TABLE 1.
Echocardiographic findings in COVID 19
| Study | Design | N | COVID‐19 severity | LV parameters (EF/ Mass index/LVOT VIT/ Takotsubo) | RV parameters (TAPSE/FAC/RV/LV ratio/PAP/ IVC parameters) | LV strain | Strain analysisRV global/free wall strain‐ | Other | Comment |
|---|---|---|---|---|---|---|---|---|---|
| Long Li et al. | Retrospective | 49 | Severe and very severe | LVEF severely reduced in severe COVID‐19 | IVC Max and Min significantly increased in severe COVID‐19. | NA | NA | NA | TAPSE is more impaired in severe ARDS as compared to mild ARDS |
| Sud et al. | Retrospective | 24 patients with significant myocardial injury defined as cardiac toponin more 1 ng/ml | 10/24 were mechanically ventilated |
13/24 patients had LV dysfunction. 11/24 had regional wall motion abnormalities, 4/11 within one single coronary vessel territory |
Isolated RV dysfunction in 4/24 patients | NA | NA |
Patients with LV dysfunction had median troponin of 12 ng/ml IQR, 5.8–27.0 ng/ml. ‐ Troponin was 1.5 ng/ml (IQR, 1.3–3.1 ng/ml in patients with isolate RV dysfunction |
In patients with severe chemical cardiac injury LV dysfunction was observed in almost 50% of patients. |
| Giustino et al. | Multicenter retrospective | 305 | Varying severity | In patients with elevated troponins, regional WMA was more frequently encountered. Apical WMA followed by mid segments were most common. LVEDV, Septal wall thickness, Pw thickness were significantly increased in those with myocardial injury | RV function was significantly more impaired in those with elevated cardiac biomarkers | NA | NA | NA | Patients with COVID‐19 with myocardial injury and WMA have a poorer prognosis than those without WMA |
| Hani M. Mahmoud‐Elsayed et al. | Retrospective study | 35 | Patients with cardiac symptoms | Right ventricle (RV) dilatation (41%) and RV dysfunction (27%). RV impairment was associated with increased D‐dimer and C‐reactive protein levels | NA | NA | NA | NA | |
| Jain et al. | Retrospective study | 72 | NA |
43 patients had normal LVEF 25 reduced LVEF |
RV size was normal in 50 patients and decreased in the rest. 34 patients had reduced RVEF |
NA | NA | NA | There is a significance correlation LVEF and HS troponin (ρ = −.34, p = .006) and LVEF and NT ProBNP (NT‐proBNP and LVEF (ρ = −.29, P = .056) |
| Bleakly et al. | Retrospective study | 10 patents received ultrasound enhancing agents on VV ECMO | NA | NA | NA | NA | NA | NA | A zero‐flow mode can be used to ensure the bubbles from contrast will not shut down the ECMO system and ensure there is no back flow in the circuit |
| Giustiniano at el. | Retrospective study | 107 prone patients with only 8 of them receiving echocardiogram while proned | ICU | When prone, 6/18 did not have change in LVEF | When prone RV diameter reduced in 5/8 patients and increased In 2 PAPs decreased in 6/8 patients and augmented only in 1 | NA | NA | 1/8 patients died, he had increased PAP after proning | NA |
| Argulian et al. | Retrospective study | 33 |
14 (ventilated) 19 (not ventilated) |
10/33 had decreased EF | 13/33 RV enlargement | NA | NA | RV /LV parameters not provided | Ultrasonic agents are safe and increase diagnostic yield of bedside echo |
| Garcia cruz et al. | Retrospective study | 15 | Severe ICU, intubated | 6/15 decreased EF via low MAPSE < 13 mm | Mean TAPSE 17.8 mm, | NA | NA | NA | Transesophageal echo is feasible in patients that are prone positioned in the ICU. |
| Jain et al. | Retrospective study | 72 | NA | 25/72 had low EF < 50% | 29/72 decrease RV systolic function | NA | NA | NA | TTE is a valuable tool in guiding management of COVID‐19 patients. |
