Prognostic impact of right ventricular dilatation and echocardiography use criteria in hospitalized COVID-19 patients

Abstract

BACKGROUND

The surge of severe acute respiratory syndrome coronavirus 2 [coronavirus disease 2019 (COVID-19)] infection created unprecedented diagnostic and logistical pressures. Given the established potential for cardiac injury and the critical need to optimize scarce resources, establishing the clinical utility and prognostic value of transthoracic echocardiography (TTE) became imperative.

AIM

To evaluate the prognostic predictors and the adherence to appropriate use criteria (AUC) for TTE in a highly affected setting.

METHODS

We performed a retrospective cohort study analyzing records from patients with confirmed COVID-19 who underwent TTE. Socio-demographic, biochemical, and echocardiographic parameters were collected. Mortality was the primary outcome. We assessed inter-observer agreement (Kappa statistic) for TTE indications (based on American College of Cardiology Foundation 2011 and American Society of Echocardiography 2020 guidelines) and the determination of clinical impact (a subsequent change in patient management).

RESULTS

Total 149 patients were analyzed. Median age was 66 years [interquartile range (IQR): 56-73], median hospital stay was 13 days (IQR: 6-23). Overall and intensive care unit mortality rates were 39.6% and 60%, respectively. Elevated biochemical markers (leukocytes, neutrophils, lactate dehydrogenase, and C-reactive protein) were associated with mortality. Crucially, right ventricular (RV) dilatation and/or strain (P = 0.008) was identified as the sole echocardiographic finding significantly predictive of mortality. Inter-observer agreement for classifying AUC was high (κ ≥ 0.798). Furthermore, TTE prompted a change in clinical management in 79.7% of the cases.

CONCLUSION

RV pathology is a potent, quantifiable prognostic indicator. While AUC demonstrated high reliability, the significant and frequent changes in management suggest that the current guidelines may possess inherent limitations when addressing the unique, acute prognostic complexities of severe COVID-19 disease.

Key Words: SARS-CoV-2; COVID-19; Echocardiography; Prognosis; Right ventricular strain; Appropriate use criteria

Core Tip: This study highlights right ventricular dilatation as the primary echocardiographic predictor of mortality in hospitalized coronavirus disease 2019 patients. While adherence to appropriate use criteria for transthoracic echocardiography (TTE) was exceptionally high (98%), the immediate clinical impact on management remained modest (12.7%). These findings suggest that during pandemics, TTE is a robust prognostic tool; however, its systematic use should be further refined to maximize therapeutic yield. This research provides a data-driven foundation for optimizing cardiac imaging resources and developing future artificial intelligence models for risk stratification in acute viral infections.

INTRODUCTION

Since its emergence, the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus has fundamentally disrupted global medical infrastructure. By mid-2020, clinical evidence revealed that coronavirus disease 2019 (COVID-19) was far more than a localized pulmonary infection, acting instead as a multi-organ pathology with profound cardiovascular repercussions[1]. Specifically, right ventricular (RV) impairment-characterized by dilatation and abnormal strain-became a pivotal indicator of clinical deterioration and fatal outcomes in critically ill cohorts[2]. Nevertheless, the massive influx of patients created a logistical bottleneck for diagnostic services. Transthoracic echocardiography (TTE), though vital for hemodynamic monitoring, faced significant availability constraints[3]. Consequently, hospital systems were forced to prioritize imaging requests, raising questions regarding how strictly the established guidelines for echocardiographic assessment were being followed during the peak of the crisis.

In this high-pressure environment, determining the true prognostic weight of specific cardiac findings was essential. TTE allows for an immediate, non-invasive look at cardiac morphology, yet its accuracy depends heavily on the sonographer's proficiency[4]. Applying standard appropriate use criteria (AUC) to COVID-19 patients proved difficult, as these individuals often presented with complex, overlapping comorbidities[5]. While international societies rapidly updated their protocols, the long-term effectiveness of these adaptations in predicting patient survival remained largely unverified. In particular, the prognostic significance of RV strain and dilatation required deeper scrutiny, as it had not been fully characterized in the early stages of the pandemic[6].

