Highlighted Paper: Right Ventricular Dysfunction and Its Association With Mortality in Coronavirus Disease 2019 Acute Respiratory Distress Syndrome

With the national board of echocardiography’s launch of the critical care echocardiography boards in 2019, the growth of this knowledge, and its application to clinical practice, we continue to grow within our profession of critical care medicine. To learn more about becoming board certified in critical care echocardiography click here.

To this end Chotalia et al wanted to investigate by evaluating the right ventricular size, right ventricular function, or the combination of the two, as to whether they could predict mortality in patients with COVID-19 Acute Respiratory Distress Syndrome (ARDS). In their study, they looked at three echocardiology views or measures 1. Right ventricular dilation defined as right ventricular:left ventricular end-diastolic area greater than 0.6 as the sole size measurement, and 2. right systolic impairment as fractional area change less than 35%. OR 3. tricuspid annular plane systolic excursion (TAPSE) less than 17mm as the functional measure. For clarity, note that EITHER the fractional area of change OR the TAPSE measurement was used. This could be valuable as in some patients one measurement might be easier to assess or be more reliable than the other.

 

To learn more about how to assess these measurements, you can visit our online educational tutorials:

1. Normal Apical 4-Chamber View and Ejection Fraction Assessment with Butterfly iQ – click here to learn about right ventricle (dilation) measurements

2. How to Obtain a Left Ventricular Fractional Shortening with the Butterfly iQ – click here, where you will learn about fractional shortening assessment of the left ventricular, in which this information can easily be translated to the right ventricle

3. How to Obtain a Tricuspid Annulus Plane Systolic Excursion (TAPSE) with the Butterfly iQ – click here to learn about how to measure a TAPSE

 

The investigators found that by looking at either RV size or function alone it did not predict an increase in mortality, but taken together they predicted a 72% 90 day mortality rate in the COVID-19 ARDS patient.

 

However, individual values provided other possibly valuable information:

1. Right ventricular fractional area change correlated with Pao2:Fio2 ratio, Paco2, chest radiograph opacification, and dynamic compliance
2. Though not discussed above as one of the three measurements highlighted, right ventricular:left ventricle end-diastolic area, which has to be measured to perform the fractional area change equation, correlated negatively with urine output

 

We at Medical Specialists Associates are excited to see literature such as this come out, as, for quite some time, we have been advocates for bedside echocardiography examinations on most, if not perhaps all, of our intensive care unit patients for the broad range of information it provides. As further studies and more information in this area is published, such a practice may become the new standard of care in ICU.

Until then, performing bedside echocardiography in the COVID-19 ARDS patient appears to be of value for both prognostication as well as for early recognition of disease processes and their hopeful prevention or reversal as a result.

 

KEY POINTS:

1. Right ventricular strain/dysfunction may play a key role in predicting mortality in COVID-19

2. Precise etiology of this maybe multifactorial and complex. Possible coagulopathy, high PEEP levels while on High-PEEP vs Low-PEEP ARDSnet, and/or increased afterload

3. Detection by Point of Care Ultrasound (POCUS) evaluation performed frequently in the ICU may be useful. Determining a screening interval, say daily or every other day to perform POCUS in this patient population, may be warranted

4. Management of RV dysfunction in COVID-19 is unclear currently. Considerations may possibly include dobutamine, milrinone, or pulmonary artery vasodilators, however, there is no guidance on this topic at the time of this writing

 

---

Authors:
Christopher Voscopoulos, MD, MBA, MS, MLS, FCCP, RPNI
President, Medical Specialists Associates
Board Certified in Anesthesiology, Critical Care, Pain Medicine, Addiction Medicine, Critical Care Echocardiography, Transesophageal Echocardiography, and Board Eligible in Neurocritical Care and Obesity Medicine

Nazir Habib, MD
Partner, Medical Specialists Associates
Board Certified in Internal Medicine and Critical Care

 

---

1. Chotalia M, Ali M, Alderman JE, Kalla M, Parekh D, Bangash MN, Patel JM. Right Ventricular Dysfunction and Its Association With Mortality in Coronavirus Disease 2019 Acute Respiratory Distress Syndrome. Crit Care Med. 2021 Oct 1;49(10):1757-1768. doi: 10.1097/CCM.0000000000005167. PMID: 34224453; PMCID: PMC8439642.