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Cardiac involvement in critically ill and mechanically ventilated patients with COVID-19 - a prospective,
Nina Norden1, Erik O Lundin1, Eva Hagberg2,3
1Department of Anaesthesia and Intensive Care Unit, Institute of Clinical Sciences, Sahlgrenska Academy at The University of Gothenburg Gothenburg, Sweden.
Insights
Right ventricular dysfunction is common in COVID-19 patients, often due to pulmonary thrombosis. Cardiac biomarker correlation was poor, and milrinone did not improve function, suggesting increased RV afterload as the primary cause.
Area of Science:
- Cardiology
- Pulmonology
- Critical Care Medicine
Background:
- COVID-19 frequently impacts cardiac function, particularly the right ventricle (RV).
- Understanding RV dysfunction and its correlation with biomarkers is crucial for managing critically ill patients.
Purpose of the Study:
- To evaluate RV and left ventricular (LV) function using echocardiography in mechanically ventilated COVID-19 patients.
- To correlate cardiac function with biomarkers (hs-TNT, NT-pro-BNP, D-dimer, fibrinogen).
- To assess the effect of inhaled milrinone on RV afterload and function.
Main Methods:
- Prospective observational study of 31 ICU COVID-19 patients requiring mechanical ventilation and norepinephrine.
- Echocardiography and hemodynamic measurements were performed.
- Biomarkers were collected on ICU admission and routinely followed up; 8 patients received inhaled milrinone.
Main Results:
- RV dilation and/or dysfunction occurred in 62% of patients; pulmonary acceleration time was abnormal in 55%.
- Cardiac index < 2.5 l/min*m² was observed in 58%; LV function was impaired in 10-16%.
- Poor correlation between echocardiographic findings and biomarkers, except for RV afterload with D-dimer. Milrinone did not improve RV function or afterload.
Conclusions:
- Right ventricular dysfunction is a prevalent finding in severe COVID-19.
- The weak correlation with biomarkers suggests limited direct myocardial injury; increased RV afterload from pulmonary thrombosis/embolism is the likely cause.
- Inhaled milrinone failed to improve RV function, reinforcing the hypothesis of afterload-induced dysfunction.
Introduction:
In this prospective, observational study, we have evaluated right (RV) and left (LV) ventricular function with echocardiography and correlated it to the levels of biomarkers, hs-TNT, NT-pro-BNP, D-dimer and fibrinogen. In a subgroup, we have evaluated the effect of inhaled milrinone on RV afterload and function.
Methods:
Thirty-one ICU patients with COVID-19 in need of mechanical ventilation and norepinephrine infusion were prospectively included. Hemodynamic and respiratory variables were measured at the time of the echocardiographic examination and biomarkers were obtained on arrival at the ICU and then followed up routinely. Eight patients received inhaled aerosolized milrinone at a dose of 2.5 mg/hour.
Results:
The most common echocardiographic pattern was RV dilation with or without systolic dysfunction, which was found in 62% of patients. Pulmonary acceleration time was abnormal in 55% and indices of RV systolic function, such as fractional area of change, RV strain, were abnormal in 30% and 31% of patients respectively. A cardiac index of < 2.5 l/min*m2 was seen in 58% of the patients. Left ventricular ejection fraction and global left ventricular strain were impaired in 10% and 16% respectively. The correlation between echocardiographic variables and cardiac biomarkers was poor. RV afterload correlated well to the levels of D-dimer. Milrinone inhalation did not improve RV function or afterload.
Conclusion:
RV dysfunction was the most common finding. The poor correlation to cardiac biomarkers argues against extensive myocardial involvement. The lack of improvement in RV function after milrinone inhalation suggests that the most likely cause of RV dysfunction is increased RV afterload caused by pulmonary thrombosis/embolism.
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