Despite the transition from a pandemic state to an endemic phase, the cardiovascular risks associated with COVID-19 remain a serious concern. Currently, there is a worrisome trend among health authorities and the general public to overlook the severity of the virus[7]. This diminished vigilance could lead to a failure in identifying cardiovascular complications in both acute and post-infectious stages[8]. Therefore, it is crucial to maintain a high clinical suspicion and utilize diagnostic tools capable of detecting subclinical cardiac damage that might otherwise be missed.

The persistence of cardiopulmonary sequelae continues to strain healthcare resources. Many patients still experience lingering RV dysfunction, making echocardiography a cornerstone of long-term follow-up. However, the scarcity of experts for precise interpretation remains a challenge. The emergence of artificial intelligence (AI) offers a path forward, providing automated, consistent quantification of ventricular geometry[9]. To succeed, these AI systems must be trained on high-quality, diverse datasets that capture the full range of echocardiographic phenotypes observed throughout the pandemic. This research addresses these gaps by linking RV dilatation and strain to clinical outcomes while auditing the application of AUC in a pandemic setting. By systematically analyzing these parameters, we provide a robust dataset that not only informs current clinical practice but also serves as a baseline for developing future AI-driven diagnostic supports. As we continue to manage both new infections and chronic cardiovascular aftereffects, optimizing TTE use remains a priority. Consequently, this study sought to determine the prognostic impact of RV abnormalities and evaluate the adherence to appropriateness criteria, establishing a scientific foundation for future technological integration in cardiac imaging.

MATERIALS AND METHODS

Study design

This was a single-center, retrospective observational cohort study. The study was conducted to identify echocardiographic predictors of prognosis and to assess adherence to AUC for TTE in hospitalized COVID-19 patients. The study population included all adult patients (≥ 18 years) for whom a TTE was requested between March and September 2020.

Study population

This study was conducted at Hospital Universitario Nacional de Colombia, a tertiary referral teaching hospital in Bogotá, Colombia, involving patients who met the predefined inclusion and exclusion criteria. The study protocol received formal approval from the Institutional Research Ethics Committee of the Hospital Universitario Nacional de Colombia and was performed in strict accordance with the principles of the Declaration of Helsinki. As this investigation was classified as a minimal-risk documentary study based exclusively on the secondary analysis of anonymized electronic medical records, the committee granted a waiver of informed consent. Patient confidentiality and data protection were strictly maintained throughout the collection and analysis phases. Confirmed SARS-CoV-2 infection by reverse transcription polymerase chain reaction (RT-PCR), antigen, or antibody testing. Suspected SARS-CoV-2 infection, defined as: Patients presenting with respiratory symptoms (cough, dyspnea, or fever), under isolation, awaiting confirmatory testing. Patients in whom the treating medical team suspected COVID-19 infection based on non-respiratory symptoms or signs, pending confirmatory results. Patients were excluded if: (1) Electronic health records were unavailable for review; (2) Clinical follow-up could not be completed until discharge or death; (3) SARS-CoV-2 infection was ruled out at the time of the echocardiogram; and (4) Echocardiographic studies other than transthoracic modality were performed. All patients meeting inclusion criteria and evaluated between March and September 2020 were included. Given the exhaustive inclusion of all eligible cases, no formal sample size calculation was performed.

Statistical analysis

Data was processed using IBM SPSS Statistics version 25. Qualitative variables were expressed as n (%), while quantitative variables were summarized using measures of central tendency (mean, standard deviation, and coefficient of variation). For non-normally distributed variables, medians and interquartile ranges were reported. Bivariate analyses were performed to explore associations between echocardiographic and biochemical variables with mortality. Categorical variables were compared using χ² tests. Quantitative variables following normal distribution were analyzed using Pearson’s correlation coefficient, whereas non-normally distributed variables were compared using the Mann-Whitney U test. Inter-observer agreement regarding TTE indication classification was evaluated using Cohen’s Kappa statistic. When discrepancies were identified due to prevalence bias, a prevalence-adjusted Kappa index was applied. Statistical significance was defined as a P value < 0.05.

