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Background: Acute myocarditis (AM) is a heart inflammatory disease that may also rarely occur as a complication of COVID-19 vaccines. Inflammation is involved in arrhythmogenic cardiomyopathy (ACM) pathogenesis. Little is known regarding the COVID-19 vaccines influence on ACM relapses. We present two cases of vaccine related AM revealing a pre-existent (silent) ACM. Cases presentation: Table shows a summary of the patients' main clinical characteristics. Discussion(s): We presented 2 cases of arrhythmic myocarditis-like clinical presentation in patients without previous cardiovascular history, whose timing was temporally related to a dose of vaccine against COVID-19. Subsequent diagnostic workup suggested the possible presence of an underlying silent ACM. In our case series, tissue characterization provided by CMR played a fundamental role as a diagnostic tool, showing in all cases a prominent left ventricle involvement and identifying both the underlying ACM disease and the superimposed myocardial inflammation. We hypothesize that a vaccine-induced AM could have revealed the presence of a pre-existent ACM, on which an inflammatory acute phase triggered the arrhythmic manifestation. Conclusion(s): Vaccine-induced AM could reveal the presence of a pre-existent ACM. Our report suggests that a high index of suspicion and a multidisciplinary approach is required, in order to continue the diagnostic process once the acute event has been resolved, as it may have fundamental implication in the patient management. Further studies are required to verify if some of the vaccine-triggered AM represent the ACM first manifestation..
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Background: protective masks have emerged as a powerful mean to contain the COVID-19 pandemic. However, a general feeling that masks alter the normal dynamics of breathing may reduce the application of this protective device. Patients with heart failure (HF) experience dyspnea even during daily life activities (ADLs). Aim of the study is to evaluate cardiorespiratory parameters during ADLs, cardiopulmonary exercise test (CPET) and sleep to highlight any difference related to protective masks. Method(s): 9 healthy subjects (age 59+/-11, 2 female) and 10 HF patients (age 64+/-11, 2 female, ejection fraction <45%, stable conditions) underwent a set of cardiopulmonary tests twice, wearing a protective surgical mask and without it. We performed the following tests: standard spirometry;CPET;a set of tests recorded by a wearable ergospirometer (Cosmed K5), including ADLs (ADL1: getting dressed, ADL2: folding eight towels, ADL3: putting away 6 bottles, ADL4: making a bed, ADL5: sweeping the floor for 4 minutes, ADL6: climbing 1 flight of stairs carrying a load), six-minute walking test (6MWT) and two 4-minute treadmill exercises (TREAD2 and TREAD3 at a speed of 2 km/h and 3 km/h, respectively);home polysomnography (HPS). Result(s): Both healthy subjects and HF patients completed the protocol with no adverse events. Spirometry showed a reduction of forced expiratory volume in 1s (3.29+/-0.75 L vs 2.65+/-0.57 L as for healthy subjects, p= 0.002;2.45+/-0.6 L vs 1.97 +/-0.54 L as for HF patients, p= 0.002) and forced vital capacity (4.14+/-0.92 L vs 3.39+/-0.83 L as for healthy subjects, p= 0.004;2.93+/-0.76 L vs 2.59+/-0.73 L as for HF patients, p= 0.01) in both the groups from no mask to mask. As for the CPET, both healthy and HF patients showed: a trend of reduction of peak oxygen pulse (p<0.005 in healthy) and peak oxygen consumption (VO2);a decrease of tidal volume (Vt) at peak exercise (peak Vt: 2.283+/-0.449 L vs 1.864+/-0.359 L in healthy, p= 0.022;1.6+/-0.41 L vs 1.448+/-0.431 L in HF, p= 0.02), with no significative variations of resting and peak ventilation (VE). HF patients experienced a statistically significative decrease of VO2 at the anaerobic threshold (AT) (794+/-227 vs 682 +/-151 mL min-1, p=0.01). No significant differences in the other CPET parameters were observed. As for tests recorded by a wearable cart, task-related VO2 was significantly reduced from no mask to mask in ALDs and 6MWT in the healthy, whereas HF patients experienced a significative reduction in ADL1, ADL4, 6MWTand TREADs (probably more physically demanding tasks). Both healthy and HF subjects showed an increase in the basal and task-related ratio of VE vs carbon dioxide production (VE/VCO2) between the two protocol conditions. No difference in the main HPS parameters were observed from no mask to mask. Conclusion(s): Surgical masks slightly influences cardiorespiratory variables in healthy and HF patients at rest and during both mild and maximal physical activity. The physiological impact of the mask is far from being clinically relevant and no main differences between the groups were noted, except for an early AT in patients with HF. Since no main limitations were observed, the use of masks seems to be safe both in the general population and in HF patients. Moreover, it does not have a significant impact on sleep neither in healthy subjects nor in patients with HF, these ones particularly at risk of sleep apneas. These data should be confirmed in a larger group of patients.
