Serial Left and Right Ventricular Strain Analysis in Patients Recovered from COVID-19

Characteristics and Outcomes of New-Onset Cardiomyopathy in Hospitalized COVID-19 Patients

Background: The association between Coronavirus Disease-2019 (COVID-19) and new-onset cardiomyopathy (NOC) is unclear. Objectives: We aim to assess the incidence of NOC in hospitalized COVID-19 patients and its impact on short- and long-term survival. Methods: We retrospectively studied 2219 COVID-19 patients hospitalized between March 2020 and February 2022 who underwent an in-hospital echocardiogram. NOC was defined as a left-ventricular ejection fraction (LVEF) reduction of >10%, resulting in an LVEF of <54% for females and <52% for males. The 30-day and 1-year survival outcomes in patients without and with NOC were studied. Results: Among 25,943 hospitalized COVID-19 patients, 2219 met our inclusion criteria, with 209 (9.4%) having NOC. NOC patients were more likely to be male (56.1% vs. 68.4%, p = 0.001) and have chronic kidney disease (51.4% vs. 60.3%, p = 0.018). They had a higher 30-day mortality rate (29.1% vs. 32%, p = 0.033), but the 1-year survival rate was similar between the patients without and with NOC (36.9% vs. 41.6%, p = 0.12). Multivariable regression revealed that advanced age, admission to intensive care unit, mechanical ventilation, treatment with glucocorticoids, and treatment with vasopressors were associated with higher odds of 30-day mortality in NOC patients. Only 74 (35.4%) NOC patients had follow-up echocardiograms after discharge, of which 47 showed persistent cardiomyopathy. Conclusions: NOC can affect around 1 out of 10 hospitalized COVID-19 patients undergoing echocardiography. While NOC was associated with worse short-term survival, it did not impact the long-term mortality of these patients. Persistent LVEF deficits in some patients emphasize the need for improved outpatient follow-up to identify at-risk individuals and optimize treatment.

Myocardial Dysfunction and Risk of Long COVID in Patients Recovered From Mild and Moderate COVID-19

PURPOSE

Numerous recovered COVID-19 patients exhibit persistent cardiovascular symptoms. However, the degree of myocardial dysfunction and its associated risk factors remain unclear. This study aims to evaluate myocardial dysfunction in recovered patients and pinpoint predictors of persistent cardiovascular symptoms.

METHODS

We reviewed the echocardiograms of patients who recovered from mild or moderate COVID-19 and presented with cardiovascular symptoms during the Omicron surge. Myocardial strain was analyzed in 546 patients before and after infection, and in 351 prepandemic healthy controls. Clinical follow-up at 12 months post-infection was used to evaluated symptom persistence, and multivariable logistic regression was used to identify independent predictors.

RESULTS

Baseline characteristics showed no significant differences between patients and controls (all p > 0.05). Although the left ventricle global longitudinal strain (LVGLS) remained stable post-infection, significant reductions emerged in regional left ventricle longitudinal strains (LVLS) and all left atrial strains (LAS) (all p < 0.05). Persistent cardiovascular symptoms affected 16.5% (90/546) of patients at 1-year follow-up. Multivariate analysis showed that only LA conduit strain (OR = 0.919, 95% CI: 0.857, 0.985, p = 0.017) and basal inferoseptal LVLS (OR = 0.883, 95% CI: 0.792, 0.986, p = 0.026) correlated with persisting cardiovascular symptoms.

CONCLUSION

Our findings demonstrate that subclinical but persistent COVID-19-associated myocardial dysfunction is characterized by regional LVLS impairment and LAS reduction. The identified strain parameters (LAScd and basal inferoseptal LVLS) serve as novel imaging markers for stratifying patients at risk of persistent cardiovascular symptoms. These results advocate for targeted echocardiographic surveillance and early intervention strategies in post-COVID care pathways.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT06170307.

Cardiac Function and Functional Capacity in Patients With Long COVID: A Comparison to Propensity-Matched Community Controls

BACKGROUND

Cardiac impairment has been associated with acute COVID-19 since the earliest reports of the pandemic. However, its role in postacute sequelae of COVID-19 ("long COVID") is undefined, and many existing observations about cardiovascular involvement in postacute sequelae of COVID-19 are uncontrolled.

OBJECTIVE

To compare the prevalence of cardiac dysfunction in patients with long COVID and noninfected controls from the same community and explore their association with functional capacity.

METHODS

Echocardiography was used to assess cardiac structure and function, including the measurement of global longitudinal strain (GLS), in 190 participants with long COVID. All underwent assessment of functional impairment by subjective (Duke Activity Status Index) and objective tests (6-minute walk test). The 190 participants from the long COVID group were matched with those from 979 patients who underwent the same tests in the pre-COVID-19 era, using a propensity score.

