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Lim V, Topiwala G, Apinova E, Diioia M. Systematic review of case reports on COVID-19 associated myocarditis: a discussion on treatments. Virol J 2024; 21:252. [PMID: 39385302 PMCID: PMC11465911 DOI: 10.1186/s12985-024-02499-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Accepted: 09/11/2024] [Indexed: 10/12/2024] Open
Abstract
Although COVID-19 is a disease consisting of mostly upper and lower respiratory symptoms, a subset of patients develop cardiac sequelae including myocarditis and pericarditis. For these patients, a standardized set of diagnostic imaging techniques and treatments has not been established. While there have been numerous case reports on this topic, there are few reviews that evaluate the effectiveness of different treatment modalities with a significant number of cases. We reviewed 146 cases of patients (ages ranging from 2 months old to mid 80 s) obtained from searches on PubMed, Google Scholar, and several case report journals. ECG abnormalities, elevated inflammatory markers, and reduced left ventricular ejection fraction were most associated with COVID-19 myocarditis. While classic symptoms of COVID-19 include upper respiratory symptoms, a subset of patients diagnosed with COVID-19 displayed no signs of respiratory disease at all. In 22% of cases, cardiac sequelae was not present until after the patient recovered from COVID-19. Steroids were given in 57.5% of cases. Cardiac MRI was used in 40.4% of cases for diagnosis of myocarditis. Of all the patients who were treated with ECMO, 82.1% of these patients were able to fully recover. The use of cardiac MRI and transthoracic echocardiogram for diagnosis of COVID-19 myocarditis should be heavily considered in any patient with COVID-19 infection. ECMO, IVIG, steroids, and anticoagulants should also be heavily considered. A randomized controlled trial should be conducted to better associate treatments with outcomes.
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Affiliation(s)
- Vanessa Lim
- West Virginia School of Osteopathic Medicine, 400 Lee Street North, Lewisburg, WV, 24901, USA.
| | - Gopal Topiwala
- Drexel University College of Medicine at Tower Health, 50 Innovation Way, Wyomissing, PA, 19610, USA
| | - Emiliya Apinova
- West Virginia School of Osteopathic Medicine, 400 Lee Street North, Lewisburg, WV, 24901, USA
| | - Marina Diioia
- West Virginia School of Osteopathic Medicine, 400 Lee Street North, Lewisburg, WV, 24901, USA
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Goldberg JF, Spinner JA, Soslow JH. Myocarditis in children 2024, new themes and continued questions. Curr Opin Cardiol 2024; 39:315-322. [PMID: 38661130 DOI: 10.1097/hco.0000000000001151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
PURPOSE OF REVIEW While pediatric myocarditis incidence has increased since the coronavirus disease 2019 (COVID-19) pandemic, there remain questions regarding diagnosis, risk stratification, and optimal therapy. This review highlights recent publications and continued unanswered questions related to myocarditis in children. RECENT FINDINGS Emergence from the COVID-19 era has allowed more accurate description of the incidence and prognosis of myocarditis adjacent to COVID-19 infection and vaccine administration as well that of multi-system inflammatory disease in children (MIS-C). As cardiac magnetic resonance technology has shown increased availability and evidence in pediatric myocarditis, it is important to understand conclusions from adult imaging studies and define the use of this imaging biomarker in children. Precision medicine has begun to allow real-time molecular evaluations to help diagnose and risk-stratify cardiovascular diseases, with emerging evidence of these modalities in myocarditis. SUMMARY Recent information regarding COVID-19 associated myocarditis, cardiac magnetic resonance, and molecular biomarkers may help clinicians caring for children with myocarditis and identify needs for future investigations.
