Short term outcome of myocarditis and pericarditis following COVID-19 vaccines: a cardiac magnetic resonance imaging study.

To evaluate clinical and cardiac magnetic resonance (CMR) short-term follow-up (FU) in patients with vaccine-associated myocarditis, pericarditis or myo-pericarditis (VAMP) following COVID-19 vaccination. We retrospectively analyzed 44 patients (2 women, mean age: 31.7 ± 15.1 years) with clinical and CMR manifestations of VAMP, recruited from 13 large tertiary national centers. Inclusion criteria were troponin raise, interval between the last vaccination dose and onset of symptoms < 25 days and symptoms-to-CMR < 20 days. 29/44 patients underwent a short-term FU-CMR with a median time of 3.3 months. Ventricular volumes and CMR findings of cardiac injury were collected in all exams. Mean interval between the last vaccination dose and the onset of symptoms was 6.2 ± 5.6 days. 30/44 patients received a vaccination with Comirnaty, 12/44 with Spikevax, 1/44 with Vaxzevria and 1/44 with Janssen (18 after the first dose of vaccine, 20 after the second and 6 after the "booster" dose). Chest pain was the most frequent symptom (41/44), followed by fever (29/44), myalgia (17/44), dyspnea (13/44) and palpitations (11/44). At baseline, left ventricular ejection fraction (LV-EF) was reduced in 7 patients; wall motion abnormalities have been detected in 10. Myocardial edema was found in 35 (79.5%) and LGE in 40 (90.9%) patients. Clinical FU revealed symptoms persistence in 8/44 patients. At FU-CMR, LV-EF was reduced only in 2 patients, myocardial edema was present in 8/29 patients and LGE in 26/29. VAMPs appear to have a mild clinical presentation, with self-limiting course and resolution of CMR signs of active inflammation at short-term follow-up in most of the cases.

The Feasibility, Effectiveness and Acceptance of Virtual Visits as Compared to In-Person Visits among Clinical Electrophysiology Patients during the COVID-19 Pandemic.

The feasibility and effectiveness of virtual visits (VVs) for cardiac electrophysiology patients are still unknown. We aimed to assess the feasibility and effectiveness of VVs as compared to in-person visits, and to describe patient experience with virtual care in clinical electrophysiology. We prospectively enrolled patients scheduled to receive a clinical electrophysiology evaluation, dividing them in two groups: a VV group and an in-person visit group. Outcomes of interest were: (1) improvement in symptoms after the index visit, (2) disappearance of remote monitoring (RM) alerts at follow-up, (3) necessity of urgent hospitalization and (4) patient satisfaction measured by the Patient Satisfaction Questionnaire-18 (PSQ-18). This study included 162 patients in the VV group and 185 in the in-office visit group. As compared to in-person visits, VVs resulted in a similar reduction in RM alerts (51.5% vs. 43.2%, p-value 0.527) and in symptomatic patient rates (73.6% vs. 56.9%, p-value 0.073) at follow-up, without differences in urgent hospitalization rates (p-value 0.849). Patient satisfaction with VVs was higher than with in-person evaluation (p-value < 0.012). VVs proved to be as feasible and as effective as in-person visits, with high patient satisfaction. A hybrid model of care including VVs and in-person visits may become the new standard of care after the COVID-19 pandemic is over.

Hypersensitivity Myocarditis after COVID-19 mRNA Vaccination.

