Background: Lung ultrasound is an easily available bedside imaging modality that has good specificity for the diagnosis of coronavirus disease-2019 (COVID-19). Limited evidence is available on its utility to predict clinical severity. Materials and methods: In this prospective observational study, adult patients with COVID-19 pneumonia admitted to the intensive care unit (ICU) of a tertiary care hospital between June 2020 and August 2020 were included. Lung ultrasound was performed in at least four areas in each examination and video loops were scored by two independent observers. The statistical relationship was assessed between median lung ultrasound score, chest X-ray score, P/F ratio (ratio of the partial pressure of oxygen in arterial blood to the fraction of inspired oxygen), ROX index, SOFA score, ICU stay, and mortality. Results: Fifty lung ultrasound examinations were performed in 29 patients of age 54.7 ± 15.3 years. P/F ratio was <300 mm Hg during 80% of the examinations. There was moderate correlation between median lung ultrasound score and both ROX index (Spearman's rho = −0.543, p < 0.001) and P/F ratio (rho = −0.522, p < 0.001), while there was weak correlation between chest X-ray score and ROX index (rho = −0.0.345, p = 0.019) and no correlation between chest X-ray score and P/F ratio. There was correlation between chest X-ray score and ICU stay (rho = 0.434, p = 0.049). There was no difference in any of the parameters between survivors and non-survivors. Moderate inter-observer agreement was present between the two observers. Conclusion: Bedside lung ultrasound examination, even with a limited number of views, can reflect the clinical severity of COVID-19 pneumonia.

Coronavirus disease-2019 (COVID-19) pandemic has created new challenges for the healthcare systems all over the world. The incidence of myocardial injury ranges between 7 and 20% in hospitalized COVID-19 patients.¹ The term myocardial injury applies to any patient in whom at least one cardiac troponin (cTn) concentration is above the 99th percentile upper reference limit. The death rate in COVID-19 patients with cardiac disease as comorbidity has around 10%. Myocardial injuries might be related to the fulminant cytokine release and systemic inflammation seen in severe COVID-19 cases.² The role of echocardiographer is crucial as echocardiography is an easily available non-invasive bedside modality to assess for cardiac involvement as well as cardiorespiratory interactions in patients with COVID-19. However, sonographers are also at risk of being infected during the performance of echocardiogram, due to the prolonged and close contact with COVID-19 patients. Hence, appropriate protective measures are necessary to enable the best medical care for patients while also maintaining the health of the sonographer, especially in the setting of a shortage of expert staff (sickness or quarantine after duty) and to prevent transmission to other staff and patients. This article presents a clinical case series of a range of cardiac involvement in COVID-19 and offers guidance on indications of echocardiogram and safe practices for performing safe and effective echocardiography during the COVID-19 pandemic, with particular focus on echocardiography of suspected or confirmed COVID-19 cases. Echocardiography during COVID-19 is a clinically useful tool. Due to concerns about transmission of disease during performing an echo, the procedure should be streamlined, performed by skilled practitioners who are not at high-risk for COVID-19 severe disease, and with a focus on obtaining the best possible transthoracic images.

Intraoperative transesophageal echocardiography (TEE) examination has evolved in cardiac and major vascular surgeries. It is not only useful in guiding hemodynamic interventions but also useful in surgical decision-making. It is necessary for the detection of intracardiac mass. Primary leiomyosarcoma confined to inferior vena cava (IVC) and without cardiac extension entails en bloc excision which seldom requires intracardiac exploration unless embolization. The embolization of the tumor causes hemodynamic alteration and can be confirmed by perioperative TEE evaluation. We are reporting a case where TEE salvaged from the wreckage by converting an extracardiac vascular procedure to intracardiac exploration under cardiopulmonary bypass.

