The Clinical Role of Right Ventricle Changes in COVID-19 Respiratory Failure Depends on Disease Severity

Abstract

We read with great interest the paper by Paternoster et al.1Paternoster G Bertini P Innelli P et al.Right ventricular dysfunction in patients with COVID-19: A systematic review and meta-analysis.J Cardiothorac Vasc Anesth. 2021; 35: 3319-3324Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar addressing the prognostic role of right ventricle (RV) dysfunction in patients with COVID-19 respiratory failure. We agree with Paternoster et al.1Paternoster G Bertini P Innelli P et al.Right ventricular dysfunction in patients with COVID-19: A systematic review and meta-analysis.J Cardiothorac Vasc Anesth. 2021; 35: 3319-3324Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar that growing evidence (and the experience of our center)2Dandel M. Timely identification of hospitalized patients at risk for COVID-19-associated right heart failure should be a major goal of echocardiographic surveillance.J Am Soc Echocardiogr. 2021; 34: 1323Abstract Full Text Full Text PDF Scopus (1) Google Scholar,3Lazzeri C Bonizzoli M Batacchi S et al.Cardiac involvment in COVID-19-related acute respiratory distress syndrome.Am J Cardiol. 2020; 132: 147-149Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar indicate that the right ventricle (RV) should be the main target of the echocardiographic assessment in COVID-19 disease, including accurate measurements of its dimensions, function, and estimation of systolic pulmonary arterial pressures (sPAP). The relationship between RV dysfunction and mortality in patients with COVID-19 seems to be dependent on the severity of disease. While papers selected in the meta-analysis by Paternoster et al.1Paternoster G Bertini P Innelli P et al.Right ventricular dysfunction in patients with COVID-19: A systematic review and meta-analysis.J Cardiothorac Vasc Anesth. 2021; 35: 3319-3324Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar included heterogeneous populations, studies including only critically ill patients with COVID-19 failed to document a relationship between mortality and RV dysfunction.4Bagate F Masi P D'Humières T et al.Advanced echocardiographic phenotyping of critically ill patients with coronavirus-19 sepsis: A prospective cohort study.J Intensive Care. 2021; 9: 12Crossref PubMed Scopus (8) Google Scholar,5Chotalia M Ali M Alderman JE et al.Right ventricular dysfunction and its association with mortality in coronavirus disease 2019 acute respiratory distress syndrome.Crit Care Med. 2021; 49: 1757-1768Crossref PubMed Scopus (16) Google Scholar Bearing in mind the complex relationship among RV dysfunction, COVID-19 disease severity, and mortality, it is important to define the clinical significance of RV changes in COVID-19 infection. Serial echocardiography and an appreciation of the characteristic features of COVID-19–induced respiratory failure may provide insights. As discussed by Dandel2Dandel M. Timely identification of hospitalized patients at risk for COVID-19-associated right heart failure should be a major goal of echocardiographic surveillance.J Am Soc Echocardiogr. 2021; 34: 1323Abstract Full Text Full Text PDF Scopus (1) Google Scholar,6Dandel M. Heart-lung interactions in COVID-19: Prognostic impact and usefulness of bedside echocardiography for monitoring of the right ventricle involvement.Heart Fail Rev. 2021; 17: 1-15Google Scholar and others,7Lazzeri C Bonizzoli M Batacchi S et al.Persistent right ventricle dilatation in SARS-CoV-2-related acute respiratory distress syndrome on extracorporeal membrane oxygenation support [e-pub ahead of print].J Cardiothorac Vasc Anesth. 2021; (S1053-0770(21)00700-X)https://doi.org/10.1053/j.jvca.2021.08.028Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar,8Bleakley C Singh S Garfield G et al.Right ventricular dysfunction in critically ill COVID-19 ARDS.Int J Cardiol. 2021; 327: 251-258Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar RV dilatation and dysfunction reflect and follow COVID-19–induced pulmonary thrombotic microangiopathy, a feature recognized as a characteristic pattern of COVID-19.9Hariri LP North CM Shih AR et al.Lung histopathology in coronavirus disease 2019 as compared with severe acute respiratory sydrome and H1N1 influenza: A systematic review.Chest. 