BACKGROUND: Myocarditis, even in a severe and lethal form, may occur after COVID-19 mRNA (BNT162b2) vaccination. However, its pathway, morphomolecular characterization and treatment are still unknown. METHODS: Routine hematochemical screening, ECG, Holter monitoring, 2D echocardiogram cardiac magnetic resonance (CMR) and invasive cardiac studies (cardiac catheterization, selective coronary angiography, left ventriculography and left ventricular endomyocardial biopsy) are reported from three patients (39F-pt1, 78M-pt2, 52M-pt3) with severe compromise of conduction tissue (junctional rhythm and syncope, pt1) or cardiac function compromise (LVEF ≤ 35%, pt2 and pt3) after COVID-19 mRNA (BNT162b2). RESULTS: Hematochemical data and coronary angiography were normal in the patients studied. Histology showed in all three patients extensive myocardial infiltration of degranulated eosinophils and elevation of serum cationic protein directly responsible for cardiomyocyte damage. These findings demonstrate myocarditis hypersensitivity to some component of the vaccine (spike protein?) acting as a hapten to some macromolecules of cardiomyocytes. Steroid administration (prednisone, 1 mg/kg die for 3 days, followed by 0.33 mg/kg for 4 weeks) was followed by complete recovery of cardiac contractility in pt2 and pt3. CONCLUSIONS: Eosinophilic myocarditis is a possible adverse reaction to the mRNA COVID-19 vaccine. Its pathway is mediated by release of cationic protein and responds to short courses of steroid administration.

Cardiac magnetic resonance imaging of myocarditis and pericarditis following COVID-19 vaccination: a multicenter collection of 27 cases.

OBJECTIVES: To assess clinical and cardiac magnetic resonance (CMR) imaging features of patients with peri-myocarditis following Coronavirus Disease 2019 (COVID-19) vaccination. METHODS: We retrospectively collected a case series of 27 patients who underwent CMR in the clinical suspect of heart inflammation following COVID-19 vaccination, from 16 large tertiary centers. Our patient's cohort was relatively young (36.6 ± 16.8 years), predominately included males (n = 25/27) with few comorbidities and covered a catchment area of approximately 8 million vaccinated patients. RESULTS: CMR revealed typical mid-subepicardial non-ischemic late gadolinium enhancement (LGE) in 23 cases and matched positively with CMR T2 criteria of myocarditis. In 7 cases, typical hallmarks of acute pericarditis were present. Short-term follow-up (median = 20 days) from presentation was uneventful for 25/27 patients and unavailable in two cases. CONCLUSIONS: While establishing a causal relationship between peri-myocardial inflammation and vaccine administration can be challenging, our clinical experience suggests that CMR should be performed for diagnosis confirmation and to drive clinical decision-making and follow-up. KEY POINTS: • Acute onset of dyspnea, palpitations, or acute and persisting chest pain after COVID-19 vaccination should raise the suspicion of possible myocarditis or pericarditis, and patients should seek immediate medical attention and treatment to help recovery and avoid complications. • In case of elevated troponin levels and/or relevant ECG changes, cardiac magnetic resonance should be considered as the best non-invasive diagnostic option to confirm the diagnosis of myocarditis or pericarditis and to drive clinical decision-making and follow-up.

Prevalence, Management, and Outcome of Atrial Fibrillation and Other Supraventricular Arrhythmias in COVID-19 Patients.

COVID-19 mainly affects the respiratory system but has been correlated with cardiovascular manifestations such as myocarditis, heart failure, acute coronary syndromes, and arrhythmias. Cardiac arrhythmias are the second most frequent complication affecting about 30% of patients. Several mechanisms may lead to an increased risk of cardiac arrhythmias during COVID-19 infection, ranging from direct myocardial damage to extracardiac involvement. The aim of this review is to describe the role of COVID-19 in the pathogenesis of cardiac arrhythmias and provide a comprehensive guidance for their monitoring and management.

Management of cardiac implantable electronic device follow-up in COVID-19 pandemic: lessons learned during Italian lock down

