Elsevier

JACC: Cardiovascular Imaging

Volume 13, Issue 11, November 2020, Pages 2287-2299
JACC: Cardiovascular Imaging

Original Research
Prognostic Value of Right Ventricular Longitudinal Strain in Patients With COVID-19

https://doi.org/10.1016/j.jcmg.2020.04.014Get rights and content
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Abstract

Objectives

The aim of this study was to investigate whether right ventricular longitudinal strain (RVLS) was independently predictive of higher mortality in patients with coronavirus disease-2019 (COVID-19).

Background

RVLS obtained from 2-dimensional speckle-tracking echocardiography has been recently demonstrated to be a more accurate and sensitive tool to estimate right ventricular (RV) function. The prognostic value of RVLS in patients with COVID-19 remains unknown.

Methods

One hundred twenty consecutive patients with COVID-19 who underwent echocardiographic examinations were enrolled in our study. Conventional RV functional parameters, including RV fractional area change, tricuspid annular plane systolic excursion, and tricuspid tissue Doppler annular velocity, were obtained. RVLS was determined using 2-dimensional speckle-tracking echocardiography. RV function was categorized in tertiles of RVLS.

Results

Compared with patients in the highest RVLS tertile, those in the lowest tertile were more likely to have higher heart rate; elevated levels of D-dimer and C-reactive protein; more high-flow oxygen and invasive mechanical ventilation therapy; higher incidence of acute heart injury, acute respiratory distress syndrome, and deep vein thrombosis; and higher mortality. After a median follow-up period of 51 days, 18 patients died. Compared with survivors, nonsurvivors displayed enlarged right heart chambers, diminished RV function, and elevated pulmonary artery systolic pressure. Male sex, acute respiratory distress syndrome, RVLS, RV fractional area change, and tricuspid annular plane systolic excursion were significant univariate predictors of higher risk for mortality (p < 0.05 for all). A Cox model using RVLS (hazard ratio: 1.33; 95% confidence interval [CI]: 1.15 to 1.53; p < 0.001; Akaike information criterion = 129; C-index = 0.89) was found to predict higher mortality more accurately than a model with RV fractional area change (Akaike information criterion = 142, C-index = 0.84) and tricuspid annular plane systolic excursion (Akaike information criterion = 144, C-index = 0.83). The best cutoff value of RVLS for prediction of outcome was −23% (AUC: 0.87; p < 0.001; sensitivity, 94.4%; specificity, 64.7%).

Conclusions

RVLS is a powerful predictor of higher mortality in patients with COVID-19. These results support the application of RVLS to identify higher risk patients with COVID-19.

Key Words

COVID-19
right ventricular function
SARS-CoV-2
speckle tracking echocardiography
strain

Abbreviations and Acronyms

2D
2-dimensional
AIC
Akaike information criterion
ARDS
acute respiratory distress syndrome
CI
confidence interval
COVID-19
coronavirus disease-2019
HR
hazard ratio
LS
longitudinal strain
LV
left ventricular
LVEF
left ventricular ejection fraction
PASP
pulmonary artery systolic pressure
ROC
receiver-operating characteristic
RV
right ventricular
RVFAC
right ventricular fractional area change
RVLS
right ventricular longitudinal strain
S’
tricuspid lateral annular systolic velocity
SARS-CoV-2
severe acute respiratory syndrome-coronavirus-2
STE
speckle-tracking echocardiography
TAPSE
tricuspid annular plane systolic excursion
TR
tricuspid regurgitation

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The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the JACC: Cardiovascular Imaging author instructions page.

Drs. Y. Li, H. Li, S. Zhu, and Y. Xie contributed equally to this work.