Coronavirus disease 2019 and the cardiologist

PURPOSE OF REVIEW

There continues to be extensive clinical and epidemiological data to suggest that coronavirus disease 2019 (COVID-19) infection is associated with numerous different types of cardiac involvement.

RECENT FINDINGS

Myocardial injury has been reported in over 25% of patients hospitalized due to COVID-19 infection and is not only associated with a worse prognosis but with higher mortality, approaching 40%. Currently proposed mechanisms of myocardial injury include direct viral infection, cytokine storm, endothelial inflammation, demand ischemia, interferon-mediated response and stress cardiomyopathy. COVID-19 infection is associated with new-onset arrhythmias and heart failure regardless of history of previous cardiovascular disease. Echocardiographic findings can be useful to predict mortality in COVID-19 patients and cardiac MRI is an effective tool to both assess COVID-19 induced myocarditis and to follow-up on cardiac complications of COVID-19 long-term. Although there is an association between COVID-19 vaccination and myocarditis, pericarditis or arrhythmias, the risk appears lower when compared to risk attributable to the natural infection.

SUMMARY

Patients with cardiovascular disease are not only more likely to suffer from severe COVID-19 infection but are at increased risk for further complications and higher mortality. Further data compilation on current and emerging treatments of COVID-19 will have additional impact on cardiovascular morbidity and mortality of COVID-19 infection.

Incidence of acute myocarditis and pericarditis during the coronavirus disease 2019 pandemic: comparison with the prepandemic period

BACKGROUND

Myocarditis and pericarditis have been proposed to account for a proportion of cardiac injury during SARS-CoV-2 infection. The impact of COVID-19 the pandemic on the incidence of this acute inflammatory cardiac disease was not systematically evaluated.

AIM

To examine the incidence and prevalence of inflammatory heart disorders prior to and during the COVID-19 pandemic.

METHODS

We compared the incidence and prevalence of acute inflammatory heart diseases (myocarditis, pericarditis) in the provinces of Pisa, Lucca and Livorno in two time intervals: prior to (PRECOVID, from 1 June 2018 to 31 May 2019) and during the COVID-19 pandemic (COVID, from 1 June 2020 to May 2021).

RESULTS

Overall 259 cases of inflammatory heart disease (myocarditis and/or pericarditis) occurred in the areas of interest. The annual incidence was of 11.3 cases per 100 000 inhabitants. Particularly, 138 cases occurred in the pre-COVID, and 121 in the COVID period. The annual incidence of inflammatory heart disease was not significantly different (12.1/100 000 in PRECOVID vs 10.3/100 000 in COVID, P = 0.22). The annual incidence of myocarditis was significantly higher in PRECOVID than in COVID, respectively 8.1/100 000/year vs. 5.9/100 000/year (P = 0.047) consisting of a net reduction of 27% of cases. Particularly the incidence of myocarditis was significantly lower in COVID than in PRECOVID in the class of age 18-24

[2022 Update on myocarditis and pericarditis following COVID-19 vaccination. Expert Opinion of the Italian Society of Cardiology]

Vaccine-associated myocarditis and pericarditis usually develop within 14 days of COVID-19 vaccination, are exceptionally rare, manifest with mild clinical pictures and are commonly characterized by a favorable evolution. Young men inoculated with two doses of an mRNA vaccine are the subgroup at higher risk. Recent epidemiological studies evaluated the incidence and risk of vaccine-associated myocarditis and pericarditis among men and women, in different ranges of age and specific types of vaccines. Long-term population analyses demonstrated that the cardiovascular risk conferred by COVID-19 extends beyond the acute phase, representing the rationale for implementing prevention strategies for SARS-CoV-2 infection, monitoring specific populations at higher risk and pursuing the completion of the vaccination campaign. This document provides an update on the most recent scientific evidence and critical interpretation of available data in constant evolution towards personalized strategies of immunization.

[Incidental Diagnosis of Giant Cell Myocarditis at Open Heart Surgery:Report of Case]

Giant cell myocarditis (GCM) is one of the rare diseases that cause fatal heart failure and suspected to be associated with autoimmune disorder. There are few reports that the patients of GCM live long because of their progressive heart failure. We report a rare case of patient who was suspected two long hospitalizations due to heart failure in her childhood and peripartum period, and incidentally diagnosed with GCM by myocardial biopsy performed at the aortic valve replacement and mitral annuloplasty for severe aortic valve regurgitation and moderate mitral regurgitation.

Simultaneous Occurrence of Immune-Mediated Thrombocytopenia and Myocarditis After mRNA-1273 COVID-19 Vaccination: A Case Report

With the global spread of severe acute respiratory syndrome coronavirus 2, several vaccines were developed; messenger RNA (mRNA) vaccines have recently been widely used worldwide. However, the incidence of myocarditis following mRNA vaccination is increasing; although the cause of myocarditis has not yet been clearly identified, it is presumed to be caused by a problem in the innate immune system. Immune-mediated thrombocytopenia (ITP) after vaccination is rare but has been reported and is also assumed to occur by the same mechanism. We report the first case of simultaneous myocarditis and ITP after mRNA vaccination. A 38-year-old woman presented with chest pain, mild dyspnea, and sweating after vaccination with mRNA-1273 vaccine (Moderna) 4 days prior to admission. Upon admission to the emergency department, cardiac enzymes were elevated; blood test performed 5 months ago showed normal platelet count, but severe thrombocytopenia was observed upon admission. After administration of intravenous immunoglobulin, the platelet count improved; subsequently, myocarditis was observed on endomyocardial biopsy. Thus, myocarditis and ITP were judged to have occurred simultaneously due to the expression of the innate immune system markers after mRNA vaccination. The patient was discharged on day 6 of admission.