Aims Remote monitoring (RM) has significantly transformed the standard of care for patients with cardiac electronic implantable devices. It provides easy access to valuable information, such as arrhythmic events, acute decompensation manifestations, and device‐related issues, without the need of in‐person visits. Methods and results Starting 1 March, 332 patients were introduced to an RM programme during the Italian lockdown to limit the risk of in‐hospital exposure to severe acute respiratory syndrome‐coronavirus‐2. Patients were categorized into two groups based on the modality of RM delivery [home (n = 229) vs. office (n = 103) delivered]. The study aimed at assessing the efficacy of the new follow‐up protocol, assessed as mean RM activation time (AT), and the need for technical support. In addition, patients’ acceptance and anxiety status were quantified via the Home Monitoring Acceptance and Satisfaction Questionnaire and the Generalized Anxiety Disorder 7‐item scale. AT time was less than 48 h in 93% of patients and 7% of them required further technical support. Despite a higher number of trans‐telephonic technical support in the home‐delivered RM group, mean AT was similar between groups (1.33 ± 0.83 days in home‐delivered vs. 1.28 ± 0.81 days in office‐delivered patients;P = 0.60). A total of 28 (2.5%) urgent/emergent in‐person examinations were required. A high degree of patient satisfaction was reached in both groups whereas anxiety status was higher in the office‐delivered group. Conclusions The adoption of RM resulted in high patient satisfaction, regardless of the modality of modem delivery;nonetheless, in‐office modem delivery was associated with a higher prevalence of anxiety symptoms.

The role of virtual visits in cardiology: from the pandemic era to future perspectives

Aims During the Coronavirus Disease 2019 (COVID-19) pandemic in-person visits were reduced to prevent potential risk of exposure. Virtual visits (VVs) represent an innovative model to take care of patients with cardiac implantable electronic devices (CIEDs). The aim of this study is to evaluate the safety and feasibility of VV in the management of CIED patients. Methods and results We performed a prospective study including all CIED patients who received a VV from July 2020 to July 2021. Blood pressure, arterial oxygen saturation, heart rate, and body weight were registered by the patient. Moreover, we sent to the patient a questionnaire to evaluate the patients’ satisfaction about VV. We enrolled 182 patients in the study period. The mean age of patients was 70.2 ± 13.5 years-old and the majority (61.1%) was male. In two cases, VVs were not performed due to technical issues. Overall, 70.9% of patients utilized a smartphone, while 20.1% and 9% used, respectively, a tablet or a personal computer. The mean duration of VV was 27.8 ± 7.8 min. Patients helped by a caregiver were 64 (35.2%). One urgent/emergent in‐person visit was performed in a patient with acute heart failure. Overall, VV was preferred to in-person evaluation. Conclusion VV is a safe and feasible approach to follow-up CIED patients. A high degree of patient satisfaction was reached after VV. The use of VV has promising potential and should be implemented beyond COVID-19 period and integrated in the healthcare system as a new model of care.

The role of virtual visits in COVID-19 cardiovascular patients

Aims The outbreak of the Coronavirus Disease 2019 (COVID-19) pandemic forced a reorganization of the healthcare system. In order to prevent potential risk of exposure, virtual visit (VV) has been implemented in the treatment and follow-up of COVID-19 patients with cardiovascular diseases. The aim of this study is to evaluate the feasibility and efficacy of VV in the management of post COVID-19 cardiovascular patients. Methods and results We enrolled all patients with cardiovascular comorbidities tested negative for Severe Acute Respiratory Syndrome-Coronavirus-2 (SARS-CoV-2) and discharged from our Cardiology Department from January 2021 to June 2021. We scheduled a VV after 30 days from discharge to check the clinical status of the patients, optimize therapy, and establish a Follow-up protocol. Blood pressure, arterial oxygen saturation, heart rate and body weight were registered. To evaluate the patients’ satisfaction of VV, a questionnaire was administered. We performed 25 VVs in the study period;the mean age of patients was 67.5 ± 15.6 and male were 15 (65.2%). The mean duration of VV was 25.9 ± 4.6 min. The caregiver had an active role in nine (36%) cases. No urgent/emergent in‐person examinations were performed. A high degree of patient satisfaction was reached and VV was preferred to in-person evaluation. Conclusions VV visit was useful to Follow-up post COVID-19 cardiovascular patients. A high degree of patient satisfaction was reached without jeopardizing quality of care.

