Evaluation of Right Ventricular Function of Patients with COVID-19 Pneumonia after Discharge with Right Ventricle Early Inflow-Outflow Index

Abstract

Aim The coronavirus disease 2019 (COVID-19) causes many cardiovascular complications. In patients with comorbidities, COVID-19 infection has a more severe course. Although some patients who do not have comorbidities, severe infection and death may occur. In studies, many echocardiographic parameters were found to be impaired in patients with COVID-19 pneumonia. The right ventricular premature inflow-output flow (RVEIO) index is a possible and indirect predictor of the severity of right ventricular dysfunction. The aim of our study is to evaluate the RVEIO index after discharge in patients with moderate-to-severe COVID-19 pneumonia without comorbidities. Methods The study was conducted in a single center, prospectively. One month after discharge, echocardiography and biochemical tests were performed in 57 patients with moderate-to-severe COVID-19 pneumonia without comorbidities. Results Pulmonary artery diameter was found to be significantly larger in the severe group [1.9 (1.8-2) vs. 2 (1.9-2.1); p=0.014]. Pulmonary artery acceleration time [140.92±11.70 vs 114.58±12.03; p=0.001)] and RVOT VTI [23.48±1.96 vs 19.18±2.2; p  <0.001] was significantly lower, while the RVEIO index was [2.51±0.54 vs 3.22±0.92; p<0.001] was found to be significantly higher in the severe group. Conclusion The long-term effects of COVID-19 infection are unknown. Therefore, follow-up studies should be conducted. Echocardiography can be used in the follow-up of inpatients and discharged patients because of its easy accessibility and low cost. Long-term follow-up should be conducted for individuals who had a severe COVID-19 pneumonia and who do not have comorbidities. The RVEIO index may be used in the follow-ups.

Keywords

• COVID‐19
• Pneumonia
• RVEIO Index
• Right Ventricular Function

COVID-19 Pnömonili Hastaların Taburculuk Sonrası Sağ Ventrikül Fonksiyonunun Sağ Ventriküler Erken Giriş-Çıkış İndeksi ile Değerlendirilmesi

Öz

Amaç Koronavirüs hastalığı 2019 (COVID-19) birçok kardiyovaküler komplikasyona neden olmaktadır. Komorbiditesi olan hastalarda, COVID-19 enfeksiyonu daha ağır seyir etmektedir. Bazı hastaların komorbiditesi olmamasına rağmen, ağır enfeksiyon ve ölüm görülebilmektedir. Çalışmalarda COVID-19 pnömonili hastalarda, birçok ekokardiyografi parametresinin bozulduğu saptanmıştır. Sağ ventrikül erken giriş-çıkış akışı (RVEIO) indeksi, sağ ventrikül disfonksiyonunun şiddetinin olası ve dolaylı bir belirtecidir. Çalışmamızın amacı, COVID-19 pnömonisini orta-ciddi geçiren, komorbiditesi olmayan hastalarda taburculuk sonrası RVEIO indeksini değerlendirmektir. Yöntemler Çalışma tek merkezde, prospektif yapıldı. Taburculuktan 1 ay sonra, komorbiditesi olmayan, 57 orta-ciddi COVID-19 pnömonili hastanın ekokardiyografisi ve biyokimyasal testleri yapıldı. Bulgular Pulmoner arter çapı ciddi grupta, anlamlı daha geniş saptandı [1,9 (1,8-2) vs 2 (1,9-2,1); p=0,014]. Pulmoner arter hızlanma süresi [140.92±11.70 vs 114.58±12.03; p=0.001)] ve RVOT VTI [23,48±1,96 vs 19,18±2,2; p  <0,001] anlamlı daha düşük, RVEIO indeksi ise [2,51±0,54 vs 3,22±0,92; p<0,001] ciddi grupta anlamlı daha yüksek saptandı. Sonuç COVID-19 enfeksiyonunun uzun süreli etkilerini bilmiyoruz. Bu nedenle takip çalışmaları yapılmalıdır. Ekokardiyografi tetkiki kolay ulaşılabilir ve az maliyetli olması nedeniyle yatan hastalar ile taburcu edilen hastaların takiplerinde kullanılabilir. Özellikle hastalığı ciddi geçiren, komorbiditeleri olmayan bireylerin bile uzun dönem takipleri yapılmalıdır. Takiplerde RVEIO indeksi kullanılabilir.