COVID-19 Myocarditis: Prognostic Role of Bedside Speckle-Tracking Echocardiography and Association with Total Scar Burden

SARS-CoV2 infection, responsible for the COVID-19 disease, can determine cardiac as well as respiratory injury. In COVID patients, viral myocarditis can represent an important cause of myocardial damage. Clinical presentation of myocarditis is heterogeneous. Furthermore, the full diagnostic algorithm can be hindered by logistical difficulties related to the transportation of COVID-19 patients in a critical condition to the radiology department. Our aim was to study longitudinal systolic cardiac function in patients with COVID-19-related myocarditis with echocardiography and to compare these findings with cardiac magnetic resonance (CMR) results. Patients with confirmed acute myocarditis and age- and gender-matched healthy controls were enrolled. Both patients with COVID-19-related myocarditis and healthy controls underwent standard transthoracic echocardiography and speckle-tracking analysis at the moment of admission and after 6 months of follow-up. The data of 55 patients with myocarditis (mean age 46.4 ± 15.3, 70% males) and 55 healthy subjects were analyzed. The myocarditis group showed a significantly reduced global longitudinal strain (GLS) and sub-epicardial strain, compared to the control (p < 0.001). We found a positive correlation (r = 0.65, p < 0.0001) between total scar burden (TSB) on CMR and LV GLS. After 6 months of follow-up, GLS showed marked improvements in myocarditis patients on optimal medical therapy (p < 0.01). Furthermore, we showed a strong association between baseline GLS, left ventricular ejection fraction (LVEF) and TSB with LVEF at 6 months of follow-up. After a multivariable linear regression analysis, baseline GLS, LVEF and TSB were independent predictors of a functional outcome at follow-up (p < 0.0001). Cardiac function and myocardial longitudinal deformation, assessed by echocardiography, are associated with TSB at CMR and have a predictive value of functional recovery in the follow-up.

A Case of Heart Transplantation for Fulminant Myocarditis After ChAdOx1 nCoV-19 Vaccination

Vaccines have become the mainstay of management against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection (coronavirus disease 2019; COVID-19) in the absence of effective antiviral therapy. Various adverse effects of COVID-19 vaccination have been reported, including cardiovascular complications such as myocarditis or pericarditis. Herein, we describe clinical records of a 63-year woman with fulminant myocarditis following ChAdOx1 nCoV-19 vaccination that was salvaged by heart transplantation. She complained chest pain, nausea, vomiting, and fever after the second vaccination. After the heart transplantation, the patient died due to necrotizing pneumonia on the 54th day of onset. Fulminant myocarditis is very rare after ChAdOx1 nCoV-19 vaccination but can be fatal.

Seronegative immune-mediated necrotising myopathy complicated by fulminant myocarditis resulting in cardiogenic shock and cardiac arrest

A woman in her late 30s recently diagnosed with viral myopericarditis presented with 1 month of worsening fatigue, diffuse myalgias and chest pain radiating to her back. While undergoing work-up for chest wall myositis, she rapidly decompensated, developing heart failure and acute hypoxaemic respiratory failure. Her clinical course was complicated by cardiac arrest and severe cardiogenic shock requiring intra-aortic balloon pump support.

Managing myocarditis in a patient with newly diagnosed dermatomyositis

A woman in her 20s presented with chest pain, dyspnoea, arthralgia, muscle weakness and skin discolouration. She was diagnosed with dermatomyositis. During her admission, she developed pleuritic chest pain and shortness of breath accompanied by a significant troponin I rise. Her echocardiogram showed a hyperdynamic left ventricle with a trivial pericardial effusion; there were no regional wall motion abnormalities. Gadolinium-diethylenetriaminepantaacetic-enhanced cardiac MRI showed extensive myocarditis. She was started on corticosteroids and azathioprine which led to an improvement of symptoms and biochemical markers.

Pericarditis and myocarditis after COVID-19 mRNA vaccination in a nationwide setting

INTRODUCTION

Despite reports suggesting an association between COVID-19 mRNA vaccination and pericarditis and myocarditis, detailed nationwide population-based data are sparsely available. We describe the incidence of pericarditis and myocarditis by age categories and sex after COVID-19 mRNA vaccination from a nationwide mass vaccination programme in Singapore.

METHODS

The incidence of adjudicated cases of pericarditis and myocarditis following COVID-19 mRNA vaccination that were reported to the vaccine safety committee between January to July 2021 was compared with the background incidence of myocarditis in Singapore.

RESULTS

As of end July 2021, a total of 34 cases were reported (9 pericarditis only, 14 myocarditis only, and 11 concomitant pericarditis and myocarditis) with 7,183,889 doses of COVID-19 mRNA vaccine administered. Of the 9 cases of pericarditis only, all were male except one. The highest incidence of pericarditis was in males aged 12-19 years with an incidence of 1.11 cases per 100,000 doses. Of the 25 cases of myocarditis, 80% (20 cases) were male and the median age was 23 years (range 12-55 years) with 16 cases after the second dose. A higher-than-expected number of cases were seen in males aged 12-19 and 20-29 years, with incidence rates of 3.72 and 0.98 case per 100,000 doses, respectively.

CONCLUSION

Data from the national registry in Singapore indicate an increased incidence of pericarditis and myocarditis in younger men after COVID-19 mRNA vaccination.

Pediatric Myopericarditis Presenting to the Emergency Department as Chest Pain: A Comparative Study With Myocarditis

METHODS

A database query was performed and identified patients over a 9-year period, and clinical data, laboratory data, and cardiac studies were extracted and analyzed from the electronic health record.