Data collection

All TTE studies performed in the cardiology unit of the Hospital Universitario Nacional were reviewed. Using the electronic medical record system, each patient’s clinical data were cross-checked to confirm suspected or confirmed SARS-CoV-2 infection at the time of TTE. Patients not meeting this criterion were excluded. Demographic information, comorbidities, clinical history, admission laboratory data, and severity scores were recorded in a structured database. Outcomes were categorized as discharge or in-hospital death. In cases of nosocomial infection, this was specifically documented along with the admission diagnosis. To identify prognostic markers and echocardiographic findings associated with mortality, a bivariate analysis compared survivors and non-survivors, calculating P values for biochemical and echocardiographic parameters. Echocardiographic Assessment and Criteria Echocardiographic parameters were measured and interpreted following the American Society of Echocardiography (ASE) guidelines for chamber quantification. RV dilatation was defined numerically as an RV basal diameter > 41 mm measured at end-diastole in the apical four-chamber view. RV dysfunction was defined by a tricuspid annular plane systolic excursion (TAPSE) < 17 mm. RV strain was assessed qualitatively by identifying signs of pressure or volume overload (e.g., D-shaped left ventricle). These standardized thresholds were used to categorize RV involvement as a binary variable for the prognostic analysis. Echocardiographic indications and clinical impact echocardiographic indications were categorized according to the 2011 American College of Cardiology Foundation (ACCF) and 2020 ASE AUC, adapted to the COVID-19 context. Each indication was independently reviewed by two certified cardiologists specialized in echocardiography, classifying each study as appropriate, inappropriate, or uncertain. The reviewers also assessed whether the TTE results led to a change in clinical management, defined as: (1) Change in management (e.g., adjustment of vasopressors, anticoagulation, or surgical decisions); (2) No change; or (3) Not considered. In cases of disagreement, a third echocardiography expert adjudicated the final classification.

RESULTS

A total of 207 patients met the inclusion criteria. Among them, 58 (28%) were classified as suspected and 149 (72%) as confirmed COVID-19 cases by RT-PCR. In the suspected cohort, infection was subsequently ruled out after verification of negative results in the central laboratory database. TTEs were performed during the initial phase of clinical suspicion, before confirmation or exclusion of infection by the treating team.

Clinical and demographic characteristics

In the confirmed COVID-19 subgroup (n = 149), the median age was 66 years (IQR: 56-73), and the median hospital stay was 13 days (IQR: 6-23). Women accounted for 47% (n = 70) of this cohort. The overall mortality rate was 39.6% (n = 59). The most frequent comorbidities identified in the confirmed group were hypertension (43.6%), obesity (25.0%), and diabetes mellitus (20.8%). The primary admission diagnoses included viral pneumonia (83.8%), acute respiratory distress syndrome (51.0%), septic shock (32.8%), acute kidney injury (30.2%), and pulmonary embolism (16.7%). Regarding critical care requirements, 50.3% (n = 75) of the confirmed patients required intensive care unit (ICU) management. Within this subset, 82.6% (n = 62) required invasive mechanical ventilation, and 81.3% (n = 61) received vasoactive agents. The mortality rate among patients admitted to the ICU was 60.0% (n = 45) (Tables 1 and 2).

Table 1 Demographic and clinical characteristics of confirmed coronavirus disease 2019 patients, n (%)/median (25^th-75^th percentiles).