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Background: Many patients recovered from COVID-19 infection present a variety of symptoms which limits overall quality of life, as reduced exercise performance, dysfunctional breathing, cough, dyspnea, weakness and anxiety. This condition has been named long COVID. The origin of this symptomatology is still unclear. This study has the aim to analyse the relation between symptoms and respiratory function, focusing on the alveolar capillary membrane. Method(s): Consecutive patients with long COVID 19 symptoms after 6 months were included. Patients underwent full clinical evaluation, laboratory tests, echocardiography, thoracic CTscan, spirometry including alveolar capillary membrane diffusion by means of combined carbon dioxide and nitric oxide lung diffusion (DLCO/ DLNO) and cardiopulmonary exercise test. We measured surfactant derive protein B (immature form) as blood marker of alveolar capillary function. A questionnaire allowed to evaluate symptoms. Result(s): We evaluated 204 post COVID-19 patients (age 56.5+/-14.5 y, 89 females (44%), BMI 25.7+/-4.0, 6% active smokers) referring to our hospital 171+/-85 days after the end of acute COVID-19 infection (Fig. 1). None of spirometry data was associated with long COVID 19 referred symptoms. SPB was not associated to differences in any of the referred symptoms. Subjects with lower capillary volume (VCap) have more frequently dyspnea, tiredness, fatigability and hair loss (Fig.2). CT scan lung damage correlated with SPB and membrane diffusion but not with VCap, exercise performance or VE/VCO2 slope. The strongest correlation of SPB were with lung parenchyma damage and Vcap. Conclusion(s): Our data suggest that a relevant reduction of alveolar capillary membrane function plays a central role in the long COVID cardiorespiratory symptoms. (Figure Presented).
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Background: Acute myocarditis (AM) is thought to be a rare cardiovascular complication of COVID-19, although minimal data are available beyond case reports. We aim to report the prevalence, baseline characteristics, in-hospital management, and outcomes for patients with COVID-19-associated AM on the basis of a retrospective cohort from 23 hospitals in the United States and Europe. Method(s): A total of 112 patients with suspected AM from 56963 hospitalized patients with COVID-19 were evaluated between February 1, 2020, and April 30, 2021. Inclusion criteria were hospitalization for COVID-19 and a diagnosis of AM on the basis of endomyocardial biopsy or increased troponin level plus typical signs of AM on cardiac magnetic resonance imaging. We identified 97 patients with possible AM, and among them, 54 patients with definite/probable AM supported by endomyocardial biopsy in 17 (31.5%) patients or magnetic resonance imaging in 50 (92.6%). We analyzed patient characteristics, treatments, and outcomes among all COVID-19-associated AM. Result(s): AM prevalence among hospitalized patients with COVID-19 was 2.4 per 1000 hospitalizations considering definite/probable and 4.1 per 1000 considering also possible AM. The median age of definite/probable cases was 38 years, and 38.9% were female. On admission, chest pain and dyspnea were the most frequent symptoms (55.5% and 53.7%, respectively). Thirty-one cases (57.4%) occurred in the absence of COVID-19-associated pneumonia. Twenty- one (38.9%) had a fulminant presentation requiring inotropic support or temporary mechanical circulatory support. The composite of in-hospital mortality or temporary mechanical circulatory support occurred in 20.4%. At 120 days, estimated mortality was 6.6%, 15.1% in patients with associated pneumonia versus 0% in patients without pneumonia (P=0.044). During hospitalization, left ventricular ejection fraction, assessed by echocardiography, improved from a median of 40% on admission to 55% at discharge (n=47;P<0.0001) similarly in patients with or without pneumonia. Corticosteroids were frequently administered (55.5%). Conclusion(s): AM occurrence is estimated between 2.4 and 4.1 out of 1000 patients hospitalized for COVID-19. The majority of AM occurs in the absence of pneumonia and is often complicated by hemodynamic instability. AM is a rare complication in patients hospitalized for COVID-19, with an outcome that differs on the basis of the presence of concomitant pneumonia.