RESULTS

A total of 36 patients were identified with the discharge diagnosis of myopericarditis and 22 with myocarditis. The median age for myopericarditis patients was 16.2 years, and 97% were male. The median initial troponin was 7.1 ng/mL, the peak was at 16.6 ng/mL, and 58% had ST changes on electrocardiogram. The median length of stay for myopericarditis patients was 1.7 days, and 50% were discharged home on nonsteroidal anti-inflammatory medication. Compared with myocarditis, myopericarditis patients were older, had a higher incidence of chest pain, and were less likely to have fever, vomiting, abdominal pain, upper respiratory infection symptoms, chest radiograph abnormalities, or T-wave inversion (P < 0.05). Myopericarditis patients also had lower Pediatric Risk of Mortality version 3 scores, B-type natriuretic peptide levels, and higher left ventricular ejection fractions on admission (67% vs 41%; P < 0.05). A classification model incorporating initial left ventricular ejection fraction, B-type natriuretic peptide, electrocardiogram, and chest radiograph findings distinguished myopericarditis from myocarditis with correct classification in 95% of patients.

CONCLUSIONS

Myopericarditis is a relatively common cause of chest pain for patients admitted to the pediatric intensive care unit, presents differently than true myocarditis, and carries a good prognosis.

Inpatient Characteristics, Complications, and Outcomes of Patients with Cardiac Sarcoidosis: A Study from The National Inpatient Sample

Although seen in ∼5% of sarcoidosis patients, cardiac sarcoidosis (CS) accounts for nearly 25% of disease-related deaths. This study aimed to describe characteristics and outcomes among CS patients. Patients diagnosed with CS in 2016-2017 in the US National Inpatient Sample Database were evaluated to study patient characteristics, reasons ascribed to admission, in-hospital outcomes, and complications. A total of 2420 patients (median age 56 years) were included in the analysis. Most admissions occurred due to ventricular tachycardia (12.8%), followed by myocarditis (9.9%) with a mean length of stay of 7±7 days. The overall incidence of in-hospital mortality was 2.5%.

Myocarditis in systemic immune-mediated diseases: Prevalence, characteristics and prognosis. A systematic review

Many systemic immune-mediated diseases (SIDs) may involve the heart and present as myocarditis with different histopathological pictures, i.e. lymphocytic, eosinophilic, granulomatous, and clinical features, ranging from a completely asymptomatic patient to life-threatening cardiogenic shock or arrhythmias. Myocarditis can be part of some SIDs, such as sarcoidosis, systemic lupus erythematosus, systemic sclerosis, antiphospholipid syndrome, dermato-polymyositis, eosinophilic granulomatosis with polyangiitis and other vasculitis syndromes, but also of some organ-based immune-mediated diseases with systemic expression, such as chronic inflammatory bowel diseases. The aim of this review is to describe the prevalence, main clinical characteristics and prognosis of myocarditis associated with SIDs.

Viral Myocarditis Mimicking ST-Segment Elevation Myocardial Infarction Complicated by Thrombocytopenia and Vasculitic Peripheral Neuropathy

Symptomatic myocarditis is classically featured by a flu-like prodrome, dyspnea on exertion, palpitations, substernal chest pain, and abnormal electrocardiogram (ECG). The clinical diagnosis has often been challenging due to its similarities to acute coronary syndrome. Our case involved a patient who presented with claudication of bilateral lower extremity and ST-segment elevation myocardial infarction (STEMI) in the inferior leads. On cardiac catheterization, nonobstructed coronary arteries with left ventricular ejection fraction (LVEF) of 30% were demonstrated. His clinical presentation was consistent with suspected myocarditis, and he improved with immunosuppression. In addition, his thrombocytopenia and severe symptoms of peripheral neuropathy responded to both immunotherapy and anticoagulation. This case highlights the interplay between history taking, physical examination, and multimodal diagnostic imaging.

Acute Myocarditis with Severe Fever and Thrombocytopenia Syndrome

A 67-year-old man, hospitalized with fever and pancytopenia, experienced cardiogenic shock on the 3rd day of hospitalization. He complained of chest pain and exhibited cardiac dysfunction, upregulated serum troponin levels, and an ST elevation on electrocardiogram. Severe fever with thrombocytopenia syndrome (SFTS) was suspected based on the symptom course after a tick bite and was definitively diagnosed using the serum polymerase chain reaction (PCR) test. An endomyocardial biopsy performed in the convalescent phase revealed a sign of myocardial inflammation with increases in CD3- and CD68-positive cells. We herein report the first case of acute myocarditis complicated with SFTS.

Myocarditis as a manifestation of the disease COVID-19 and after vaccination against this disease

Although the involvement of the heart muscle in the coronavirus disease 2019 (COVID-19) is relatively common (5-10%), myocarditis is a complication with a much lower incidence, depending, however, on the diagnostic methods used. The pathophysiological mechanisms have been described, but there are significant gaps in current knowledge. Myocarditis in connection with vaccination against the disease COVID-19 is a separate nosological unit. Even here, the pathophysiological processes are not explored in detail. The incidence of this complication is estimated in the low tens per million vaccinated.

Targeting Mediators of Inflammation in Heart Failure: A Short Synthesis of Experimental and Clinical Results

Inflammation has emerged as an important contributor to heart failure (HF) development and progression. Current research data highlight the diversity of immune cells, proteins, and signaling pathways involved in the pathogenesis and perpetuation of heart failure. Chronic inflammation is a major cardiovascular risk factor. Proinflammatory signaling molecules in HF initiate vicious cycles altering mitochondrial function and perturbing calcium homeostasis, therefore affecting myocardial contractility. Specific anti-inflammatory treatment represents a novel approach to prevent and slow HF progression. This review provides an update on the putative roles of inflammatory mediators involved in heart failure (tumor necrosis factor-alpha; interleukin 1, 6, 17, 18, 33) and currently available biological and non-biological therapy options targeting the aforementioned mediators and signaling pathways. We also highlight new treatment approaches based on the latest clinical and experimental research.

Left Heart Decompression on Veno-Arterial Extracorporeal Membrane Oxygenation in Children With Dilated Cardiomyopathy and Myocarditis: An Extracorporeal Life Support Organization Registry Review

OBJECTIVES

To describe the association between left heart decompression on veno-arterial extracorporeal membrane oxygenation and survival in patients with myocarditis and dilated cardiomyopathy. The secondary outcome is to study association of left heart decompression with survival in children with myocarditis compared with those with dilated cardiomyopathy.