| Bursi et al. | Retrospective study | 49 | Mild, mod, severe 11 patients were intubated, 1 was in bilevel positive airway pressure, 17 were in continuous positive airway pressure, 9 were in face mask with high oxygen flow, and 11 were in nasal cannula | LVEF 53 ± 12% | TAPSE 20 ± 4 mm, FAC 41 ± 8%, | LV GLS −15 ± 4% | RV‐GLS −15 ± 5% | NA | Offline 2D echo with speckle tracking can be used in cardiac evaluation of COVID 19 patients. RV strain and TAPSE are associated with higher mortality, RV dysfunction is also a common finding. |
| Bursi F et al. | Prospective study | 49 |
Survivors‐33 Non‐survivors‐16 |
NA | TAPSE, TAPSE/ PASP were significantly reduced in non survivors compared to survivors. No significant difference in RVFAC and PASP | LVGLS was significantly reduced in non survivors compared to survivors | RVGLS and RVFWS were significantly reduced in non‐survivors compared to survivors | NA | Both RVFWS and RVGLS are predictive of death in COVID 19 patients (AUC .77 ± .08 in, p = 0.008, and .79 ± .04, p = 0.004, and this remained significant after controlling for multiple parameters |
| Liu et al. | Prospective study | 43 | ICU | LVSVi and E/E` were significantly reduced in non survivors compared to survivors (p < 0.01 and 0.01 respectively) |
Non‐survivors versus survivors RVDbasal, RVDbasal to apex and PASP were significanly increased (p 0.049, 0.049, and 0.02 respectively) TAPSE, S` were significantly less (p < 0.001 for both) |
NA | NA | the strongest predictor of in‐ICU death was decreased cardiac index [hazard ratio (HR), .67, 95% confidence interval (CI), .45–.98; p = 0.041 |
Pericardial effusion (90.7%), increased left ventricular mass index (60.5%), LV mass was increased in 22 patients, however not different between survivals and non‐ survivals |
| Krishnamoorthi P et al. | Prospective study | 12 | No‐intubation or death versus intubated or died | LVEF and LVGLS was not significantly different between both groups (.71 and .52 respectively) |
RVGLS and RVFWS were significantly higher in patients who did not need intubation or survived (p = 0.007 for both) RVSP was not significantly different between both groups |
NA | NA | NA | LVGLS was reduced in both groups, RVGLS and RVFWS were decreased in patients with poor outcomes. |
| Baycan et al. | Prospective study | 100 | NA | GLS was more in severe group compared to non‐severe and control. LV‐GLS: ‐ 14.5 ± 1.8 versus ‐ 16.7 ± 1.3 versus ‐ 19.4 ± 1.6, respectively [p < 0.001] | RV‐LS: Severe‐ 17.2 ± 2.3 versus non severe ‐ 20.5 ± 3.2 versus Control ‐ 27.3 ± 3.1, respectively [p < 0.001] | Patients in the severe group, LV‐GLS and RV‐LS were decreased compared to patients in the non‐severe and control groups (LV‐GLS: ‐ 14.5 ± 1.8 vs ‐ 16.7 ± 1.3 vs ‐ 19.4 ± 1.6, respectively [p < 0.001]; RV‐LS: ‐ 17.2 ± 2.3 vs ‐ 20.5 ± 3.2 vs ‐ 27.3 ± 3.1, respectively [p < 0.001]) | LV‐GLS and RV‐LS are independent predictors of in‐hospital mortality in patients with COVID‐19. | ||
| D`Alto et al | Prospective | 94 | Severe | No significant difference in any of the LV parameters between patients who survived and those who did not | TAPSE, PASP, TAPSE/PASP ratio, and IVC were significantly different in patients who survived versus those who did not | NA | NA | NA | TAPSE/PASP ratio(RV uncoupling) and PaO2/FiO2 ratio are independent predictors of mortality of patients with severe COVID‐19 |
| Szekely et al. | Prospective study | 100 | Mild, moderate, severe | LV systolic dysfunction n = 10, EF < 50% LV diastolic dysfunction n = 16 | RV dilation/dysfunction, n = 39 | NA | NA | NA | In COVID19, LV systolic function is preserved, but diastolic and RV function are impaired. Elevated troponin and poorer clinical grade are associated with worse RV function. |
