Korean Journal of Anesthesiology



Magoon: Left-ventricular diastolic dysfunction in coronavirus disease: opening Pandora’s box!

Left-ventricular diastolic dysfunction in coronavirus disease: opening Pandora’s box!

Rohan Magoon
Received January 7, 2021       Accepted January 11, 2021
As I read through the articles featured in a recent issue of the Korean Journal of Anesthesiology [1,2] that outlined the perioperative implications of coronavirus disease (COVID-19), I felt motivated to highlight the importance of COVID-19-related left-ventricular (LV) diastolic dysfunction (LVDD) in the management of this predisposed subset, particularly since the cardiovascular consequences of COVID-19 continue to be ardently discussed [3].
A systematic echocardiographic evaluation of 100 COVID-19 patients with a mean age of 66 years by Szekely et al. [4] revealed a 16% incidence rate of LVDD despite a preserved LV systolic function in as high as 90% of their patients. In addition to subclinical ventricular relaxation impairment given the advanced age of the patients and comorbidities such as systemic hypertension, the conglomeration of factors specific to COVID-19, such as systemic inflammatory milieu, endothelial dysfunction, microvascular thrombosis, arrhythmias, disturbed ventricular cross-talk (owing to the concomitant right ventricular dysfunction resulting from pulmonary hypertension), and myocardial oxygen supply-demand perturbations, can contribute significantly to LVDD, with a subsequent accentuated potential to culminate in heart failure with a preserved ejection fraction (HFpEF) [3,4].
Moreover, the use of high positive end-expiratory pressure (PEEP), which is quite commonly employed while ventilating hypoxemic COVID-19 patients, can result in an attenuated cardiac output in addition to the already impaired ventricular filling in HFpEF. This observation is supported by Chin et al. [5], who elaborated on progressive deterioration in LV lusitropy with the application of high PEEP in patients with pre-existing LV relaxation abnormalities. In addition, the underlying cardiopulmonary interactions present unique challenges in weaning mechanically ventilated patients with coexistent LVDD [3,5].
An improved comprehension of the likelihood of an altered diastology in COVID-19 patients is pivotal in staging a more well-directed management approach wherein targeted echocardiographic surveillance, cardiac biomarkers, and combined heart-lung ultrasound and inodilators can assist in the overall management of this critically ill cohort.



Conflicts of Interest

No potential conflict of interest relevant to this article was reported.


1. Ong S, Lim WY, Ong J, Kam P. Anesthesia guidelines for COVID-19 patients: a narrative review and appraisal. Korean J Anesthesiol 2020; 73: 486-502.
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2. Yek JL, Kiew SC, Ngu JC, Lim JG. Perioperative considerations for COVID-19 patients: lessons learned from the pandemic -a case series. Korean J Anesthesiol 2020; 73: 557-61.
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3. Magoon R. COVID-19 and congenital heart disease: cardiopulmonary interactions for the worse! Paediatr Anaesth 2020; 30: 1160-1.
[Article] [PubMed] [PMC]
4. Szekely Y, Lichter Y, Taieb P, Banai A, Hochstadt A, Merdler I, et al. Spectrum of cardiac manifestations in covid-19: a systematic echocardiographic study. Circulation 2020; 142: 342-53.
[Article] [PubMed] [PMC]
5. Chin JH, Lee EH, Kim WJ, Choi DK, Hahm KD, Sim JY, et al. Positive end-expiratory pressure aggravates left ventricular diastolic relaxation further in patients with pre-existing relaxation abnormality. Br J Anaesth 2013; 111: 368-73.
[Article] [PubMed]

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