DESIGN

Retrospective study of a multicenter registry database.

SETTING

Data reported to Extracorporeal Life Support Organization from international extracorporeal membrane oxygenation centers.

PATIENTS

Patients less than or equal to 18 years old with a diagnosis of myocarditis or dilated cardiomyopathy receiving extracorporeal membrane oxygenation.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A total of 1,438 pediatric extracorporeal membrane oxygenation runs were identified. Thirty-seven percent of the patients had myocarditis (n = 532), whereas the rest had dilated cardiomyopathy. Survival to hospital discharge was 63%. Median extracorporeal membrane oxygenation duration was 148 hours with interquartile range (84-248 hr). Nineteen percent of patients (n = 274) had left heart decompression. Multivariable analysis revealed using left heart decompression (adjusted odds ratio, 1.42; 95% CI, 1.06-1.89; p = 0.02), e-cardiopulmonary resuscitation (adjusted odds ratio, 0.63; 95% CI, 0.51-0.79; p < 0.001), higher pH (adjusted odds ratio, 3.69; 95% CI, 1.80-7.53; p < 0.001), and diagnosis of myocarditis (adjusted odds ratio, 1.69; 95% CI, 1.35-2.08; p < 0.001) were associated with greater odds of survival. In the multivariable analysis for patients with dilated cardiomyopathy, left heart decompression failed to reveal a significant association with survival (20% among survivors vs 17% among nonsurvivors, 95% CI, -2.2% to 8.0%). Meanwhile in patients with myocarditis, the multivariable analysis failed to exclude the possibility that left heart decompression was associated with up to a three-fold greater odds of survival (adjusted odds ratio, 1.77; 95% CI, 0.99-.15).

CONCLUSIONS

Retrospective review of the Extracorporeal Life Support Organization registry revealed an association between left heart decompression and greater odds of survival in children with myocarditis and dilated cardiomyopathy on extracorporeal membrane oxygenation. When comparing patients with dilated cardiomyopathy against those with myocarditis, we could not exclude a three-fold greater odds of survival associated with the use of left heart decompression. This finding warrants further prospective evaluation.

Myocarditis-induced Sudden Death after BNT162b2 mRNA COVID-19 Vaccination in Korea: Case Report Focusing on Histopathological Findings

We present autopsy findings of a 22-year-old man who developed chest pain 5 days after the first dose of the BNT162b2 mRNA vaccine and died 7 hours later. Histological examination of the heart revealed isolated atrial myocarditis, with neutrophil and histiocyte predominance. Immunohistochemical C4d staining revealed scattered single-cell necrosis of myocytes which was not accompanied by inflammatory infiltrates. Extensive contraction band necrosis was observed in the atria and ventricles. There was no evidence of microthrombosis or infection in the heart and other organs. The primary cause of death was determined to be myocarditis, causally-associated with the BNT162b2 vaccine.

Advanced Heart Failure in Special Population: Cardiomyopathies and Myocarditis

Cardiomyopathies are a heterogeneous group of heart muscle diseases and an important cause of heart failure (HF) in young populations. The variety of causes, multiple underlying pathophysiological mechanisms, and different phenotypic expressions influence their presentation and response to treatment. Dilated cardiomyopathy is the most prevalent cause of HF. Advanced HF in hypertrophic, restrictive, and arrhythmogenic cardiomyopathies is rare, but its development portends a poor prognosis. The active phase of fulminant myocarditis may result in acute HF requiring advanced strategies to support the systemic circulation or may determine an irreversible persisting left ventricular failure with end-stage HF.

[Acute neonatal myocarditis with cardiogenic shock caused by enterovirus infection]

In this case report, a 16-days-old boy presented with reduced feeding, vomiting, respiratory distress and pallor. He developed cardiogenic shock with cardiac arrest and was resuscitated. Echocardiography showed reduced left ventricular systolic function and he was diagnosed with enterovirus myocarditis since enterovirus RNA was found in the blood by polymerase chain reaction. After one month of hospitalization, the patient was discharged without any apparent sequelae. The condition is rare but associated with a high mortality. Early diagnosis and initiation of treatment is essential for survival.

Index Case of COVID-19 Myocarditis Requiring BiV-ICD for Primary Prevention of Sudden Cardiac Death

INTRODUCTION

The severity of clinical presentation of COVID-19 myocarditis ranges from incidental identification of depressed left ventricular ejection fraction, cardiogenic shock requiring percutaneous mechanical circulatory support, to fatal fulminant myocarditis. In previously reported cases, surviving patients experienced improvement in left ventricular ejection fraction with the use of glucocorticoids and antivirals (+/- intravenous immunoglobulin/ convalescent plasma). We report the first case of COVID-myocarditis in a surviving patient where a persistently depressed left ventricular ejection fraction (less than 35 percent) despite optimal therapy prompted implantable cardioverter-defibrillator (ICD) implantation for primary prevention of sudden cardiac death.

CASE PRESENTATION

A previously healthy 67-year-old man, diagnosed with mild COVID-19 pneumonia five days prior, presented to the emergency department with suspected STEMI (hypoxia, substernal chest pain and known left bundle branch block). Left heart catheterization showed patent coronary arteries. Transthoracic echocardiogram showed severely depressed ejection fraction (15-20 percent). CT showed bilateral infiltrates: treatment was started with dexamethasone, remdesivir and convalescent plasma for acute hypoxic respiratory failure due to COVID-19 pneumonia. After a four-day hospitalization, guideline-directed medical therapy at maximum tolerated doses over three months did not improve left ventricular ejection fraction.

CONCLUSION

This is the index case of COVID-19 myocarditis-mediated heart failure with reduced ejection fraction requiring ICD for primary prevention of sudden cardiac death.

