Subacute and chronic post-covid myoendocarditis: clinical presentation, role of coronavirus persistence and autoimmune mechanisms

Abstract

Aim To study clinical features of myoendocarditis and its possible mechanisms, including persistence of SARS-Cov-2 in the myocardium, in the long-term period following COVID-19.Material and methods This cohort, prospective study included 15 patients aged 47.8±13.4 years (8 men) with post-COVID myocarditis. The COVID-19 diagnosis was confirmed for all patients. Median time to seeking medical care after COVID-19 was 4 [3; 7] months. The diagnosis of myocarditis was confirmed by magnetic resonance imaging (MRI) of the heart (n=10) and by endomyocardial biopsy of the right ventricle (n=6). The virus was detected in the myocardium with PCR; immunohistochemical (IHC) study with antibody to SARS-Cov-2 was performed; anticardiac antibody level was measured; and echocardiography and Holter monitoring were performed. Hemodynamically significant coronary atherosclerosis was excluded for all patients older than 40 years.Results All patients showed a clear connection between the emergence or exacerbation of cardiac symptoms and COVID-19. 11 patients did not have any signs of heart disease before COVID-19; 4 patients had previously had moderate arrhythmia or heart failure (HF) without myocarditis. Symptoms of myocarditis emerged at 1–5 months following COVID-19. MRI revealed typical late gadolinium accumulation, signs of hyperemia, and one case of edema. The level of anticardiac antibodies was increased 3-4 times in 73 % больных. Two major clinical variants of post-COVID myocarditis were observed. 1. Arrhythmic (n=6), with newly developed extrasystole or atrial fibrillation without systolic dysfunction. 2. Decompensated variant with systolic dysfunction and biventricular HF (n=9). Mean left ventricular ejection fraction was 34.1±7.8 %, and left ventricular end-diastolic dimension was 5.8±0.7 cm. In one case, myocarditis was associated with signs of IgG4‑negative aortitis. SARS-Cov-2 RNA was found in 5 of 6 biopsy samples of the myocardium. The longest duration of SARS-Cov-2 persistence in the myocardium was 9 months following COVID-19. By using antibody to the Spike antigen and nucleocapsid, SARS-Cov-2 was detected in cardiomyocytes, endothelium, and macrophages. Five patients were diagnosed with lymphocytic myocarditis; one with giant-cell myocarditis; three patients had signs of endocarditis (infectious, lymphocytic with mural thrombosis).Conclusion Subacute/chronic post-COVID myocarditis with isolated arrhythmias or systolic dysfunction is characterized by long-term (up to 9 months) persistence of SARS-Cov-2 in the myocardium in combination with a high immune activity. Endocarditis can manifest either as infectious or as nonbacterial thromboendocarditis. A possibility of using corticosteroids and anticoagulants in the treatment of post-COVID myoendocarditis should be studied.

COVID-19 associated changes in the right departments of the heart in the elderly people

“…The detected changes among the symptomatic patients with carried COVID-19 definitely need treatment. Taking into account, that right departments of the heart have been mostly affected the with the formation of chronic pulmonary heart disease, it is advisable to use drugs of neurohumoral blockade of the renin-angiotensinaldosterone system [15,16]. As the patients have been already taking ACE inhibitors and beta-blockers before the treatment, it was advisable to add a mineralocorticoid receptor antagonist, spironolactone, which blocks the biological effects of aldosterone: sodium and water retention, potassium and magnesium loss, the development of generalized fibrosis, heart and vascular remodeling [17,18].…”

Myocarditis Related to COVID-19 and SARS-CoV-2 Vaccination

“…Heparin may be a defining factor in the evolution and prognosis of the disease in patients with COVID-related myocarditis. [ 21 ]. The fact that the binding of heparin to spike glycoprotein inhibits SARS-CoV2 infection has led to the proposal of heparin as a drug with antiviral activity [ 22 ].…”

“…Endocarditis can manifest as infectious or nonbacterial thromboendocarditis. The authors propose to study the possibility of using corticosteroids and anticoagulants in the treatment of post-COVID myoendocarditis [ 21 ].…”

Clinical and Morphological Characteristics of Covid-19 Associated Myocarditis

“…At the same time, this period after acute COVID-19 vary from several months to six months or even more. [2][3][4]. Cardiovascular manifestation in COVID-19 is diverse: acute myocardial infarction, myocarditis, stress-induced cardiomyopathy, nonischemic cardiomyopathy, coronary spasm [5][6][7].…”