• Vincent I Lau, Graham D Mah, Xiaoming Wang, Leon Byker, Andrea Robinson, Lazar Milovanovic, Aws Alherbish, Jeffrey Odenbach, Cristian Vadeanu, David Lu, Leo Smyth, Mitchell Rohatensky, Brian Whiteside, Phillip Gregoire, Warren Luksun, Sean van Diepen, Dustin Anderson, Sanam Verma, Jocelyn Slemko, Peter Brindley, Demetrios J Kustogiannis, Michael Jacka, Andrew Shaw, Matt Wheatley, Jonathan Windram, Dawn Opgenorth, Nadia Baig, Oleksa G Rewa, Sean M Bagshaw, and Brian M Buchanan.
• Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada.
• Crit. Care Med. 2023 Aug 1; 51 (8): 102310321023-1032.

ObjectivesStudies have suggested intrapulmonary shunts may contribute to hypoxemia in COVID-19 acute respiratory distress syndrome (ARDS) with worse associated outcomes. We evaluated the presence of right-to-left (R-L) shunts in COVID-19 and non-COVID ARDS patients using a comprehensive hypoxemia workup for shunt etiology and associations with mortality.DesignProspective, observational cohort study.SettingFour tertiary hospitals in Edmonton, Alberta, Canada.PatientsAdult critically ill, mechanically ventilated, ICU patients admitted with COVID-19 or non-COVID (November 16, 2020, to September 1, 2021).InterventionsAgitated-saline bubble studies with transthoracic echocardiography/transcranial Doppler ± transesophageal echocardiography assessed for R-L shunts presence.Measurements And Main ResultsPrimary outcomes were shunt frequency and association with hospital mortality. Logistic regression analysis was used for adjustment. The study enrolled 226 patients (182 COVID-19 vs 42 non-COVID). Median age was 58 years (interquartile range [IQR], 47-67 yr) and Acute Physiology and Chronic Health Evaluation II scores of 30 (IQR, 21-36). In COVID-19 patients, the frequency of R-L shunt was 31 of 182 COVID patients (17.0%) versus 10 of 44 non-COVID patients (22.7%), with no difference detected in shunt rates (risk difference [RD], -5.7%; 95% CI, -18.4 to 7.0; p = 0.38). In the COVID-19 group, hospital mortality was higher for those with R-L shunt compared with those without (54.8% vs 35.8%; RD, 19.0%; 95% CI, 0.1-37.9; p = 0.05). This did not persist at 90-day mortality nor after adjustment with regression.ConclusionsThere was no evidence of increased R-L shunt rates in COVID-19 compared with non-COVID controls. R-L shunt was associated with increased in-hospital mortality for COVID-19 patients, but this did not persist at 90-day mortality or after adjusting using logistic regression.Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine and Wolters Kluwer Health, Inc.

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