How to assess the left ventricle in COVID-19 patients using echocardiography

Left ventricular function may be impaired in patients who have contracted SARS-CoV-2. In this video, from our COVID Mini: Handheld Echocardiography course, we'll take a look at how to assess the left ventricle as part of a handheld echocardiography study.

COVID-19 has changed the delivery of inpatient echocardiography in order to prevent cross-infection with healthcare professionals. This course will teach you how to use point-of-care cardiac ultrasound to rapidly assess the hemodynamic effects of SARS-CoV-2 on patients, while limiting the risk to yourself. Learn how to use these findings to guide your management of the ensuing COVID-19 clinical syndrome.

In this Medmastery lesson, we will learn how to assess the left ventricle as part of a handheld echocardiography study. The left ventricular dimensions and function can be assessed qualitatively. Left ventricular size is reduced when the ventricular cavity appears small in an underfilled patient.

Conversely, left ventricular dimensions may be increased where there is left ventricular dysfunction, or volume overload states, such as severe mitral or aortic regurgitation. Left ventricular function is described qualitatively by assessing myocardial wall thickening, and motion towards the center of the left ventricular cavity in systole and outward in diastole.

Each myocardial segment should be assessed and the presence of regional wall motion abnormalities should be described. In this parasternal long axis view, we see regional wall motion abnormalities affecting the anteroseptal wall. Ventricular function should be described as normal or impaired. Where myocardial contraction is more pronounced than normal, the term hyperdynamic is applied.

Although this is not necessarily synonymous with normal function. This is illustrated in these parasternal images, we can see that the left ventricle has hyperdynamic systolic function. This vigorous contraction of the left ventricle can be seen in pathological states, such as sepsis, or hypovolemia.

Case reports of patients infected with SARS coronavirus two, have shown evidence of myocarditis. On cardiac ultrasound, there may be evidence of reduced myocardial thickness and a reduction in left ventricular systolic function. Myocarditis may cause global or regional ventricular impairment, the pattern of which typically does not correspond to coronary territory.

In this parasternal long axis image we see globally impaired left ventricular function in a patient with myocarditis following coronavirus infection. There have also been documented cases of acute Takotsubo or stress induced cardiomyopathy following SARS coronavirus two infection. Typically, there is transient left ventricular dysfunction with a characteristic pattern of apical and mid segments hypokinesia, giving rise to the classical apical ballooning appearance.

There are also widespread ECG changes with raised troponin levels. Where doubt remains and infection control measures allow, cardiac magnetic resonance imaging can provide incremental information allowing the detection of relevant functional and tissue changes useful in differentiating Takotsubo’s from acute coronary syndrome.