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Kersten J, Schellenberg J, Jerg A, Kirsten J, Persch H, Liu Y, Steinacker JM. Strain Echocardiography in Acute COVID-19 and Post-COVID Syndrome: More than Just a Snapshot. Biomedicines 2023; 11:1236. [PMID: 37189854 PMCID: PMC10135834 DOI: 10.3390/biomedicines11041236] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 04/19/2023] [Accepted: 04/20/2023] [Indexed: 05/17/2023] Open
Abstract
Speckle-tracking echocardiography (STE) has become an established, widely available diagnostic method in the past few years, making its value clear in cases of COVID-19 and the further course of the disease, including post-COVID syndrome. Since the beginning of the pandemic, many studies have been published on the use of STE in this condition, enabling, on the one hand, a better understanding of myocardial involvement in COVID-19 and, on the other, a better identification of risk to patients, although some questions remain unanswered in regard to specific pathomechanisms, especially in post-COVID patients. This review takes a closer look at current findings and potential future developments by summarising the extant data on the use of STE, with a focus on left and right ventricular longitudinal strain.
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Affiliation(s)
- Johannes Kersten
- Division for Sports and Rehabilitation Medicine, University Hospital of Ulm, 89075 Ulm, Germany
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Wodschow HZ, Davidovski FS, Christensen J, Lassen MCH, Skaarup KG, Nygaard H, Møller N, Rungby J, Biering-Sørensen T, Rossing P, Jensen NJ, Laursen JC. Oral ketone esters acutely improve myocardial contractility in post-hospitalized COVID-19 patients: A randomized placebo-controlled double-blind crossover study. Front Nutr 2023; 10:1131192. [PMID: 36845050 PMCID: PMC9947401 DOI: 10.3389/fnut.2023.1131192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Accepted: 01/24/2023] [Indexed: 02/11/2023] Open
Abstract
Background COVID-19 is associated with subclinical myocardial injury. Exogenous ketone esters acutely improve left myocardial function in healthy participants and patients with heart failure, but the effects have not been investigated in participants previously hospitalized for COVID-19. Methods This is a randomized placebo-controlled double-blind crossover study comparing a single oral ketone ester dose of 395 mg/kg with placebo. Fasting participants were randomized to either placebo in the morning and oral ketone ester in the afternoon or vice versa. Echocardiography was performed immediately after intake of the corresponding treatment. Primary outcome was left ventricular ejection fraction (LVEF). Secondary outcomes were absolute global longitudinal strain (GLS), cardiac output and blood oxygen saturation. Linear mixed effects models were used to assess differences. Results We included 12 participants previously hospitalized for COVID-19 with a mean (±SD) age of 60 ± 10 years. The mean time from hospitalization was 18 ± 5 months. Oral ketone esters did not increase LVEF between placebo and oral ketone ester [mean difference: -0.7% (95% CI -4.0 to 2.6%), p = 0.66], but increased GLS [1.9% (95% CI: 0.1 to 3.6%), p = 0.04] and cardiac output [1.2 L/min (95% CI: -0.1 to 2.4 L/min), p = 0.07], although non-significant. The differences in GLS remained significant after adjustment for change in heart rate (p = 0.01). There was no difference in blood oxygen saturation. Oral ketone esters increased blood ketones over time (peak level 3.1 ± 4.9 mmol/L, p < 0.01). Ketone esters increased blood insulin, c-peptide, and creatinine, and decreased glucose and FFA (all p ≤ 0.01) but did not affect glucagon, pro-BNP, or troponin I levels (all p > 0.05). Conclusion In patients previously hospitalized with COVID-19, a single oral dose of ketone ester had no effect on LVEF, cardiac output or blood oxygen saturation, but increased GLS acutely. Clinical trial registration https://clinicaltrials.gov/, identifier NCT04377035.
