Reversible cardiac dysfunction in severe COVID-19 infection, mechanisms and case report

Fulminant Myocarditis with SARS-CoV-2 Infection: A Narrative Review from the Case Studies

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).

Myo-inositol oxygenase (MIOX) accelerated inflammation in the model of infection-induced cardiac dysfunction by NLRP3 inflammasome

BACKGROUND

Cardiac dysfunction is an important component of multiple organ failure caused by sepsis, and an important cause of high mortality in patients with sepsis. Herein, we attempted to determine whether myo-inositol oxygenase (MIOX) has proinflammation enzyme in infection-induced cardiac dysfunction (IICD) and its underlying mechanism.

METHODS

Patients with IICD were collected by our hospital. A mouse model of IICD was induced into male db/db mice by cecal ligation and puncture (CLP). All mice were injected with 20 μL of LV-MIOX or LV-control short hairpin RNA using a 0.5-mL insulin syringe. On the second day, all mice were induced by CLP. H9C2 cell was also induced with lipopolysaccharide and adenosine triphosphate. Quantitative analysis of messenger RNAs (mRNAs) and gene microarray hybridization was used to analyze the mRNA expression levels. Enzyme-linked immunosorbent assay, immunofluorescence, and Western blot analysis were used to analyze the protein expression levels.

RESULTS

The serum expressions of MIOX mRNA level in patients with IICD were upregulated compared to normal healthy volunteers. MIOX promoted inflammation levels in the in vitro model of IICD. Si-MIOX inhibited inflammation levels in the in vitro model of IICD. MIOX accelerated inflammation and cardiac dysfunction in infection-induced mice. MIOX interacted with NLR family pyrin domain containing 3 (NLRP3) protein to reduce the degradation of NLRP3. The inhibition of MIOX reversed the effects of NLRP3 in the in vitro model of cardiac dysfunction.

CONCLUSIONS

Taken together, these findings demonstrate that MIOX accelerates inflammation in the model of IICD, which may be, at least in part, attributable to NLRP3 activity by the suppression of NLRP3 degradation in IICD.

Takotsubo syndrome and COVID‐19: A systematic review

Background and Aims

Takotsubo syndrome (TTS), also known as stress cardiomyopathy, is characterized by acute and transient left ventricular dysfunction and has increased during the COVID-19 pandemic. Herein, we aim to review studies on TTS that were associated with COVID-19 infection, vaccine, and other COVID-19-related etiologies including psychosocial stressors.

Methods

We systematically searched PubMed, EMBASE, and Scopus up to May 12, 2022. We included case reports, case series, and original articles that reported at least one TTS case associated with COVID-19, or TTS cases after receiving COVID-19 vaccines, or TTS cases secondary to psychological stress due to the COVID-19 pandemic. The quality assessment was conducted using the Joanna Briggs Institute checklist.

Results

Sixty-seven articles including 102 cases were included. Hypertension was the most frequently accompanying comorbidity (N = 67 [65.6%]) and the mean left ventricular ejection fraction was 36.5%. Among COVID-19 patients, the in-hospital mortality rate was 33.3%. On the other hand, only one COVID-19-negative individual expired (2.3%). The most common presenting clinical symptom was dyspnea in 42 (73.6%) patients. the mean time interval from the first symptom to admission was 7.2 days. The most common chest imaging finding was ground-glass opacity which was reported in 14 (31.1%) participants. The most common abnormalities were T-wave inversion in 35 (43.2%) and ST-segment elevation in 30 (37%). Brain natriuretic peptide and troponin were elevated in 94.7% and 95.9% of participants, respectively.

Conclusion

The TTS in patients with COVID-19 is almost rare, whereas it could lead to a great mortality and morbidity. An individual with COVID-19, especially an elderly woman, presented with dyspnea in addition to a rise in brain natriuretic peptide and troponin should be evaluated for TTS.

Clinical variants of myocardial involvement in COVID-19-positive patients: a cumulative experience of 2020

Myocardial injury, diagnosed by troponin elevation, is common in COVID-19 patients, but cardiac involvement with clinical manifestations occurs less frequently. We analyzed the literature on COVID-19 (2020) and systematically reviewed the cases where individual patient data were presented. We searched PubMed and Google Scholar for "COVID," "COVID-19," and "coronavirus" in combination with "myocarditis," "heart failure," "takotsubo," "cardiomyopathy," and "cardiogenic shock." We identified 90 cases of COVID-19 with myocardial involvement, mean age 52.9 ± 18.3 years, 54.5% males. Of them, 55 survived (61.1%), 20 died (22.2%), and in 15 (16.7%) the outcome was unknown at the time of publication. Among patients with known outcome, mortality was 26%. The nadir LVEF was 31.7 ± 13.1% and recovered to 50.1 ± 16.0%. Pericardial effusion was a common finding, reported in 21 (23.3%) of patients, including moderate size effusion in 8.9% and large in 7.8%. The effusion caused tamponade in 11 (12.2%) of patients. Out of 83 patients who experienced a decrease in LVEF, 30 could be classified as takotsubo syndrome. The takotsubo patients were older than those with myocarditis, and with relatively high proportion of males. About one third of the cases was complicated by cardiogenic shock. Myocardial involvement in COVID-19 patients most often presents as a new, rapid decrease in LVEF, although normal LVEF or takotsubo-like wall motion pattern does not rule out myocarditis. Moderate and large pericardial effusion is common, and cardiac tamponade occurs in 12.2% of patients. Cardiogenic shock develops in one third of the patients. Mortality appears to be high at 26%.