Comparison of the Limb-lead Electrocardiogram to the 12-Lead Electrocardiogram for Identifying Conditions Associated with Sudden Cardiac Death in Youth Athletes

The optimal screening strategy to prevent sudden cardiac death (SCD) in athletes remains unknown. Pre-participation screening with electrocardiogram (ECG) remains controversial. The utility and accuracy of limb-lead (LL) ECG alone in identifying cardiac abnormalities associated with SCD has not been studied. This study was a comparative secondary data analysis, comparing the interpretation accuracy of 4 physicians evaluating publicly available ECGs of the most common cardiac conditions associated with SCD in athletes. Each physician interpreted a total of 100 ECGs: 50 normal ECGs (25 LL and 25 standard 12L) and 50 abnormal ECGs (25 LL and 25 standard 12L). The agreement between LL ECGs and 12L ECGs was assessed by Cohen's kappa coefficient and the accuracy of identifying an abnormal ECG was compared across LL and 12L ECGs using a chi-squared test. Inter-rater reliability was assessed by estimating the Fleiss's kappa coefficient. The sensitivity of LL ECG and 12L ECG was identical at 86%. The specificity of LL ECG was 75% (95% CI = 65% to 83%) and 12L ECG was 82% (95% CI = 73% to 89%). Substantial agreement was seen between LL ECG and 12L ECG interpretation across all readers (k = 0.63; 95% CI = 0.49 to 0.77). Interpretation accuracy was 81% (95% CI = 74% to 86%) and 84% (95% CI 78% to 89%) using LL ECG and 12L ECG, respectively (p = 0.43). In conclusion, the accuracy, sensitivity, and specificity were high and comparable for both LL ECG and 12L ECG in identifying cardiovascular conditions associated with SCD. Agreement between LL ECG and 12L ECG was substantial.

[The Apical Left Ventricle Aneurysm, Eighteen Years After the Fulminant Myocarditis:Report of a Case]

Ventricular aneurysm after myocarditis is a rare complication. It has been reported that scarred areas of the myocardium may become aneurysm. Here, we report a case of apical left ventricle aneurysm at 18 years after the fulminant myocarditis. The patient is a 36-year-old female with a history of fulminant myocarditis at the age of 18. Eighteen years after the onset of the disease, she was referred to our hospital because of an apex ventricular aneurysm. Her computed tomography scan showed an apex ventricular aneurysm sized 45×40 mm with a wall width of 1.8 mm. We performed resection of ventricular aneurysm and reconstruction using Linear technique. The postoperative course was uneventful and discharged on the 17th post operative day.

Toll-Like Receptors: Are They Taking a Toll on the Heart in Viral Myocarditis?

Myocarditis is an inflammatory disease of the heart with viral infections being the most common aetiology. Its complex biology remains poorly understood and its clinical management is one of the most challenging in the field of cardiology. Toll-like receptors (TLRs), a family of evolutionarily conserved pattern recognition receptors, are increasingly known to be implicated in the pathophysiology of viral myocarditis. Their central role in innate and adaptive immune responses, and in the inflammatory reaction that ensues, indeed makes them prime candidates to profoundly affect every stage of the disease process. This review describes the pathogenesis and pathophysiology of viral myocarditis, and scrutinises the role of TLRs in every phase. We conclude with directions for future research in this field.

Vascular Endothelial Integrity Affects the Severity of Enterovirus-Mediated Cardiomyopathy

Coxsackievirus and adenovirus receptor (CAR) is present in epithelial and vascular endothelial cell junctions. We have previously shown a hemorrhagic phenotype in germ-line CAR knock-out mouse embryos; we have also found that CAR interacts with ZO-1 and β-catenin. However, the role of CAR in vascular endothelial junction permeability has not been proven. To understand the roles of CAR in the vascular endothelial junctions, we generated endothelium-specific CAR knockout (CAR-eKO) mice. In the absence of CAR, the endothelial cell layer showed an increase in transmembrane electrical resistance (TER, Ω) and coxsackievirus permeability. Evans blue dye and 70 kDa dextran-FITC were delivered by tail vein injection. We observed increased vascular permeability in the hearts of adult CAR-eKO mice compare with wild-type (WT) mice. There was a marked increase in monocyte and macrophage penetration into the peritoneal cavity caused by thioglycolate-induced peritonitis. We found that CAR ablation in endothelial cells was not significantly increased coxsackievirus B3 (CVB3) induced myocarditis in murine model. However, tissue virus titers were significantly higher in CAR-eKO mice compared with WT. Moreover, CVB3 was detected in the brain of CAR-eKO mice. Endothelial CAR deletion affects the expression of major endothelial junction proteins, such as cadherin and platelet endothelial cell adhesion molecule-1 (PECAM-1) in the cultured endothelial cells as well as liver vessel. We suggest that CAR expression is required for normal vascular permeability and endothelial tight junction homeostasis. Furthermore, CVB3 organ penetration and myocarditis severities were dependent on the endothelial CAR level.

Prevalence of Cardiovascular Complications in Malaria: A Systematic Review and Meta-Analysis

Recent studies have suggested that malaria may affect the cardiovascular system. The aim of this systematic review and meta-analysis was to determine the prevalence of cardiovascular complications in symptomatic malaria patients. We searched databases such as Pubmed, Embase, Cochrane, and Web of Science (January 1950-April 2020) for studies reporting on cardiovascular complications in adults and children with malaria. Cardiovascular complications were defined as abnormalities in electrocardiogram (ECG), cardiac biomarkers, and echocardiography on admission or during outpatient examination. Studies of patients with known heart disease or cardiovascular evaluation performed after the start of intravenous antimalarial medication were excluded. The study was registered in International Prospective Register of Systematic Reviews (PROSPERO) (No.: CRD42020167672). The literature search yielded 1,243 studies, and a total of 43 studies with symptomatic malaria patients were included. Clinical studies (n = 12 adults; n = 5 children) comprised 3,117 patients, of which a majority had Plasmodium falciparum (n = 15) and were diagnosed with severe malaria (n = 13). In random-effects models of adults, the pooled prevalence estimate for any cardiovascular complication was 7% (95% CI: 5-9). No meta-analysis was conducted in children, but the range of abnormal ECG was 0-8%, cardiac biomarkers 0-57%, and echocardiography 4-9%. We analyzed 33 cases (n = 10 postmortem), in which the most common cardiovascular pathologies were myocarditis and acute coronary syndrome. All histopathological studies found evidence of parasitized red blood cells in the myocardium. Cardiovascular complications are not uncommon in symptomatic adults and children with malaria. Additional studies investigating malaria and cardiovascular disease are encouraged.