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Ono R, Iwahana T, Aoki K, Kato H, Okada S, Kobayashi Y. Fulminant Myocarditis with SARS-CoV-2 Infection: A Narrative Review from the Case Studies. THE CANADIAN JOURNAL OF INFECTIOUS DISEASES & MEDICAL MICROBIOLOGY = JOURNAL CANADIEN DES MALADIES INFECTIEUSES ET DE LA MICROBIOLOGIE MEDICALE 2024; 2024:9000598. [PMID: 38469104 PMCID: PMC10927348 DOI: 10.1155/2024/9000598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Revised: 02/15/2024] [Accepted: 02/16/2024] [Indexed: 03/13/2024]
Abstract
One of the severe complications of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is myocarditis. However, the characteristics of fulminant myocarditis with SARS-CoV-2 infection are still unclear. We systematically reviewed the previously reported cases of fulminant myocarditis associated with SARS-CoV-2 infection from January 2020 to December 2022, identifying 108 cases. Of those, 67 were male and 41 female. The average age was 34.8 years; 30 patients (27.8%) were ≤20 years old, whereas 10 (9.3%) were ≥60. Major comorbidities included hypertension, obesity, diabetes mellitus, asthma, heart disease, gynecologic disease, hyperlipidemia, and connective tissue disorders. Regarding left ventricular ejection fraction (LVEF) at admission, 93% of the patients with fulminant myocarditis were classified as having heart failure with reduced ejection fraction (LVEF ≤ 40%). Most of the cases were administered catecholamines (97.8%), and mechanical circulatory support (MCS) was required in 67 cases (62.0%). The type of MCS was extracorporeal membrane oxygenation (n = 56, 83.6%), percutaneous ventricular assist device (Impella®) (n = 19, 28.4%), intra-aortic balloon pumping (n = 12, 12.9%), or right ventricular assist device (n = 2, 3.0%); combination of these devices occurred in 20 cases (29.9%). The average duration of MCS was 7.7 ± 3.8 days. Of the 76 surviving patients whose cardiac function was available for follow-up, 65 (85.5%) recovered normally. The overall mortality rate was 22.4%, and the recovery rate was 77.6% (alive: 83 patients, dead: 24 patients; outcome not described: 1 patient).
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Affiliation(s)
- Ryohei Ono
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba 260-8670, Japan
| | - Togo Iwahana
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba 260-8670, Japan
| | - Kaoruko Aoki
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba 260-8670, Japan
| | - Hirotoshi Kato
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba 260-8670, Japan
| | - Sho Okada
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba 260-8670, Japan
| | - Yoshio Kobayashi
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba 260-8670, Japan
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Yan J, Hong J. COVID-19 Associated Myocarditis: Prevalence, Pathophysiology, Diagnosis, and Management. Cardiol Rev 2023:00045415-990000000-00141. [PMID: 37607078 DOI: 10.1097/crd.0000000000000597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/24/2023]
Abstract
Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has been a pandemic and affected public health greatly. While COVID-19 primarily damages the lungs, leading to cough, sore throat, pneumonia, or acute respiratory distress syndrome, it also infects other organs and tissues, including the cardiovascular system. In particular, myocarditis is a well-recognized severe complication of COVID-19 infection and could result in adverse outcomes. Angiotensin-Converting Enzyme2 is thought to play a pivotal role in SARS-CoV-2 infection, and immune overresponse causes overwhelming damage to the host's myocardium. Direct viral infection and injury do take a part as well, but more evidence is needed to strengthen this proposal. The clinical abnormalities include elevated cardiac biomarkers and electrocardiogram changes and impaired cardiac function that might be presented in echocardiography and cardiovascular magnetic resonance imaging. If necessary, the endomyocardial biopsy would give more forceful information to diagnosis and aid in treatment. Comparisons between COVID-19 myocarditis and other viral myocarditis are also discussed briefly.