Stress-Induced Cardiomyopathy—Considerations for Diagnosis and Management during the COVID-19 Pandemic

The novel coronavirus disease 2019 (COVID-19) is associated with several cardiovascular manifestations including myocardial injury, myocarditis, arrhythmia, and pulmonary embolism. Rare cases of stress-induced cardiomyopathy, or takotsubo syndrome have also been reported during the acute infection, and secondary to stress following lockdown and self-isolation. Diagnosis in the setting of the acute infection is challenging since conventional imaging modalities such as transthoracic echocardiography and coronary angiography should be restricted to minimize physician-patient contact until the patients is tested negative for COVID-19. The use of point of care hand-held ultrasound is appropriate for this purpose. The overall course of the disease seems to be similar to takotsubo in the general population. Physicians should be familiar with the clinical presentation, possible complications, and management of takotsubo during COVID-19 outbreak. Here, we review the special considerations in the diagnosis and management of takotsubo syndrome during the current pandemic.

Acute and Subclinical Myocardial Injury in COVID-19

Coronavirus disease 2019 (COVID-19) is a global pandemic that, at the time of this writing, has led to 178,000,000 cases worldwide and more than 3,875,000 deaths. Cardiovascular complications of COVID-19 have become the focus of investigation after many hospitalized COVID-19 patients-with or without established cardiovascular disease-incurred clinical or subclinical myocardial injury, including isolated biomarker elevations, myocardial infarction, arrhythmia, heart failure, myocarditis, and cardiogenic shock. In this review, we highlight the most recent evidence of the prevalence and potential etiologies of acute and subclinical myocardial injury in COVID-19 patients.

Characteristics of Takotsubo cardiomyopathy in patients with COVID-19: Systematic scoping review

Background

COVID-19 has recently been associated with the development of Takotsubo cardiomyopathy (TCM). This scoping review aims to summarize the existing evidence regarding TCM in COVID-19 and offer future direction for study.

Methods

Following the PRISMA Extension for Scoping Reviews, MEDLINE and EMBASE were searched for all peer-reviewed articles with relevant keywords including “Takotsubo”, “Stress-induced cardiomyopathy” and “COVID-19” from their inception to September 25, 2021.

Results

A total of 40 articles with 52 cases were included. Patients with TCM and COVID-19 showed only slight female predominance (59.6%), median age of 68.5 years, and were mostly of the apical subtype (88.6%). All-cause mortality was 36.5%. The median LVEF was 30%. Compared to those without TCM, those with TCM in COVID-19 had more critical illness, higher mortality, lower LVEF, and higher cardiac and inflammatory biomarkers. Notably, the diagnostic criteria of TCM were considerably different between case reports and observational studies.

Conclusion

This scoping review identifies that TCM in COVID-19 may have distinct features that distinguish this condition from TCM without COVID-19. Future studies are warranted to help describe risk factors, determine the utility of inflammatory biomarkers and serum catecholamine levels, and establish disease-specific diagnostic criteria.

Skewed Cytokine Responses Rather Than the Magnitude of the Cytokine Storm May Drive Cardiac Dysfunction in Multisystem Inflammatory Syndrome in Children

Background

Cardiac dysfunction is a prominent feature of multisystem inflammatory syndrome in children (MIS‐C), yet the etiology is poorly understood. We determined whether dysfunction is global or regional, and whether it is associated with the cytokine milieu, microangiopathy, or severity of shock.

Methods and Results

We analyzed echocardiographic parameters of myocardial deformation and compared global and segmental left ventricular strain between 43 cases with MIS‐C ≤18 years old and 40 controls. Primary outcomes included left ventricular global longitudinal strain, right ventricular free wall strain), and left atrial strain. We evaluated relationships between strain and profiles of 10 proinflammatory cytokines, microangiopathic features (soluble C5b9), and vasoactive‐inotropic requirements. Compared with controls, cases with MIS‐C had significant impairments in all parameters of systolic and diastolic function. 65% of cases with MIS‐C had abnormal left ventricular function (|global longitudinal strain|<17%), although elevations of cytokines were modest. All left ventricular segments were involved, without apical or basal dominance to suggest acute stress cardiomyopathy. Worse global longitudinal strain correlated with higher ratios of interleukin‐6 (ρ −0.43) and interleukin‐8 (ρ −0.43) to total hypercytokinemia, but not absolute levels of interleukin‐6 or interleukin‐8, or total hypercytokinemia. Similarly, worse right ventricular free wall strain correlated with higher relative interleukin‐8 expression (ρ −0.59). There were no significant associations between function and microangiopathy or vasoactive‐inotropic requirements.