Anahtar Kelimeler

• COVID‐19
• Pnömoni
• RVEIO Index
• Sağ Ventrikül Fonksiyonu

Kaynakça

1. 1. Guan WJ, Ni ZY, Hu Y, Liang WH, Ou CQ, He JX, et al. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med. 2020;382:1708–1720. doi: 10.1056/NEJMoa2002032.
2. 2. Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020 Feb 15;395(10223):497-506. doi: 10.1016/S0140-6736(20)30183-5.
3. 3. Higgins V, Sohaei D, Diamandis EP, Prassas I. COVID-19: from an acute to chronic disease? Potential long-term health consequences. Crit Rev Clin Lab Sci. 2021 Aug;58(5):297-310. doi: 10.1080/10408363.2020.1860895.
4. 4. Puri A, He L, Giri M, Wu C, Zhao Q. Comparison of comorbidities among severe and non-severe COVID-19 patients in Asian versus non-Asian populations: A systematic review and meta-analysis. Nurs Open. 2022 Jan;9(1):733-751. doi: 10.1002/nop2.1126.
5. 5. Yin T, Li Y, Ying Y, Luo Z. Prevalence of comorbidity in Chinese patients with COVID-19: systematic review and meta-analysis of risk factors. BMC Infect Dis. 2021 Feb 22;21(1):200. doi: 10.1186/s12879-021-05915-0.
6. 6. Luo J, Zhu X, Jian J, Chen X, Yin K. Cardiovascular disease in patients with COVID-19: evidence from cardiovascular pathology to treatment. Acta Biochim Biophys Sin (Shanghai). 2021 Mar 2;53(3):273-282. doi: 10.1093/abbs/gmaa176.
7. 7. Adu-Amankwaah J, Mprah R, Adekunle AO, Ndzie Noah ML, Adzika GK, Machuki JO. The cardiovascular aspect of COVID-19. Ann Med. 2021 Dec;53(1):227-236. doi: 10.1080/07853890.2020.1861644.
8. 8. Hamouche W, Bisserier M, Brojakowska A, Eskandari A, Fish K, Goukassian DA, et al. Pathophysiology and pharmacological management of pulmonary and cardiovascular features of COVID-19. J Mol Cell Cardiol. 2021 Apr;153:72-85. doi: 10.1016/j.yjmcc.2020.12.009.