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Affiliation(s)
- Helena Zander Wodschow
- Department of Endocrinology, Copenhagen University Hospital, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark,*Correspondence: Helena Zander Wodschow,
| | - Filip Søskov Davidovski
- Department of Cardiology, Copenhagen University Hospital, Gentofte Hospital, Copenhagen, Denmark
| | - Jacob Christensen
- Department of Cardiology, Copenhagen University Hospital, Gentofte Hospital, Copenhagen, Denmark
| | | | | | - Hanne Nygaard
- Department of Emergency Medicine, Copenhagen University Hospital, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
| | - Niels Møller
- Institute of Clinical Medicine, Aarhus University Hospital, Skejby Hospital, Aarhus, Denmark
| | - Jørgen Rungby
- Department of Endocrinology, Copenhagen University Hospital, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark,Complications Research, Steno Diabetes Center Copenhagen, Copenhagen, Denmark,Copenhagen Center for Translational Research, Copenhagen, Denmark
| | - Tor Biering-Sørensen
- Department of Cardiology, Copenhagen University Hospital, Gentofte Hospital, Copenhagen, Denmark
| | - Peter Rossing
- Complications Research, Steno Diabetes Center Copenhagen, Copenhagen, Denmark,Copenhagen Center for Translational Research, Copenhagen, Denmark,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Nicole Jacqueline Jensen
- Department of Endocrinology, Copenhagen University Hospital, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
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Altersberger M, Goliasch G, Khafaga M, Schneider M, Cho Y, Winkler R, Funk G, Binder T, Huber G, Zwick R, Genger M. Echocardiography and Lung Ultrasound in Long COVID and Post-COVID Syndrome, a Review Document of the Austrian Society of Pneumology and the Austrian Society of Ultrasound in Medicine. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2023; 42:269-277. [PMID: 35906952 PMCID: PMC9353420 DOI: 10.1002/jum.16068] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 07/01/2022] [Accepted: 07/08/2022] [Indexed: 05/08/2023]
Abstract
Lung ultrasound has the potential to enable standardized follow-up without radiation exposure and with lower associated costs in comparison to CT scans. It is a valuable tool to follow up on patients after a COVID-19 infection and evaluate if there is pulmonary fibrosis developing. Echocardiography, including strain imaging, is a proven tool to assess various causes of dyspnea and adds valuable information in the context of long COVID care. Including two-dimensional (2D) strain imaging, a better comprehension of myocardial damage in post-COVID syndrome can be made. Especially 2D strain imaging (left and the right ventricular strain) can provide information about prognosis.
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Affiliation(s)
- Martin Altersberger
- Department of CardiologyNephrology and Intensive Care Medicine, State Hospital SteyrSteyrAustria
| | - Georg Goliasch
- Department of Internal Medicine II, Division of CardiologyMedical University of ViennaViennaAustria
| | - Mounir Khafaga
- Rehabilitation Center Hochegg for Cardiovascular and Respiratory DiseasesGrimmensteinAustria
| | - Matthias Schneider
- Department of Internal Medicine II, Division of CardiologyMedical University of ViennaViennaAustria
| | - Yerin Cho
- Department of CardiologyNephrology and Intensive Care Medicine, State Hospital SteyrSteyrAustria
| | - Roland Winkler
- Rehabilitation Center Hochegg for Cardiovascular and Respiratory DiseasesGrimmensteinAustria
| | - Georg‐Christian Funk
- Department of Internal Medicine II, Division of PulmonologyHospital OttakringViennaAustria
| | - Thomas Binder
- Medical University of Vienna, Teaching CenterViennaAustria
| | | | - Ralf‐Harun Zwick
- Therme Wien Med—Outpatient Pulmonary RehabilitationViennaAustria
| | - Martin Genger
- Department of CardiologyNephrology and Intensive Care Medicine, State Hospital SteyrSteyrAustria
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Aragona CO, Bagnato G, Tomeo S, Rosa DL, Chiappalone M, Tringali MC, Singh EB, Versace AG. Echocardiography in Coronavirus Disease 2019 Era: A Single Tool for Diagnosis and Prognosis. J Cardiovasc Echogr 2023; 33:10-16. [PMID: 37426709 PMCID: PMC10328134 DOI: 10.4103/jcecho.jcecho_11_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Revised: 03/07/2023] [Accepted: 03/18/2023] [Indexed: 07/11/2023] Open
Abstract
Coronavirus disease 2019 (COVID-19) is characterized by multi-organ involvement, including respiratory and cardiac events. Echocardiography is widely considered the first-choice tool for the evaluation of cardiac structures and function because of its reproducibility, feasibility, easy to use at bedside, and for good cost-effectiveness. The aim of our literature review is to define the utility of echocardiography in the prediction of prognosis and mortality in COVID-19 patients with mild to critical respiratory illness, with or without known cardiovascular disease. Moreover, we focused our attention on classical echocardiographic parameters and the use of speckle tracking to predict the evolution of respiratory involvement. Finally, we tried to explore the possible relationship between pulmonary disease and cardiac manifestations.
