PMC:7295558 / 11439-15438 JSONTXT

{"target":"https://pubannotation.org/docs/sourcedb/PMC/sourceid/7295558","sourcedb":"PMC","sourceid":"7295558","source_url":"https://www.ncbi.nlm.nih.gov/pmc/7295558","text":"Discussion\nWe found several cardiac manifestations in subjects with confirmed COVID-19. One subject had ventricular concentric remodeling, one had a tricuspid vegetation and two heart failure with a reduced ejection fraction (one was a young patient with no other comorbidity). Also, subjects available for GLS analysis showed signs of ventricular dysfunction.\nSeveral recent studies have explored the relationship between COVID-19 and myocardial damage. Two recent studies have reported increased mortality in subjects with an elevation in hs-troponins, and have proposed cardiac injury as an independent risk factor for mortality (hazard ratio (HR): 4.26) [5, 6]. Importantly, the study by Guo et al [5] also showed that elevations in cardiac troponins were associated with higher C-reactive protein (CRP), D-dimer, cytokines and N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels, suggesting there might be a link between myocardial injury, inflammation and ventricular dysfunction. None of these trials have reported echocardiographic evidence of myocardial dysfunction. Similar to other reports, our subjects had normal baseline levels of hs-troponins.\nIn this series, serial measurements of troponins or D-dimer determination were not available, but increased levels of other cardiac markers such as CK, CK-MB and myocardial dysfunction detected by TTE were found. None of our patients had previous known CVD. Therefore, myocardial dysfunction could represent a direct manifestation of COVID-19, and also myocardial abnormalities seen in critically ill patients [13]. One of our patients had a tricuspid vegetation, severe tricuspid regurgitation and repeated negative blood cultures. Interestingly, previous reports in subjects with SARS-CoV infection show the presence of endocarditis with marantic vegetations [14]. Recently, the presence of a COVID-19-associated coagulopathy (CAC) characterized by hypercoagulability has been proposed, and recent studies have found a presence of thrombotic events in 31% of subjects with COVID-19, mainly pulmonary embolism [15, 16]. We were unable to perform a pathologic evaluation of our subject’s vegetation for this report, and computed tomography (CT)-pulmonary angiography was not available because of his clinical condition. Although all of our subjects were receiving thromboprophylaxis, the possibility of this being a thrombus attached to the valve remains.\nCurrently, the impact on the prognosis of a diminished LVEF or LV GLS in subjects with COVID-19 is not clear. A recent study in a cohort of 120 subjects with COVID-19, found that tricuspid annular plane systolic excursion (TAPSE) and right ventricular GLS were significantly related to mortality, even though the values found in deceased subjects were within normal reference values, like the patients here presented [17]. No information is presented about LV GLS. More research is urgently needed to elucidate the pathophysiological affection of the cardiovascular system in COVID-19. Tools for the detection of high-risk subjects for management and resource allocation are vital, considering the strain of health systems because of the COVID-19 pandemic.\nThis report has several limitations. First, image acquisition in these subjects is difficult: PPE is required to minimize exposure of all the personnel involved, and all equipments need to be sterilized between studies. Currently, the use of TTE must be evaluated on a case-by-case basis at every location. Second, we were not able to obtain D-dimer values or CT for our subjects. Also, our sample size is small. Finally, even though none of our subjects had previous known CVD, some of the findings we report could predate the acquisition of COVID-19. However, amid this pandemic, the data are of value.\nIn conclusion, all of our subjects showed an altered LV function, assessed by LVEF and GLS. Subjects with COVID-19 present several types of myocardial dysfunction assessed by TTE, even in the absence of prior 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