Response by Szekely et al to Letters Regarding Article, “Spectrum of Cardiac Manifestations in COVID-19: A Systematic Echocardiographic Study”
Authors: Yishay Szekely, Yael Lichter, Yan Topilsky
Journal: Circulation (2021)

HomeCirculationVol. 143, No. 9Response by Szekely et al to Letters Regarding Article, "Spectrum of Cardiac Manifestations in COVID-19: A Systematic Echocardiographic Study" Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBResponse by Szekely et al to Letters Regarding Article, "Spectrum of Cardiac Manifestations in COVID-19: A Systematic Echocardiographic Study" Yishay Szekely, Yael Lichter and Yan Topilsky Yishay SzekelyYishay Szekely Tel Aviv Sourasky Medical Center, Sackler School of Medicine, Tel Aviv University, Israel. , Yael LichterYael Lichter https://orcid.org/0000-0002-1805-4600 Tel Aviv Sourasky Medical Center, Sackler School of Medicine, Tel Aviv University, Israel. and Yan TopilskyYan Topilsky https://orcid.org/0000-0002-6101-8242 Tel Aviv Sourasky Medical Center, Sackler School of Medicine, Tel Aviv University, Israel. Originally published1 Mar 2021https://doi.org/10.1161/CIRCULATIONAHA.120.051635Circulation. 2021;143:e753–e754In Response:We read the letters by Vazgiourakis et al and Carrizales-Sepúlveda et al with great interest, and we thank them for their insightful comments.Carrizales-Sepúlveda et al suggest left ventricular global longitudinal strain (LVGLS) as a better measurement of left ventricular dysfunction in patients with coronavirus disease 2019 (COVID-19). We recently published our experience with speckle tracking echocardiography of both the left ventricle and the right ventricle (RV)1 in the same cohort the authors refer to in their letter.2 Left ventricular tracking echocardiography evaluation was feasible in 93 of 100 patients. Although only 11% of patients had abnormal ejection fraction (≤ 50%), abnormal LVGLS (≤16.6) was observed in 42%. Patients with poorer clinical grade levels had worse LVGLS (P<0.05). Survival was reduced with abnormal LVGLS compared with normal LVGLS (74±7% versus 92±8% at 30-day follow-up; P=0.05). Unadjusted, LVGLS was associated with mortality (hazard ratio, 0.8 [95% CI, 0.68–0.92]; P=0.003) and with a composite of mortality or need for mechanical ventilation (hazard ratio, 0.8 [95% CI, 0.69–0.91]; P=0.005). The association persisted when adjusted for ejection fraction or for tricuspid annular plane systolic excursion and brain natriuretic peptide (hazard ratio for mortality, 0.56 [95% CI, 0.19–0.95]; P=0.02; hazard ratio for the composite event, 0.70 [95% CI, 0.48–0.94]; P=0.01). As hypothesized in the letter, we showed that abnormal LVGLS is more sensitive and superior to ejection fraction for predicting adverse outcome in patients with COVID-19.Vazgiourakis et al point out that mechanical ventilation may be a potential contributor to RV dysfunction in patients with COVID-19. Following their suggestion, we present the data on mechanical ventilation variables and other parameters of the patient's respiratory system and reanalyzed the data on associations between mechanical ventilation parameters and echocardiographic patterns in 16 patients who were ventilated and underwent repeat echocardiography. In these patients, mean positive end-expiratory pressure (PEEP), tidal volume, and fraction of inspired oxygen were 11.1±3.2 cm H2O, 445±58 mL, and 61.8±21%, respectively. Lung compliance was documented in only 4 patients (28.7±10.5 mL/cm H2O). Pao2/fraction of inspired oxygen was <300 mm Hg in 7, <200 mm Hg in 3, and <100 mm Hg in 6 patients. Our analyses show that PEEP values were correlated with RV end-diastolic area index (Spearman ρ, 0.79; P=0.01) and end-systolic area (Spearman ρ, 0.53; P=0.07), but not with other RV-related parameters. Although RV dilatation after initiation of mechanical ventilation was related to positive pressure ventilation itself, we have several reasons to believe this is just 1 piece of the puzzle. First, RV dilatation/dysfunction was the main abnormality in patients with COVID-19 in our cohort, including those who were not ventilated in any stage of their hospitalization. Second, in the general cohort, patients with RV dysfunction were more likely to have worse lung disease (worse oxygen saturation, chest x-ray film findings, and lung ultrasound score), suggesting that RV dysfunction is also related to the pulmonary parenchymal and vascular effects of the disease. Third, the fact that 5 of 16 deteriorating patients had confirmed proximal deep vein thrombosis strengthens the hypothesis on pulmonary vascular thrombosis as a major component in the pathophysiology of the disease, leading also to RV dysfunction. Last, the fact that PEEP correlated with RV size does not solve the mystery. The causation is still a matter left for future research. Is it a higher PEEP that causes RV deterioration? Does worsening lung disease impair the RV and require higher PEEP for adequate oxygenation? Or is it a combination of both? Daily echocardiography of patients with moderate to severe COVID-19, assuming some of them will require invasive mechanical ventilation along their clinical course, with PEEP adjusted not only by gas exchange and lung parameters but also by RV parameters, as suggested by the authors in their letter, may shed some more light on this intriguing and clinically relevant question.Disclosures None.Footnoteshttps://www.ahajournals.org/journal/circReferences1. Rothschild E, Baruch G, Szekely Y, Lichter Y, Kaplan A, Taieb P, Laufer-Perl M, Beer G, Kapusta L, Topilsky YThe predictive role of left and right ventricular speckle-tracking echocardiography in coronavirus disease 2019.JACC Cardiovasc Imaging. 2020. doi: 10.1016/j.jcmg.2020.07.026CrossrefGoogle Scholar2. Szekely Y, Lichter Y, Taieb P, Banai A, Hochstadt A, Merdler I, Gal Oz A, Rothschild E, Baruch G, Peri Y, et al. Spectrum of cardiac manifestations in COVID-19: a systematic echocardiographic study.Circulation. 2020; 142:342–353. doi: 10.1161/CIRCULATIONAHA.120.047971LinkGoogle Scholar eLetters(0)eLetters should relate to an article recently published in the journal and are not a forum for providing unpublished data. Comments are reviewed for appropriate use of tone and language. Comments are not peer-reviewed. Acceptable comments are posted to the journal website only. Comments are not published in an issue and are not indexed in PubMed. Comments should be no longer than 500 words and will only be posted online. References are limited to 10. Authors of the article cited in the comment will be invited to reply, as appropriate.Comments and feedback on AHA/ASA Scientific Statements and Guidelines should be directed to the AHA/ASA Manuscript Oversight Committee via its Correspondence page.Sign In to Submit a Response to This Article Previous Back to top Next FiguresReferencesRelatedDetailsCited By AFŞİN A, SÜNER A, HOŞOĞLU Y and HOŞOĞLU A (2021) Evaluation of the right and left ventricular functions of patients that recovered from COVID‑19 at home, Dicle Tıp Dergisi, 10.5798/dicletip.1001933, (678-687) March 2, 2021Vol 143, Issue 9 Advertisement Article InformationMetrics © 2020 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.120.051635PMID: 33646829 Originally publishedMarch 1, 2021 PDF download Advertisement SubjectsEchocardiographyEmbolismThrombosisUltrasound