Introduction: Hereby, we describe a series of four critically ill COVID-19 patients where point-of-care ultrasound (POCUS) helped in guiding specific management. Case description: The first case is a 62-year-old COVID-19 positive woman where severe aortic stenosis and severe left ventricular dysfunction were diagnosed by POCUS, which led to the institution of specific medical management leading to resolution of her symptoms and referral to the cardiac surgical department for further surgical management. The second case is a 51-year-old woman admitted with severe hypoxia secondary to COVID-19 infection. She was being considered for tocilizumab therapy. However, POCUS revealed the presence of pericardial effusion, which, on evaluation, was found to be due to tubercular. This led to withholding tocilizumab therapy. Anti-tubercular therapy, instead, was instituted. The third case is a 13-month-old child, who presented with a history of recurrent syncopes and was diagnosed as a case of congenital heart block on electrocardiography (ECG). However, due to his COVID-19 positive status, rescue temporary pacing could not be performed at the catheterization laboratory. Point-of-care ultrasound helped in the successful placement of a temporary pacemaker lead at the bedside, leading to the achievement of optimum heart rate till he got an epicardial pacemaker inserted at a later date. The fourth case is of a 45-year-old man, who had to undergo endotracheal intubation due to refractory COVID-19 related hypoxia. Upon connection to the mechanical ventilator, the peak airway pressure was found to be unusually high. On POCUS, lung sliding on the left side was missing, which led to the diagnosis of right-mainstem endobronchial intubation. Repositioning of the endotracheal tube led to a decrease in peak airway pressures and optimal delivery of mechanical ventilation to the patient. Conclusion: Point-of-care ultrasound can help diagnose and manage significant underlying diseases, help take/modify decisions on specific therapies, and overcome resource limitations for performing specialized therapeutic procedures in COVID-19 patients.

Introduction: Anesthesia at high altitudes is challenging due to vast variations in physiology, which are further complicated by the positioning and pneumoperitoneum during laparoscopic surgeries. These changes can be better understood and managed with the help of echocardiography. Here, we demonstrate the effect of laparoscopy on hemodynamics with the help of transesophageal echocardiography (TEE) at high altitudes in three patients. Materials and methods: Three ASA I patients (patient 1, laparoscopic cholecystectomy; patient 2, laparoscopic vaginal hysterectomy; patient 3, laparoscopic hernioplasty with mesh repair) who underwent laparoscopic surgeries at an altitude of 3,500 m were studied. Various parameters were measured by TEE which included left ventricle ejection fraction (EF), left ventricular outflow tract (LVOT) velocity time integral (VTI), cardiac output (CO), E/A, E/e^I, tricuspid annular plane systolic excursion (TAPSE), and pulmonary artery acceleration time (PAAT). The mean arterial pressure (MAP), heart rate, SpO₂, and end-tidal carbon dioxide were also measured. These parameters were recorded at 10-time points: before induction of anesthesia (T1), before insufflation (T2), after positioning (T3), 5 mm Hg pneumoperitoneum (T4), 10 mm Hg pneumoperitoneum (T5), 14 mm Hg pneumoperitoneum (T6), 10 minutes after 14 mm Hg pneumoperitoneum (T7), 20 minutes after 14 mm Hg pneumoperitoneum (T8), 30 minutes after 14 mm Hg pneumoperitoneum (T9), and 5 minutes after desufflation (T10). Results: We observed a decrease in MAP, LVOT VTI, and CO after pneumoperitoneum when associated with reverse RT position and an increase in MAP, LVOT VTI, and CO when associated with Trendelenburg position. The right ventricular systolic function measured by TAPSE, left ventricular EF, and LV diastolic function remained the same throughout the procedure in all the three patients. Pulmonary artery acceleration time gradually decreased after pneumoperitoneum in all the three patients but stayed in a normal range throughout the procedure. The results of our study are consistent with the previous studies performed at sea level. Conclusion: The present study showed that laparoscopic surgeries may be safely performed in healthy individuals at high altitudes. However, the study was limited by small sample size and done only in healthy subjects.

Sinus of Valsalva aneurysm is an uncommon disease. Rarely, the aneurysm presents with evidence of obstruction of the right ventricular outflow tract, aortic insufficiency, coronary artery compression, or conduction abnormalities in the absence of rupture. We report a case with an unruptured aneurysm of the right sinus of Valsalva extending into the interventricular septum causing complete heart block, which was managed successfully by surgery. We emphasize the rarity of this pathology and highlighting the importance of multiplane transesophageal echocardiography in its assessment, providing a complete anatomic functional characterization, allowing precise identification of structural anomalies, valve abnormalities, and cardiac function, thereby guiding appropriate surgical management.