| Demerck et al. | Prospective study | 1216 | NA | 19/1216 takotsubo decreased EF 455/1216 | 313/1216 | NA | NA | RV/LV parameters not provided | In this global survey cardiac abnormalities were detected with ECHO in patients with ECHO |
| Li S, Qu YL, et al. | Prospective study | 91 | severe | NA | NA | NA | NA | NA |
This study is for the utility of lung US in assessing COVID complications, TTE and cardiac findings were not addressed. Lung US scores not assessed. |
| Schott JP et al. | Prospective study | 66, African American, male, obese, with hypertension, and with diabetes | Severe |
EF by simpson method 60+‐12 12 out of 66 had impaired LVEF not specified how low, out of which seven previously known to have low EF. Normal LV dimensions in 85%. |
RV/LV ratio ranged from .9 ± .3. RV function preserved 72% TAPSE 20.9 ± 5.0 S’ 12.8 ± 3.3. RV dilated in 81.7% mostly mild in 45% RV base 3.7 ± .8. PAP and IVC not properly assessed and were mostly within normal. |
NA | NA | Increased left ventricular (LV) wall thickness was present in 46 (69.7%) with similar incidence of elevated troponin and average troponin levels compared to normal wall thickness (66.7% vs 52.4%, p = 0.231; 0.88 ± 1.9 vs 1.36 ± 2.4 ng/ml, p = .772). LV dilation was rare (n = 6, 9.1%), as was newly reduced LV ejection fraction (n = 2, 3.0%). | RV dil ation is common in SARS‐CoV‐2 but does not correlate with elevated D‐dimer levels. Increased LV wall thickness is common, while newly reduced LV ejection fraction is rare, and neither correlates with troponin levels. |
| Kerrilynn C. Hennessey et al. | Prospective study | 135 | NA | NA | NA | NA | NA | NA | TTE triage /deferring and cancelling non ICU patients did not affect the patient care. |
| Dweck et al. | Prospective study | 1216 | NA |
55/100 – abnormal echo Left ventricular abnormalities were reported in 479 (39%) In those without pre‐existing cardiac disease (n = 901), the echocardiogram was abnormal in 46%, and 13% had severe disease. |
Right ventricular abnormalities ‐ 397 (33%) | NA | NA | new myocardial infarction in 36 (3%), myocarditis in 35 (3%), and takotsubo cardiomyopathy in 19 (2%). Severe cardiac disease (severe ventricular dysfunction or tamponade) was observed in 182 (15%) patients. | Half the patients with COVID 19 had new abnormalities on echocardiogram, it changed management in third of patients |
| Edgar García‐Cruz et al. | Cross sectional study | 14 | Severe | 6/14 had moderately reduced EF (not specified), those patient had low MAPSE (less than 13), no other characteristics entioned for LV other than 4/16 had LVOT variability(no numbers) | The mean TAPSE was 17.8 mm, the RV S wave 11.5 cm/s, and RV basal diameter 36.6 mm. RV/LV ratio was < 1 in all patients | NA | NA | NA | The study aim was to prove that TT echocardiographic images can be obtained to measure multiple parameters during the prone position ventilation |
| Edgar Garcia et al. | Cross sectional study | 82 | Severe, ICU admission | 11/82 EF < 50% |
23/82 had RV basal diameter > 41 mm 22/82 had TAPSE < 17 mm |
NA | NA | NA | The ORACLE protocol is fast way to evaluate covid‐19 patients. The most frequent ultrasonographic findings were elevated pulmonary artery systolic pressure (69.5%), E/e’ ratio > 14 (29.3%), and right ventricular dilatation (28%) and dysfunction (26.8%) |
| Beyls et al. | Cross sectional study | 54 | Severe, ICU | NA |
Median RV FAC was 43.6% (33.3% to 52.8%), median RV GLS was ‐24.7% (‐22.6% to ‐28.5%) median TMADlat was 23.5 mm (19.0 to 27.9 mm) |