9. 9. Li Y, Li H, Zhu S, Xie Y, Wang B, He L, et al. Prognostic value of right ventricular longitudinal strain in patients with COVID-19. JACC Cardiovasc Imaging. 2020 Nov;13(11):2287-2299. doi: 10.1016/j.jcmg.2020.04.014.
10. .10. Wibowo A, Pranata R, Astuti A, Tiksnadi BB, Martanto E, Martha JW, et al. Left and right ventricular longitudinal strains are associated with poor outcome in COVID-19: a systematic review and meta-analysis. J Intensive Care. 2021 Jan 12;9(1):9. doi: 10.1186/s40560-020-00519-3.
11. 11. Gul M, Inci S, Aktas H, Yildirim O, Alsancak Y. Hidden danger of COVID-19 outbreak: evaluation of subclinical myocardial dysfunction in patients with mild symptoms. Int J Cardiovasc Imaging. 2021 doi: 10.1007/s10554-021-02318-9.
12. 12. Sirico D, Di Chiara C, Costenaro P, Bonfante F, Cozzani S, Plebani M, et al. Left ventricular longitudinal strain alterations in asymptomatic or mildly symptomatic paediatric patients with SARS-CoV-2 infection. Eur Heart J Cardiovasc Imaging. 2021 doi: 10.1093/ehjci/jeab127.
13. 13. Wu Q, Zhou L, Sun X, Yan Z, Hu C, Wu J. Altered lipid metabolism in recovered SARS patients twelve years after infection. Sci Rep. 2017 Aug 22;7(1):9110. doi: 10.1038/s41598-017-09536-z.
14. 14. Acar E, İzci S, Inanir M, Yılmaz MF, Izgi IA, Kirma C. Right ventricular early inflow-outflow index-a new method for echocardiographic evaluation of right ventricle dysfunction in acute pulmonary embolism. Echocardiography. 2020 Feb;37(2):223-230. doi: 10.1111/echo.14591.
15. 15. Kahyaoglu M, Guney MC, Deniz D, Kılıc E. Right ventricle early inflow‐outflow index may inform about the severity of pneumonia in patients with COVID‐19. J Clin Ultrasound.2022;50:7–13. doi.org/10.1002/jcu.23066.
16. 16. WHO 2020. Global surveillance for COVID-19 caused by human infection with COVID-19 virus.
17. 17. Lang RM, Badano LP, Mor-Avi V, Afilalo J, Armstrong A, Ernande L, et al. Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr. 2015 Jan;28(1):1-39.e14. doi: 10.1016/j.echo.2014.10.003.
18. 18. Rudski LG, Lai WW, Afilalo J, Hua L, Handschumacher MD, Chandrasekaran K, et al. Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography. J Am Soc Echocardiogr. 2010 Jul;23(7):685-713; quiz 786-8. doi: 10.1016/j.echo.2010.05.010.
19. 19. Lan Y, Liu W, Zhou Y. Right ventricular damage in COVID-19: association between myocardial ınjury and COVID-19. Front Cardiovasc Med. 2021 Feb 16;8:606318. doi: 10.3389/fcvm.2021.606318. eCollection 2021.
20. 20. Li Y, Li H, Zhu S, Xie Y, Wang B, He L, et al. Prognostic value of right ventricular longitudinal strain in patients with COVID-19. JACC Cardiovasc Imaging. 2020 Nov;13(11):2287-2299. doi: 10.1016/j.jcmg.2020.04.014.
21. 21. Silverio A, Di Maio M, Scudiero F, Russo V, Esposito L, Attena E, et al. Clinical conditions and echocardiographic parameters associated with mortality in COVID-19. Eur J Clin Invest. 2021 doi: 10.1111/eci.13638.
22. 22. Carrizales-Sepúlveda EF, Vera-Pineda R, Flores-Ramírez R, Hernández-Guajardo DA, Pérez-Contreras E, Lozano-Ibarra MM et al. Echocardiographic manifestations in COVID-19: a review. Heart Lung Circ. 2021 Aug;30(8):1117-1129. doi: 10.1016/j.hlc.2021.02.004.
23. 23. Corrales-Medina VF, Alvarez KN, Weissfeld LA, Angus DC, Chirinos JA, Chang CC, et al. Association between hospitalization for pneumonia and subsequent risk of cardiovascular disease. JAMA. 2015 Jan 20;313(3):264-74. doi: 10.1001/jama.2014.18229.
24. 24. Kytömaa S, Hegde S, Claggett B, Udell JA, Rosamond W, Temte J, et al. Association of influenza-like illness activity with hospitalizations for heart failure: the atherosclerosis risk in communities study. JAMA Cardiol. 2019 Apr 1;4(4):363-369. doi: 10.1001/jamacardio.2019.0549.
25. 25. Cool CD, Rai PR, Yeager ME, Hernandez-Saavedra D, Serls AE, Bull TM, et al. Expression of human herpesvirus 8 in primary pulmonary hypertension. N Engl J Med. 2003 Sep 18;349(12):1113-22. doi: 10.1056/NEJMoa035115.
26. 26. Speich R, Jenni R, Opravil M, Pfab M, Russi EW. Primary pulmonary hypertension in HIV infection. Chest. 1991;100(5):1268–1271. doi: 10.1378/chest.100.5.1268.
27. 27. Potus F, Mai V, Lebret M, Malenfant S, Breton-Gagnon E, Lajoie AC, et al. Novel insights on the pulmonary vascular consequences of COVID-19. Am J Physiol Lung Cell Mol Physiol. 2020 Aug 1;319(2):L277-L288. doi: 10.1152/ajplung.00195.2020.
28. 28. Patel BV, Arachchillage DJ, Ridge CA, Bianchi P, Doyle JF, Garfield B, et al. Pulmonary angiopathy in severe COVID-19: physiologic, imaging, and hematologic observations. Am J Respir Crit Care Med. 2020 Sep 1;202(5):690-699. doi: 10.1164/rccm.202004-1412OC.
29. 29. Ai J, Hong W, Wu M, Wei X. Pulmonary vascular system: A vulnerable target for COVID-19. MedComm (2020). 2021 Oct 17;2(4):531-47. doi: 10.1002/mco2.94.
30. 30. Wang X, Tu Y, Huang B, Li Y, Li Y, Zhang S, et al. Pulmonary vascular endothelial injury and acute pulmonary hypertension caused by COVID‐19: the fundamental cause of refractory hypoxemia? Cardiovasc Diagn Ther. 2020 Aug;10(4):892-897. doi: 10.21037/cdt-20-429.
31. 31. Varga Z, Flammer AJ, Steiger P, Haberecker M, Andermatt R, Zinkernagel AS, et al. Endothelial cell infection and endotheliitis in COVID‐19. Lancet. 2020 May 2;395(10234):1417-1418. doi: 10.1016/S0140-6736(20)30937-5
32. 32. Ackermann M, Verleden SE, Kuehnel M, Haverich A, Welte T, Laenger F, et al. Pulmonary vascular endothelialitis, thrombosis, and angiogenesis in Covid‐19. N Engl J Med. 2020 Jul 9;383(2):120-128. doi: 10.1056/NEJMoa2015432.
33. 33. Karagodin I, Singulane CC, Besser SA, Singh A, Addetia K, DeCara JM, et al. Comparison of clinical and echocardiographic features of first and second waves of COVID-19 at a large, tertiary medical center serving a predominantly African American patient population. Int J Cardiovasc Imaging. 2021 doi: 10.1007/s10554-021-02393-y.
34. 34. Mostafavi A, Tabatabaei SA, Fard SZ, Majidi F, Mohagheghi A , Shirani S. Utility of the Right Ventricular Early Inflow-Out Flow Index in the Assessment of Mortality in COVID-19. Iranian Heart Journal 2021; 22(3): 104-114.
35. 35. BJ Kimura, CM Mansour. The RVEIO and RV function: More, please. Journal of Clinical Ultrasound. 18 January 2022. doi.org/10.1002/jcu.23078.