Echocardiographic Findings in Patients with COVID-19 with Significant Myocardial Injury.

To the Editor:

Myocardial injury has been commonly described in patients with coronavirus disease 2019 (COVID-19) and has been suggested to have prognostic significance. Multiple possible mechanisms have been suggested. , Echocardiography allows the noninvasive assessment of biventricular function and can provide important insights into possible mechanisms. We aimed to describe echocardiographic findings in hospitalized patients with COVID-19 with significant myocardial injury.

In this retrospective study, we enrolled consecutive hospitalized patients with COVID-19 who underwent clinically indicated transthoracic echocardiography at Mount Sinai Morningside Hospital. Echocardiography was performed following a time-efficient protocol with appropriate protective gear. Portable ultrasound machines were used: CX50 (Philips Medical Systems, Andover, MA) and VividS70 (GE Healthcare, Little Chalfont, United Kingdom). Echocardiographic studies were interpreted by experienced, board-certified echocardiography attending physicians. Significant myocardial injury was defined as a peak cardiac troponin I level >1 ng/mL (reference <0.01 ng/mL). Continuous variables are presented as mean ± SD or as median (interquartile range [IQR]) and categorical variables as proportions.

A total of 24 patients with significant myocardial injury were identified among 110 patients who underwent echocardiography (five were excluded because of poor study quality). The mean age was 64.5 ± 13.8 years, and 11 patients (46%) were women. Ten patients (42%) were mechanically ventilated at the time of echocardiography. Five patients (21%) had known histories of coronary artery disease. The median troponin level was 5.0 ng/mL (IQR, 1.8–14.0 ng/mL). Among these 24 patients, three had electrocardiographic findings consistent with ST-segment elevation myocardial infarction, and one patient had diffuse ST-segment elevation consistent with pericarditis. The remaining did not have any distinct clinical or electrocardiographic characteristic to suggest the underlying mechanism of injury. Left ventricular (LV) dysfunction, defined as regional and/or global systolic dysfunction, was present in 13 patients (54%). Eleven (46%) had regional wall motion abnormalities (median troponin level, 12.4 ng/mL; IQR, 5.8–27.0 ng/mL): three confirming aforementioned ST-segment elevation myocardial infarction, two with preexisting wall motion abnormalities, and six with presumed new abnormalities (three of these six had previous echocardiograms depicting preserved LV function). Among patients with new wall motion abnormalities, wall motion pattern was confined to a single coronary territory in four patients and more than single territory in one patient; one patient had a typical wall motion pattern suggestive of stress cardiomyopathy. Only two patients (8%) had diffuse LV hypokinesis. Other findings included isolated right ventricular dysfunction in four patients (17%), with a median troponin level of 1.5 ng/mL (IQR, 1.3–3.1 ng/mL). The presence of more than trivial pericardial effusion was noted in eight patients (33%). Importantly, five patients (21%) had no significant echocardiographic findings with preserved biventricular function and no pericardial effusion (Figure 1 ). The median troponin level in these patients was 2.1 ng/mL (IQR, 1.3–4.3 ng/mL). Among patients without significant myocardial injury (n = 81), 15 patients (19%) had isolated regional or global LV dysfunction, 19 patients (24%) had isolated right ventricular dysfunction, and five patients (6%) had biventricular dysfunction.

Figure 1

Venn diagram depicting the pattern distribution of echocardiographic findings in patients with COVID-19 with significant myocardial injury. RV, Right ventricular.

This was a small, retrospective, single-center study. The population was selected from the total number of patients with COVID-19 admitted to our hospital during this time period. Confirmatory testing including advanced cardiac imaging and coronary angiography was lacking in most patients.

In conclusion, among hospitalized patients with COVID-19 and significant myocardial injury, 37% had isolated LV dysfunction, 17% had isolated right ventricular dysfunction, 17% had biventricular dysfunction, and remaining 29% had preserved biventricular function. Regional LV dysfunction appears to be the most common echocardiographic finding, which suggests that ischemia due to large- or small-vessel obstruction and prothrombotic state may be a common mechanism of injury.