Cardiovascular Imaging for Longitudinal Sequelae
To the editor:
With the appearance of the new SARS-COV2 virus, additional challenges
are being imposed to the cardiovascular imaging community after
resolution of acute COVID-19 illness resulting in specific
pathophysiologic mechanism that while acutely damage the lung parenchyma
(i.e. diffuse alveolar hemorrhage, intra-alveolar organizing fibrin)
might chronically impact the cardiopulmonary system (1).
We report the case of a 26-year-old man with prior mild COVID-19
illness, with negative serology test (IgG+ / IgM-) and lung tomography
without fibrosis neither pulmonary embolism, who while in
cardiopulmonary rehabilitation referred due to premature ventricular
complexes associated with mild dyspnea on exertion. Decision was made to
proceed with stress echocardiography are requested to evaluate the right
ventricle (RV) contractile reserve. At rest, we encountered normal RV
function with a low probability of pulmonary hypertension with systolic
pulmonary artery pressure (SPAP) 32 mmHg followed by stress suggestive
of exercise-induced pulmonary hypertension (SPAP 60 mmHg) (Figure 1).
Comparing other variables (rest vs. stress) showed differences in the
strain of RV free wall (32 vs 38), a delta on TAPSE of 12: (20 vs 32), a
delta on S wave of 10: (13 vs 23) suggestive of good contractile RV
reserve (2). Evaluation of right ventricle arterial coupling (surrogate
of right ventricular stiffness) was adequate at 0.35; however, the
shortening of the pulmonary artery during exercise was reduced by - 60,
which translates into increased pulmonary vascular resistance. The
pulmonary vascular reserve in this patient was decreased, which may
indicate a subclinical phase of pulmonary vascular disease.
Assessment of left ventricular function was normal, with an adequate
increment of the ejection fraction during stress (60% vs 72%) and a
delta on e´ wave of 7 (4 vs 11) (3).
These findings highlight the need for all patients recovering from
COVID-19, even though present mild pneumonia, to undergo to risk
stratification with stress echocardiographic evaluation to diagnose and
monitor early signs of pulmonary hypertension as this presented case.
Furthermore opens the dialogue for targeting specific therapies and
addressing progression or regression of abnormalities associated with
the right heart unit. Importantly, as we enter a new era in the
longitudinal cardiovascular evaluation in the midst of a pandemic, our
case highlights the need for further studying the role of exercise
echocardiography among patients recovering from COVID-19 illness.
- Xu, Z., Shi, L., Wang, Y., Zhang, J., Huang, L., Zhang, C., … &
Tai, Y. (2020). Pathological findings of COVID-19 associated with
acute respiratory distress syndrome. The Lancet respiratory
medicine , 8 (4), 420-422.
- D’Alto, M., Pavelescu, A., Argiento, P., Romeo, E., Correra, A., Di
Marco, G. M., … & Naeije, R. (2017). Echocardiographic assessment
of right ventricular contractile reserve in healthy
subjects. Echocardiography , 34 (1), 61-68.
- Larsen, A. H., Clemmensen, T. S., Wiggers, H., & Poulsen, S. H.
(2018). Left ventricular myocardial contractile reserve during
exercise stress in healthy adults: a two-dimensional speckle-tracking
echocardiographic study. Journal of the American Society of
Echocardiography , 31 (10), 1116-1126.