Follow-up of hospitalized COVID-19 survivors: assessment of short- and long-term cardiovascular sequelae after SARS-CoV-2 infection

Aims Cardiovascular sequelae in COVID-19 survivors remain largely unclear and can potentially go unrecognized. Reports on follow-up focused on cardiovascular evaluation after hospital discharge are currently scarce. Aim of this prospective study was to assess cardiovascular sequelae in previously hospitalized COVID-19 survivors. Methods and results The study was conducted at ‘Sapienza’ University of Rome—Policlinico ‘Umberto I’. After 2 months from discharge, n = 230 COVID-19 survivors underwent a follow-up visit at a dedicated ‘post-COVID Outpatient Clinic’. A cardiovascular evaluation including electrocardiogram (ECG), Troponin and echocardiography was performed. Further tests were requested when clinically indicated. Medical history, symptoms, arterial-blood gas, blood tests, chest computed tomography, and treatment of both in-hospital and follow-up evaluation were recorded. A 1-year telephone follow-up was performed. A total of 36 (16%) COVID-19 survivors showed persistence or delayed onset of cardiovascular disease at 2-months follow-up visit. Persistent condition was recorded in 62% of survivors who experienced an in-hospital cardiovascular disease. Delayed cardiovascular involvement included: myocarditis, pericarditis, ventricular disfunction, new onset of systemic hypertension and arrhythmias. At 1-year telephone follow-up, 105 (45%) survivors reported persistent symptoms, with dyspnoea and fatigue being the most frequent. 60% of survivors showed persistent chest CT abnormalities and among those 28% complained of persistent cardiopulmonary symptoms at long term follow-up. Conclusions Our preliminary data showed persistent or delayed onset of cardiovascular involvement (16%) at short-term follow-up and persistent symptoms (45%) at long-term follow-up. These findings suggest the need for monitoring COVID-19 survivors.

Home delivery of the communicator for remote monitoring of cardiac implantable devices: a multicentre experience during the COVID-19 lockdown

Aims During the COVID-19 pandemic in-person visits for patients with cardiac implantable electronic devices should be replaced by remote monitoring (RM), in order to prevent viral transmission. A direct home-delivery service of the RM communicator has been implemented at 49 Italian arrhythmia centres. Methods and results According to individual patient preference or the organizational decision of the centre, patients were assigned to the home-delivery group or the standard in-clinic delivery group. In the former case, patients received telephone training on the activation process and use of the communicator. In June 2020, the centres were asked to reply to an ad hoc questionnaire to describe and evaluate their experience in the previous 3 months. RM was activated in 1324 patients: 821 (62%) received the communicator at home and the communicator was activated remotely. Activation required one additional call in 49% of cases, and the median time needed to complete the activation process was 15 min (25th–75th percentile: 10–20). 753 (92%) patients were able to complete the correct activation of the system. At the time when the questionnaire was completed, 743 (90%) communicators were regularly transmitting data. The service was generally deemed useful (96% of respondents) in facilitating the activation of RM during the COVID-19 pandemic and possibly beyond. Conclusions Home delivery of the communicator proved to be a successful approach to system activation, and received positive feedback from clinicians. The increased use of a RM protocol will reduce risks for both providers and patients, while maintaining high-quality care.

Prevalence and Clinical Implications of COVID-19 Myocarditis.

The clinical manifestations of COVID-19 are widely variable and may involve several districts. Although the clinical course is mostly characterized by respiratory involvement, up to 30% of hospitalized patients have evidence of myocardial injury due to acute coronary syndrome, cardiac arrhythmias, myocarditis, and cardiogenic shock. In particular, myocarditis is a well-recognized severe complication of COVID-19 and is associated with fulminant cardiogenic shock and sudden cardiac death. In this article, the authors aim to present a comprehensive review about COVID-19-related myocarditis, including clinical characteristics, diagnostic workup, and management.

Impact of COVID-19 Pandemic on Cardiac Electronic Device Management and Role of Remote Monitoring.

