Right ventricular (RV) involvement
RV involvement seems to be the most common with multiple studies demonstrating RV dilatation and a range of systolic dysfunction from mild to severe including documented instance of an acute cor pulmonale like presentation [16–21]. Pulmonary artery systolic pressure (PASP) was also found to be significantly elevated in a large number of patients presenting with COVID-19[4,18]. These findings may in part be attributed to a hypercoagulable state associated with systematic inflammation , endothelial dysfunction of the pulmonary vasculature leading to pulmonary emboli or microthrombi affecting the smaller segmental pulmonary arteries, hypoxemia secondary to infection itself or adverse effects of positive pressure ventilation[4,18,22–25]. Further, tricuspid annular plane systolic excursion (TAPSE) was found to be significantly decreased in critically ill COVID-19 patients and was more profoundly affected in severe acute respiratory distress syndrome (ARDS) as compared to mild ARDS and was found to have the best inter-observer variability [26](51). A study by D‘Alto et al. demonstrated that right ventricular-arterial uncoupling expressed as TAPSE/PASP is an independent predictor of mortality in COVID-19 patients [27].