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Affiliation(s)
- Ji Yan
- From the Department of Internal and Emergency Medicine, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jiang Hong
- From the Department of Internal and Emergency Medicine, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Hsu HT, Kuo NC, Chen PY, Jan SL. Case report: VA-ECMO for fulminant myocarditis in an infant with acute COVID-19. Front Pediatr 2023; 11:1180534. [PMID: 37441568 PMCID: PMC10333478 DOI: 10.3389/fped.2023.1180534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 06/15/2023] [Indexed: 07/15/2023] Open
Abstract
Fulminant myocarditis in children was rare during the coronavirus disease 2019 pandemic, but it had the potential for high morbidity and mortality. We describe the clinical course of a previously healthy 9-month-old young male infant who rapidly deteriorated into cardiogenic shock due to coronavirus disease 2019-related fulminant myocarditis. He developed severe heart failure and multiple organ dysfunction syndrome that were treated promptly with central venoarterial extracorporeal membrane oxygenation and continuous venovenous hemofiltration. He made a good recovery without significant morbidity.
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Affiliation(s)
- Hao-Ting Hsu
- Department of Pediatrics, Children's Medical Center, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Ni-Chun Kuo
- Department of Pediatrics, Children's Medical Center, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Po-Yen Chen
- Department of Pediatrics, Children's Medical Center, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Sheng-Ling Jan
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan
- Department of Pediatrics, School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Department of Pediatrics, School of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
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Watanabe A, Yasuhara J, Karube T, Watanabe K, Shirasu T, Takagi H, Sumitomo N, Lee S, Kuno T. Extracorporeal Membrane Oxygenation in Children With COVID-19: A Systematic Review and Meta-Analysis. Pediatr Crit Care Med 2023; 24:406-416. [PMID: 36516348 PMCID: PMC10153595 DOI: 10.1097/pcc.0000000000003113] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVES The indication, complications, and outcomes of extracorporeal membrane oxygenation (ECMO) in children with COVID-19-related illnesses remain unelucidated. Our study aimed to investigate the characteristics and outcomes of ECMO in children with COVID-19-related illnesses. DATA SOURCES We searched PubMed and EMBASE databases in March 2022. STUDY SELECTION We retrieved all studies involving children (age ≤ 18 yr) with COVID-19-related illnesses who received ECMO. DATA EXTRACTION Two authors independently extracted data and assessed the risk of bias. Mortality, successful weaning rate, and complications while on ECMO were synthesized by a one-group meta-analysis using a random-effect model. Meta-regression was performed to explore the risk factors for mortality. DATA SYNTHESIS We included 18 observational studies, four case series, and 22 case reports involving 110 children with COVID-19-related illnesses receiving ECMO. The median age was 8 years (range, 10 d to 18 yr), and the median body mass index was 21.4 kg/m 2 (range, 12.3-56.0 kg/m 2 ). The most common comorbidities were obesity (11% [7/63]) and congenital heart disease (11% [7/63]), whereas 48% (30/63) were previously healthy. The most common indications for ECMO were multisystem inflammatory syndrome in children (52% [47/90]) and severe acute respiratory distress syndrome (40% [36/90]). Seventy-one percent (56/79) received venoarterial-ECMO. The median ECMO runtime was 6 days (range, 3-51 d) for venoarterial ECMO and 11 days (range, 3-71 d) for venovenous ECMO. The mortality was 26.6% (95% CI, 15.9-40.9), and the successful weaning rate was 77.0% (95% CI, 55.4-90.1). Complications were seen in 37.0% (95% CI, 23.1-53.5) while on ECMO, including stroke, acute kidney injury, pulmonary edema, and thromboembolism. Corticosteroids and IV immunoglobulin therapies were associated with lower mortality. CONCLUSIONS The mortality of children on ECMO for COVID-19 was relatively low. This invasive treatment can be considered as a treatment option for critically ill children with COVID-19.
