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G Model ARTICLE IN PRESS Medicina Clínica xxx (xxxx) xxx–xxx www.elsevier.es/medicinaclinica Scientific letter Role of echocardiography in the diagnosis of had involvement of main pulmonary arteries and another of sub- pulmonary embolism during SARS-CoV-2 segmental arteries. PE was bilateral in 45.45% of cases. infection夽 Echocardiography was performed during admission in 11 patients. Right ventricular (RV) involvement was observed in 4 Papel de la ecocardiografía en el diagnóstico de la embolia (36.36%) patients, in the form of RV hypocontractility in 2 (18.2%) pulmonar durante la infección por SARS-CoV-2 patients, RV dilatation in one (9.1%) patient and a combination of hypocontractility and dilatation in another patient (9.1%). Signs Dear Editor: of pulmonary hypertension were observed in 2 (18.2%) patients and left ventricular dysfunction only in one (9.1%) patient. In The clinical manifestations of SARS-CoV-2 (COVID-19) infec- terms of laboratory tests, at the acute time of PE diagnosis (48 h tion range from mild respiratory symptoms to acute respiratory peri-diagnosis), peak values of markers for myocardial damage distress, requiring admission to an intensive care unit (ICU).1,2 Car- (troponin T and N-terminal pro-brain natriuretic peptide) were diac involvement by the virus has been described in 20%–25% of observed in 4 patients (36.36%), 3 of whom also had radiographic patients and is associated with a worse prognosis.3,4 This cardiac and echocardiographic RV involvement. abnormality has been defined as an elevation of laboratory mark- Although cardiological abnormalities (mainly RV hypocontrac- ers for myocardial damage, but without any accompanying cardiac tility) could be found at the time of PE diagnosis in almost 40% of imaging test.3 patients, this did not influence the therapeutic approach and it was On the other hand, infection is associated with an increased observed that these abnormalities were corrected in subsequent incidence of thrombosis explained by the cytokine storm and the ultrasound scans during admission. Furthermore, there seems to increased expression of tissue factor produced by infection, added be a correlation between radiological, echocardiographic and lab- to the severity and immobilisation of any admitted patient.4 oratory findings of cardiac involvement, such that all patients with Echocardiography is the mainstay of cardiac imaging tech- signs of RV involvement on CT angiography had RV involvement on niques, and its use is of great interest for the monitoring of patients echocardiography, and almost all had elevated markers of myocar- hospitalized in ICUs, as well as for the diagnosis and follow-up of dial damage on blood tests. Thus, cardiac involvement in PE could pulmonary embolism (PE) in hemodynamically unstable and sta- be inferred from the radiological and analytical findings that we see ble patients, respectively.5 However, its use has been limited during in patients without SARS-CoV-2.5 the pandemic due to the risk of spreading the infection. The aim of The current findings support the fact that the presence of PE in our work is to describe the echocardiographic findings in patients the context of SARS-CoV-2 infection does not justify a change in the diagnosed with PE in the context of COVID-19. indications for echocardiography already established by the 2019 We report 11 patients diagnosed with SARS-CoV-2 infection clinical practice guidelines.5 This may be due to the fact that most who presented with PE and underwent an echocardiography during of these events occur in secondary arteries and/or are small in size hospital admission. These patients were 8 men and 3 women with and therefore do not usually cause haemodynamic instability. How- a mean age of 60 years who had obesity (72%), hypertension (54%) ever, according to our results, the finding of RV hypocontractility in and dyslipidaemia (45%) as the most important comorbidities. patients with COVID-19 could indicate undiagnosed PE. Finally, we Diagnosis of infection was made by reverse transcriptase poly- believe that the use of echocardiography in PE during SARS-CoV- merase chain reaction test performed on admission, diagnosis of PE 2 infection should be limited as a diagnostic and monitoring tool was made by computed tomography angiography (CT angiography) to haemodynamically unstable patients, or those who while stable and echocardiography was performed by cardiology and/or inten- show clinical deterioration. sive care physicians. Five patients (45.5%) were admitted to the ICU, five to a conventional hospital ward and one to the emergency Acknowledgements department. The time from hospital admission to PE diagnosis was 14.36 The authors wish to thank Doctors Beatriz Vaquerizo and María days, with a minimum of 0 (one patient) and a maximum of 44 del Pilar Gracia for their collaboration during the development of (one patient). this study. According to radiological findings most PEs (54.54%) occurred in segmental arteries and 27.27% in lobar arteries; one patient References 1. Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020;395:497–506, http://dx.doi.org/10.1016/S0140-6736(20)30183-5. 夽 Please cite this article as: Izquierdo A, Molina L, Rodríguez-Chiaradía DA. Papel de 2. Guan W, Ni Z, Hu Y, Liang W, Ou C, He J, et al. Clinical characteristics la ecocardiografía en el diagnóstico de la embolia pulmonar durante la infección por of coronavirus disease 2019 in China. N Engl J Med. 2020;382:1708–20, SARS-CoV-2. Med Clin (Barc). 2021. https://doi.org/10.1016/j.medcli.2021.03.020 http://dx.doi.org/10.1056/NEJMoa2002032. 2387-0206/© 2021 Elsevier España, S.L.U. All rights reserved. MEDCLE-5669; No. of Pages 2 G Model ARTICLE IN PRESS A. Izquierdo, L. Molina and D.A. Rodríguez-Chiaradía Medicina Clínica xxx (xxxx) xxx–xxx 3. Szekely Y, Lichter Y, Taieb P, Banai A, Hochstadt A, Merdler I, et al. The a spectrum of cardiac manifestations in coronavirus disease 2019 (COVID- Servicio de Cardiología, Hospital del Mar, Barcelona, Spain b Universidad Autónoma de Barcelona, Barcelona, Spain 19) – a systematic echocardiographic study. Circulation. 2020;142:342–53, http://dx.doi.org/10.1161/CIRCULATIONAHA.120.047971. c Grupo de investigación sobre enfermedades cardiovasculares 4. Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, (GREC), Hospital del Mar, Barcelona, Spain d Instituto de Investigación del Hospital del Mar (IMIM), Hospital del China: a retrospective cohort study. Lancet. 2020;395:1054–62, http://dx.doi.org/10.1016/S0140-6736(20)30566-3. Mar, Barcelona, Spain 5. Konstantinides SV, Meyer G, Becattini C, Bueno H, Geersing GJ, Harjola VP, e Servicio de Neumología, Hospital del Mar, Barcelona, Spain et al. ESC Scientific Document Group. 2019 ESC Guidelines for the diagno- f Universitat Pompeu Fabra (UPF), Barcelona, Spain sis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS). Eur Heart J. 2020;41:543–603, g CIBERES (ISCIII), Madrid, Spain http://dx.doi.org/10.1093/eurheartj/ehz405. ∗ Corresponding author. Andrea Izquierdo a,b , Lluis Molina a,b,c,d , E-mail address: darodriguez@parcdesalutmar.cat Diego A. Rodríguez-Chiaradía d,e,f,g,∗ (D.A. Rodríguez-Chiaradía). 2