DETERMINATION OF INTERVENTRICULAR WALL TISSUE DENSITY AS EARLY PREDICTOR

OF CARDIAC MYOPATHY ON UNENHANCED CHEST CT STUDIES COVID-CONFIRMED

PATIENTS OF DJNRMHS
Christiane Yves Lloyd E. Rada, MD
Radiology Resident
Dr. Jose N. Rodriguez Memorial Hospital and Sanitarium

BACKGROUND
Since the emergence of SARS-COV2 virus (also known as COVID19), medical professionals were faced
with new challenges in determining the effect of the virus on different body systems. The clinical
observations of disease patterns reveal that infections have a direct impact on the cardiovascular system
and, hence demanding special care for patients with heart diseases. The SARS-COV2 enters the cells
through the angiotensin-converting enzyme 2 (ACE2) receptor. The higher risk of COVID-19 infection has
been connected with various direct and indirect complications, including myocarditis, acute myocardial
injury, venous thromboembolism, and arrhythmias. [1] This study aims to determine if there is
significant difference of tissue density on interventricular wall of the heart that may attribute to clinical
complications and mechanisms responsible for the same with COVID-19 infection. In this way, risk
stratification and classification will aid the healthcare provider for better management of the patient.

INTRODUCTION
Coronavirus disease 2019 (COVID-19), the highly contagious infectious disease caused by severe acute
respiratory syndrome coronavirus 2 (SARS-CoV-2), has had a catastrophic effect on the world’s
demographics resulting in more than 2.9 million deaths worldwide, emerging as the most consequential
global health crisis since the era of the influenza pandemic of 1918. After the first cases of this
predominantly respiratory viral illness were first reported in Wuhan, Hubei Province, China, in late
December 2019, SARS-CoV-2 rapidly disseminated across the world in a short span of time, compelling
the World Health Organization (WHO) to declare it as a global pandemic on March 11, 2020. Since being
declared a global pandemic, COVID-19 has ravaged many countries worldwide, overwhelming many
healthcare systems. [2]

In the Philippines, infection arrived at the Philippines on January 30, 2020, when the principal instance
of the malady was affirmed in Metro Manila. After longer than a month without recording any cases,
the Philippines had affirmed its first neighborhood transmission on March 7, 2020, and from that point
forward, the infection spread to the nation with at any rate one case being affirmed in the entirety of
the nation's 17 districts. [3]

Dr. Jose N. Rodriguez Memorial Hospital and Sanitarium (DJNRMHS), formerly known as Central Luzon
Sanitarium, was established in 1940, to accommodate patients suffering from Hansen's Disease in the
entire Luzon region in the Philippines. Due to the significant drop of Hansen patients through
advancement in medical management, the hospital then considered admission of general cases. During
the declaration of pandemic in March 2020, the institution heed to the call to be one of the primary
COVID referral facility in Metro Manila. [4]
The role of CT has been pivotal since the time of the pandemic. Recommendations advised the use of CT
imaging in hospitalized, symptomatic patients and may be used as a comprehensive, non-invasive
imaging modality which allows for the evaluation of lung parenchyma, patency of pulmonary and
coronary arteries and myocardial damage. [5,6]

Despite the tropism for the lungs where it causes interstitial pneumonitis, in the most severe cases
multiorgan failure develops. The cardiovascular (CV) system appears to have complex interactions with
COVID-19.

The interventricular septum consists of a thin membranous portion located immediately beneath the
aortic valve and a larger muscular septum. Lack of visualization of blood flow between two ventricular
chambers assures an intact ventricular septum with mean normal tissue density of 144 Hounsfield units.
[7, 8] A change in tissue density could possibly reflect the perfusion or inflammation status of the said
structure. Though Cardiac Magnetic Resonance imaging is the gold standard for the study, recent
advancements on CT enables multiplanar reconstructions in any desired orientation and can evaluate
the echo-window limited areas such as the apex, the posterior portion of the interventricular septum,
and the anterolateral wall. Therefore, CCT offers a comprehensive insight into the anatomy and function
of cardiac chambers and rendering it complimentary to CMR and echocardiogram studies. [9]

GENERAL OBJECTIVES
 The study aims to identify the tissue density of the interventricular septum of the heart on
unenhanced Chest CT studies of COVID Confirmed patients admitted at the DJNRMHS

SPECIFIC OBJECTIVES
 Be able to determine the tissue density of the interventricular septum of COVID Confirmed
patients admitted at DJNRMHS
 Compare the acquired data to the normal tissue density value of the interventricular septum
 Be able to correlate the data to the clinical presentation of the patients for stratification of
prognosis

SIGNIFICANCE OF THE STUDY

By determining the tissue density of the interventricular septum, the study may play a role in the
stratification of the prognosis in admitted COVID confirmed patients at the institution.