2021; 159: 73-84Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar,10Margaroli C Benson P Sharma NS et al.Spatial mapping of SARS-CoV-2 and H1N1 lung injury identifies differential transcriptional signatures.Cell Rep Med. 2021; 2100242Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar Thus, RV dilatation and dysfunction may be considered a marker of COVID-19 disease severity but may not fully explain why these changes are not directly related to mortality, especially in critically ill patients.4Bagate F Masi P D'Humières T et al.Advanced echocardiographic phenotyping of critically ill patients with coronavirus-19 sepsis: A prospective cohort study.J Intensive Care. 2021; 9: 12Crossref PubMed Scopus (8) Google Scholar,5Chotalia M Ali M Alderman JE et al.Right ventricular dysfunction and its association with mortality in coronavirus disease 2019 acute respiratory distress syndrome.Crit Care Med. 2021; 49: 1757-1768Crossref PubMed Scopus (16) Google Scholar In contrast, RV dilatation is known to adversely affect prognosis in adult respiratory distress syndrome resulting from other causes.11Zochios V Parhar K Tunnicliffe W et al.The right ventricle in ARDS.Chest. 2017; 152: 181-193Abstract Full Text Full Text PDF PubMed Scopus (92) Google Scholar,12Lazzeri C Cianchi G Bonizzoli M et al.Right ventricle dilation as a prognostic factor in refractory acute respiratory distress syndrome requiring veno-venous extracorporeal membrane oxygenation.Minerva Anestesiol. 2016; 82: 1043-1049PubMed Google Scholar COVID-19–related respiratory changes also demonstrate atypical heart-lung interactions. The relationship between the RV and the pulmonary vasculature in COVID-19 respiratory failure is emphasized by the role of echocardiographic indices of coupling between RV function and pulmonary circulation as prognostic indicators, such as the tricuspid annular plane systolic excursion-to-sPAP ratio.4Bagate F Masi P D'Humières T et al.Advanced echocardiographic phenotyping of critically ill patients with coronavirus-19 sepsis: A prospective cohort study.J Intensive Care. 2021; 9: 12Crossref PubMed Scopus (8) Google Scholar The tricuspid annular plane systolic excursion and/or sPAP recently was investigated in 92 patients with COVID-19–related acute respiratory failure (64%) requiring ventilatory support, and was shown to be an independent predictor of death, with a calculated cut-off of 0.635 mm/mmHg.6Dandel M. Heart-lung interactions in COVID-19: Prognostic impact and usefulness of bedside echocardiography for monitoring of the right ventricle involvement.Heart Fail Rev. 2021; 17: 1-15Google Scholar Because RV failure is more frequent and pronounced in more severe forms of COVID-19 respiratory failure, it can be presumed that different echocardiographic patterns may be detectable across disease severity progression, probably from isolated systolic pulmonary hypertension to overt RV dilatation and dysfunction. Accordingly, in 28 patients with COVID-19–related acute respiratory distress syndrome (ARDS) admitted to our intensive care unit (ICU) assessed by serial echocardiography, sPAP was elevated in all patients on ICU admission but subsequently declined during ICU stay.3Lazzeri C Bonizzoli M Batacchi S et al.Cardiac involvment in COVID-19-related acute respiratory distress syndrome.Am J Cardiol. 2020; 132: 147-149Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar In mechanically ventilated patients with COVID-19 weaned from extracorporeal membrane oxygenation support, serial echocardiography documented a progressive reduction in sPAP. In nonsurvivors (all on extracorporeal membrane oxygenation support), 2 different echocardiographic patterns were identifiable. One group was characterized by RV dysfunction; all of these patients died because of unfavorable progression of COVID-19 pulmonary disease characterized by bilateral pulmonary consolidations. The second group showed higher values of left ventricular ejection fraction and normal RV dimensions and function, but these patients died from septic shock.7Lazzeri C Bonizzoli M Batacchi S et al.Persistent right ventricle dilatation in SARS-CoV-2-related acute respiratory distress syndrome on extracorporeal membrane oxygenation support [e-pub ahead of print].J Cardiothorac Vasc Anesth. 2021; (S1053-0770(21)00700-X)https://doi.org/10.1053/j.jvca.2021.08.028Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar Thus, the detection of RV dilatation and dysfunction in a patient with a COVID-19 infection suggests a severe form of COVID-19, characterized by increased pulmonary vascular resistance and RV afterload increase. Echocardiographic monitoring is strongly suggested to detect dynamic RV changes. None. Right Ventricular Dysfunction in Patients With COVID-19: A Systematic Review and Meta-analysisJournal of Cardiothoracic and Vascular AnesthesiaVol. 35Issue 11PreviewThis systematic review and meta-analysis aimed to describe the features of right ventricular impairment and pulmonary hypertension in coronavirus disease (COVID-19) and assess their effect on mortality. Full-Text PDF