Israeli researchers at Tel Aviv Sourasky Medical Center (Ichilov Hospital) have found in a landmark study completed last month that 40 percent of hospitalized COVID-19 patients suffer primary cardiac damage.
The research was led by Dr. Yishay Szekely and Dr. Yan Topilsky, the latter, director of the non invasive cardiology unit in the Cardiology Division of Ichilov Hospital, listed as corresponding author on the report.
The findings of the research published May 29, 2020 in the American Heart Association medical journal Circulation, found that in hospitalized COVID-19 patients, left ventricular systolic function is preserved most of the time, but left ventricular diastolic and right ventricular function are impaired. In addition, elevated troponin and lower clinical grade are associated with worse right ventricular function as well. When patients had clinical deterioration at follow up, acute right ventricular dysfunction is also more common.
Method and Findings
The team evaluated 100 consecutive patients ages 18 and up within 24 hours of admission, using echocardiographic imaging. The diagnosis of the patients, admitted to the hospital for COVID-19 symptoms between March 21 and April 16 2020, was confirmed with a SARS-CoV-2 respiratory tract sample.
The echocardiographic studies included left ventricular (LV) systolic and diastolic function, valve hemodynamics and right ventricular (RV) assessment as well as lung ultrasound. A second exam was performed in case of clinical deterioration, the researchers said in their report.
At baseline, 32 percent of the patients had a normal echocardiogram. But the majority were those who displayed cardiac damage (39 percent); they showed enlargement and dysfunction of the right ventricle. There were also patients who displayed left ventricle diastolic dysfunction (16 percent) and systolic dysfunction (10 percent) as well.
Patients with elevated troponin (20 percent) — a protein found in the skeletal cardiac muscle fibers that regulates muscular contraction – or who experienced a worse clinical condition, displayed worse right ventricular function (12 patients) but not any significant difference (5 patients) in left ventricular systolic function. Femoral vein thrombosis (DVT) was diagnosed in five out of 12 patients with right ventricular failure.
Similar Research at Same Time in NYC
A team of physicians at the Icahn School of Medicine at Mount Sinai Medical Center in New York City carried out a similar study – in fact, nearly in parallel — between March 26 and April 22, 2020.
The team, led by Assistant Professor of Medicine Dr. Edgar Argulian reviewed the health records of 105 COVID-19 patients who were hospitalized at Mount Sinai Morningside in the city, all of whom had been evaluated with echocardiograms.
The study, accepted on May 7 2020 for publication in the Journal of the American College of Cardiology, found that 31 percent of the patients had dilation of the right ventricle (32 patients).
Of those with RV damage, 41 percent died by the conclusion of the study, compared to 11 percent of those without damage to the right ventricle.
“This study provides important evidence associating right heart strain with adverse outcomes in hospitalized patients with COVID-19 infection,” Dr. Argulian said in a statement. “Clinicians can use bedside echocardiography as a readily available tool to identify patients with COVID-19 infection at the highest risk of adverse hospital outcomes.”
RV Strain, Dysfunction Noted by Chinese Doctors First
Researchers at the Huazhong University of Science and Technology and the Hubei Province Key Laboratory of Molecular Imaging in Wuhan had noted the increasing prevalence of higher mortality among COVID-19 patients with right heart dysfunction before either of the above two study teams.
“It has been reported that SARS-CoV-2 infection could cause both pulmonary and systemic inflammations, which may contribute to RV failure through RV overload and direct damage to [the] cardiomyocyte,” wrote Yuman Li, MD, PhD, and colleagues in reporting on their findings, accepted April 14 2020 for publication in the medical journal of the American College of Cardiology, JACC: Cardiovascular Imaging.
Li and colleagues reported that right ventricular dysfunction was “not only a sign of increased pulmonary pressures,” but that COVID-19 patients with this symptom “might benefit from vigilant monitoring.”
The researchers concluded in their study, “RVLS is a powerful predictor of higher mortality in patients with COVID-19. Our study supports the application of RVLS to identify higher risk COVID-19 patients.”
A physician at New York-Presbyterian / Columbia University Irving Medical Center commented on the study in an article for tctMD/the heart beat.
Dr. Rebecca Hahn noted that “no matter what, it’s interesting to look at the COVID population because we have seen in our experience at Columbia a lot of right heart dilatation and dysfunction. And the etiologies of these findings are numerous.”