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. 2024 Feb 12;14(1):25.
doi: 10.1186/s13613-024-01241-1.

Comprehensive temporal analysis of right ventricular function and pulmonary haemodynamics in mechanically ventilated COVID-19 ARDS patients

Vasiliki Tsolaki  1 , George E Zakynthinos  2 , Nikitas Karavidas  1 , Vasileios Vazgiourakis  1 , John Papanikolaou  3 , Kyriaki Parisi  1 , Paris Zygoulis  1 , Demosthenes Makris  1 , Epaminondas Zakynthinos  4
Affiliations

Comprehensive temporal analysis of right ventricular function and pulmonary haemodynamics in mechanically ventilated COVID-19 ARDS patients

Vasiliki Tsolaki et al. Ann Intensive Care. .

Abstract

Background: Cardiac injury is frequently reported in COVID-19 patients, the right ventricle (RV) is mostly affected. We systematically evaluated the cardiac function and longitudinal changes in severe COVID-19 acute respiratory distress syndrome (ARDS) admitted to the intensive care unit (ICU) and assessed the impact on survival.

Methods: We prospectively performed comprehensive echocardiographic analysis on mechanically ventilated COVID-19 ARDS patients, using 2D/3D echocardiography. We defined left ventricular (LV) systolic dysfunction as ejection fraction (EF) < 40%, or longitudinal strain (LS) > - 18% and right ventricular (RV) dysfunction if two indices among fractional area change (FAC) < 35%, tricuspid annulus systolic plane excursion (TAPSE) < 1.6 cm, RV EF < 44%, RV-LS > - 20% were present. RV afterload was assessed from pulmonary artery systolic pressure (PASP), PASP/Velocity Time Integral in the right ventricular outflow tract (VTIRVOT) and pulmonary acceleration time (PAcT). TAPSE/PASP assessed the right ventriculoarterial coupling (VACR).

Results: Among 176 patients included, RV dysfunction was common (69%) (RV-EF 41.1 ± 1.3%; RV-FAC 36.6 ± 0.9%, TAPSE 20.4 ± 0.4mm, RV-LS:- 14.4 ± 0.4%), usually accompanied by RV dilatation (RVEDA/LVEDA 0.82 ± 0.02). RV afterload was increased in most of the patients (PASP 33 ± 1.1 mmHg, PAcT 65.3 ± 1.5 ms, PASP/VTIRVOT, 2.29 ± 0.1 mmHg/cm). VACR was 0.8 ± 0.06 mm/mmHg. LV-EF < 40% was present in 21/176 (11.9%); mean LV-EF 57.8 ± 1.1%. LV-LS (- 13.3 ± 0.3%) revealed a silent LV impairment in 87.5%. A mild pericardial effusion was present in 70(38%) patients, more frequently in non-survivors (p < 0.05). Survivors presented significant improvements in respiratory physiology during the 10th ICU-day (PaO2/FiO2, 231.2 ± 11.9 vs 120.2 ± 6.7 mmHg; PaCO2, 43.1 ± 1.2 vs 53.9 ± 1.5 mmHg; respiratory system compliance-CRS, 42.6 ± 2.2 vs 27.8 ± 0.9 ml/cmH2O, all p < 0.0001). Moreover, survivors presented significant decreases in RV afterload (PASP: 36.1 ± 2.4 to 20.1 ± 3 mmHg, p < 0.0001, PASP/VTIRVOT: 2.5 ± 1.4 to 1.1 ± 0.7, p < 0.0001 PAcT: 61 ± 2.5 to 84.7 ± 2.4 ms, p < 0.0001), associated with RV systolic function improvement (RVEF: 36.5 ± 2.9% to 46.6 ± 2.1%, p = 0.001 and RV-LS: - 13.6 ± 0.7% to - 16.7 ± 0.8%, p = 0.001). In addition, RV dilation subsided in survivors (RVEDA/LVEDA: 0.8 ± 0.05 to 0.6 ± 0.03, p = 0.001). Day-10 CRS correlated with RV afterload (PASP/VTIRVOT, r: 0.535, p < 0.0001) and systolic function (RV-LS, 0.345, p = 0.001). LV-LS during the 10th ICU-day, while ΔRV-LS and ΔPASP/RVOTVTI were associated with survival.

Conclusions: COVID-19 improvements in RV function, RV afterload and RV-PA coupling at day 10 were associated with respiratory function and survival.

Keywords: ARDS; COVID-19; Cardiac function; Hemodynamics; PEEP; Pulmonary vascular resistance; RV dysfunction; Strain.

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Conflict of interest statement

The authors declare no competing interests related to the present study.

Figures

Fig. 1
Fig. 1
Flow chart. ACP acute cor pulmonale, ARDS acute respiratory distress syndrome, CAD coronary artery disease, COPD chronic obstructive pulmonary disease, ICU Intensive Care Unit, LBBB left bundle branch block, LVEF left ventricular ejection fraction, MV mechanical ventilation, PE pulmonary embolism;=
Fig. 2
Fig. 2
Echocardiographic findings in patients with COVID-19 ARDS. A Non-survivor patient. (Αi) non-survivor with RV dilation on ICU admission; (Aii) PAcT: 64.6 ms Red arrows indicate the early systolic notch in the ascending part of the RVOT envelope. Please not the triangular spahe of the RVOT envelope indicating increased PVRs. (Aiii) RV dilatation upon re-evaluation; (Aiv) TRV: 3.6 m/sec ≥ PASP = 51.81 mmHg + (CVP: 13 mmHg) = 64.25 mmHg (Av) TAPSE: 1.6 cm (re-evaluation); (Avi) PAcT: 42 ms Red arrows indicate the early systolic notch in the ascending part of the RVOT envelope. Please not the triangular spahe of the RVOT envelope indicating increased PVRs. B Survivor patient. (Bi) survivor with RV dilatation upon ICU admission; (Bii) PAcT: 76.75 ms Red arrows indicate the early systolic notch in the ascending part of the RVOT envelope. Please not the triangular spahe of the RVOT envelope indicating increased PVRs, (Biii) normal size of the RV upon re-evaluation; (Biv) TRV: 2.54 m/sec ≥ PASP = 25.82 mmHg + (CVP: 8 mmHg) = 33.82 mmHg (Bv) TAPSE: 2 cm; (Bvi) PAcT: 95 ms, Please not the normal parabolic shape of the RVOT envelope in indicating normal PVRs. ARDS acute respiratory distress syndrome, CVP central venous pressure, COVID-19 coronavirus disease 2019, PASP pulmonary artery systolic pressure, PVR pulmonary vascular resistance, PAcT pulmonary acceleration time, RV right ventricle, TAPSE tricuspid annular plane systolic excursion, TRV tricuspid regurgitation velocity
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