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Affiliation(s)
- Caterina Oriana Aragona
- Department of Emergency, Unit of Emergency Mecicine, AOU Policlinico “G.Martino”, University of Messina, Messina, Italy
| | - Gianluca Bagnato
- Department of Emergency, Unit of Emergency Mecicine, AOU Policlinico “G.Martino”, University of Messina, Messina, Italy
| | - Simona Tomeo
- Department of Emergency, Unit of Emergency Mecicine, AOU Policlinico “G.Martino”, University of Messina, Messina, Italy
| | - Daniela La Rosa
- Department of Emergency, Unit of Emergency Mecicine, AOU Policlinico “G.Martino”, University of Messina, Messina, Italy
| | - Marianna Chiappalone
- Department of Emergency, Unit of Emergency Mecicine, AOU Policlinico “G.Martino”, University of Messina, Messina, Italy
| | - Maria Concetta Tringali
- Department of Emergency, Unit of Emergency Mecicine, AOU Policlinico “G.Martino”, University of Messina, Messina, Italy
| | - Emanuele Balwinder Singh
- Department of Emergency, Unit of Emergency Mecicine, AOU Policlinico “G.Martino”, University of Messina, Messina, Italy
| | - Antonio Giovanni Versace
- Department of Emergency, Unit of Emergency Mecicine, AOU Policlinico “G.Martino”, University of Messina, Messina, Italy
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McErlane J, McCall P, Willder J, Berry C, Shelley B. Right ventricular free wall longitudinal strain is independently associated with mortality in mechanically ventilated patients with COVID-19. Ann Intensive Care 2022; 12:104. [PMID: 36370220 PMCID: PMC9652604 DOI: 10.1186/s13613-022-01077-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 10/22/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Right ventricular (RV) dysfunction has been commonly reported in patients with Coronavirus disease 2019 (COVID-19), and is associated with mortality in mixed cohorts of patients requiring and not requiring invasive mechanical ventilation (IMV). Using RV-speckle tracking echocardiography (STE) strain analysis, we aimed to identify the prevalence of RV dysfunction (diagnosed by abnormal RV-STE) in patients with COVID-19 that are exclusively undergoing IMV, and assess association between RV dysfunction and 30 day mortality. We performed a prospective multicentre study across 10 ICUs in Scotland from 2/9/20 to 22/3/21. One-hundred-and-four echocardiography scans were obtained from adult patients at a single timepoint between 48 h after intubation, and day 14 of intensive care unit admission. We analysed RV-STE using RV free-wall longitudinal strain (RVFWLS), with an abnormal cutoff of > -20%. We performed survival analysis using Kaplan-Meier, log rank, and multivariate cox-regression (prespecified covariates were age, gender, ethnicity, severity of illness, and time since intubation). RESULTS Ninety-four/one-hundred-and-four (90.4%) scans had images adequate for RVFWLS. Mean RVFWLS was -23.0% (5.2), 27/94 (28.7%) of patients had abnormal RVFWLS. Univariate analysis with Kaplan-Meier plot and log-rank demonstrated that patients with abnormal RVFWLS have a significant association with 30-day mortality (p = 0.047). Multivariate cox-regression demonstrated that abnormal RVFWLS is independently associated with 30-day mortality (Hazard-Ratio 2.22 [1.14-4.39], p = 0.020). CONCLUSIONS Abnormal RVFWLS (> -20%) is independently associated with 30-day mortality in patients with COVID-19 undergoing IMV. Strategies to prevent RV dysfunction, and treatment when identified by RVFWLS, may be of therapeutic benefit to these patients. TRIAL REGISTRATION Retrospectively registered 21st Feb 2021. CLINICALTRIALS gov Identifier: NCT04764032.
