Clinical Investigation
Echocardiography in COVID-19 Infection
Echocardiographic Correlates of In-Hospital Death in Patients with Acute COVID-19 Infection: The World Alliance Societies of Echocardiography (WASE-COVID) Study

https://doi.org/10.1016/j.echo.2021.05.010Get rights and content

Highlights

  • A total of 870 patients admitted with COVID-19 were enrolled in nine countries.

  • LV size and function were analyzed by a core lab and AI.

  • LV and RV dysfunction are common in acute COVID-19 illness and portend a poor prognosis.

  • Age, lung disease, LDH, LVLS, and RVFWS were associated with in-hospital mortality.

  • World regional LV/RV differences highlight differences in patient acuity and echo utilization.

Background

The novel severe acute respiratory syndrome coronavirus-2 virus, which has led to the global coronavirus disease-2019 (COVID-19) pandemic is known to adversely affect the cardiovascular system through multiple mechanisms. In this international, multicenter study conducted by the World Alliance Societies of Echocardiography, we aim to determine the clinical and echocardiographic phenotype of acute cardiac disease in COVID-19 patients, to explore phenotypic differences in different geographic regions across the world, and to identify parameters associated with in-hospital mortality.

Methods

We studied 870 patients with acute COVID-19 infection from 13 medical centers in four world regions (Asia, Europe, United States, Latin America) who had undergone transthoracic echocardiograms. Clinical and laboratory data were collected, including patient outcomes. Anonymized echocardiograms were analyzed with automated, machine learning–derived algorithms to calculate left ventricular (LV) volumes, ejection fraction, and LV longitudinal strain (LS). Right-sided echocardiographic parameters that were measured included right ventricular (RV) LS, RV free-wall strain (FWS), and RV basal diameter. Multivariate regression analysis was performed to identify clinical and echocardiographic parameters associated with in-hospital mortality.

Results

Significant regional differences were noted in terms of patient comorbidities, severity of illness, clinical biomarkers, and LV and RV echocardiographic metrics. Overall in-hospital mortality was 21.6%. Parameters associated with mortality in a multivariate analysis were age (odds ratio [OR] = 1.12 [1.05, 1.22], P = .003), previous lung disease (OR = 7.32 [1.56, 42.2], P = .015), LVLS (OR = 1.18 [1.05, 1.36], P = .012), lactic dehydrogenase (OR = 6.17 [1.74, 28.7], P = .009), and RVFWS (OR = 1.14 [1.04, 1.26], P = .007).

Conclusions

Left ventricular dysfunction is noted in approximately 20% and RV dysfunction in approximately 30% of patients with acute COVID-19 illness and portend a poor prognosis. Age at presentation, previous lung disease, lactic dehydrogenase, LVLS, and RVFWS were independently associated with in-hospital mortality. Regional differences in cardiac phenotype highlight the significant differences in patient acuity as well as echocardiographic utilization in different parts of the world.

Keywords

Echocardiography
WASE
International
COVID-19
Mortality
Strain

Abbreviations

2CH
Two-chamber
4CH
Four-chamber
ACC
American College of Cardiology
AI
Artificial intelligence
ASE
American Society of Echocardiography
AUC
Area under the curve
BNP
Brain natriuretic peptide
COVID-19
Coronavirus disease 2019
CRP
C-reactive protein
EF
Ejection fraction
EACVI
European Association of Cardiovascular Imaging
FWS
Free-wall strain
ICU
Intensive care unit
LDH
Lactic dehydrogenase
LV
Left ventricular
LS
Longitudinal strain
LVEDV
Left ventricular end-diastolic volume
LVEF
Left ventricular ejection fraction
LVESV
Left ventricular end-systolic volume
LVLS
Left ventricular longitudinal strain
MICE
Multiple imputations by chained equations
OR
Odds ratio
Q1
Quartile 1
Q3
Quartile 3
ROC
Receiver-operating characteristic
RV
Right ventricular, ventricle
RVBD
Right ventricular basal diameter
RVFWS
Right ventricular free-wall strain
RVLS
Right ventricular longitudinal strain
SARS-CoV-2
Severe acute respiratory syndrome coronavirus-2
TTE
Transthoracic echocardiogram
ULN
Upper limit of normal
WASE
World Alliance Societies of Echocardiography

Cited by (0)

Conflicts of Interests: G.M.W. and T.D. are employees of Ultromics. M.J.M. is on the advisory board and speaker's bureau for Bracco and Philips. R.M.L. is on the advisory board and speaker's bureau for Philips and the advisory board for Caption Health. F.M.A. received institutional (MedStar Health) research grants from TOMTEC, Ultromics, GE, and Caption Health and nonpaid scientific advisory committee for Ultromics. All other authors have no conflicts to disclose related to this work.

This work was supported by the American Society of Echocardiography Foundation, University of Chicago, and MedStar Health with in-kind support from Ultromics and TOMTEC.

1

A full list of additional WASE-COVID investigators is provided after the conclusion.

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