Right ventricular-arterial uncoupling independently predicts survival in COVID-19 ARDS

Michele D'Alto, Alberto M Marra, Sergio Severino, Andrea Salzano, Emanuele Romeo, Rosanna De Rosa, Francesca Maria Stagnaro, Gianpiero Pagnano, Raffaele Verde, Patrizia Murino, Andrea Farro, Giovanni Ciccarelli, Maria Vargas, Giuseppe Fiorentino, Giuseppe Servillo, Ivan Gentile, Antonio Corcione, Antonio Cittadini, Robert Naeije, Paolo Golino, Michele D'Alto, Alberto M Marra, Sergio Severino, Andrea Salzano, Emanuele Romeo, Rosanna De Rosa, Francesca Maria Stagnaro, Gianpiero Pagnano, Raffaele Verde, Patrizia Murino, Andrea Farro, Giovanni Ciccarelli, Maria Vargas, Giuseppe Fiorentino, Giuseppe Servillo, Ivan Gentile, Antonio Corcione, Antonio Cittadini, Robert Naeije, Paolo Golino

Abstract

Aim: To investigate the prevalence and prognostic impact of right heart failure and right ventricular-arterial uncoupling in Corona Virus Infectious Disease 2019 (COVID-19) complicated by an Acute Respiratory Distress Syndrome (ARDS).

Methods: Ninety-four consecutive patients (mean age 64 years) admitted for acute respiratory failure on COVID-19 were enrolled. Coupling of right ventricular function to the pulmonary circulation was evaluated by a comprehensive trans-thoracic echocardiography with focus on the tricuspid annular plane systolic excursion (TAPSE) to systolic pulmonary artery pressure (PASP) ratio RESULTS: The majority of patients needed ventilatory support, which was noninvasive in 22 and invasive in 37. There were 25 deaths, all in the invasively ventilated patients. Survivors were younger (62 ± 13 vs. 68 ± 12 years, p = 0.033), less often overweight or usual smokers, had lower NT-proBNP and interleukin-6, and higher arterial partial pressure of oxygen (PaO2)/fraction of inspired O2 (FIO2) ratio (270 ± 104 vs. 117 ± 57 mmHg, p < 0.001). In the non-survivors, PASP was increased (42 ± 12 vs. 30 ± 7 mmHg, p < 0.001), while TAPSE was decreased (19 ± 4 vs. 25 ± 4 mm, p < 0.001). Accordingly, the TAPSE/PASP ratio was lower than in the survivors (0.51 ± 0.22 vs. 0.89 ± 0.29 mm/mmHg, p < 0.001). At univariate/multivariable analysis, the TAPSE/PASP (HR: 0.026; 95%CI 0.01-0.579; p: 0.019) and PaO2/FIO2 (HR: 0.988; 95%CI 0.988-0.998; p: 0.018) ratios were the only independent predictors of mortality, with ROC-determined cutoff values of 159 mmHg and 0.635 mm/mmHg, respectively.

Conclusions: COVID-19 ARDS is associated with clinically relevant uncoupling of right ventricular function from the pulmonary circulation; bedside echocardiography of TAPSE/PASP adds to the prognostic relevance of PaO2/FIO2 in ARDS on COVID-19.

Keywords: ARDS; COVID-19; Echocardiography; Prognosis; Right ventricular-arterial uncoupling.

Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Coupling of right ventricular function to the pulmonary circulation evaluated by the tricuspid annular plane systolic excursion (TAPSE) to systolic pulmonary artery pressure (PASP) ratio. a Normal echocardiographic phenotype with increased pulmonary artery systolic pressure (PASP), normal tricuspid annulus plane systolic excursion (TAPSE), and preserved TAPSE/PASP. b Typical right heart echocardiographic phenotype with increased PASP, reduced TAPSE, low TAPSE/PASP, and right/left ventricular basal diameter ratio > 1. IVC inferior vena cava
Fig. 2
Fig. 2
Individual values for TAPSE/PASP and PaO2/FIO2 ratios. Individual values for the tricuspid annulus plane systolic excursion (TAPSE)/pulmonary artery systolic pressure (PASP) ratio (panel a), and arterial partial pressure of oxygen (PaO2)/fraction of inspired O2 (FIO2) ratio (panel b). Means are indicated by horizontal bars. Both ratios were markedly decreased in non-survivors (p < 0.001)
Fig. 3
Fig. 3
ROC curves to predict outcome of as a function of TAPSE/PASP and PaO2/FIO2. Both ratios predicted outcome with Youden indices (highest combination of sensitivity and specificity) of, respectively, 0.625 mm/mmHg and 159 mmHg. Abbreviations see Fig. 2
Fig. 4
Fig. 4
Survival according to TAPSE/PASP and PaO2/FIO2. Kaplan–Meyer curves of % survival over time as a function of TAPSE/PASP and PaO2/FIO2 above or below the ROC-determined cutoff values of 0.625 mm/mmHg and 159 mmHg, alone (upper panels) or in combination (lower panel). Abbreviations see Fig. 2

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