The acute coronavirus disease 2019 (COVID-19), due to Severe Respiratory Syndrome Coronavirus-2 causes an inflammatory state with cytokine release.1 Heart function may be affected, particularly in patients presenting with comorbidities and previous cardiovascular disease.2 In the meantime, the COVID-19 causes lung injury and acute respiratory distress syndrome (ARDS), a frequent complication in critically ill patients.3 The ARDS management requires specific lung ventilation strategies using recruiting maneuvers, prone position, high level of positive end-expiatory pressure and low tidal volumes. However, in intensive care unit, ARDS may be associated with hemodynamic instability and right ventricular (RV) dysfunction. The RV, in comparison with the left ventricle, discloses a thin wall with high dispensibility and acts normally in a low resistance system, in spontaneous ventilation. The afterload of the RV is determined by the pulmonary vascular resistance. In ARDS, the presence mechanical ventilation reduces the venous return, due the positive intrathoracic pressure. Also, in this situation, the RV afterload increases, secondary to the increase of the transpulmonary pressure and of the pulmonary vascular resistance and the vasoconstriction related to hypoxemia and hypercapnia.4 The onset of RV dysfunction and RV dilation (Figure 1 ) may also affect the left ventricular function and loading. This is explained by ventricular interdependence and paradoxical septum. In this case, a reduced cardiac output occurs, depressing the systemic perfusion and exposing the patient to RV ischemia. In addition, COVID-19 patients disclose a hyper coagulate state avec a significant incidence of pulmonary thrombotic complications, aggravated the RV afterload.5 The onset of right ventricular dysfunction and RV dilatation (acute cor pulmonale) is associated with excess mortality in ARDS.4 The acute cor pulmonale is classically associated with the following parameters: the driving pressure, the PaCO2 and the PaO2/FiO2 ratio.4 Finally, the RV function, measured by the tricuspid annular plane systolic excursion, the right ventricular fractional area change and the right ventricular longitudinal strain, is a significant predictive factor of mortality in COVID-19 infected patients.6 In this context, in addition with the left ventricular function analysis, it is of importance to check and assess the right ventricle in COVD-19 infected patients, particularly in critical situation.
Figure 1.
COVID-19 pattern and acute respiratory distress syndrome. (A) Right ventricular dilation on computed tomography. (B) Severe pulmonary involvement detected by computed tomography. (C) Echocardiographic right ventricular dilation (apical 4-chamber view). (D) Depressed longitudinal right ventricular strain.
Conflict of Interest
The authors have no conflicts of interest to declare.
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