Association of the changes in pulmonary artery diameters with clinical outcomes in hospitalized patients with COVID-19 infection: A crosssectional study

Abstract

Objective: Enlarged pulmonary artery diameter (PAD) can be associated with mortality risk in coronavirus disease 2019 (COVID-19) patients. Our aim is to find the factors that cause changes in PAD and the relationship between radiological findings and clinical outcomes in COVID-19 patients. Patients and Methods: In this descriptive, retrospective, and single centered study, among the hospitalized 3264 patients, 209 patients with previous chest computed tomography (CT) were included. Findings of current chest CTs of patients obtained during COVID-19 were compared with that of previous chest CTs. Pulmonary involvements, World Health Organization (WHO) Clinical Progression Scale scores and laboratory variables were recorded. Intensive Care Unit (ICU) admission, intubation and mortality were clinical outcomes that were evaluated by using uni – and multivariate analyses. Results: Patients with high D-dimer had significantly increased risk for enlarged PAD and increase in PAD compared to previous chest CT (ΔPAD) (OR=1.18, p<0.05, OR=1.2 p<0.05). Both high D-dimer and an increase over 2 mm in PAD (ΔPAD 2mm) had significant risks for ICU admission, intubation, and mortality (OR= 1.18 p<0.01, OR=1.22 p<0.01, OR=2.62 p<0.05, OR=2.12 p<0.01, OR=2.32 p<0.01, OR=2.09 p<0.001 respectively). It was found that with enlarged PAD, risk of ICU admission and mortality increased. (OR=3.03 p<0.001, OR=2.52 p<0.01). Combined with age and lymphocyte counts, PAD predicted mortality with a 50% sensitivity, 88% specificity (AUC=0.83, p<0.001). Conclusion: PPatients with an increase over 2 mm (ΔPAD 2mm) in PAD had significantly increased clinical severity, ICU admission, intubation, and mortality. High levels of D-dimer and CRP in patients suggest that increased inflammation and thrombosis may be effective in pathogenesis.

Keywords

• Pulmonary artery diameter
• COVID-19
• Thromboembolism
• CoRad
• WHO score

References

1. Suh YJ, Hong H, Ohana M, et al. Pulmonary embolism and deep vein thrombosis in COVID-19: A Systematic review and meta-analysis. Radiology 2021;298: 70-80. doi: 10.1148/ RADIOL.202.020.3557
2. Fox SE, Akmatbekov A, Harbert JL, Li G, Brown JQ, Heide RSV. Pulmonary and cardiac pathology in African American patients with COVID19: an autopsy series from New Orleans. The Lancet Respir Med 2020; 8, 681-9. doi: 10.1016/S2213- 2600(20)30243-5
3. Jiménez D, García-Sanchez A, Rali P, et al. Incidence of VTE and bleeding among hospitalized patients with coronavirus disease 2019: A systematic review and meta-analysis. Chest 2021;159, 1182-96. doi: 10.1016/j.chest.2020.11.005
4. Helms J, Tacquard C, Severac F, et al. High risk of thrombosis in patients with severe SARS-CoV-2 infection: A multicenter prospective cohort study. Intensive Care Med 2020; 46, 1089- 98. doi: 10.1007/s00134.020.06062-x Jevnikar M, Sanchez O, Chocron R, et al. Prevalence of pulmonary embolism in patients with COVID-19 at the time of hospital admission. Eur Respir J 2021;58:2100116. doi: 10.1183/13993.003.00116-2021
5. D’Andrea, A, Scarafile R, Riegler L, et al. Right ventricular function and pulmonary pressures as independent predictors of survival in patients with COVID-19 Pneumonia. JACC: Cardiovasc Imaging 2020;13:2467-8. doi: 10.1016/j. jcmg.2020.06.004
6. Jalde FC, Beckman MO, Svensson AM, et al. Widespread parenchymal abnormalities and pulmonary embolism on contrast-enhanced CT predict disease severity and mortality in hospitalized COVID-19 patients. Front Med 2021;8:666723. doi: 10.3389/fmed.2021.666723
7. Ackermann M, Verleden SE, Kuehnel M, et al. Pulmonary vascular endothelialitis, thrombosis, and angiogenesis in Covid-19. NEJM 2020; 38: 120-8. doi: 10.1056/nejmoa2015432
8. Truong Q. A., Bhatia HS, Szymonifka J, et al. A fourtier classification system of pulmonary artery metrics on computed tomography for the diagnosis and prognosis of pulmonary hypertension. J Cardiovasc Comput Tomogr 2018; 12:60-6. doi: 10.1016/j.jcct.2017.12.001