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Affiliation(s)
- James McErlane
- Anaesthesia, Critical Care & Peri-Operative Medicine Research Group, University of Glasgow, Glasgow, UK.
- Department of Anaesthesia, Golden Jubilee National Hospital, Clydebank, UK.
| | - Philip McCall
- Anaesthesia, Critical Care & Peri-Operative Medicine Research Group, University of Glasgow, Glasgow, UK
- Department of Anaesthesia, Golden Jubilee National Hospital, Clydebank, UK
| | - Jennifer Willder
- West of Scotland School of Anaesthesia, NHS Education for Scotland, Glasgow, UK
| | - Colin Berry
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Ben Shelley
- Anaesthesia, Critical Care & Peri-Operative Medicine Research Group, University of Glasgow, Glasgow, UK
- Department of Anaesthesia, Golden Jubilee National Hospital, Clydebank, UK
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Beyls C, Ghesquières T, Hermida A, Booz T, Crombet M, Martin N, Huette P, Jounieaux V, Dupont H, Abou-Arab O, Mahjoub Y. Feasibility, Prediction and Association of Right Ventricular Free Wall Longitudinal Strain with 30-Day Mortality in Severe COVID-19 Pneumonia: A Prospective Study. J Clin Med 2022; 11:jcm11133629. [PMID: 35806914 PMCID: PMC9267479 DOI: 10.3390/jcm11133629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 06/13/2022] [Accepted: 06/21/2022] [Indexed: 11/22/2022] Open
Abstract
Introduction: Right ventricular (RV) systolic dysfunction (RVsD) is a common complication of coronavirus infection 2019 disease (COVID-19). The right ventricular free wall longitudinal strain parameter (RV-FWLS) is a powerful predictor of mortality. We explored the performance of RVsD parameters for predicting 30-day mortality and the association between RV-FWLS and 30-day mortality. Methods: COVID-19 patients hospitalized at Amiens University Hospital in the critical care unit with transthoracic echocardiography were included. We measured tricuspid annular plane systolic excursion (TAPSE), the RV S’ wave, RV fractional area change (RV-FAC), and RV-FWLS. The diagnostic performance of RVsD parameters as predictors for 30-day mortality was evaluated by the area under the receiver operating characteristic (ROC) curve (AUC). RVsD was defined by an RV-FWLS < 21% to explore the association between RVsD and 30-day mortality. Results: Of the 116 patients included, 20% (n = 23/116) died and 47 had a RVsD. ROC curve analysis showed that RV-FWLS failed to predict 30-day mortality, as did conventional RV parameters (all p > 0.05). TAPSE (21 (19−26) mm vs. 24 (21−27) mm; p = 0.024) and RV-FAC (40 (35−47)% vs. 47 (41−55)%; p = 0.006) were lowered in the RVsD group. In Cox analysis, RVsD was not associated with 30-day mortality (hazard ratio = 1.12, CI 95% (0.49−2.55), p = 0.78). Conclusion: In severe COVID-19 pneumonia, RV-FWLS was not associated with 30-day mortality.