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Affiliation(s)
- Atsuyuki Watanabe
- Division of Hospital Medicine, University of Tsukuba Hospital, Tsukuba, Ibaraki, Japan
| | - Jun Yasuhara
- Center for Cardiovascular Research, The Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH
- The Heart Center, Nationwide Children's Hospital, Columbus, OH
| | - Takaharu Karube
- Division of Pediatric Cardiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Kae Watanabe
- Department of Surgery and Division of Vascular and Endovascular Surgery, School of Medicine, University of Virginia, Charlottesville, VA
| | - Takuro Shirasu
- Division of Cardiovascular Surgery, Shizuoka Medical Center, Shizuoka, Japan
| | - Hisato Takagi
- Department of Pediatric Cardiology, Saitama Medical University International Medical Center, Saitama, Japan
| | - Naokata Sumitomo
- Department of Pediatric Cardiology, Saitama Medical University International Medical Center, Saitama, Japan
| | - Simon Lee
- The Heart Center, Nationwide Children's Hospital, Columbus, OH
| | - Toshiki Kuno
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY
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Abstract
PURPOSE OF REVIEW Cardiac consequences occur in both acute COVID-19 and post-acute sequelae of COVID-19 (PASC). Here, we highlight the current understanding about COVID-19 cardiac effects, based upon clinical, imaging, autopsy, and molecular studies. RECENT FINDINGS COVID-19 cardiac effects are heterogeneous. Multiple, concurrent cardiac histopathologic findings have been detected on autopsies of COVID-19 non-survivors. Microthrombi and cardiomyocyte necrosis are commonly detected. Macrophages often infiltrate the heart at high density but without fulfilling histologic criteria for myocarditis. The high prevalences of microthrombi and inflammatory infiltrates in fatal COVID-19 raise the concern that recovered COVID-19 patients may have similar but subclinical cardiac pathology. Molecular studies suggest that SARS-CoV-2 infection of cardiac pericytes, dysregulated immunothrombosis, and pro-inflammatory and anti-fibrinolytic responses underlie COVID-19 cardiac pathology. The extent and nature by which mild COVID-19 affects the heart is unknown. Imaging and epidemiologic studies of recovered COVID-19 patients suggest that even mild illness confers increased risks of cardiac inflammation, cardiovascular disorders, and cardiovascular death. The mechanistic details of COVID-19 cardiac pathophysiology remain under active investigation. The ongoing evolution of SARS-CoV-2 variants and vast numbers of recovered COVID-19 patients portend a burgeoning global cardiovascular disease burden. Our ability to prevent and treat cardiovascular disease in the future will likely depend on comprehensive understanding of COVID-19 cardiac pathophysiologic phenotypes.
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Affiliation(s)
- Lorenzo R. Sewanan
- Department of Medicine, Columbia University Irving Medical Center, New York, NY USA
| | - Kevin J. Clerkin
- Center for Advanced Cardiac Care, Division of Cardiology, Columbia University Irving Medical Center, New York, NY USA
| | | | - Emily J. Tsai
- Center for Advanced Cardiac Care, Division of Cardiology, Columbia University Irving Medical Center, New York, NY USA
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Selection criteria and triage in extracorporeal membrane oxygenation during coronavirus disease 2019. Curr Opin Crit Care 2022; 28:674-680. [PMID: 36302196 DOI: 10.1097/mcc.0000000000000998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
PURPOSE OF REVIEW Coronavirus disease 2019 (COVID-19) pandemic changed the way we had to approach hospital- and intensive care unit (ICU)-related resource management, especially for demanding techniques required for advanced support, including extracorporeal membrane oxygenation (ECMO). RECENT FINDINGS Availability of ICU beds and ECMO machines widely varies around the world. In critical conditions, such a global pandemic, the establishment of contingency capacity tiers might help in defining to which conditions and subjects ECMO can be offered. A frequent reassessment of the resource saturation, possibly integrated within a regional healthcare coordination system, may be of help to triage the patients who most likely will benefit from advanced techniques, especially when capacities are limited. SUMMARY Indications to ECMO during the pandemic should be fluid and may be adjusted over time. Candidacy of patients should follow the same prepandemic rules, taking into account the acute disease, the burden of any eventual comorbidity and the chances of a good quality of life after recovery; but the current capacity of healthcare system should also be considered, and frequently reassessed, possibly within a wide hub-and-spoke healthcare system. VIDEO ABSTRACT http://links.lww.com/COCC/A43.