Conclusions

Myocardial function is globally decreased in MIS‐C and not explained by acute stress cardiomyopathy. Cardiac dysfunction may be driven by the relative skew of the immune response toward interleukin‐6 and interleukin‐8 pathways, more so than degree of hyperinflammation, refining the current paradigm of myocardial involvement in MIS‐C.

Takotsubo syndrome during the COVID-19 pandemic, state-of -the- art review

The current coronavirus disease 2019 (COVID-19) presents an ongoing medical challenge, as it involves multiple organs, including the cardiovascular system. Takotsubo syndrome (TTS) has been described in the context of COVID-19 in 2 different scenarios: as a direct complication of the infection, and as an indirect outcome secondary to the psychological burden of quarantine and social isolation (ie, stress-induced cardiomyopathy). Confirming the diagnosis of TTS in COVID-19 may be challenging due to the limited use of coronary angiography consistent with the recommended guidelines aimed at minimizing contact with infected individuals. The use of natriuretic peptide as a diagnostic and prognostic marker in this context may not be reliable as this peptide is already elevated in severe cases of COVID-19 regardless of TTS diagnosis. A relatively high incidence of complications has been reported in these cases, probably related to the severity of the underlying infectious disease. Although quarantine-induced stress cardiomyopathy is an unsurprising outcome of the powerful stress resulting from the current pandemic, conflicting results have been reported, and further studies are encouraged to determine the true incidence.

High Prevalence of Pericardial Involvement in College Student Athletes Recovering From COVID-19

OBJECTIVES

This study sought to explore the spectrum of cardiac abnormalities in student athletes who returned to university campus in July 2020 with uncomplicated coronavirus disease 2019 (COVID-19).

BACKGROUND

There is limited information on cardiovascular involvement in young individuals with mild or asymptomatic COVID-19.

METHODS

Screening echocardiograms were performed in 54 consecutive student athletes (mean age 19 years; 85% male) who had positive results of reverse transcription polymerase chain reaction nasal swab testing of the upper respiratory tract or immunoglobulin G antibodies against severe acute respiratory syndrome coronavirus type 2. Sequential cardiac magnetic resonance imaging was performed in 48 (89%) subjects.

RESULTS

A total of 16 (30%) athletes were asymptomatic, whereas 36 (66%) and 2 (4%) athletes reported mild and moderate COVID-19 related symptoms, respectively. For the 48 athletes completing both imaging studies, abnormal findings were identified in 27 (56.3%) individuals. This included 19 (39.5%) athletes with pericardial late enhancements with associated pericardial effusion. Of the individuals with pericardial enhancements, 6 (12.5%) had reduced global longitudinal strain and/or an increased native T1. One patient showed myocardial enhancement, and reduced left ventricular ejection fraction or reduced global longitudinal strain with or without increased native T1 values was also identified in an additional 7 (14.6%) individuals. Native T2 findings were normal in all subjects, and no specific imaging features of myocardial inflammation were identified. Hierarchical clustering of left ventricular regional strain identified 3 unique myopericardial phenotypes that showed significant association with the cardiac magnetic resonance findings (p = 0.03).

CONCLUSIONS

More than 1 in 3 previously healthy college athletes recovering from COVID-19 infection showed imaging features of a resolving pericardial inflammation. Although subtle changes in myocardial structure and function were identified, no athlete showed specific imaging features to suggest an ongoing myocarditis. Further studies are needed to understand the clinical implications and long-term evolution of these abnormalities in uncomplicated COVID-19.

COVID-19-associated takotsubo cardiomyopathy

The novel COVID-19 has had an unprecedented and devastating spread internationally. COVID-19 infection can lead to a number of cardiovascular sequelae, including heart failure, which may portend worse clinical outcomes. Here, we report a rare case of a 57-year-old woman who developed acute left ventricular systolic dysfunction with apical ballooning consistent with takotsubo cardiomyopathy (TCM), and mixed cardiogenic and septic shock in the setting of COVID-19 disease. We briefly review the pathophysiology and diagnosis of TCM (also described as apical ballooning syndrome and stress-induced cardiomyopathy). Additionally, this case highlights the importance of a multidisciplinary approach to clinical decision-making and resource allocation in diagnosis and management of critical illness in the setting of the ongoing international COVID-19 pandemic.

Reversible cardiac dysfunction in severe COVID-19 infection, mechanisms and case report

A previously healthy 49-year-old male patient presented with COVID-19 infection and required mechanical ventilation and extracorporeal membrane oxygenation due to severe hypoxemia. Echocardiography showed cardiac dysfunction with an apical sparing strain pattern, which rapidly normalized within a week. Apical sparing myocardial strain in patients with COVID-19 infection may suggest reverse-type stress cardiomyopathy.