Left ventricular (LV) involvement
LV systolic and diastolic dysfunction have also been reported in COVID-19 patients, especially in those with elevated troponin levels[28,29]. Interestingly, despite conventional ECHO studies demonstrating only mild LV systolic and diastolic dysfunction, a recent myocardial deformation analysis study revealed patients who had a normal LV ejection fraction (LVEF) measured by conventional ECHO had abnormal LV deformation. This was in the form of abnormal regional longitudinal deformation (rLS), regional radial strain (rRS) and regional circumferential strain (rCS) affecting predominantly the basal segments. Such a pattern is suggestive of a reverse basal takotsubo-like syndrome in patients with COVID-19, similar to what is seen in Fabry’s or Friedrich’s disease[30–32]. Myocardial involvement in the basal/mid infero-/anterolateral LV segments was thought to be partly a result of hydrostatic edema due to the supine position of the patient. Such reverse basal takotsubo-like syndrome picture could also be explained by the edema leading to abnormal basal rRS curves without significant alterations during systole[30]. Furthermore, COVID myocarditis exhibits a transmural myocardial involvement as evidenced by the severely impaired CS, as it is triggered by cytokine storm. This finding differs from typical viral myocarditis which often affects the epi-myopericardial segments.[30]. In a multicenter study by Giustino et al., patients with myocardial injury as defined by elevated cardiac biomarkers, had more wall motion abnormalities (WMAs) in apical and mid segments, while basal WMAs were numerically higher in patients with no myocardial injury. Furthermore, WMAs were more frequently observed in patients with regional ST-segment deviations[33].