1
|
Liu-Fei F, McKinney J, McManus BM. Viral Heart Disease: Diagnosis, Management, and Mechanisms. Can J Cardiol 2023; 39:829-838. [PMID: 37003416 DOI: 10.1016/j.cjca.2023.03.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 03/14/2023] [Accepted: 03/27/2023] [Indexed: 04/03/2023] Open
Abstract
"Viral heart disease" is a term encompassing numerous virus-triggered heart conditions, wherein cardiac myocytes are injured, causing contractile dysfunction, cell death, or both. Cardiotropic viruses may also damage interstitial cells and vascular cells. Clinical presentation of the disorder varies widely. In most cases, patients are asymptomatic. Presentation includes-but is not limited to-flu-like symptoms, chest pain, cardiac arrhythmias, heart failure, cardiogenic shock, and sudden cardiac death. Laboratory studies, including blood-based heart injury indicators and cardiac imaging, may be needed. Management of viral heart disease requires a graded approach. Watchful observation at home may be the first step. Closer observation, with additional testing such as echocardiography in the clinic or hospital is less common yet may inform the use of cardiac magnetic resonance imaging. Intensive care may be indicated in severe acute illness. Viral heart disease mechanisms are complex. Initially, damage is predominantly virus mediated, whereas, in the second week, immune responses bring unintended obverse consequences for the myocardium. Innate immunity is largely beneficial in initial attempts to quell viral replication, whereas adaptive immunity brings helpful and antigen-specific mechanisms to fight the pathogen but also introduces the capability of autoimmunity. Each cardiotropic virus family has its own pathogenesis signature, including attack on myocytes, vascular cells, and other constitutive cells of myocardial interstitium. The stage of disease and preponderant viral pathways lend opportunities for potential intervention but also the likelihood of uncertainty about management. Overall, this review provides a novel glimpse into the depth of and need for solutions in viral heart disease.
Collapse
Affiliation(s)
- Felicia Liu-Fei
- Department of Pathology and Laboratory Medicine, University of British Columbia, Delta, British Columbia, Canada
| | - James McKinney
- Department of Medicine, Division of Cardiology, University of British Columbia, Delta, British Columbia, Canada
| | - Bruce M McManus
- Department of Pathology and Laboratory Medicine, University of British Columbia, Delta, British Columbia, Canada.
| |
Collapse
|
2
|
Hanson PJ, Liu-Fei F, Ng C, Minato TA, Lai C, Hossain AR, Chan R, Grewal B, Singhera G, Rai H, Hirota J, Anderson DR, Radio SJ, McManus BM. Characterization of COVID-19-associated cardiac injury: evidence for a multifactorial disease in an autopsy cohort. J Transl Med 2022; 102:814-825. [PMID: 35437316 PMCID: PMC9015288 DOI: 10.1038/s41374-022-00783-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 03/20/2022] [Accepted: 03/22/2022] [Indexed: 11/09/2022] Open
Abstract
As the coronavirus disease 2019 (COVID-19) pandemic evolves, much evidence implicates the heart as a critical target of injury in patients. The mechanism(s) of cardiac involvement has not been fully elucidated, although evidence of direct virus-mediated injury, thromboembolism with ischemic complications, and cytokine storm has been reported. We examined suggested mechanisms of COVID-19-associated heart failure in 21 COVID-19-positive decedents, obtained through standard autopsy procedure, compared to clinically matched controls and patients with various etiologies of viral myocarditis. We developed a custom tissue microarray using regions of pathological interest and interrogated tissues via immunohistochemistry and in situ hybridization. Severe acute respiratory syndrome coronavirus 2 was detected in 16/21 patients, in cardiomyocytes, the endothelium, interstitial spaces, and percolating adipocytes within the myocardium. Virus detection typically corresponded with troponin depletion and increased cleaved caspase-3. Indirect mechanisms of injury-venous and arterial thromboses with associated vasculitis including a mixed inflammatory infiltrate-were also observed. Neutrophil extracellular traps (NETs) were present in the myocardium of all COVID-19 patients, regardless of injury degree. Borderline myocarditis (inflammation without associated myocyte injury) was observed in 19/21 patients, characterized by a predominantly mononuclear inflammatory infiltrate. Edema, inflammation of percolating adipocytes, lymphocytic aggregates, and large septal masses of inflammatory cells and platelets were observed as defining features, and myofibrillar damage was evident in all patients. Collectively, COVID-19-associated cardiac injury was multifactorial, with elevated levels of NETs and von Willebrand factor as defining features of direct and indirect viral injury.