RESULTS

The 190 patients with long COVID had similar age and risk factor profiles to those of their matched controls. Left ventricular dimensions and geometry, but not diastolic parameters, were significantly altered in the long COVID group. The long COVID group had subclinical systolic dysfunction (GLS 18.5% ± 2.6% vs 19.3% ± 2.7%, P = .005), and more long COVID patients had abnormal (<16%) GLS (13% vs 8%, P = .035). The association of long COVID with abnormal GLS (odds ratio, 1.49 [1.04, 2.45]) was independent of-and had a similar or greater effect size than-age and risk factors. There was no interaction of long COVID with the association of risk factors with GLS. As expected, the long COVID group had significant subjective (<85% predicted METS; 72% vs 5%, P < .001) and objective functional impairment (29% vs 24%, P = .026), but GLS was only weakly associated with both subjective (r = 0.30, P = .005) and objective (r = 0.21, P = .05) functional impairment. The presence of long COVID was independently associated with subjective (odds ratio = 159.7 [95% CI, 61.6-414.2]) and objective functional impairment (odds ratio = 2.8 [95% CI, 1.5-5.2]).

CONCLUSIONS

Impaired GLS and left ventricular dimensions are the echocardiographic features that are overrepresented in long COVID, and this association is similar to and independent of other risk factors. Impaired GLS is weakly associated with functional impairment.

COVID-19 is associated with cardiac structural and functional remodelling in healthy middle-aged and older individuals

BACKGROUND

Coronavirus disease 2019 (COVID-19) was declared a global pandemic in 2019. It remains uncertain to what extent COVID-19 effects the heart in heathy individuals. To evaluate the effect of the COVID-19 on cardiac structure and function in middle-aged and older individuals.

METHODS

A single-centre prospective observational study enroled a total of 124 participants (84 with history of COVID-19 [COVID-19 group] and 40 without a history of COVID-19 [non-COVID group]). All participants underwent echocardiography with speckle tracking to assess cardiac structure and function at rest and during peak exercise.

RESULTS

There were no differences in left and right ventricular diastolic function (p ≥ 0.05) between the COVID-19 and non-COVID-19 groups. Participants in COVID-19 group demonstrated higher left ventricular mass (130 ± 39.8 vs. 113 ± 27.2 g, p = 0.008) and relative wall thickness (0.38 ± 0.07 vs. 0.36 ± 0.13, p = 0.049). Left ventricular global longitudinal strain was reduced in the COVID-19 group at rest and at peak-exercise (rest: 18.3 ± 2.01 vs. 19.3 ± 1.53%, p = 0.004; peak exercise: 19.1 ± 2.20 vs. 21.0 ± 1.58%, p ≤ 0.001). However, no difference was seen in resting left ventricular ejection fraction (58 ± 2.89 vs. 59 ± 2.51%, p = 0.565) between groups. Right ventricular fractional area change was reduced in the COVID-19 group (p = 0.012).

CONCLUSION

Cardiac structural and functional remodelling was observed in middle-aged and older otherwise healthy individuals with a history of COVID-19.

Baseline echocardiographic variables as predictors of hemodynamically significant cytokine release syndrome in adults treated with CD19 CAR T-cell therapy for hematological malignancies

BACKGROUND

CD19 CAR T-cell therapy is a novel anti-cancer treatment that has produced remarkable responses in relapsed or refractory B-cell hematological malignancies. Cytokine Release Syndrome (CRS) is a dysregulated immune response that frequently occurs after CAR T-cell infusion. It can cause cardiac dysfunction and circulatory collapse negatively impacting outcomes and survival. To endure the insults of CRS, patients are typically screened for adequate cardiac reserve before treatment. The relationship between baseline cardiac function by echocardiography and the development of moderate to severe presentations of CRS is unclear.

METHODS

This study aimed to identify baseline echocardiographic variables that can predict the development of hemodynamically significant CRS (CRS ≥ 2), evaluate their behavior at follow-up, and investigate the incidence of cancer therapy-related cardiac dysfunction (CTRCD). An observational retrospective cohort study of patients treated with CD19 CAR T-cell therapy with a baseline echocardiogram was performed. Demographic, clinical and echocardiographic variables were abstracted from the electronic health record. Patients were grouped and compared by the occurrence of CRS < 2 and ≥ 2. Adjusted logistic regression analysis was used to evaluate the association between echocardiographic variables and the development of CRS ≥ 2.