During the coronavirus disease 2019 (COVID-19) worldwide pandemic, patients with cardiac implantable electronic device (CIED) refused scheduled follow-up visits because of the risk of infection. In this scenario, different telemedicine strategies have been implemented to ensure continuity of care to CIED patients. Patients can be monitored through dedicated applications, telephone calls, or virtual visits providing easy access to valuable information, such as arrhythmic events, acute decompensation manifestations, and device-related issues, without the need for in-person visits. This review provides a comprehensive description of the many possible applications of telemedicine for CIED patients during the COVID-19 period.

Virus-Negative Necrotizing Coronary Vasculitis with Aneurysm Formation in Human SARS-CoV-2 Infection.

We report a case of myopericarditis associated to SARS-CoV-2 infection with necrotizing coronary vasculitis of intramural vessels, giving rise to biventricular apical microaneurysms and to electrical instability. Negativity of myocardial polymerase chain reaction for the most common cardiotropic viruses and for SARS-CoV-2 suggested an immune-mediated myocardial and pericardial inflammatory disease. High dose (1 mg/Kg daily) prednisone and anti-viral (Remdesivir, IDA Business, Carrigtohill, County Cork, T45 DP77, Ireland) therapy led to resolution of cardiac inflammation and ventricular arrhythmias. Morpho-molecular characterization of endomyocardial tissue may improve the outcome in subjects with SARS-CoV-2-associated myopericarditis and coronary vasculitis.

Cardiac involvement in consecutive unselected hospitalized COVID-19 population: In-hospital evaluation and one-year follow-up.

BACKGROUND: Cardiovascular disease (CVD) can occur in COVID-19 and has impact on clinical course. Data on CVD prevalence in hospitalized COVID-19 patients and sequelae in survivors is limited. Aim of this prospective study carried out on consecutive unselected COVID-19 population, was to assess: 1) CVD occurrence among hospitalized COVID-19 patients, 2) persistence or new onset of CVD at one-month and one-year follow-up. METHODS: Over 30 days n = 152 COVID-19 patients underwent cardiovascular evaluation. Standard electrocardiogram (ECG), Troponin and echocardiography were integrated by further tests when indicated. Medical history, arterial blood gas, blood tests, chest computed tomography and treatment were recorded. CVD was defined as the occurrence of a new condition during the hospitalization for COVID-19. Survivors attended a one-month follow-up visit and a one-year telephone follow-up. RESULTS: Forty-two patients (28%) experienced a wide spectrum of CVD with acute myocarditis being the most frequent. Death occurred in 32 patients (21%) and more frequently in patients who developed CVD (p = 0.032). After adjustment for confounders, CVD was independently associated with death occurrence. At one-month follow-up visit, 7 patients (9%) presented persistent or delayed CVD. At one-year telephone follow-up, 57 patients (48%) reported persistent symptoms. CONCLUSION: Cardiovascular evaluation in COVID-19 patients is crucial since the occurrence of CVD in hospitalized COVID-19 patients is common (28%), requires specific treatment and increases the risk of in-hospital mortality. Persistence or delayed presentation of CVD at 1-month (9%) and persistent symptoms at 1-year follow-up (48%) suggest the need for monitoring COVID-19 survivors.

Ischemic Heart Disease Pathophysiology Paradigms Overview: From Plaque Activation to Microvascular Dysfunction

Ischemic heart disease still represents a large burden on individuals and health care resources worldwide. By conventions, it is equated with atherosclerotic plaque due to flow-limiting obstruction in large–medium sized coronary arteries. However, clinical, angiographic and autoptic findings suggest a multifaceted pathophysiology for ischemic heart disease and just some cases are caused by severe or complicated atherosclerotic plaques. Currently there is no well-defined assessment of ischemic heart disease pathophysiology that satisfies all the observations and sometimes the underlying mechanism to everyday ischemic heart disease ward cases is misleading. In order to better examine this complicated disease and to provide future perspectives, it is important to know and analyze the pathophysiological mechanisms that underline it, because ischemic heart disease is not always determined by atherosclerotic plaque complication. Therefore, in order to have a more complete comprehension of ischemic heart disease we propose an overview of the available pathophysiological paradigms, from plaque activation to microvascular dysfunction.