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A 71-year-old woman, known to have a non-ischemic dilated cardiomyopathy with reduced ejection fraction (EF), and a previous transcatheter edge-to-edge mitral valve repair (MitraClip), was admitted after a routine echocardiogram showing new onset multiple, highly mobile, left ventricle (LV) masses. The patient, fully vaccinated against Sars-Cov-2, experienced a paucisymptomatic COVID-19 infection 1 month before, followed by a full recovery. A transthoracic echocardiogram performed 3 months before showed no LV masses. On admission she was completely asymptomatic with no clinical signs of heart failure or systemic embolization. A multimodality imaging evaluation (contrast ecocardiography, cardiac computed tomography, cardiac magnetic resonance) confirmed a severe dilation of the LV with severe EF reduction, and 3 mobile LV masses;the largest mass was adhered to the middle portion of the anterolateral wall (maximum diameter 49x15 mm). mm). A diagnostic endomyocardial biopsy and cardiac surgery were excluded due to prohibitive embolic/procedural risk and an anticoagulant treatment with warfarin was started with a progressive reduction of the masses' dimension at transthoracic echocardiography. Thus, a diagnosis of exclusion of LV thrombosis was made. After 2-week a complete resolution of the masses was documented with no clinical or embolic events. Cardiovascular complications of the coronavirus disease have been documented both in the acute phase and in convalescence;one such complication is the formation of LV thrombus;the pro-thrombotic nature of COVID-19 infection is well known: the coagulation activation mechanism is currently uncler, but it might be correlated to excessive inflammation, COVID-induced hypoxia, direct cytopathic effects on the cardiac endothelial cells, immobilization. This case demonstrates how vulnerable patients, i.e. those with heart failure, may experience thrombotic complications following non-severe COVID-19 infection and despite having completed the vaccine course. Although currently unconfirmed by dedicated clinical trials, more assiduous echocardiographic monitoring could yield a benefit in selected patients;current guidelines do not support the use of anticoagulation prophylaxis for non-severe COVID.19, but further studies regarding anticoagulant prophylaxis for COVID-19 patients with chronic heart diseases, including DCM, are warranted. (Figure Presented).
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Aims: Several risk factors have been identified to predict worse outcomes in patients affected by SARS-CoV-2 infection. Prediction models are needed to optimize clinical management and to early stratify patients at a higher mortality risk. Machine learning (ML) algorithms represent a novel approach to identify a prediction model with a good discriminatory capacity to be easily used in clinical practice. Methods and results: The Cardio-COVID is a multicentre observational study that involved a cohort of consecutive adult Caucasian patients with laboratory-confirmed COVID-19 [by real time reverse transcriptase-polymerase chain reaction (RT-PCR)] who were hospitalized in 13 Italian cardiology units from 1 March to 9 April 2020. Patients were followed-up after the COVID-19 diagnosis and all causes in-hospital mortality or discharge were ascertained until 23 April 2020. Variables with more than 20% of missing values were excluded. The Lasso procedure was used with a λ=0.07 for reducing the covariates number. Mortality was estimated by means of a Random Forest (RF). The dataset was randomly divided in two subsamples with the same percentage of death/alive people of the entire sample: training set contained 80% of the data and test set the remaining 20%. The training set was used in the calibration procedure where a RF models in-hospital mortality with the covariates selected by Lasso. Its accuracy was measured by means of the ROC curve, obtaining AUC, sensitivity, specificity, and related 95% confidence interval (CI) computed with 10 000 stratified bootstrap replicates. From the RF the relative Variable Importance Measure (relVIM) was extracted to understand which of the selected variables had the greatest impact on outcome, providing a ranking from the most (relVIM=100) to the less important variable. The model obtained was compared with the Gradient Boosting Machine (GBM) and with the logistic regression, where the predictions were cross validated. Finally, to understand if each model has the same performance in sample (training) and out of sample (test), the two AUCs were compared by means of the DeLong's test. Among 701 patients enrolled (mean age 67.2±13.2 years, 69.5% males), 165 (23.5%) died during a median hospitalization of 15 (IQR, 9-24) days. Variables selected by the Lasso were: age, Oxygen saturation, PaO2/FiO2, Creatinine Clearance and elevated Troponin. Compared with those who survived, deceased patients were older, had a lower blood oxygenation, a lower creatinine clearance levels and higher prevalence of elevated Troponin (all P<0.001). Training set included 561 patients and test set 140 patients. The best performance out of sample was provided by the RF with an AUC of 0.78 (95% CI: 0.68-0.88) and a sensitivity of 0.88 (95% CI: 0.58-1.00). Moreover, RF is the unique methodology that provided similar performance in sample and out of sample (DeLong test P=0.78). On the contrary, prediction model was less accurate by using GBM and logistic regression. The relVIM ranked the variables from the most to the less important in predicting the outcome as follows: clearance creatinine, PaO2/FiO2, age, oxygen saturation, and elevated Troponin. Conclusions: In a large COVID-19 population, we showed that a customizable MLbased score derived from clinical variables, is feasible and effective for the prediction of in-hospital mortality.
