Coronavirus disease 2019 (COVID‐19) outbreak is a current global healthcare burden, leading to the life‐threatening severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2). However, evidence showed that, even if the prevalence of COVID‐19 damage consists in pulmonary lesions and symptoms, it could also affect other organs, such as heart, liver, and spleen. Particularly, some infected patients refer to the emergency department for cardiovascular symptoms, and around 10% of COVID‐19 victims had finally developed heart injury. Therefore, the use of echocardiography, according to the safety local protocols and ensuring the use of personal protective equipment, could be useful firstly to discriminate between primary cardiac disease or COVID‐19–related myocardial damage, and then for assessing and monitoring COVID‐19 cardiovascular complications: acute myocarditis and arrhythmias, acute heart failure, sepsis‐induced myocardial impairment, and right ventricular failure derived from treatment with high‐pressure mechanical ventilation. The present review aims to enlighten the applications of transthoracic echocardiography for the diagnostic and therapeutic management of myocardial damage in COVID‐19 patients.
Coronavirus disease 2019 (COVID‐19) pandemic is currently affecting 212 countries throughout the world, with high morbidity and mortality rates.1 Severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infection could be easily transmitted through human‐to‐human contact or respiratory droplets, and individuals with underlying cardiovascular disease are at highest risk for severe disease and death, reaching 10.5% fatality rate.2 Even though the clinical manifestations of COVID‐19 are dominated by respiratory symptoms,3 some infected patient initially presents typical cardiovascular symptoms (ie, chest discomfort, palpitations, dyspnea).4 In these cases, it could be challenging for the clinician to establish whether symptoms represent the first expression of SARS‐CoV‐2 cardiac involvement, or they derive from a primary cardiac pathologic condition. Moreover, several cases of COVID‐19–induced myocardial damage has been observed, particularly in critical subjects (in China, 11.8% of dead subjects without underlying cardiovascular disease had myocardial injury5), consisting in acute myocardial injury and myocarditis, cardiac arrest, heart failure (HF) due to pulmonary hypertension (PH), or shock states.6 This is probably due to coronavirus‐related damage which also involves heart and other organs, provoking degeneration and necrosis of parenchymal cells and formation of hyaline thrombus in small vessels, as shown in a postmortem examination of 3 COVID‐19 victims.7 In two studies by Shi et al8 and Guo et al,9 among 460 and 187 patients hospitalized for COVID‐19, respectively, 20% and 28% had acute myocardial injury, which was associated with higher mortality and incidence of complications, such as acute respiratory distress syndrome (ARDS), malignant arrhythmias, acute renal injury, and coagulopathy. Echocardiography is considered the first‐choice diagnostic technique for the evaluation of myocardial structure and function, due to its high availability and cost‐effectiveness.10 For this reason, a conscious inhospital application of transthoracic echocardiography (TTE), using a focused and safe approach, according to the latest European Association of Cardiovascular Imaging (EACVI) and American Society of

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