Variable	Total (n = 149)	ICU patients (n = 75)	Non-ICU patients (n = 74)	P value
Age (years)	66 (56-73)	66 (56-73)	64 (54-72)	0.450
Male sex	79 (53.0)	42 (56.0)	37 (50.0)	0.460
Body mass index (kg/m2)	26.8 (24-30)	27.2 (24-31)	26.4 (23-29)	0.310
Comorbidities
Hypertension	65 (43.6)	35 (46.7)	30 (40.5)	0.450
Obesity	37 (25.0)	21 (28.0)	16 (21.6)	0.370
Diabetes mellitus	31 (20.8)	18 (24.0)	13 (17.6)	0.340
Hypothyroidism	23 (15.4)	12 (16.0)	11 (14.9)	0.850
Chronic obstructive pulmonary disease	15 (10.1)	9 (12.0)	6 (8.1)	0.430
Smoking history	12 (8.1)	7 (9.3)	5 (6.8)	0.570
Chronic kidney disease	8 (5.4)	5 (6.7)	3 (4.1)	0.480
Ischemic heart disease	10 (6.7)	6 (8.0)	4 (5.4)	0.530
Heart failure (previous)	7 (4.7)	4 (5.3)	3 (4.1)	0.720

ICU: Intensive care unit.

Table 2 Echocardiographic and clinical outcomes in confirmed coronavirus disease 2019 patients, n (%)/median (25^th-75^th percentiles).

Variable	Total (n = 149)	ICU patients (n = 75)	Non-ICU patients (n = 74)	P value
Echocardiographic findings
Left ventricular ejection fraction < 40%	12 (8.0)	7 (9.3)	5 (6.7)	0.560
Segmental wall motion abnormalities	15 (10.1)	9 (12.0)	6 (8.1)	0.430
Right ventricular dilatation/overload	40 (26.8)	26 (34.7)	14 (18.9)	0.033
Right ventricular dysfunction (TAPSE < 17 mm)	9 (6.0)	6 (8.0)	3 (4.1)	0.310
PASP > 35 mmHg	134 (89.9)	69 (92.0)	65 (87.8)	0.390
Left atrial enlargement	15 (10.1)	8 (10.7)	7 (9.5)	0.810
Diastolic dysfunction (grade ≥ II)	26 (17.4)	15 (20.0)	11 (14.9)	0.410
Pericardial effusion	4 (2.7)	3 (4.0)	1 (1.4)	0.360
Clinical outcomes
In-hospital mortality	59 (39.6)	45 (60.0)	14 (18.9)	< 0.001
Invasive mechanical ventilation	62 (41.6)	62 (82.7)	0 (0.0)	< 0.001
Acute kidney injury	45 (30.2)	37 (49.3)	8 (10.8)	< 0.001
Length of hospital stay, (days)	13 (6-23)	18 (11-26)	6 (4-11)	< 0.001

ICU: Intensive care unit; TAPSE: Tricuspid annular plane systolic excursion; PASP: Pulmonary artery systolic pressure.

Biochemical markers

Baseline laboratory data from the referring institution in confirmed cases (n = 149) showed a median lactate dehydrogenase (LDH) of 415 U/L (IQR: 301-562), D-dimer of 958 ng/mL (IQR: 454-2180), ferritin of 1031 ng/mL (IQR: 749-1538), C-reactive protein (CRP) of 75.3 mg/L (IQR: 23.2-157), and a lymphocyte count of 820 × 10³ cells/μL. At our center, the laboratory values for the confirmed cohort were as follows: Lymphocytes 790 × 10³ cells/μL (IQR: 460-1230), D-dimer 2059 ng/mL (IQR: 587-4780), LDH 445 U/L (IQR: 316-621), troponin I 0.031 ng/mL (IQR: 0.017-0.25), ferritin 958 ng/mL (IQR: 494-2102), and CRP 112.9 mg/L (IQR: 50-185). Variables significantly associated with in-hospital mortality in the bivariate analysis included leukocyte count (P = 0.001), neutrophil count (P < 0.001), lymphocyte count (P = 0.003), hemoglobin (P = 0.026), LDH (P = 0.018), and CRP (P = 0.006) (Table 3).

Table 3 Laboratory, echocardiographic and prognostic parameters in confirmed coronavirus disease 2019 patients (survivors vs non-survivors), n (%)/median (25^th-75^th percentiles).