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Affiliation(s)
- Christophe Beyls
- Department of Anesthesiology and Critical Care Medicine, Amiens University Hospital, F-80054 Amiens, France; (T.G.); (T.B.); (M.C.); (P.H.); (H.D.); (O.A.-A.); (Y.M.)
- UR UPJV 7518 SSPC (Simplification of Care of Complex Surgical Patients) Research Unit, University of Picardie Jules Verne, F-80000 Amiens, France
- Correspondence:
| | - Tristan Ghesquières
- Department of Anesthesiology and Critical Care Medicine, Amiens University Hospital, F-80054 Amiens, France; (T.G.); (T.B.); (M.C.); (P.H.); (H.D.); (O.A.-A.); (Y.M.)
| | - Alexis Hermida
- Department of Cardiology, Amiens University Hospital, F-80054 Amiens, France; (A.H.); (N.M.)
| | - Thomas Booz
- Department of Anesthesiology and Critical Care Medicine, Amiens University Hospital, F-80054 Amiens, France; (T.G.); (T.B.); (M.C.); (P.H.); (H.D.); (O.A.-A.); (Y.M.)
| | - Maxime Crombet
- Department of Anesthesiology and Critical Care Medicine, Amiens University Hospital, F-80054 Amiens, France; (T.G.); (T.B.); (M.C.); (P.H.); (H.D.); (O.A.-A.); (Y.M.)
| | - Nicolas Martin
- Department of Cardiology, Amiens University Hospital, F-80054 Amiens, France; (A.H.); (N.M.)
| | - Pierre Huette
- Department of Anesthesiology and Critical Care Medicine, Amiens University Hospital, F-80054 Amiens, France; (T.G.); (T.B.); (M.C.); (P.H.); (H.D.); (O.A.-A.); (Y.M.)
- UR UPJV 7518 SSPC (Simplification of Care of Complex Surgical Patients) Research Unit, University of Picardie Jules Verne, F-80000 Amiens, France
| | - Vincent Jounieaux
- Respiratory Department, Amiens University Hospital, F-80054 Amiens, France;
| | - Hervé Dupont
- Department of Anesthesiology and Critical Care Medicine, Amiens University Hospital, F-80054 Amiens, France; (T.G.); (T.B.); (M.C.); (P.H.); (H.D.); (O.A.-A.); (Y.M.)
- UR UPJV 7518 SSPC (Simplification of Care of Complex Surgical Patients) Research Unit, University of Picardie Jules Verne, F-80000 Amiens, France
| | - Osama Abou-Arab
- Department of Anesthesiology and Critical Care Medicine, Amiens University Hospital, F-80054 Amiens, France; (T.G.); (T.B.); (M.C.); (P.H.); (H.D.); (O.A.-A.); (Y.M.)
| | - Yazine Mahjoub
- Department of Anesthesiology and Critical Care Medicine, Amiens University Hospital, F-80054 Amiens, France; (T.G.); (T.B.); (M.C.); (P.H.); (H.D.); (O.A.-A.); (Y.M.)
