Utility of RV Remodeling Over Risk Stratification in COVID-19
- In this cohort of 510 patients hospitalized with COVID-19 in New York City, RV dilation was more common in men and among those who were mechanically ventilated.
- Adverse RV remodeling (RV dilation and/or dysfunction) was independently associated with a >2-fold increase in risk for mortality in multivariable models.
What are the prognostic implications of right ventricular (RV) dilation and dysfunction in patients hospitalized with coronavirus disease 2019 (COVID-19)?
This cohort study was conducted at three New York City hospitals from March–May 2020, including consecutive adult inpatients with COVID-19 who had transthoracic echocardiograms (TTEs) performed as part of clinical care. RV dysfunction was defined by impairment of both tricuspid annular plane systolic excursion (TAPSE) and tricuspid annular tissue Doppler systolic velocity (S’). RV dilation was defined as RV diameter >4.1 cm in the apical four-chamber view. Clinical endpoints included in-hospital mortality and hospital discharge.
A total of 510 patients (66% male, mean age 64 years) were included. Intensive care unit (ICU) admission occurred in 68% of patients, and 60% were mechanically ventilated. Median follow-up duration after hospital admission was 20 days. RV dilation and dysfunction were quantifiable in 97% and 53% of patients, respectively. RV dilation was present in 35% of patients, and RV dysfunction in 15%. RV dilation was more common in men, among patients who were admitted to the ICU, among those who were mechanically ventilated, and in those with elevated D-dimer. RV dysfunction was more common among patients with left ventricular ejection fraction <55% and in those with elevated troponin and ferritin.
In univariable models, RV dysfunction was associated with greater risk for mortality than RV dilation (RV dysfunction hazard ratio [HR], 2.57; 95% confidence interval [CI], 1.49-4.43; p = 0.001; RV dilation HR, 1.43; 95% CI, 1.05-1.96; p = 0.02). In multivariable models, adverse RV remodeling (RV dilation and/or dysfunction) was independently associated with a >2-fold increase in risk for mortality (p < 0.01). Patients without adverse RV remodeling were more likely to survive to hospital discharge (HR, 1.39; 95% CI, 1.01-1.90; p = 0.041).
RV dilation and dysfunction are associated with increased mortality in patients hospitalized with COVID-19.
This study contributes to the growing body of literature illustrating the adverse prognostic implications of RV dilation and dysfunction in the setting of severe COVID-19. Mechanistic explanations for RV failure in this population are diverse and include hypoxic pulmonary vasoconstriction, left-sided heart failure, and thromboembolic disease. It is important to note that only patients with clinically indicated TTEs were included in this study, and the findings should not be interpreted to suggest that all patients with COVID-19 should have TTEs performed.
A limitation of this study is the fact that RV function was not quantifiable in nearly half of the cohort. This is not surprising, given that TTE image quality and completeness were constrained by mechanical ventilation and infection control considerations. As TAPSE and S’ may be falsely normal, especially in patients with mild RV dysfunction, it is likely that >15% of this population had some degree of RV dysfunction. Future study of convalescent COVID-19 patients will be needed to define the role of advanced imaging techniques, including cardiac magnetic resonance imaging and 3D TTE, in long-term prognostication.
Keywords: Coronavirus, COVID-19, Dilatation, Diagnostic Imaging, Echocardiography, Ferritins, Heart Failure, Hospital Mortality, Patient Discharge, Respiration, Artificial, Risk Assessment, Secondary Prevention, Thromboembolism, Troponin, Vasoconstriction, Ventricular Dysfunction, Right, Ventricular Remodeling
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