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Background and Aim of the Study: During the last months, a pandemic by a novel coronavirus (Sars-Cov-2) has spread worldwide, putting hospitals under enormous pressure. Although follow-up data in this setting are scarce, early reports suggested that more than 80% of patients who had recovered from COronaVIrus Disease 19 (COVID-19) reported persistence of at least one symptom during follow-up, particularly fatigue and dyspnea. Therefore, a prolonged post-discharge monitoring for long-lasting effects is advisable. We assessed the feasibility of cardiorespiratory home monitoring through a wearable device in post-COVID-19 patients. Methods: in this pilot study, we enrolled subjects with a confirmed diagnosis of COVID-19 after hospital discharge at home. A wearable device used (L.I.F.E.) (a technologically advanced T-Shirt device composed of ink-based dry electrodes linked to standard 12-lead ECG monitoring, 5 respiratory strain sensors, 1 accelerometer, a digital pulse oximeter) was used (Figure 1). Monitoring was carried out for at least 7 days and comprehended a two-hour monitoring period a day during rest and a short exercise (6 minutes of brisk walking) and an overnight sleep monitoring on the last day. Results: Seventeen COVID-19 patients (male 8;age 54.4±15.3 year old;BMI 25.1±3.1) were enrolled at hospital discharge. They underwent 12.5±2.5 (7-17) days of monitoring. Clinical characteristics of the population and data monitoring are shown in Figure 2. Twelve patients (70.6%) performed the nighttime monitoring. Among them, one showed an apnea-hypopnea index (AHI) of 20, suggestive of moderate sleep apnea syndrome. An example of ECG monitoring is shown in Figure 3. Conclusions: Our study demonstrated that a post-discharge home monitoring program for COVID-19 patients is feasible and safe. The L.I.F.E. T-Shirt device was able to collect a full set of cardiorespiratory parameters (i.e. heart rate, a full ECG, respiratory rate, SpO2), both at rest and during a brief exercise. Finally, we were able to identify only one patient without any previous disease who presented post-COVID sleep apnea syndrome. Further studies are certainly needed to assess the prevalence and the clinical impact of this complication in post-COVID-19 patients.
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Background: During the current COVID-19 pandemic, the use of protective masks is essential to reduce contagions. However, public opinion reports an associated subjective shortness of breath. We aimed to evaluate cardiorespiratory parameters, both at rest and during maximal exertion, to highlight any differences with the use of surgical masks and FFP2 masks compared to standard conditions in healthy subjects. Methods: Twelve subjects underwent three consecutive cardiopulmonary exercise tests (CPETs): without wearing protection mask, with surgical mask and with FFP2 mask (Figure 1). Subjects' degree of dyspnea was assessed by Borg Scale. Standard pulmonary function tests were performed at rest. Findings: All the subjects (40.8±12.4 years;6 male) completed the study protocol with no adverse event. At spirometry, from no mask to surgical to FFP2 a progressive reduction of FEV1 and FVC was observed (3.94±0.91L/s, 3.23±0.81L/s, 2.94±0.98L/ s and 4.70±1.21L, 3,77±1.02L, 3.52±1.21L, respectively, p<0.001) (Figure 2). Rest ventilation, O2 intake (VO2) and CO2 production (VCO2) were progressively lower due to a respiratory rate reduction. At peak exercise, subjects revealed a progressive higher Borg scale value when wearing surgical and FFP2 (Figure 3). At peak exercise VO2 (30.9±623.40, 27.50±6.92, 28.24±8.79ml/Kg/min, p=0.001), ventilation (92.29±25.99, 76.19±21.62, 71.63±21.19L, p=0.003), respiratory rate (41.52±8.02, 37.73±5.52, 37.11±4.53, p=0.04) and tidal volume (2.28±0.72, 2.05±0,60, 1.96±0.65L, p=0.001) were lower from no mask to surgical to FFP2. We did not observe a significant inter-group difference in oxygen sat-uration. Interpretation: Protective masks are associated with a significant but modest worsening spirometry and cardiorespiratory parameters at rest and peak exercise. The effect is driven by a ventilation reduction due to an increased air-flow resistance. However, since signs of exercise ventilatory limitation are far away to be reached, their use is safe even during maximal exercise, albeit with a slight reduction in performance.
