Recognizing Right Ventricular Dysfunction in COVID-19 Related Respiratory Illness

Milligan GP, Alam A, Guerrero-Miranda C.  Journal of Cardiac Failure published on line:

Key Points

  • In COVID – 19, Echoes may be limited in scope for safety so specific findings are important.
  • The mechanism of Acute Cor Pulmonale (ACP) occurs in the setting of ARDS secondary to hypoxemia, pulmonary edema and microvascular thrombosis producing acute right ventricular (RV) afterload.
  • Biomarkers (Troponin and brain natriuretic) predict extent of D-dimer elevation and mortality, recently confirmed at autopsy with micro pulmonary thrombosis.
  • ACP findings on point of care echocardiograms ultrasound:
    • RV enlargement on apical 4 chamber view with RV area >60% of Left Ventricular (LV) area at end-diastole.
    • A “D-shaped” ventricular septum caused by a lengthened RV contraction best seen in the parasternal short axis at end-systole
    • Reduced systolic excursion of the tricuspid annular plane.
    • McConnell’s sign (Regional RV dysfunction characterized by akinesia in mid free wall but preserved apical wall motion.) A specific echocardiographic sign of acute pulmonary embolism.
  • The authors recommend use of a right heart catheterization to optimally understand the complex and conflicting hemodynamics of hypoxemic pulmonary vasoconstriction and elevated positive end-expiratory pressure (PEEP) impacting RV preload and afterload.
  • A pulmonary artery catheter can support optimization of cardiac output, RV preload as well as pulmonary vascular resistance based on choosing and titrating treatments such as inhaled pulmonary vasodilators and inotropic support while limiting the potential risk of adverse complications such as cardiogenic pulmonary edema.
  • The authors recommend determining and treating the specific cardiac abnormalities, emphasizing that the RV, not infrequently, is the most effected chamber requiring support.