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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.
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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
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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.
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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
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