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Background: Peripartum cardiomyopathy (PPCM) is a rare cardiomyopathy with systolic dysfunction that presents in late pregnancy. A number of coronavirus disease 19 (COVID-19)-related myocarditis cases have been reported. In a pandemic situation, the coexistence of COVID-19 and PPCM can be relatively frequent, making it difficult to assess the weight of the individual components on the heart condition. Case Presentation: A 34-year-old girl develops COVID-19 at the 31st week of pregnancy. In the following 2 weeks she recovered and, after 4 days from the disappearance of symptoms, she gave birth without complications. Three weeks after delivery she presented to the ED with worsening dyspnea and elevated troponine and BNP values. Echocardiogram showed severe biventricular systolic dysfunction, mitral regurgitation, pulmonary hypertension and biventricular thrombosis. She was treated with oxygen, diuretics, heparin and transferred to our center. Cardiac MRI showed dilation and severe biventricular dysfunction with positive LGE and T1 mapping values diffusely increased. A treatment with betablockers, Sacubitril/valsartan, anti-aldosterone drugs, ivabradine and bromocriptine was started. An Endomyocardial biopsy (EMB) was performed showing a picture consistent with dilated cardiomyopathy and a final diagnosis of peripartum cardiomyopathy was made. However, after a few days the molecular biology report arrived showing EMB positivity for Sars-Cov-2 and Parvovirus B19. The patient was discharged and after 6 months she is well and a control MRI showed complete recovery of biventricular systolic function. Discussion: Cardiovascular complications of COVID-19 are well known and cases of related myocarditis have been reported. Anatomopathological and biopsy studies show the presence of Sars-Cov-2 in the heart of a significant number of patients with COVID-19, however the virus is often found at the interstitial level, suggesting in most cases more an endothelial localization than a real invasiveness of cardiomyocytes. It is not impossible that a patient with PPCM could be simultaneously affected by Sars-Cov-2. Only a multidisciplinary clinical, imaging, histological, functional evaluation and a congruent follow-up can help to understand the weight of the single etiological components on cardiac dysfunction. Conclusions: We described a case of a patient with PPCM and concomitant cardiac localization of COVID-19 with severe acute biventricular dysfunction. (Figure Presented).
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Background and aim. In December 2019, in the city of Wuhan (China), a potential new causative agent of pneumonia, called the new coronavirus 2019 (nCoV-2019) was identified. Since then, the need to contain the global spread of the infection has become urgent through specific social distancing procedures and through the use of individual protection devices (i.e. airway protection masks). In the media doubts were raised about the impact of different types of masks on daily physical activity, in particular for those who perform physical exercise. In this context, we aimed to evaluate cardiorespiratory parameters, assessable through a cardiopulmonary exercise test (CPET), to highlight any differences with the use of surgical mask or filtering facepiece particles class 2 (FFP2) mask compared to the test performed under normal conditions. Methods. 12 healthy subjects, enrolled in July 2020, performed three consecutive CPETs at least 24 hours apart, but within 2 weeks, without wearing airway protection mask, with surgical mask and with FFP2 mask. The execution order of the CPETs was assigned in order to cover all possible combinations. During the CPETs, the consumption of Watts reached will be obscured to the subject. Before the start and immediately after the end of each CPET, maximum inspiratory pressure (MIP) and the maximum expiratory pressure (MEP) was also assessed. Results. Comparing the three conditions, we observed a progressive significant reduction in oxygen intake, carbon dioxide output, ventilation and respiratory rate at rest as well as at peak exercise (Table 1). The workload also decreased. We did not notice differences in blood oxygen saturation nor adverse events such as arrhythmias or ischemic events. MIP/MEP comparison did not reveal significant respiratory muscles fatigue. Discussion and Conclusions. The use of airway protection masks during pandemics (e.g. nCoV-2019) is a key safeguard to contain viral transmission. In healthy subjects it reduces, both at rest and during exercise, ventilation values (mainly due to reduction of respiratory rate) without detectable alteration of arterial saturation, heart rate, respiratory muscle fatigue and/or adverse events even during a maximum effort. Our speculative hypothesis is that the effect is likely to be related to the presence of a mechanical obstacle to ventilation. Our data show that the use of masks is still compatible with the execution of physical activity even if the maximum workload is slightly reduced. In conclusion airway protection masks (both surgical mask and FFP2) can be safely used in daily life despite a slight impact on ventilation and metabolic parameters.