RESULTS

291 patients were included in the study. Median age was 60 (IQR: 51, 67 years), 73% were male, and 71% had diffuse large B-cell lymphoma. Logistic regression analysis did not reveal any significant baseline echocardiographic predictors of CRS ≥ 2, including left ventricular ejection fraction and global longitudinal strain. Systolic and diastolic echocardiographic variables remained within normal limits at follow-up overall and in both CRS groups. The incidence of CTRCD was 4.5% and occurred mostly in the setting of CRS ≥ 2.

CONCLUSION

No specific echocardiographic variables predicted the development of CRS ≥ 2, and therefore the mechanism leading to hemodynamic decompensation and producing worsening hypoxia and hypotension could be multifactorial and not directly cardiac mediated.

Trajectories of functional and structural myocardial parameters in post-COVID-19 syndrome-insights from mid-term follow-up by cardiovascular magnetic resonance

Introduction

Myocardial tissue alterations in patients with post-Coronavirus disease 2019 syndrome (PCS) are often subtle and mild. Reports vary in the prevalence of non-ischemic and ischemic injuries as well as the extent of ongoing myocardial inflammation. The exact relevance of these myocardial alterations is not fully understood. This study aimed at describing the trajectories of myocardial alterations in PCS patients by mid-term follow-up with cardiovascular magnetic resonance (CMR).

Methods

This study entails a retrospective analysis of symptomatic PCS patients referred for follow-up CMR between August 2020 and May 2023 due to mildly affected or reduced left or right ventricular function (LV and RV, respectively) and structural myocardial alterations, e.g., focal and diffuse fibrosis, on baseline scans. Follow-up CMR protocol consisted of cine images and full coverage native T1 and T2 mapping. Baseline and follow-up scans were compared using t-tests or Wilcoxon tests. Post-hoc analysis was carried out in a subgroup based on the change of LV stroke volume (SV) between scans.

Results

In total, 43 patients [median age (interquartile range) 46 (37-56) years, 33 women] received follow-ups 347 (167-651) days after initial diagnosis. A decrease in symptoms was recorded on follow-ups (p < 0.03) with 23 patients being asymptomatic at follow-ups [symptomatic at baseline 43/43 (100%) vs. symptomatic at follow-up 21/43 (49%), p < 0.001]. Functional improvement was noted for LV-SV [83.3 (72.7-95.0) vs. 84.0 (77.0-100.3) ml; p = 0.045], global radial [25.3% (23.4%-27.9%) vs. 27.4% (24.4%-33.1%); p < 0.001], and circumferential strains [-16.5% (-17.5% to -15.6%) vs. -17.2% (-19.5% to -16.1%); p < 0.001]. In total, 17 patients had an LV-SV change >10% on follow-up scans (5 with a decrease and 12 with an increase), with LV-SV, RV-SV, and global longitudinal strain being discriminatory variables on baseline scans (p = 0.01, 0.02, and 0.04, respectively). T1- or T2-analysis revealed no changes, remaining within normal limits.

Conclusion

Symptomatic load as well as blood pressures decreased on follow-up. CMR did not detect significant changes in tissue parameters; however, volumetric, specifically LV-SV, and deformation indexes improved during mid-term follow-up.

Serial echocardiographic evaluation of COVID-19 patients without prior history of structural heart disease: a 1-year follow-up CRACoV-HHS study

Background

It is a well-known fact that COVID-19 affects the cardiovascular system by exacerbating heart failure in patients with preexisting conditions. However, there is a poor insight into the cardiovascular involvement and sequelae in patients without preexisting conditions. The aim of the study is to analyse the influence of COVID-19 on cardiac performance in patients without prior history of structural heart disease. The study is part of the CRACoV project, which includes a prospective design and a 12-month follow-up period.

Material and methods

The study included 229 patients hospitalised with a diagnosis of COVID-19 (median age of 59 years, 81 were women). A standard clinical assessment and laboratory tests were performed in all participants. An extended echocardiographic image acquisition was performed at baseline and at a 3-, 6-, and 12-month follow-up. All analyses were performed off-line. A series of echocardiographic parameters was compared using repeated measures or Friedman analysis of variance.