Parameter	Survivors (n = 90)	Non-survivors (n = 59)	P value
Biomarkers
Lymphocytes (× 103/μL)	980 (629-1270)	700 (550-910)	0.003
Leukocytes (cells/μL)	9125 (7155-14037)	11805 (9238-16473)	0.001
Neutrophils (cells/μL)	7460 (5426-11965)	9945 (7883-13869)	< 0.001
Hemoglobin (g/dL)	15.0 (11-17)	14.0 (13-15)	0.026
Platelets (×103/μL)	291 (224-381)	234 (174-331)	0.003
D-dimer (ng/mL)	2,023 (750-3450)	2,761 (879-6900)	0.155
LDH (U/L)	454 (307-610)	506 (379-736)	0.018
C-reactive protein (mg/L)	95 (43-146)	148 (84-196)	0.006
Quantitative echo parameters
E/e′ ratio	10 (10-12)	10 (9-12.8)	0.334
PASP (mmHg)	42.5 (39.5-51.8)	48 (44-51)	0.087
LVEF (%)	60 (55.5-65)	60 (55-65)	0.959
TAPSE (mm)	22 (20-23)	23 (19.8-25)	0.590
Qualitative findings
Prone position during imaging	3 (3.3)	8 (13.6)	0.026
RV dilatation/overload	17 (18.9)	22 (37.3)	0.008
Regional wall-motion abnormality	9 (10.0)	6 (10.)	0.062
Diastolic dysfunction (any)	43 (47.8)	43 (72.9)	0.197

LDH: Lactate dehydrogenase; PASP: Pulmonary artery systolic pressure; TAPSE: Tricuspid annular plane systolic excursion; LVEF: Left ventricular ejection fraction; RV: Right ventricular.

Echocardiographic findings

In confirmed COVID-19 patients (n = 149), the median left ventricular ejection fraction (LVEF) was 60% (IQR: 57-65), and the left ventricular outflow tract velocity-time integral was 19.4 cm (IQR: 17.2-22.1). Segmental wall motion abnormalities were identified in 10.1% (n = 15) of patients. Left ventricular diastolic dysfunction was present in 100 patients (67.1%), predominantly grade I (72%), followed by grade II (19%) and grade III (7%); classification was indeterminate in 2%. The median E/e′ ratio was 10 (IQR: 8.25-12.85). Regarding RV assessment, 26.8% (n = 40) of patients exhibited RV dilatation or signs of pressure/volume overload. The median TAPSE was 22 mm (IQR: 20-24) and the median pulmonary artery systolic pressure was 46 mmHg (IQR: 41-51). Valvular abnormalities were observed in 14.1% (n = 21) of cases, primarily involving the mitral valve, and pericardial findings were noted in five cases (four effusions and one pneumopericardium). Among echocardiographic and procedural parameters in the bivariate analysis, performing the study in the prone position (P = 0.026) and the presence of RV dilatation or overload (P = 0.008) were significantly associated with in-hospital mortality (Table 3).

Indications and inter-observer concordance

An institutional algorithm for urgent echocardiography in patients with confirmed COVID-19 was developed based on regional and international consensus recommendations. The most frequent clinical indications in this cohort were suspected heart failure, hemodynamic instability, and significant biomarker elevation. According to the ASE 2020 priority criteria, 147 studies (98.6%) were categorized as high-priority, primarily due to new or worsening cardiovascular symptoms or the need for pre-therapeutic evaluation in the critically ill. The prevalence-adjusted bias-adjusted kappa between the two cardiologists for ASE priority was 0.96, reflecting excellent inter-observer agreement. In this high-priority confirmed group, TTE findings led to a change in clinical management (clinical impact) in 80.5% of cases.

Using the ACCF 2011 AUC specifically for the confirmed cohort, the most frequent indications were follow-up of known structural disease (24.8%), suspected pulmonary embolism (13.4%), and assessment of ventricular function in acute coronary syndrome (10.1%). The Cohen’s kappa for appropriateness classification (appropriate, inappropriate, or uncertain) remained robust at 0.798, indicating good agreement. Within the confirmed cases, 118 (79.2%) studies were deemed appropriate, 27 (18.1%) inappropriate, and 4 (2.7%) uncertain. A change in clinical management occurred in 83%, 67%, and 75% of these groups, respectively. Notably, in 25 patients (16.8%) of the confirmed cohort, TTE findings were not explicitly integrated into the final clinical decision-making process (Table 4).