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Nasso G, Santarpino G. SARS‐CoV‐2 myocarditis in pediatric patients: We are ready to do whatever it takes to save them! J Card Surg 2022; 37:1444. [PMID: 35152471 PMCID: PMC9115211 DOI: 10.1111/jocs.16321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 01/27/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Giuseppe Nasso
- Department of Cardiac Surgery Anthea Hospital, GVM Care & Research Bari Italy
| | - Giuseppe Santarpino
- Department of Experimental and Clinical Medicine Magna Graecia University Catanzaro Italy
- Department of Cardiac Surgery Città di Lecce Hospital, GVM Care & Research Lecce Italy
- Department of Cardiac Surgery Paracelsus Medical University Nuremberg Germany
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Phan PH, Nguyen DT, Dao NH, Nguyen HTT, Vu AV, Hoang ST, Nguyen LV, Cao TV, Tran DM. Case Report: Successful Treatment of a Child With COVID-19 Reinfection-Induced Fulminant Myocarditis by Cytokine-Adsorbing oXiris® Hemofilter Continuous Veno-Venous Hemofiltration and Extracorporeal Membrane Oxygenation. Front Pediatr 2022; 10:946547. [PMID: 35903158 PMCID: PMC9315247 DOI: 10.3389/fped.2022.946547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 06/15/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Indirect cardiomyocyte damage-related hyperinflammatory response is one of the key mechanisms in COVID-19-induced fulminant myocarditis. In addition to the clinical benefit of using cytokines absorption hemofiltration, the effectiveness of instituting veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support for cardiac compromise has been reported. However, current literature enunciates a paucity of available data on the effectiveness of these novel modalities. CASE PRESENTATION We reported a 9-year-old boy with recurrent COVID-19 infection-causing fulminant myocarditis, who was treated successfully by using novel modalities of oXiris ® hemofilter continuous venovenous hemofiltration (CVVH) and VA-ECMO. The patient made a full recovery without any sequelae. CONCLUSION We conclude that the novel highly-absorptive hemofilter CVVH and VA-ECMO may be effective treatment modalities in managing SARS-CoV-2-induced fulminant myocarditis. Our report highlights the need for further well-designed investigations to confirm this extrapolation.
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Affiliation(s)
- Phuc H Phan
- Pediatric COVID-19 Intensive Care Unit, Vietnam National Children's Hospital, Hanoi, Vietnam
| | - Dung T Nguyen
- Pediatric COVID-19 Intensive Care Unit, Vietnam National Children's Hospital, Hanoi, Vietnam
| | - Nam H Dao
- Pediatric COVID-19 Intensive Care Unit, Vietnam National Children's Hospital, Hanoi, Vietnam
| | - Ha T T Nguyen
- Pediatric COVID-19 Intensive Care Unit, Vietnam National Children's Hospital, Hanoi, Vietnam
| | - An V Vu
- Pediatric COVID-19 Intensive Care Unit, Vietnam National Children's Hospital, Hanoi, Vietnam
| | - Son T Hoang
- Cardiovascular Center, Vietnam National Children's Hospital, Hanoi, Vietnam
| | - Lam V Nguyen
- Pediatric COVID-19 Intensive Care Unit, Vietnam National Children's Hospital, Hanoi, Vietnam
| | - Tung V Cao
- Pediatric COVID-19 Intensive Care Unit, Vietnam National Children's Hospital, Hanoi, Vietnam
| | - Dien M Tran
- Pediatric COVID-19 Intensive Care Unit, Vietnam National Children's Hospital, Hanoi, Vietnam
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