Study of Right Ventricular Function in Post COVID Syndrome in Recovered Mild Severity COVID-19 Patients Using Conventional and Speckle Tracking Echocardiography
Authors: Salem Ahmed Adel , Kamel Heba , Shabana Adel , Galal Wagdy 
Published: July 2024

Abstract

Background
Many patients seek medical help for COVID-19’s longer term physical and mental effects. The term post COVID syndrome is used by the World Health Organization (WHO) to identify individuals with a history of probable or confirmed COVID-19 infection, usually 3 months from the onset of infection with symptoms that last for at least 2 months and cannot be explained by an alternative diagnosis. Symptoms may be due to persistent chronic inflammation, sequelae of organ damage, and hospitalization and social isolation. These symptoms may persist from the initial infection, or appear after a period of recovery. RV dimensions (RVD) and RV function (RVF) are closely correlated to symptom occurrence and to exercise capacity in many clinical conditions. Consequently, a comprehensive and accurate evaluation of the RV is essential. Echocardiography is the modality of choice for the assessment of RVD and RVF in clinical practice owing to its numerous advantages. It is widely available, relatively cheaper than other modalities, non-invasive, and doesn’t require radiation or contrast injection. Nevertheless, the RV special anatomy, its retrosternal position and its complex architecture pose a challenge to conventional echocardiographic imaging. Novel modalities of echocardiography, such as myocardial deformation imaging by speckle tracking echocardiography (STE), provide the solution to overcome most of these challenges owing to the fact that it is independent of cardiac translation, angle-independent and load-independent.

Aim and Objectives
The aim was to study RV function in post COVID syndrome in recovered mild severity COVID-19 patients using 2D RV STE and correlate these findings with the patients’ symptomatology.

Patients and Methods
This study included 96 subjects divided into 3 age and gender matched groups; the first group consisted of 32 mild severity COVID-19 patients 3-6 months after recovery and not complaining of post COVID-19 syndrome, the second group consisted of 32 mild severity COVID-19 patients 3-6 months after recovery and complaining of post COVID-19 syndrome and the third group consisted of 32 healthy controls who didn’t get COVID-19. This study was conducted at Ain Shams University Hospitals. The patients were recruited from the outpatient ECHO clinic in the cardiology department during the period from March 2022 to August 2022. The entire study population was evaluated via 2D conventional echocardiography and STE imaging.

Results
Our study assessed RV functions at 3-6 months after recovery from mild severity COVID-19 disease. At the follow-up, TAPSE, RV-FAC, RV S’, RV-GLS and RV-FWLS parameters were significantly lower in patients with mild severity COVID-19 disease than healthy controls. They also showed lower values in patients with post COVID syndrome than those without post COVID syndrome with P-value = 0.032, 0.034, 0.003, 0.010 and 0.029 respectively. In addition, RV diameters (longitudinal, mid and basal RVEDD), RV MPI and sPAP values were significantly higher in patients with mild severity COVID-19 disease than healthy controls. They also showed higher values in patients with post COVID syndrome than those without post COVID syndrome with P-value = 0.043, 0.026, 0.014, 0.000 and 0.025 respectively. LV-GLS showed lower value in patients with post COVID syndrome than control group with P-value = 0.002. It also showed lower value in patients with post COVID syndrome than those without post COVID syndrome with P-value = 0.018. We also found that the most common symptom in post COVID syndrome was fatigue, with a percentage of 65.6%, followed by palpitations (40.6%) and chest pain (31%). These three symptoms showed a significant negative relation with RV 2D STE parameters. Additionally, a negative correlation between inflammatory markers including CRP, TLC, PLT, ferritin and D-dimer levels during active infection and long term echocardiographic parameters such as RV-GLS, RV-FWLS and LV-GLS was detected in our study.

Conclusion
We concluded that RV-GLS and RV-FWLS decreased at 3-6 month follow-up of patients with history of mild severity COVID-19 disease especially those complaining of post COVID syndrome. Additionally, it is demonstrated that increased CRP, TLC, PLT, ferritin and D-dimer levels during acute infection is related to RV-GLS, RV-FWLS and LV-GLS values. 2D STE may be used for both detection and follow-up for possible long term right ventricular dysfunction after mild severity COVID-19 disease.
Key words: Post-COVID Syndrome, Speckle Tracking Echocardiography, RV-GLS, RV-FWLS, LV-GLS Abbreviations.
Abbreviations:
RV Right Ventricle
STE Speckle Tracking Echocardiography
2D 2-Dimensional
TAPSE Tricuspid Annular Plane Systolic Excursion
RV-FAC Right Ventricular Fractional Area Change
RV-GLS Right Ventricular Global Longitudinal Strain
RV-FWLS Right Ventricular Free Wall Longitudinal Strain
LV-GLS Left Ventricular Global Longitudinal Strain
RVEDD Right Ventricular End Diastolic Dimension
RV MPI Right Ventricular Myocardial Performance Index
sPAP Systolic Pulmonary Artery Pressure
CRP C – Reactive Protein
TLC Total Leucocytic Count
PLT Platelets
WHO World Health Organization
LVEDD Left Ventricular End Diastolic Dimension
LVESD Left Ventricular End Systolic Dimension
FS Fractional Shortening
EF Ejection Fraction