Results

In all subjects, the left ventricular (LV) ejection fraction at baseline was preserved [63.0%; Q1:Q3 (60.0-66.0)]. Elevated levels of high-sensitivity cardiac troponin T were detected in 21.3% of the patients, and elevated NT-proBNP levels were detected in 55.8%. At the 1-year follow-up, no significant changes were observed in the LV diameter and volume (LV 48.0 ± 5.2 vs. 47.8 ± 4.8 mm, p = 0.08), while a significant improvement of the parameters in the biventricular strain was observed (LV -19.1 ± 3.3% vs. -19.7 ± 2.5%, p = 0.01, and right ventricular -19.9 ± 4.5% vs. -23.2 ± 4.9%, p = 0.002). In addition, a decrease in the LV wall thickness was also observed (interventricular septum 10.4 ± 1.6 vs. 9.7 ± 2.0 mm, p < 0.001; LV posterior wall 9.8 ± 1.4 vs. 9.1 ± 1.5 mm, p < 0.001).

Conclusions

In an acute phase of COVID-19, the elevation of cardiac biomarkers in patients with normal left ventricular ejection fraction is a frequent occurrence; however, it does not translate into clinically significant cardiac dysfunction after 1 year. The serial echocardiographic evaluations conducted in patients without preexisting structural heart disease demonstrate an overall trend towards an improved cardiac function and a reduced myocardial thickening at 1-year follow-up. This suggests that the acute cardiac consequences of COVID-19 are associated with systemic inflammation and haemodynamic stress in patients without preexisting conditions.

Echocardiographic manifestations during the first 3 months after an episode of COVID-19 and their relationship with disease severity and persistence of symptoms

BACKGROUND

Cardiovascular manifestations in patients with COVID-19 are associated with dire outcomes. Long COVID syndrome is the persistence of symptoms after acute disease and is found in up to 40% of subjects. There is little information regarding subacute echocardiographic manifestations after COVID-19, and no study has included a Mexican mestizo population.

METHODS

This cross-sectional study included subjects older than 18 with an episode of COVID-19 in the last 3 months. Those with previously known cardiovascular disease were excluded. The patient´s medical history and COVID-19 information were obtained from clinical charts. We performed a transthoracic echocardiogram in every subject and determined left ventricular (LV) index mass, LV ejection fraction (LVEF), left ventricular global longitudinal strain (LV GLS), right ventricular (RV) GLS, and tricuspid annular plane systolic excursion (TAPSE). A descriptive and comparative analysis was performed based on symptom severity and persistence.

RESULTS

One hundred subjects were included; 63% were classified with mild and 37% with moderate to severe COVID-19. The median of LVEF was 60% (55-60), LV GLS and RV GLS was impaired in 34% and 74% of patients, respectively. Patients with moderate to severe disease had significantly lower LVEF (Mean Difference: -3.3), TAPSE (mean difference: -1.8), and higher (worse) LV GLS (Mean Difference: 2.5) and RV GLS (mean difference: 2.9). Persistent symptoms were associated with lower TAPSE and higher RVGLS.

CONCLUSIONS

Patients who recover from COVID-19 have a high prevalence of subtle RV and LV dysfunction using GLS analysis. A moderate to severe episode was associated with worse RV and LV function measured by RV GLS, TAPSE, and LV GLS. Subjects with persistent symptoms had worse RVGLS and TAPSE.

Strain Echocardiography in Acute COVID-19 and Post-COVID Syndrome: More than Just a Snapshot

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.

Abnormal right ventricular echocardiographic findings in recovered patients associated with severe acute respiratory syndrome in COVID-19

BACKGROUND

Right ventricular (RV) echocardiographic changes such as dilation or systolic dysfunction, and pulmonary arterial hypertension were observed in patients with COVID-19. The aim of our study was to determine the frequency of RV echocardiographic changes in patients who have recovered from COVID-19 and to verify the association between severe acute respiratory syndrome (SARS) and echocardiographic findings.

METHODS

Patients who had recovered from COVID-19 undergoing outpatient follow-up underwent transthoracic echocardiography, and based on the findings, were divided into two groups: normal and abnormal. It was then verified whether there is an association between SARS and RV echocardiographic abnormalities in recovered patients.

RESULTS

The study included 61 patients, with a mean age of 54.2 ± 12.0 years, 57.4% had presented with SARS. The mean period of time between COVID-19 and the echocardiographic examination was 11.9 ± 7.0 months. Patients presented normal left ventricular systolic function. The frequency of RV echocardiographic changes in patients who had recovered from COVID-19 was 44.3%. RV systolic dysfunction was identified in 31.1%, followed by ventricular dilation in 14.7% and pulmonary hypertension in 9.8%. An association was observed between SARS and RV echocardiographic changes in recovered patients during outpatient follow-up (OR: 4.96; 95% CI: 1.37-17.9; p = 0.015). An association was also demonstrated between SARS and RV dilation (p = 0.007) and between SARS and systolic dysfunction (p = 0.028).

CONCLUSION

SARS is a risk factor for abnormal RV echocardiographic findings in patients recovered from COVID-19.