzable echocardiograms at either baseline or follow-up (dashed lines and boxes), 153 patients with paired echocardiograms were included in the current substudy. These were all surviving patients that returned for follow-up, which occurred 129 ± 60 days after the initial admission for acute COVID-19 infection. FU, Follow-up.

Figure 2

Overall trends in LV and RV function from baseline to follow-up. Using a pairwise analysis to compare baseline and follow-up echocardiograms, there were no significant differences between baseline and follow-up in LV and RV function. The width of each “violin” reflects the number of cases for each echocardiographic variable in the vertical axis, a compact display of a continuous distribution of each data population. The central values displayed on these plots are the mean and SD values.

Figure 3

Changes in LVEF grouped by baseline LV function. In patients with hyperdynamic EF (>70%) at baseline, there was a significant decrease in LVEF at the time of follow-up. In patients with normal but not hyperdynamic LVEF (50%–70%), there was no significant change. In patients with abnormal LVEF at baseline (<50%), there was significant improvement in LVEF at the time of follow-up. The width of each “violin” reflects the number of cases for each echocardiographic variable in the vertical axis, a compact display of a continuous distribution of each data population. The central values displayed on these plots are the mean and SD values.

Figure 4

Changes in LVLS grouped by baseline function. In patients with normal LVLS (<−18%) at baseline, there was a significant worsening of LVLS at the time of follow-up, while in patients with reduced LVLS at baseline, there was a significant improvement. The width of each “violin” reflects the number of cases for each echocardiographic variable in the vertical axis, a compact display of a continuous distribution of each data population. The central values displayed on these plots are the mean and SD values.

Figure 5

Changes in RVGLS and RVFWS grouped by baseline RV function. Patients with reduced RV function (global longitudinal strain for free wall strain) improved at the time of follow-up (significant only for RVGLS), and there was no change in those with normal baseline RV function. The width of each “violin” reflects the number of cases for each echocardiographic variable in the vertical axis, a compact display of a continuous distribution of each data population. The central values displayed on these plots are the mean and SD values.

Figure 6

Changes in RVBD grouped by baseline RV size. In patients with abnormal RVBD (>4.5 cm) at baseline, there was significant improvement at the time of follow-up, while in patients with normal RVBD (<4.5 cm) at baseline, there was no significant change. The width of each “violin” reflects the number of cases for each echocardiographic variable in the vertical axis, a compact display of a continuous distribution of each data population. The central values displayed on these plots are the mean and SD values.