REVIEW OF RELATED LITERATURE

The ongoing pandemic has opened opportunities for physicians to revisit present medical managements
and review clinical findings of viral infections, most especially COVID-19, which led to conduction of
several studies to improve the stratification and prognostication of patients infected with COVID-19.
Though the common findings are noted through Pulmonary manifestations, the effect of infection is also
demonstrated in other systems such as the Cardiovascular system. Some institutions have observed
several cases of COVID Myocarditis, usually noted fatal and unexpected. A study conducted by C. Liguori
et al reviewed the pathophysiology and imaging characteristics of COVID and its relation to myocarditis,
which led to the conclusion that COVID causes cardiovascular injury through cardiomyocyte injury,
pericardial inflammation with effusion and microvascular damage which may eventually cause arrythmia
and ultimately sudden cardiac deaths. [9]

In the study conducted by Sung Min Ko et al, they recognized that the role of CT is far more different
from the Cardiac Magnetic Resonance in assessment of cardiovascular diseases, they believed that CT is
easily accessible, with faster image acquisition time, and is useful enough to determine characterization
of myocardial diseases based on anatomical morphology, function, density, and enhancement pattern.
Although CT is not recommended as the primary method of choice in cases of suspected LV myocardial
diseases, CT enables multiplanar reconstructions in any desired orientation and can evaluate the echo-
window limited areas such as the apex, the posterior portion of the interventricular septum, and the
anterolateral wall. Therefore, CT offers a comprehensive insight into the anatomy and function of
cardiac chambers. Recent studies have demonstrated that CT may be an attractive imaging tool for the
characterization of LV myocardial diseases based on gross morphology, function, and enhancement, as
well as the extracellular volume fraction (ECV). Therefore, CT is considered complementary to
echocardiography and CMR [7]

METHODOLOGY
The research design is retrospective cohort study that aims to focus on the COVID-19 Confirmed
patients admitted at Dr. Jose N. Rodriguez Memorial Hospital and Sanitarium from March 2020 up to
present.

Inclusion criteria: Any patient (Both male and nonpregnant female) between age 18-80 years with
confirmed RT-PCR result who underwent nonenhanced CT of thorax for any indication were included in
the study.

Exclusion criteria: Patient previously diagnosed cardiovascular disease and surgical interventions were
excluded from the study.

Procedure: Hitachi 16 slice CT scanner will be used for the study.

Variables: For every patient, variables taken into the consideration were age, gender of the patient
along with the presence or absence of cardiovascular comorbidities.

Interpretation: All the CT examinations will be interpreted by a single assessor with at least 2 years in
the Radiology Department.
During interpretation, soft tissue window will be used in all the patients (WW:200 HU; WL:75 HU). A
standard circular Region of Interest (ROI) measuring 0.25 cm2 will be applied for the whole study. The
researcher will assign HU of +144 as the basis of mean normal value for interventricular density. All
patients, whether with normal or increased tissue density, will be subjected for clinical assessment for
correlation if they currently present with signs and symptoms pertaining to cardiovascular diseases.

REFERENCES
[1] Impact of COVID-19 on the Cardiovascular System: A Review of Available Reports, R. Soumya et al,
Sep 14 2020

[2] Features, Evaluation, and Treatment of Coronavirus (COVID-19), M. Cascella MD et al, July
17, 2021
[3] https://www.iomcworld.org/medical-journals/coronavirus-impact-in--philippines-
56533.html
[4] https://www.cnnphilippines.com/news/2020/3/20/Lung-Center-Jose-Rodriguez-Memorial-
Caloocan-COVID-exclusive-hospitals-DOH.html
[5] Role of computed tomography in COVID-19, Gianluca Pontone MD et al, Jan 2021

[6] The Role of Chest Imaging in Patient Management during the COVID-19 Pandemic: A Multinational
Consensus Statement from the Fleischner Society, Geoffrey Rubin MD et al, Aug 2020

[7] Assessment of Left Ventricular Myocardial Disease with Cardiac Computed Tomography, Sung Min Ko
MD et al, Feb. 19, 2019

[8] Imaging pitfalls, normal anatomy, and anatomical variants that can simulate disease on cardiac
imaging as demonstrated on multidetector computed tomography, S. Terpenning et al, January 9, 2015

[9] Myocarditis: imaging up to date, C. Liguori MD et, Oct 6, 2020