Implications of SARS-CoV-2-Associated Myocarditis in the Medical Evaluation of Athletes

CONTEXT

Myocarditis is a known cause of death in athletes. As we consider clearance of athletes to participate in sports during the COVID-19 pandemic, we offer a brief review of the myocardial effects of SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) through the lens of what is known about myocarditis and exercise. All athletes should be queried about any recent illness suspicious for COVID-19 prior to sports participation.

EVIDENCE ACQUISITION

The PubMed database was evaluated through 2020, with the following keywords: myocarditis, COVID-19, SARS-CoV-2, cardiac, and athletes. Selected articles identified through the primary search, along with position statements from around the world, and the relevant references from those articles, were reviewed for pertinent clinical information regarding the identification, evaluation, risk stratification, and management of myocarditis in patients, including athletes, with and without SARS-CoV-2.

STUDY DESIGN

Systematic review.

LEVEL OF EVIDENCE

Level 3.

RESULTS

Since myocarditis can present with a variety of symptoms, and can be asymptomatic, the sports medicine physician needs to have a heightened awareness of athletes who may have had COVID-19 and be at risk for myocarditis and should have a low threshold to obtain further cardiovascular testing. Symptomatic athletes with SARS-CoV-2 may require cardiac evaluation including an electrocardiogram and possibly an echocardiogram. Athletes with cardiomyopathy may benefit from cardiac magnetic resonance imaging in the recovery phase and, rarely, endocardial biopsy.

CONCLUSION

Myocarditis is a known cause of sudden cardiac death in athletes. The currently reported rates of cardiac involvement of COVID-19 makes myocarditis a risk, and physicians who clear athletes for participation in sport as well as sideline personnel should be versed with the diagnosis, management, and clearance of athletes with suspected myocarditis. Given the potentially increased risk of arrhythmias, sideline personnel should practice their emergency action plans and be comfortable using an automated external defibrillator.

The effects of novel coronavirus (SARS-CoV-2) infection on cardiovascular diseases and cardiopulmonary injuries

COVID-19 caused by a novel coronavirus named SARS-CoV-2, can elites severe acute respiratory syndrome, severe lung injury, cardiac injury, and even death and became a worldwide pandemic. SARS-CoV-2 infection may result in cardiac injury via several mechanisms, including the expression of angiotensin-converting enzyme 2 (ACE2) receptor and leading to a cytokine storm, can elicit an exaggerated host immune response. This response contributes to multi-organ dysfunction. As an emerging infectious disease, there are limited data on the effects of this infection on patients with underlying cardiovascular comorbidities. In this review, we summarize the early-stage clinical experiences with COVID-19, with particular focus on patients with cardiovascular diseases and cardiopulmonary injuries, and explores potential available evidence regarding the association between COVID-19, and cardiovascular complications.

Sudden cardiac death-update

Sudden cardiac death (SCD) is one of the most common causes of death worldwide with a higher frequency especially in the young. Therefore, SCD is represented frequently in forensic autopsy practice, whereupon pathological findings in the heart can explain acute death. These pathological changes may not only include myocardial infarction, coronary thrombosis, or all forms of myocarditis/endocarditis but also rare diseases such as hereditary structural or arrythmogenic anomalies, lesions of the cardiac conduction system, or primary cardiac tumours.

SARS-CoV-2 infection in an infant with severe dilated cardiomyopathy

A four- and a half-month-old girl with severe dilated cardiomyopathy due to neonatal enterovirus myocarditis, treated with diuretics and milrinone for the past 4 months, was infected with SARS-CoV-2. The disease course was characterised by high fever and gastrointestinal symptoms. Cardiac function, as measured by echocardiography, remained stable. The treatment focused on maintaining a normal heart rate and a stable fluid balance. In children with severe underlying cardiac disease, even a mild SARS-CoV-2 infection can require close monitoring and compound treatment.

Fatal SARS-CoV-2 Inflammatory Syndrome and Myocarditis in an Adolescent: A Case Report

BACKGROUND

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causes coronavirus disease 2019 (COVID-19), an entity in children initially characterized by milder case presentations and better prognoses as compared with adults. Recent reports, however, raise concern for a new hyperinflammatory entity in a subset of pediatric COVID-19 patients.

METHODS

We report a fatal case of confirmed COVID-19 with hyperinflammatory features concerning for both multi-inflammatory syndrome in children (MIS-C) and primary COVID-19.

RESULTS

This case highlights the ambiguity in distinguishing between these two entities in a subset of pediatric patients with COVID-19-related disease and the rapid decompensation these patients may experience.

CONCLUSIONS

Appropriate clinical suspicion is necessary for both acute disease and MIS-C. SARS-CoV-2 serologic tests obtained early in the diagnostic process may help to narrow down the differential but does not distinguish between acute COVID-19 and MIS-C. Better understanding of the hyperinflammatory changes associated with MIS-C and acute COVID-19 in children will help delineate the roles for therapies, particularly if there is a hybrid phenotype occurring in adolescents.