Collapse
Affiliation(s)
- Paul J. Hanson
- UBC Centre for Heart Lung Innovation, Vancouver, BC, Canada,UBC Department of Pathology and Laboratory Medicine, Vancouver, BC, Canada
| | | | - Coco Ng
- UBC Centre for Heart Lung Innovation, Vancouver, BC, Canada
| | | | - Chi Lai
- UBC Department of Pathology and Laboratory Medicine, Vancouver, BC, Canada,Department of Pathology and Laboratory Medicine, Providence Health Care – St. Paul's Hospital, Vancouver, BC, Canada
| | | | - Rebecca Chan
- Department of Pathology and Laboratory Medicine, Providence Health Care – St. Paul's Hospital, Vancouver, BC, Canada
| | - Bobby Grewal
- Department of Pathology and Laboratory Medicine, Providence Health Care – St. Paul's Hospital, Vancouver, BC, Canada
| | - Gurpreet Singhera
- UBC Department of Pathology and Laboratory Medicine, Vancouver, BC, Canada
| | - Harpreet Rai
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
| | - Jeremy Hirota
- Department of Biology, University of Waterloo, N2L 3G1, Waterloo, ON, Canada,Michael G. DeGroote Institute for Infectious Disease Research, McMaster University, L8S 4K1, Hamilton, ON, Canada,McMaster Immunology Research Centre, McMaster University, L8S 4K1, Hamilton, ON, Canada,Firestone Institute for Respiratory Health – Division of Respirology, Department of Medicine, McMaster University, L8N 4A6, Hamilton, ON, Canada
| | - Daniel R. Anderson
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Stanley J. Radio
- Department of Pathology and Microbiology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Bruce M. McManus
- UBC Centre for Heart Lung Innovation, Vancouver, BC, Canada,UBC Department of Pathology and Laboratory Medicine, Vancouver, BC, Canada,PROOF Centre of Excellence, Vancouver, BC, Canada
| |
Collapse
|
3
|
Hanson PJ, Liu-Fei F, Lai C, Toma M, McManus BM. COVID-19-positivity in a heart transplant recipient—antibody-mediated rejection or SARS-CoV-2-associated cardiac injury? Oxf Med Case Reports 2022; 2022:omab143. [PMID: 35083057 PMCID: PMC8787635 DOI: 10.1093/omcr/omab143] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 10/26/2021] [Accepted: 12/04/2021] [Indexed: 01/01/2023] Open
Abstract
Through the ongoing and heightening coronavirus disease 2019 (COVID-19) pandemic, the heart has been implicated as a central target of injury associated with significantly increased morbidity and mortality. Correspondingly, heart transplant recipients are a vulnerable population for which insufficient research has been conducted. Pathologic antibody-mediated rejection (pAMR) of cardiac allografts shares many characteristics with COVID-19-associated cardiac injury. In this case study, we investigate a 57-year-old female who contracted COVID-19 11 days postheart transplant and was observed to have pAMR while positive for laboratory-confirmed COVID-19, resulting in a diagnostic conundrum.