NA | NA | NA | TMAD can be used and is reproducible in assessment of RV function in patients with COVID‐19 related ARDS and prone positioned. |
| Stobe et al. | Cross sectional study | 18 | 14/18 severe, 4/18 mild |
Left‐ventricular mass index (g/m2) 97±19.0 Left‐ventricular ejection fraction (%) 62±6.5 |
NA | NA | Reduced longitudinal strain in more than one basal LV segment 10/14 | Right‐ventricular GLS (%) −26.9±5.8 (for 10 severe, 4 mild) | Study shows myocardial involvement is highly prevalent in patients with COVID‐19. |
| Churchill et al. | Cross sectional study | 125 | 85/125 ICU | 28/125 decreased EF (< 50%) | NA | NA | NA | NA | LV dysfunction is common in patients with elevated troponin |
| Evrard et al. | Case series | 5 patients underwent TEE in prone position | TEE was more useful in determining eccentricity index | NA | NA | NA | NA | TEE may be more useful in prone patient to diagnose acute cor pulmonale and determine eccentricity index | |
| Pacileo et al. | Review article | NA | NA | NA | NA | NA | NA | Mainly addressing logistics of doing TTE and TEE in COVID pandemic with no mention on TTE findings or relation to severity | NA |
| Teran F, et al. | Expert opinions | Severe | NA | NA | NA | NA | NA | The article discusses when TEE is of choice compared to TTE, no Echo parameters not discussed, no patient population mentioned, consensus and advisory for TEE | TEE is of choice in when TTE is inadequate in VV ecmo, cardiac arrest and prone ventilation and also for lung eval, no lung US scores. |
| C. Beyls et al. | Prospective study | 29 | Moderate to severe | NA |
Ten (34%) out of 29 patients had RV dysfunction. ACP was diagnosed in 12 patients (41%). For RV parameters (TAPSE, RV‐S0, and RV‐FAC), no differences were found between the ACP and non‐ACP groups. |
NA | NA | 2D‐STE parameters (RV‐LSF and RVFWLS) were altered markedly in the ACP group compared with the non‐ACP group |
Classic RV function parameters were not altered by ACP in patients with CARDS, contrary to 2D‐STE parameters. RV‐LSF seems to be a valuable parameter to detect early RV systolic dysfunction in CARDS patients with ACP |
| Gonzalez, Filipe et al. | Prospective study | 30 | ICU patients |
Fair relationship between LVEF and LV GLS. The GLS cut‐off value of − 22% identified a LVEF < 50% with a sensitivity of 63% and a specificity of 80%. All patients with a GLS > − 17% had a LVEF < 50% |
NA | NA | NA | left ventricular GLS was useful to assess left ventricular systolic function. However, right ventricular GLS was poorly correlated with FAC, TAPSE and S’. | |
| Bhatia, Harpreet S et al. | retrospective cohort study | 67 | Moderate to severe | LV EF was normal in 94% of patients |
GLS was abnormal in 91% of patients, Compared to pre‐COVID‐19 echocardiograms, EF was unchanged, but median GLS was significantly worse |
no significant correlation between GLS and hsTnT levels. NT‐proBNP was also not significantly correlated with GLS (r = .08, p = 0.66, n = 38). |
Patients with COVID‐19 had evidence of subclinical cardiac dysfunction manifested by reduced GLS despite preserved EF | ||
| Krishna, Hema et al. | Retrospective cohort study | 179 | NA | EF < 50% in 29 (16%), RWMA in 26 (15%), global dysfunction in 21 (12%), left ventricular hypertrophy in 36 | RV enlargement in 64 (37%), RV systolic dysfunction in 54 (31%), (RVSP) of 35 mm Hg or greater in 44 (44%), tricuspid regurgitation (TR) of mild‐moderate or greater severity in 49 (27%) |
Left ventricular GLS was performed in 11 patients with events and 18 patients without events and was lower in those with events |
