Diagnostic dilemma: COVID-19 related cardiomyopathy or peripartum cardiomyopathy?

Abstract

Peripartum cardiomyopathy is a relatively rare condition, that usually presents with features of heart failure in the peripartum period. The ongoing pandemic caused by coronavirus disease 2019 (COVID-19) has been reported to be associated with myocarditis, with progression to dilated cardiomyopathy and heart failure. Dilated cardiomyopathy in a peripartum patient with COVID-19 infection may present a diagnostic dilemma. We report a case of dilated cardiomyopathy in a peripartum patient with COVID-19 infection. She presented with shortness of breath in the peripartum period. Chest X-ray showed a grossly enlarged heart with bilateral pulmonary infiltrates consistent with congestive heart failure or viral pneumonia. Echocardiography revealed dilated chambers with 22% left ventricular ejection fraction (LVEF) and global hypokinesis. Despite completing 5 days of remdesivir and dexamethasone, she had worsening dyspnea on postpartum day 10, a repeat echocardiogram showed further reduction in LVEF to 10-15% and was discharged with a life-vest after acute management. She had multiple hospital admissions for decompensated heart failure. Myocardial core biopsy showed marked acute inflammation and necrosis. She had an intra-aortic balloon pump, left ventricular and right ventricular assist devices placed on account of persistent hemodynamic instability, and is now scheduled to have a cardiac transplant.

Severe Heart Failure After Fetal Loss and COVID-19: A Diagnostically Challenging Case With Complicated Timing

“…As to how COVID-19 causes heart failure, the exact pathogenesis still remains unclear [16] and there may be varying mechanisms at play. One proposed theory is the direct attachment of the virus to the angiotensinconverting enzyme 2 (ACE2) receptors found in the heart [12,14,16]. ACE2, an aminopeptidase bound by a membrane that is extensively expressed in the cardiovascular system, is a coronavirus receptor.…”

“…Other possible explanations include inflammation leading to myocarditis and atherosclerotic plaque disruption leading to myocardial infarction, ischemia-induced cardiomyocyte injury from hypoxemic respiratory failure, and coronary obstruction secondary to hypercoagulability [15,16]. Furthermore, due to coagulation dysfunction, right-sided heart failure can occur secondary to pulmonary embolism [14].…”

Peripartum cardiomyopathy and Coronavirus Disease 2019 (COVID-19) associated cardiomyopathy: case series and review of literature

“…Juusela et al (10) reported 2 cases of which both patients were still hospitalized at the time of publication thus their outcome was not clear. Akintayo et al (12) and Mapelli et al (14) reported their cases as conference posters. None of the reported cases deceased, however, case 1 reported by Juusela et al (10) had developed pulseless electrical activities and underwent cardiopulmonary resuscitation for 5 minutes.…”