[Cardiac tamponade and myocarditis in a patient with acute SARS-CoV-2 infection]

We describe a patient with COVID-19, with pericardial effusion, cardiac tamponade and severe myocardial depression. A 51-year-old woman, previously healthy, with mild COVID-19 presented with three episodes of syncope. She was admitted to the emergency room. An electrocardiogram showed sinus rhythm, diffuse superior concavity ST 2 mv; a CT scan showed pericardial effusion, without lung pathological findings. Due to shock, dyspnoea and encephalopathy, the patient was admitted to intensive care, where she received vasopressor support and mechanical ventilation. A bedside ultrasound showed pericardial effusion and tamponade; drainage was performed; transoesophageal ultrasound showed moderate deterioration of biventricular systolic function; global longitudinal strain -14.2%, estimated Fey 43%; global circumferential strain -10.1%. Seven days after admission, CT scan revealed bilateral infiltrates and pericardial thickening with post-contrast enhancement and mild pericardial effusion. On day 12 post admission, inotropic support was discontinued; patient on mechanical ventilation weaning and haemodynamically stable.

Association Between Low T3 Syndrome and Poor Prognosis in Adult Patients With Acute Myocarditis

BACKGROUND

This study aims to investigate the role of free triiodothyronine (fT3) in predicting poor prognosis of adult patients with acute myocarditis.

METHODS

A total of 173 consecutive adult patients with acute myocarditis completed thyroid function evaluations. They were divided into two groups according to fT3 levels: low fT3 group (n = 54, fT3 < 3.54 pmol/liter) and normal fT3 group (n = 119, fT3 ≥ 3.54 pmol/liter). The primary endpoint was major adverse cardiac events (MACE).

RESULTS

During the 3.5 ± 2.8 years follow-up, the rate of MACE was 29.6% versus 3.5% in low fT3 group versus normal fT3 group, respectively (P < 0.0001). Long-term at 8 years MACE-free survival were lower in low fT3 group versus normal fT3 group (52.9% versus 92.3%, log-rank P < 0.0001), respectively. Univariate Cox analysis showed that left ventricular ejection fraction (LVEF) < 50% [hazard ratio (HR) 10.231, 95% confidence interval (CI): 3.418-30.624, P < 0.0001) and low fT3 level (HR 0.360, 95% CI: 0.223-0.582, P < 0.0001) were strongest two predictors of MACE. After adjustment for traditional risk predictors, the prognostic value of fT3 status was still significant (HR 0.540, 95% CI: 0.316-0.922, P = 0.024). Compared with normal fT3 group, those in low fT3 group were at a much higher risk of MACE (HR 5.074, 95% CI: 1.518-16.964, P = 0.008).

CONCLUSIONS

Low T3 syndrome was a strong predictor of poor prognosis in adult patients with acute myocarditis. These findings suggest that fT3 level could serve as a biomarker for risk stratification in acute myocarditis patients.

Recurrent Fulminant Myocarditis Accompanied by Lymphoid Follicle Formation in Myocardium

A 76-year-old man developed repeated fulminant myocarditis in a short period, and immunosuppressive therapy was remarkably effective. A pathologic evaluation showed that inflammatory cells had infiltrated the myocardium. Not only invasion of inflammatory cells but also the formation of lymphoid follicle was noted. Chronic myocardial inflammation was proven, but cardiac sarcoidosis was negative according to the results of various examinations. This is the first report of recurrent autoimmune myocarditis with a lymphoid follicle in the myocardium. These findings may suggest a novel pathogenesis of myocarditis.

COVID-19-Myocarditis and Return to Play: Reflections and Recommendations From a Canadian Working Group

The COVID-19–related pandemic has resulted in profound health, financial, and societal impacts. Organized sporting events, from recreational to the Olympic level, have been cancelled to both mitigate the spread of COVID-19 and protect athletes and highly active individuals from potential acute and long-term infection-associated harms. COVID-19 infection has been associated with increased cardiac morbidity and mortality. Myocarditis and late gadolinium enhancement as a result of COVID-19 infection have been confirmed. Correspondingly, myocarditis has been implicated in sudden cardiac death of athletes. A pragmatic approach is required to guide those who care for athletes and highly active persons with COVID-19 infection. Members of the Community and Athletic Cardiovascular Health Network (CATCHNet) and the writing group for the Canadian Cardiovascular Society/Canadian Heart Rhythm Society Joint Position Statement on the Cardiovascular Screening of Competitive Athletes recommend that highly active persons with suspected or confirmed COVID-19 infection refrain from exercise for 7 days after resolution of viral symptoms before gradual return to exercise. We do not recommend routine troponin testing, resting 12-lead electrocardiography, echocardiography, or cardiac magnetic resonance imaging before return to play. However, medical assessment including history and physical examination with consideration of resting electrocardiography and troponin can be considered in the athlete manifesting new active cardiac symptoms or a marked reduction in fitness. If concerning abnormalities are encountered at the initial medical assessment, then referral to a cardiologist who cares for athletes is recommended.

Influenza-associated Fulminant Myocarditis Complicated by Guillain-Barré Syndrome

We herein report the case of a 47-year-old woman who was admitted with weakness and numbness of the limbs and dyspnea after being infected with influenza virus A. She had a history of Guillain-Barré syndrome (GBS) 7 years prior to this presentation. On admission, she was in shock, and transthoracic echocardiography showed severely reduced left-ventricular function. She was diagnosed with fulminant myocarditis by an endomyocardial biopsy, which was complicated by GBS. Venoarterial extracorporeal membrane oxygenation was required to manage the cardiogenic shock. After her condition improved, immunoadsorption for GBS was performed, and the motor and sensory disorders gradually improved.