Collapse
Affiliation(s)
- Paul J Hanson
- UBC Centre for Heart Lung Innovation, Vancouver, British Columbia, Canada
- UBC Department of Pathology and Laboratory Medicine, Vancouver, British Columbia, Canada
| | - Felicia Liu-Fei
- UBC Centre for Heart Lung Innovation, Vancouver, British Columbia, Canada
| | - Chi Lai
- UBC Department of Pathology and Laboratory Medicine, Vancouver, British Columbia, Canada
- St. Paul’s Hospital, Department of Pathology and Laboratory Medicine, Vancouver, British Columbia, Canada
| | - Mustafa Toma
- St. Paul’s Hospital, Division of Cardiology, Vancouver, British Columbia, Canada
| | - Bruce M McManus
- PROOF Centre of Excellence, Vancouver, British Columbia, Canada
- UBC Centre for Heart Lung Innovation, Vancouver, British Columbia, Canada
- UBC Department of Pathology and Laboratory Medicine, Vancouver, British Columbia, Canada
| |
Collapse
|
4
|
Hanson PJ, Liu-Fei F, Minato TA, Hossain AR, Rai H, Chen VA, Ng C, Ask K, Hirota JA, McManus BM. Advanced detection strategies for cardiotropic virus infection in a cohort study of heart failure patients. J Transl Med 2022; 102:14-24. [PMID: 34608239 PMCID: PMC8488924 DOI: 10.1038/s41374-021-00669-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 08/20/2021] [Indexed: 12/11/2022] Open
Abstract
The prevalence and contribution of cardiotropic viruses to various expressions of heart failure are increasing, yet primarily underappreciated and underreported due to variable clinical syndromes, a lack of consensus diagnostic standards and insufficient clinical laboratory tools. In this study, we developed an advanced methodology for identifying viruses across a spectrum of heart failure patients. We designed a custom tissue microarray from 78 patients with conditions commonly associated with virus-related heart failure, conditions where viral contribution is typically uncertain, or conditions for which the etiological agent remains suspect but elusive. Subsequently, we employed advanced, highly sensitive in situ hybridization to probe for common cardiotropic viruses: adenovirus 2, coxsackievirus B3, cytomegalovirus, Epstein-Barr virus, hepatitis C and E, influenza B and parvovirus B19. Viral RNA was detected in 46.4% (32/69) of heart failure patients, with 50% of virus-positive samples containing more than one virus. Adenovirus 2 was the most prevalent, detected in 27.5% (19/69) of heart failure patients, while in contrast to previous reports, parvovirus B19 was detected in only 4.3% (3/69). As anticipated, viruses were detected in 77.8% (7/9) of patients with viral myocarditis and 37.5% (6/16) with dilated cardiomyopathy. Additionally, viruses were detected in 50% of patients with coronary artery disease (3/6) and hypertrophic cardiomyopathy (2/4) and in 28.6% (2/7) of transplant rejection cases. We also report for the first time viral detection within a granulomatous lesion of cardiac sarcoidosis and in giant cell myocarditis, conditions for which etiological agents remain unknown. Our study has revealed a higher than anticipated prevalence of cardiotropic viruses within cardiac muscle tissue in a spectrum of heart failure conditions, including those not previously associated with a viral trigger or exacerbating role. Our work forges a path towards a deeper understanding of viruses in heart failure pathogenesis and opens possibilities for personalized patient therapeutic approaches.
Collapse
Affiliation(s)
- Paul J Hanson
- UBC Centre for Heart Lung Innovation, Vancouver, BC, Canada.
- UBC Department of Pathology and Laboratory Medicine, Vancouver, BC, Canada.
| | | | | | | | - Harpreet Rai
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
| | | | - Coco Ng
- UBC Centre for Heart Lung Innovation, Vancouver, BC, Canada
| | - Kjetil Ask
- Firestone Institute for Respiratory Health - Division of Respirology, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Jeremy A Hirota
- Firestone Institute for Respiratory Health - Division of Respirology, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Bruce M McManus
- UBC Centre for Heart Lung Innovation, Vancouver, BC, Canada
- UBC Department of Pathology and Laboratory Medicine, Vancouver, BC, Canada
- PROOF Centre of Excellence, Vancouver, BC, Canada
| |
Collapse
|