- UR UPJV 7518 SSPC (Simplification of Care of Complex Surgical Patients) Research Unit, University of Picardie Jules Verne, F-80000 Amiens, France
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Association between the Right Ventricular Longitudinal Shortening Fraction and Mortality in Acute Respiratory Distress Syndrome Related to COVID-19 Infection: A Prospective Study. J Clin Med 2022; 11:jcm11092625. [PMID: 35566751 PMCID: PMC9103975 DOI: 10.3390/jcm11092625] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 04/29/2022] [Accepted: 05/04/2022] [Indexed: 02/01/2023] Open
Abstract
Introduction: Right ventricular systolic dysfunction (RVsD) increases acute respiratory distress syndrome mortality in COVID-19 infection (CARDS). The RV longitudinal shortening fraction (RV-LSF) is an angle-independent and automatically calculated speckle-tracking parameter. We explored the association between RV-LSF and 30-day mortality in CARDS patients. Methods: Moderate-to-severe CARDS patients hospitalized at Amiens University Hospital with transesophageal echocardiography performed within 48 h of intensive care unit admission were included. RVsD was defined by an RV-LSF of <20%. The patients were divided into two groups according to the presence of RVsD. Using multivariate Cox regression, clinical and echocardiographic risk factors predicting 30-day mortality were evaluated. Results: Between 28 February 2020 and 1 December 2021, 86 patients were included. A total of 43% (n = 37/86) of the patients showed RVsD and 22% (n = 19/86) of the patients died. RV-LSF was observed in 26 (23.1−29.7)% of the no-RVsD function group and 16.5 (13.7−19.4)% (p < 0.001) of the RVsD group. Cardiogenic shock (n = 7/37 vs. 2/49, p = 0.03) and acute cor pulmonale (n = 18/37 vs. 10/49, p = 0.009) were more frequent in the RVsD group. The 30-day mortality was higher in the RVsD group (15/37 vs. 4/49, p = 0.001). In a multivariable Cox model, RV-LSF was an independent mortality factor (HR 4.45, 95%CI (1.43−13.8), p = 0.01). Conclusion: in a cohort of moderate-to-severe CARDS patients under mechanical ventilation, RVsD defined by the RV-LSF was associated with higher 30-day mortalities.
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Altersberger M, Schneider M, Schiller M, Binder-Rodriguez C, Genger M, Khafaga M, Binder T, Prosch H. Point of care echocardiography and lung ultrasound in critically ill patients with COVID-19. Wien Klin Wochenschr 2021; 133:1298-1309. [PMID: 34714384 PMCID: PMC8553894 DOI: 10.1007/s00508-021-01968-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 08/25/2021] [Indexed: 01/08/2023]
Abstract
Hundreds of millions got infected, and millions have died worldwide and still the number of cases is rising.Chest radiographs and computed tomography (CT) are useful for imaging the lung but their use in infectious diseases is limited due to hygiene and availability.Lung ultrasound has been shown to be useful in the context of the pandemic, providing clinicians with valuable insights and helping identify complications such as pleural effusion in heart failure or bacterial superinfections. Moreover, lung ultrasound is useful for identifying possible complications of procedures, in particular, pneumothorax.Associations between coronavirus disease 2019 (COVID-19) and cardiac complications, such as acute myocardial infarction and myocarditis, have been reported. As such, point of care echocardiography as well as a comprehensive approach in later stages of the disease provide important information for optimally diagnosing and treating complications of COVID-19.In our experience, lung ultrasound in combination with echocardiography, has a great impact on treatment decisions. In the acute state as well as in the follow-up setting after a severe or critical state of COVID-19, ultrasound can be of great impact to monitor the progression and regression of disease.
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Affiliation(s)
- Martin Altersberger
- Rehabilitation Center Hochegg for Cardiovascular and Respiratory Diseases, Friedrich Hillegeist Straße 2, 2840 Grimmenstein, Austria
- Department of Cardiology, Nephrology and Intensive Care Medicine, State Hospital Steyr, Steyr, Austria
| | - Matthias Schneider
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria Waehringer Guertel 18–20, 1090
| | - Martina Schiller
- Department of Radiology, State hospital Neunkirchen, Neunkirchen, Austria
| | - Christina Binder-Rodriguez
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria Waehringer Guertel 18–20, 1090
| | - Martin Genger
- Department of Cardiology, Nephrology and Intensive Care Medicine, State Hospital Steyr, Steyr, Austria
| | - Mounir Khafaga
- Rehabilitation Center Hochegg for Cardiovascular and Respiratory Diseases, Friedrich Hillegeist Straße 2, 2840 Grimmenstein, Austria
| | - Thomas Binder
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria Waehringer Guertel 18–20, 1090
| | - Helmut Prosch
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Vienna, Austria
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