9. Yildiz M, Yadigar S, Yildiz BŞ, et al. Evaluation of the relationship between COVID-19 pneumonia severity and pulmonary artery diameter measurement. Herz 2021; 46: 56- 62. doi: 10.1007/s00059.020.05014-x
10. Hayama H, Ishikane M, Sato R, et al. Association of plain computed tomography-determined pulmonary arterytoaorta ratio with clinical severity of coronavirus disease 2019. Pulm Circ 2020;10: 204.589.4020969492. doi: 10.1177/204.589.4020969492
11. Schiaffino S, Codari M, Cozzi A, et al. Machine learning to predict in-hospital mortality in covid-19 patients using computed tomography-derived pulmonary and vascular features. J Pers Med 2021;11:501. doi: 10.3390/jpm11060501
12. Esposito A. Palmisano A, Toselli M, et al. Chest CT-derived pulmonary artery enlargement at the admission predicts overall survival in COVID-19 patients: insight from 1461 consecutive patients in Italy. Eur Radiol 2020; 31:4031-41. doi:10.1007/s00330.020.07622-x/Published.
13. Spagnolo P, Cozzi A, Foà RA, et al. CT-derived pulmonary vascular metrics and clinical outcome in COVID19 patients. Quant Imaging Med Surg 2020;10:1325-33. doi: 10.21037/ QIMS-20-546
14. van Dam L F, Kroft LJM, van der Wal LI, et al. Clinical and computed tomography characteristics of COVID-19 associated acute pulmonary embolism: A different phenotype of thrombotic disease? Thromb Res 2020;193:86-9. doi: 10.1016/j.thromres.2020.06.010
15. Bernheim, A. Mei X, Huang M, et al. Chest CT findings in coronavirus disease 2019 (COVID-19): Relationship to duration of infection. Radiology 2020;295,685-91. doi: 10.1148/radiol.202.020.0463
16. Chamorro M E, Tascón D A, Sanz LI, Velez SO, Nacenta S B. Radiologic diagnosis of patients with COVID-19. Radiología (English Edition) 2021;63:56-73. doi: 10.1016/j. rxeng.2020.11.001
17. Marshall JC, Murthy S, Diaz J, et al. A minimal common outcome measure set for COVID-19 clinical research. 20, Lancet Infect Dis 2020; p. e192-7. doi: 10.1016/S1473- 3099(20)30483-7
18. Simadibrata DM, Calvin J, Wijaya AD, Ibrahim NAA. Neutrophil-to-lymphocyte ratio on admission to predict the severity and mortality of COVID-19 patients: A metaanalysis. Am J Emerg Med 2021; 42:60-9. doi: 10.1016/j. ajem.2021.01.006
19. Lagunas-Rangel F A. Neutrophil-to-lymphocyte ratio and lymphocyte-to-C-reactive protein ratio in patients with severe coronavirus disease 2019 (COVID-19): A meta-analysis. J Med Virol 2020; 92:1733-4. doi: 10.1002/jmv.25819
20. Rapkiewicz A v, Mai X, Carsons SE, et al. Megakaryocytes and platelet-fibrin thrombi characterize multi-organ thrombosis at autopsy in COVID-19: A case series. EClinicalMedicine 2020; 24:100434. doi: 10.1016/j.eclinm.2020.100434
21. Tang N, Li D, Wang X, Sun z. Abnormal coagulation parameters are associated with poor prognosis in patients with novel coronavirus pneumonia. J Thromb Haemost 2020;18: 844-7. doi: 10.1111/jth.14768
22. Zhu QQ, Gong T, Huang GQ, et al. Pulmonary artery trunk enlargement on admission as a predictor of mortality in inhospital patients with COVID-19. Jpn J Radiol 2021;39:589- 97. doi: 10.1007/s11604.021.01094-9
23. Meng LB, Yu ZM, Guo P, et al. Neutrophils and neutrophillymphocyte ratio: Inflammatory markers associated with intimal-media thickness of atherosclerosis. Thromb Res 2018;170:45-52. doi: 10.1016/j.thromres.2018.08.002
24. Okugawa Y, Toiyama Y, Yamamoto A, et al. Lymphocyte-Creactive protein ratio as promising new marker for predicting surgical and oncological outcomes in colorectal cancer. Ann Surg 2020;272:342-51. doi: 10.1097/SLA.000.000.0000003239
25. Erdoğan M, Öztürk S, Erdöl MA, et al. Prognostic utility of pulmonary artery and ascending aorta diameters derived from computed tomography in COVID-19 patients. Echocardiography 2021;38:1543-51. doi: 10.1111/echo.15170
26. Eslami V, Abrishami A, Zarei E, Khalili N, Baharvand Z, Sanei-Taheri S. The association of CT-measured cardiac indices with lung involvement and clinical outcome in patients with COVID-19. Acad Radiol 2021;28: 8-17. doi: 10.1016/j. acra.2020.09.012
27. Aoki R, Iwasawa T, Hagiwara E, Komatsu S, Utsunomiya D, Ogura T. Pulmonary vascular enlargement and lesion extent on computed tomography are correlated with COVID-19 disease severity. Jpn J Radiol 2021;39:451-8. doi: 10.1007/ s11604.020.01085-2
28. Ippolito D, Giandola T, Maino C, et al. Acute pulmonary embolism in hospitalized patients with SARS-CoV- 2related pneumonia: multicentric experience from Italian endemic area. Radiol Med 2021;126: 669-78. doi: 10.1007/ s11547.020.01328-2