Table 4 Echocardiographic indications, appropriateness criteria, and clinical impact in confirmed coronavirus disease 2019 patients (n = 149).

Parameter	n (%)
Echocardiographic Indications (institutional algorithm)
Suspicion of heart failure	127 (85.2)
Elevated biomarkers with hemodynamic instability	38 (25.5)
Hemodynamic instability refractory to fluids/vasopressors	23 (15.4)
Myocardial infarction (universal definition)	19 (12.8)
Tachyarrhythmias (sinus or ventricular)	12 (8.1)
Cardiomegaly on imaging	9 (6.0)
No urgent indication	6 (4.0)
ASE 2020 clinical priority
High priority-change in cardiovascular symptoms	144 (96.6)
High priority-pre-therapy evaluation	3 (2.0)
Intermediate/low priority	2 (1.4)
ACCF 2011 appropriateness criteria
Appropriate	118 (79.2)
Inappropriate	27 (18.1)
Uncertain	4 (2.7)
Clinical impact of echocardiographic findings
Overall change in clinical management (impact)	120 (80.5)
Specific changes (within impact group)
Non-cardiac etiology identified	66 (55.0)
Cardiac primary etiology documented	47 (39.1)
Change in pharmacologic therapy	33 (27.5)
Request for additional diagnostic tests	21 (17.5)
Adjustment of vasopressors or inotropic agents	14 (11.6)
Consultation to other specialties	7 (5.8)
Adjustment in mechanical ventilation	4 (3.3)
No change in clinical management	29 (19.5)
Integration into clinical decision-making
Findings explicitly considered	124 (83.2)
Findings not considered in medical records	25 (16.8)

ACCF: American College of Cardiology Foundation; ASE: American Society of Echocardiography.

Clinical impact of echocardiography

The most frequent effect was clarification toward a non-cardiac etiology, followed by identification of a primary cardiac cause and adjustment of pharmacologic therapy (Table 4). Inter-observer agreement for the “clinical impact” variable yielded a Cohen’s kappa = 0.887 (95%CI: 0.81-0.96), demonstrating strong consistency in classification between reviewers (change, no change, or not assessable).

