COVID-19 in patients with primary cardiomyopathies: clinical course and outcomes, role of verified post-COVID myocarditis

• Blagova O.V.
• Kogan E.A.
• Lutokhina Yu.A.
• Savina P.O.
• Ainetdinova D.H.
• Pavlenko E.V.
• Sedov A.V.
• Zaitsev A.Yu.
• Alexandrova S.A.

Abstract

Aim. To evaluate the clinical course and outcomes of COVID-19 in patients with cardiomyopathies (CMP) and the role of verified SARS-CoV-2-induced myocarditis in their progression.

Material and methods. 33 patients with various CMP who underwent COVID-19 were included in the study (18 men, 48.4±14.9 years old): left ventricular non-compaction (LVNC, 11 patients), hypertrophic CMP (HCM, 6 patients, including one with dilated phenotype and mutation in MyBPC3 gene), LVNC with HCM combination (n=1), arrhythmogenic right ventricular CMP (ARVC, n=1, FLNC), ARVC combination with LVNC (n=3, DSP) and a heterozygous form of hemochromatosis (n=1, HFE), Danon disease (n=2, LAMP2), Fabry disease (n=1, GLA), restrictive CMP (RCM, n=2), laminopathy (n=1, LMNA) and AL cardiac amyloidosis (n=4). The diagnosis of COVID-19 was confirmed by nasopharyngeal swab (in 24 patients) and by subsequent seroconversion in all patients. Endomyocardial biopsy (EMB, n=6), cardiac MRI (n=9), and anti-heart antibodies titers evaluation (n=20) were performed after COVID-19.

Results. Death due to COVID-19 and its consequences occurred in 5 patients (with HCM, DCM and LVNC). The immediate causes of death were ischemic stroke, terminal respiratory and heart failure. In 12 patients, the appearance/progression of heart failure symptoms and an increase of ventricular arrhythmias severity were noted. Post-COVID lymphocytic myocarditis was diagnosed by EMB (including immunohistochemical staining for CD3, CD45, CD20, and CD68 lymphocytes) in 6 patients (with LVNC, RCM, ARCV, Danone disease, AL amyloidosis) and by MRI in 6 patients. The mean time from COVID-19 to the diagnosis of myocarditis was 7 [5; 10.5] months, and in 2 cases it was also preceded by vaccination. Spike and nucleocapsid coronavirus proteins were detected in all biopsies in infiltrate cells, endothelial cells, and individual cardiomycytes, SARS-CoV-2 RNA by PCR was found in 5 out of 6. The level of anti-heart antibodies was elevated 3–4 times in 6 patients (in patients with amyloidosis it was not assessed). 4 patients receive methylprednisolone monotherapy as myocarditis treatment; there were no deaths at 6 [1.5; 8.5] months follow-up.

Conclusion. Among the patients with CMP who underwent COVID-19 the direct mortality (during acute COVID-19) was 9.1%, delayed – 15.2%. Post-COVID myocarditis was diagnosed between 4 and 11 months, it manifested with the appearance/increase of arrhythmias and heart failure and required immunosupressive therapy. Genetic impairment of the myocardium is a favorable background for the development of post-COVID myocarditis and an adverse prognostic factor with regard to the clinical course of new coronavirus infection.

Keywords:COVID-19; myocarditis; cardiomyopathy; endomyocardial biopsy; corticosteroids

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