Skip to main content

Cardiovascular phenotypes in ventilated patients with COVID-19 acute respiratory distress syndrome

Approximately two-thirds of patients admitted to the intensive care unit (ICU) for coronavirus disease-19 (COVID-19) pneumonia present with the acute respiratory distress syndrome (ARDS) [1]. COVID-19-associated acute cardiac injury is frequently reported based on troponin and electrocardiographic changes [2], but its impact on cardiac function is yet unknown [3]. Accordingly, we sought to describe cardiovascular phenotypes identified using transesophageal echocardiography (TEE) in ventilated COVID-19 patients with ARDS and to compare them to those of patients with flu-induced ARDS.

All patients with confirmed COVID-19 who were mechanically ventilated for ARDS in our medical-surgical ICU underwent prospectively a TEE assessment during the first 3 days and whenever required by clinical events during ICU stay, as a standard of care. Similarly, all patients ventilated for flu-associated ARDS who underwent a TEE assessment over the last 2 years were retrospectively analyzed for comparison. Cardiovascular phenotypes were identified using previously reported TEE criteria [4]. Same applied for acute cor pulmonale (ACP) [5]. TEE studies were read by two independent experts who had no access to the cause of ARDS and examination date. Results are expressed as medians and 25th–75th percentiles. Friedman ANOVA was used to compare quantitative parameters over time in COVID-19 patients, while Mann-Whitney U test and Fisher’s exact test were used for comparison of continuous and categorical variables, respectively, with flu patients. No use of previous value or interpolation rule was used in the presence of missing data.

Eighteen consecutive COVID-19 patients and 23 flu patients (21 A-H1N1) were studied. COVID-19 patients were significantly older (70 [57–75] vs. 58 [49–64] years, p = 0.006), less severe (SAPSII 34 [30–38] vs. 43 [32–54], p = 0.015; SOFA 4 [2–4] vs. 6 [4–9], p < 0.001), required less vasopressor support (2/18 [11%] vs. 10/23 [43%], p = 0.038), and had longer time lag between first symptoms and ICU admission, tracheal intubation, and TEE examination when compared to flu patients (Table 1). The prevalence of left ventricular (LV) failure (3/18 [17%] vs. 14/23 [61%], p = 0.009), ACP (3/18 [17%] vs. 11/23 [48%], p = 0.051), and severe ACP (1/18 [5.5%] vs. 8/23 [35%], p = 0.054) was significantly lower in COVID-19 patients. Hypovolemic and hyperkinetic phenotypes were similarly observed in both groups (Table 1). Despite similar tidal volume and PEEP level, COVID-19 patients had significantly higher P/F ratio and respiratory-system compliance, and lower driving pressure than flu patients (Table 1). Pulmonary embolism was identified in none of COVID-19 patients but in one flu patient with ACP. COVID-19 patients with ACP tended to exhibit lower respiratory-system compliance (34, 32, and 30 mL/cmH2O) when compared to others (40 [31–45] mL/cmH2O). Hemodynamic profile of COVID-19 patients remained stable during the first 3 days of ICU stay (Table 2).

Table 1 Characteristics, presentation and outcome of ventilated patients with COVID-19 and flu-related ARDS
Table 2 Evolution of hemodynamic profile during daily transesophageal echocardiography assessments of COVID-19 patients ventilated for ARDS

The higher prevalence of LV failure and lower cardiac index in patients with flu-related ARDS is presumably related to septic cardiomyopathy since they sustained associated septic shock more frequently than COVID-19 patients. Depressed indices of RV systolic function and elevated central venous pressure reflecting systemic venous congestion reflect the higher prevalence of RV failure in flu ARDS patients (Table 1). This presumably results from the lower P/F, higher driving pressure, and lower respiratory-system compliance observed in this group. COVID-19 patients with ACP tended to have lower respiratory-system compliance than their counterparts, presumably due to distinct ARDS phenotypes [6]. This pilot study is limited by its small sample size and the retrospective comparison with historical flu-related ARDS patients.

This first study assessing hemodynamically ventilated COVID-19 patients with TEE shows a lower prevalence of LV and RV failure than in flu-related ARDS patients. Whether herein reported cardiovascular phenotypes are influenced by the type of COVID-19 ARDS remains to be determined [6]. These preliminary data warrant confirmation in large-scale multicenter cohorts.

Availability of data and materials

N/A

Abbreviations

ACP:

Acute cor pulmonale

ARDS:

Acute respiratory distress syndrome

COVID-19:

Coronavirus disease 2019

ICU:

Intensive care unit

LV:

Left ventricle

RV:

Right ventricle

SAPS II:

Simplified acute physiology score II

SOFA:

Sepsis-related organ failure assessment

References

  1. Yang X, Yu Y, Xu J, Shu H, Xia J, Liu H, Wu Y, Zhang L, Yu Z, Fang M, Yu T, Wang Y, Pan S, Zou X, Yuan S, Shang Y. Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study. Lancet Respir Med. 2020. https://doi.org/10.1016/S2213-2600(20)30079-5.

  2. Hendren NS, Drazner MH, Bozkurt B, Cooper LT. Description of the acute COVID-19 cardiovascular syndrome. Circulation. 2020. https://doi.org/10.1161/CIRCULATIONAHA.120.047349.

  3. Li J-W, Han T-W, Woodward M, Anderson CS, Zhou H, Chen Y-D, Neal B. The impact of 2019 novel coronavirus on heart injury: a systematic review and meta-analysis. Prog Cardiovasc Dis. 2020. https://doi.org/10.1016/j.pcad.2020.04.008.

  4. Geri G, Vignon P, Aubry A, Fedou AL, Charron C, Silva S, Repessé X, Vieillard-Baron A. Cardiovascular clusters in septic shock combining clinical and echocardiographic parameters: a post hoc analysis. Intensive Care Med. 2019;45(5):657–67. https://doi.org/10.1007/s00134-019-05596-z.

    Article  PubMed  Google Scholar 

  5. Mekontso Dessap A, Boissier F, Charron C, Bégot E, Repessé X, Legras A, Brun-Buisson C, Vignon P, Vieillard-Baron A. Acute cor pulmonale during protective ventilation for acute respiratory distress syndrome: prevalence, predictors, and clinical impact. Intensive Care Med. 2016;42(5):862–70. https://doi.org/10.1007/s00134-015-4141-2.

    Article  PubMed  Google Scholar 

  6. Gattinoni L, Chiumello D, Rossi S. COVID-19 pneumonia: ARDS or not? Crit Care. 2020;24(1):154. https://doi.org/10.1186/s13054-020-02880-z.

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Acknowledgements

N/A

Funding

None

Author information

Authors and Affiliations

Authors

Contributions

BE, MG, ALF, and PV included patients, analyzed the data, and drafted the manuscript. NM and TL collected and analyzed the data and reviewed the manuscript. All authors read and approved the final version of the manuscript.

Corresponding author

Correspondence to Philippe Vignon.

Ethics declarations

Ethics approval and consent to participate

Local Ethical Committee approval #368-2020-24, which waived the need for informed consent. All patients agreed on the use of anonymized information as per the French law on the General Data Protection Regulation (GDPR).

Consent for publication

N/A

Competing interests

None

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Evrard, B., Goudelin, M., Montmagnon, N. et al. Cardiovascular phenotypes in ventilated patients with COVID-19 acute respiratory distress syndrome. Crit Care 24, 236 (2020). https://doi.org/10.1186/s13054-020-02958-8

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1186/s13054-020-02958-8

Keywords