Prior echocardiography was available in 36 (20%) patients and pre‐existing abnormalities were seen in 28 (78%) | bedside Doppler assessment of RVSP may be a useful predictive tool for short‐term risk stratification of hospitalized patients with COVID‐19. Caution should be there as pre‐existing abnormalities were common | |
| Shmueli, Hezzy et al. | Retrospective | 60 | NA |
Reduced LVEF (< 50%) 23%. Diastolic Dysfunction 75%. Grade 1:52.5%. Grade 2:17.5%. Grade 3:5.0%. Abnormal LV global longitudinal strain 80%. RWMA + (22%). |
RV systolic function: Normal 47 (81%) Mild: 6 (10.3%) Moderate: 4 (6.9%) Severe: 1 (1.7%) |
abnormal GLS in (80%) of patients. LV‐GLS was significantly reduced in patients with RWMA, compared with those without RWMA. | NA | Subclinical myocardial dysfunction as measured via reduced LV‐GLS is frequent, occurring in 80% of patients hospitalized with COVID‐19, while prevalent LV function parameters such as reduced EF and wall motion abnormalities were less frequent findings | |
| Jain, Renuka et al | Retrospective | 52 | ICU patients |
EF (50%; 64%). 11 had new worsening LV dysfunction. LV function was not associated with morbidity or mortality |
RV enlargement was present in (38%) patients. PAH: 10 (19%). |
Abnormal RV GLS: 28 (78%). |
The most common echocardiographic abnormality is right ventricular dysfunction, which can be assessed more accurately using state‐of‐the‐art echocardiography. | ||
| Li, Yuman et al | Retrospective | 157 | NA |
LV diastolic dysfunction (9.0%), LV systolic dysfunction (5.6%) in CVD patients. CVD patients with high‐sensitivity troponin demonstrated similar systolic or diastolic function compared to normal troponin |
RV dysfunction (30.3%) in CVD patients CVD patients with high troponin showed worsening RV function versus normal troponin |
NA | NA | COVID‐19 patients with CVD had a significantly higher mortality compared to those without |
RV dysfunction is more common than LV dysfunction among COVID‐19 patients with underlying CVD. RV dysfunction is associated with higher mortality. RV function and elevated hs‐TNI level were independent predictors of higher mortality in COVID‐19 patients with CVD. |
| Tudoran, Mariana et al | Retrospective | 125 | Mild to moderate | DD (in 16%). Reduced LV‐SF in 10%. | the prevalence of RVD was only 14.4%. | NA | NA | Alterations of LV‐SF and DD are frequent in post‐acute COVID‐19 infection and are responsible for the persistence of symptoms. | |
| Zhou, Mi et al | Prospective | 97 | Mild cases | impaired left ventricular systolic function with LVEF 44% in 1% only | NA | NA | NA | The most common abnormality was sinus bradycardia | Cardiac abnormality is common amongst COVID‐survivors with mild disease, which is mostly self‐limiting. |
| Norderfeldt, Joakim et al | RETROSPECTIVE | 67 | ICU patients. | NA | 26 patients (39%) displayed a sPAP value of > 35 mm Hg and were designated as having aPH. | NA | NA |
Patients with aPH displayed higher NTproBNP and troponin T plasma levels compared to non‐aPH group. Mortality is higher in the aPH group (46% vs 7%) |
aPH was linked to biomarker‐defined myocardial injury and cardiac failure, as well as an almost sevenfold increase in 21‐d mortality. |
| Günay, Nuran et al. |
Prospective Case‐control |
51 patients 32 healthy |
Moderate to severe | LVEDD and LVESD, IVS and PW, LVEF and LA diameters were similar between the groups |
RVFAC was significantly less in the patient group. Pulmonary artery pressure was significantly higher in the patient group |
RV GLS was less than the control Group. RV free wall strain was significantly less in the patient group. |