Role of troponin in COVID-19 pandemic: a review of literature

Acute SARS-CoV-2 respiratory disease is an infectious respiratory disease caused by the virus SARS-CoV-2 belonging to the coronaviridae family. A pandemic is still present as of May 2020. In addition to causing pneumonia, SARS-CoV-2 may induce a direct damage to the heart, causing myocarditis, with significant impairment of cardiac contractility, and/or pericarditis. Elderly patients and those with cardiovascular risk factors, such as hypertension and diabetes mellitus, are at increased risk of heart complications from COVID-19. In this review, we focused on the correlation between COVID-19 infection and the high sensitivity troponin T and I, and their significance in the development of myocarditis. Data emerging from the studies so far conducted indicate that a high value of high-sensitivity troponin represents a negative prognostic indicator when associated with heart damage on an infectious-inflammatory basis (i.e. myopericarditis). We should identify a safe and clear diagnostic algorithm, possibly combining patient clinical history, troponin levels and cardiac ultrasound findings that could help us in the prediction of myopericarditis.

Possible new options and benefits to detect myocarditis, right ventricular remodeling and coronary anomalies by echocardiography in systematic preparticipation screening of athletes

Exclusion of cardiac abnormalities should be performed at the beginning of the athlete's career. Myocarditis, right ventricular remodeling and coronary anomalies are well-known causes of life-threatening events of athletes, major cardiovascular events and sudden cardiac death. The feasibility of an extended comprehensive echocardiographic protocol for the detection of structural cardiac abnormalities in athletes should be tested. This standardized protocol of transthoracic echocardiography includes two- and three-dimensional imaging, tissue Doppler imaging, and coronary artery scanning. Post processing was performed for deformation analysis of all compounds including layer strain. During 2017 and 2018, the feasibility of successful image acquisition and post processing analysis was retrospectively analyzed in 54 male elite athletes. In addition, noticeable findings inside the analyzed cohort are described. The extended image acquisition and data analyzing was feasible from 74 to 100%, depending on the used modalities. One case of myocarditis was detected in the present cohort. Coronary anomalies were not found. Right ventricular size and function were within normal ranges. Isovolumetric right ventricular relaxation time showed significant regional differences. One case of hypertrophic cardiomyopathy and two subjects with bicuspid aortic valves were found. Due to the excessive cardiac stress in highly competitive sports, high-quality and precise screening modalities are necessary, especially with respect to acquired cardiac diseases like acute myocarditis and pathological changes of left ventricular and RV geometry. The documented feasibility of the proposed extended protocol underlines the suitability to detect distinct morphological and functional cardiac alterations and documents the potential added value of a comprehensive echocardiography.

Gastric bypass surgery is associated with reduced subclinical myocardial injury and greater activation of the cardiac natriuretic peptide system than lifestyle intervention

AIMS

Morbid obesity is a risk factor for cardiovascular disease. The relative effects of Roux-en-Y gastric bypass surgery (GBS) and intensive lifestyle intervention (ILI) on subclinical myocardial injury, the activity of the cardiac natriuretic system, and systemic inflammation remain unclear.

METHODS

In a 59-week non-randomized clinical trial that included 131 patients with morbid obesity, we compared the effects ofGBS and ILI on concentrations of cardiac troponin T (cTnT) and I (cTnI), N-terminal pro-B-type natriuretic peptide (NT-proBNP) and C-reactive protein (CRP).

RESULTS

In the GBS and ILI group, median body mass index (BMI) was reduced by 14.4 kg/m² versus 3.9 kg/m², respectively (p value < 0.001). Cardiac troponins decreased after GBS, p = 0.014 (cTnT) and p = 0.065 (cTnI) and increased significantly in those treated with ILI (p values ≤ 0.021) (between-group differences for deltas: p ≤ 0.003). NT-proBNP increased in both groups, but significantly more in the GBS than in the ILI group (between-group differences for deltas: p = 0.008). CRP decreased significantly within the GBS and the ILI group, with this change significantly greater in the GBS group (between-group differences for deltas p < 0.001). The dominating mediator of the biomarker changes was weight loss. Prior coronary artery disease and diabetes were predictive of the magnitude of the changes in cTnI and NT-proBNP, respectively.

CONCLUSION

Compared to ILI, GBS was associated with reduced subclinical myocardial injury and systemic inflammation, and enhancement of the cardiac natriuretic peptide system. The biomarker changes were predominantly mediated by weight loss.

Approach to Acute Cardiovascular Complications in COVID-19 Infection

The novel coronavirus disease 2019, otherwise known as COVID-19, is a global pandemic with primary respiratory manifestations in those who are symptomatic. It has spread to >187 countries with a rapidly growing number of affected patients. Underlying cardiovascular disease is associated with more severe manifestations of COVID-19 and higher rates of mortality. COVID-19 can have both primary (arrhythmias, myocardial infarction, and myocarditis) and secondary (myocardial injury/biomarker elevation and heart failure) cardiac involvement. In severe cases, profound circulatory failure can result. This review discusses the presentation and management of patients with severe cardiac complications of COVID-19 disease, with an emphasis on a Heart-Lung team approach in patient management. Furthermore, it focuses on the use of and indications for acute mechanical circulatory support in cardiogenic and/or mixed shock.

Cardiovascular Considerations for Patients, Health Care Workers, and Health Systems During the COVID-19 Pandemic

The coronavirus disease 2019 (COVID-19) is an infectious disease caused by severe acute respiratory syndrome coronavirus 2 that has significant implications for the cardiovascular care of patients. First, those with COVID-19 and pre-existing cardiovascular disease have an increased risk of severe disease and death. Second, infection has been associated with multiple direct and indirect cardiovascular complications including acute myocardial injury, myocarditis, arrhythmias, and venous thromboembolism. Third, therapies under investigation for COVID-19 may have cardiovascular side effects. Fourth, the response to COVID-19 can compromise the rapid triage of non-COVID-19 patients with cardiovascular conditions. Finally, the provision of cardiovascular care may place health care workers in a position of vulnerability as they become hosts or vectors of virus transmission. We hereby review the peer-reviewed and pre-print reports pertaining to cardiovascular considerations related to COVID-19 and highlight gaps in knowledge that require further study pertinent to patients, health care workers, and health systems.