DISCUSSION

Echocardiography remains a multifaceted cornerstone in cardiovascular diagnostics, providing critical, real-time data on cardiac architecture and hemodynamics. In the context of severe respiratory failure, the ability to obtain immediate bedside information is invaluable. Prior research has consistently underscored the predictive utility of this modality in tailoring therapies for hospitalized patients facing suspected coronary syndromes, acute heart failure, or undifferentiated circulatory collapse[10]. Furthermore, the ACCF emphasizes that a systematic application of ultrasound can fundamentally alter clinical trajectories[11]. Consequently, TTE should be viewed not merely as an imaging technique, but as a decisive clinical instrument that bridges diagnostic precision with immediate therapeutic action in complex acute care environments. The fact that suspected heart failure was the primary driver for referral in our cohort (85.2%) reinforces its established role in quantifying ventricular function and volume status. This clinical pattern mirrors large-scale international registries where inpatient scans are primarily utilized to adjudicate systolic impairment or the severity of congestion[12]. Moreover, our findings suggest that when bedside imaging is integrated with biomarkers—such as troponins or natriuretic peptides—the resulting "multimodal" assessment significantly refines the predictive power of cardiac evaluation in viral pneumonias[13]. This investigation provides a comprehensive analysis of patients with confirmed COVID-19, offering a window into the cardiovascular landscape of the pandemic’s most severe cases. Our cohort’s profile-median age of 66 with a high prevalence of hypertension (43.6%), diabetes (20.8%), and obesity (25%)-aligns with comorbidities that global meta-analyses have linked to poor hospital outcomes[14]. With a 60% mortality rate in the ICU subgroup, our data reflects the profound lethality of cardiac-pulmonary interactions during severe outbreaks[15]. The strong correlation observed between invasive mechanical ventilation (82.6% in ICU) and adverse outcomes highlights the necessity of early cardiovascular monitoring to guide lung-protective ventilation and fluid management[16]. Systemic inflammation remains the common thread in these fatal cases. Metabolic conditions like hypertension and diabetes likely prime the endothelium for a more aggressive inflammatory response, increasing the risk of myocardial injury[17,18]. Our results show that leukocytosis, neutrophilia, and elevated CRP or LDH levels were significantly higher in non-survivors. This “inflammatory phenotype”, particularly the severe lymphopenia observed (P = 0.003), points to a state of immune dysregulation that directly impacts right-sided cardiac performance through increased pulmonary vascular resistance[19,20]. A pivotal finding in this study was the role of the RV. RV dilatation or overload was identified in 26.8% of cases and stood as the sole echocardiographic predictor significantly associated with mortality (P = 0.008). This impairment is often a consequence of acute pressure overload-driven by pulmonary microthrombi, hypoxic vasoconstriction, or high airway pressures-rather than primary myocardial disease[21,22]. Interestingly, while LVEF remained preserved in 92% of patients, diastolic dysfunction was remarkably prevalent (67.1%). This suggests that COVID-19-related cardiac stress affects ventricular relaxation and compliance long before it compromises global contractility[23]. Regarding the technical execution, the study highlights the inherent difficulties of performing TTE in the critically ill. We found that performing imaging in the prone position (P = 0.026) was a significant predictor of death. This association is multifaceted: First, it serves as a clinical surrogate for refractory hypoxemia and extreme disease severity. Second, it reflects a substantial technical challenge; obtaining adequate acoustic windows in a prone patient requires advanced maneuvers, often resulting in sub-optimal views of the apical and subcostal regions. This limitation forces the clinician to rely on parasternal long and short-axis views, which may underestimate certain valvular or segmental pathologies. Despite these hurdles, our data shows that even limited “focused” scans in such positions provide enough data to steer management in 80% of cases. Adherence to institutional algorithms based on ASE/ACCF guidelines reached an exceptional 98.6%. This high compliance, paired with a robust inter-observer reliability (κ = 0.798-0.96), proves that standardized protocols can maintain diagnostic integrity even during healthcare crises. Finally, the 80.5% clinical impact rate observed-significantly higher than pre-pandemic reports[24-26], suggests that in high-uncertainty environments, TTE is used with greater judiciousness and yields higher diagnostic value. Even in cases where indications were borderline, 67% resulted in management changes, reinforcing the need for flexible appropriateness frameworks that can adapt to the evolving demands of novel infectious diseases[27]. The mortality in our study remained inextricably tied to an inflammatory phenotype characterized by high LDH, CRP, and neutrophil counts[28,29]. The lack of a significant difference in LVEF between survivors and non-survivors reinforces the premise that death in these patients is primarily driven by systemic inflammation and right-sided heart failure rather than classic left-sided ischemic failure[30]. Ultimately, this integrated approach confirms echocardiography as a robust tool for guiding management in high-risk, resource-limited scenarios.

CONCLUSION

Data from this investigation establish that RV dilatation or overload stands as the sole significant echocardiographic predictor of mortality in patients with confirmed COVID-19. The strong association between RV impairment and fatal outcomes (P = 0.008) suggests that right-heart strain-triggered by acute pulmonary vascular resistance and extensive parenchymal damage-is a primary driver of clinical deterioration in these patients. Furthermore, the research demonstrated a remarkable adherence to international prioritization and appropriateness standards, with 98.6% of studies meeting high-priority criteria. The high clinical impact observed (80.5%) confirms that echocardiography, when guided by structured institutional algorithms, remains a high-yield diagnostic tool even in resource-constrained environments. These findings suggest that while current appropriateness criteria are effective, future protocols should prioritize early and focused assessment of the right heart to refine risk stratification and therapeutic intervention in severe viral pneumonia.