subclinical right ventricular dysfunction in the echocardiographic analysis of COVID‐19 patients although there were no risk factors | ||
| Li, Rui et al. | Prospective |
218 patients 23 healthy |
52 critically ill 166 non‐critical |
22% of all patients had reduced LV EF (< 50%). critically ill group had more patients with reduced EF |
83% of all patients had reduced GLS (< −21.0%), critically ill group had more patients with reduced GLS. |
cTnI was elevated in 23 patients (10.8%), including 15 critical cases (28.8%) and eight noncritical cases (4.8%) NT‐proBNP was elevated in 32 patients (15.3%), including 18 critical (34.6%) versus 14 noncritical patients (8.9% |
myocardial dysfunction is common in COVID‐19 patients, particularly those who are critically sick | ||
|
The alteration of GLS was more prominent in the sub‐epicardium than in the sub‐endocardium (p < 0.001) |
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| Özer, Savaş et al | prospective | 74 | NA | Left ventricular EF was lower in the group with myocardial injury (58.9 ± 2.1 vs 59.9 ± 1.7, p = 0.032). | NA |
LV‐GLS was found above ‐18 in 28 (37.8%) patients. Sixteen (57.1%) were in the group with the myocardial injury, and 12 (26.1%) were in the group without myocardial injury (p = 0.014) |
NA | troponin levels were correlated with LV‐GLS values (r = .22, p = 0.045). | Subclinical left ventricular dysfunction was observed in approximately one‐third of the patients at the one‐month follow‐up after COVID‐19 infection. This rate was higher in those who develop myocardial injury during hospitalization |
| Bieber, Stéphanie et al. | Prospective | 32 | NA | LV EF was preserved in both troponin + AND – groups. | systolic dysfunction of the right ventricle was observed more often in patients with myocardial injury group. |
impaired left ventricular (LV (GLS) in patients with myocardial injury. GLS significantly improved in follow up |
RV‐FWS significantly improved from baseline to follow‐up. | Concomitant biventricular dysfunction was common in Trop + group | Myocardial dysfunction partially recovered in hsTNT + patients after 52 days of follow‐up. |
| Zhang, Yanting et al. | Prospective case‐controlled |
128 patients 31 healthy |
Severe to critical | NA |
3D‐RVEF was significantly lower in COVID‐19 patients than in controls. critical patients exhibited significantly higher mitral E/e′, larger RA, RV and worse FAC, 2D‐RVFWLS, and 3D‐RVEF and PAH. |
NA | 2D‐RVFWLS was significantly lower in COVID‐19 patients than in controls | RVFAC, 2D‐RVFWLS, and 3D‐RVEF were associated with mortality | 3D‐RVEF was an independent predictor of mortality in COVID‐19 patients and provided an incremental prognostic value superior to RVFWLS |
| Xie, Yuji et al | Prospective | 132 | NA | NA | Higher PH in severe cases and ARDS. | LV GLS4CH is lower in patient with cardiac injury, ARDS and non‐survivors. | RV FWLS is lower in ptn with cardiac injury, ARDS and non‐survivors. |
LV GLS4CH and RV FWLS are independent and strong predictors of higher mortality in COVID‐19 patients. Forty‐six survivors at 3 months after discharge Had significant improvements in LV GLS4CH, RV FWLS in recovered patients, |
Abbreviations: LVSVi (ml/m2, Left ventricular stroke volume index; PASP, pulmonary artery systolic pressure; TAPSE, tricuspid annular plane systolic excursion; LVEF, Left ventricular ejection fraction; LVGLS, Left ventricular global longitudinal strain; RVFWS, Right ventricular free wall strain; RVGLS, Right ventricular global longitudinal strain; RVSP, Right ventricular systolic pressure; WMA, Wall motion abnormality; Pw, posterior wall thickness.