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Objectives: Cases of fulminant myocarditis after mRNA COVID-19 vaccination have been reported. The most severe may need venoarterial extracorporeal membrane oxygenation (V-A ECMO) support. Here we report two cases successfully rescued with V-A ECMO. Method(s): We included all the cases supported with V-A ECMO for refractory cardiogenic shock due to myocarditis secondary to a mRNA SARS-COV2 vaccine in the high-volume adult ECMO Program in Vall Hebron University Hospital since January 2020. Result(s): We identified two cases (table). One of them was admitted for out-of-hospital cardiac arrest. In both, a peripheral V-A ECMO was implanted in the cath lab. An intra-aortic balloon pump was needed in one case for left ventricle unloading. Support could be successfully withdrawn in a mean of five days. No major bleeding or thrombosis complications occurred. Definite microscopic diagnosis could be reached in one case (Image, 3). Treatment was the same, using 1000mg of methylprednisolone/day for 3 days. A cardiac magnetic resonance 10 days after admission showed a significant improvement in systolic function and diffuse oedema and subepicardial contrast intake in different segments (Image, 1-2). Both patients were discharged fully recovered. Conclusion(s): V-A ECMO should be established in cases of COVID-19 vaccine-associated myocarditis with refractory cardiogenic shock during the acute phase. (Table Presented).
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BackgroundOutcomes of patients hospitalized for cardiogenic shock during the midst of the COVID-19 pandemic in the United States have yet to be well described. This study aimed to examine if the COVID-19 pandemic led to gender differences in in-hospital outcomes, length of stay, and total hospital charges.MethodsData was extracted from the National Inpatient Sample database for the calendar year 2020. Patients who were admitted with a principal diagnosis of cardiogenic shock (R57.0) were identified using relevant International Classification of Disease, and Clinical Modification codes. The key outcomes of mortality, use of mechanical ventilation, use of mechanical circulatory support, hemodialysis, vasopressors use, length of stay, and total hospital charges were then accessed.ResultsThere were 2,670 hospitalizations for a principal diagnosis of cardiogenic shock in 2020, of which 955 were females. After adjusting for age, race, hospital bed size, hospital location, hospital teaching status, insurance status, income level, and Elixhauser comorbidities;we found that females admitted with cardiogenic shock were more likely to require mechanical ventilation (aOR 1.54, 95% CI 1.02- 2.34), but had no difference in mortality, vasopressor use, mechanical circulatory support use, hemodialysis initiation, length of hospital stay and total hospital charges relative males.ConclusionOur study found that females admitted for cardiogenic shock during the first year of the pandemic had significantly higher rates of mechanical ventilation but no difference in other outcomes. Further studies are needed to investigate the effect of COVID-19 on the outcomes of female patients admitted for cardiogenic shock.Conflict of InterestNone
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Objectives: To evaluate the outcomes and risk factors associated with mortality of patients cannulated on ECMO in the context of covid infection during the pandemics in a newly implemented ECMO center Methods: This was a unicentric observational retrospective study performed at Real Hospital Portugues, in Recife, state of Pernambuco, Brazil. All consecutive patients with laboratory confirmed SARS-CoV-2 infection cannulated for VV-ECMO or VA-ECMO for severe ARDS from march 2020 to december 2021 were included retrospectively. Patients recieving ECMO for isolated refratory cardiogenic shock were excluded. Descriptive statistics and association tests were used to analyze characteristics, management and patient outcomes during that period. Result(s): In our cohort of 47 ECMO for covid associated ARDS (CARDS), 39 patients (83%) were admitted by our emergency department. 8 patients (17%) had been transferred from other hospitals as soons as they had been cannulated. 32 patients (68%) were male, median age was 50 years (18-69). Mean body mass index was 31 (21,4-46,3). 37 patients (78%) had at least 1 comorbidity. Major bleeding occurred in 34 (72%) patients. Venous thromboembolism and hemolysis ocurred in 19 (40%) and 13 (23%) patients, respectively. When we compared treatments before ECMO initiation (imunoglobulin, tocilizuman, nitric oxide, neuromuscular blockade and proning), proning was associated with better survival (RR 0,67 IC 0,46-0,97 p 0,029). The mean duration in mechanical ventilation until ECMO cannulation was 9,69 days and mean time in ECMO was 23 days. The 90- day mortality was approximately 72%. Conclusion(s): The only variable associated with a better chance of survival was proning before ECMO. Our mortality (72%) is higher than reported from a recent meta-analysis of 1986 ECMO patients implanted during the first pandemic year(37,1%). However it is similar to a German populational registry of covid patients receiving VV-ECMO (73%). Althought it;s impossible to make causal inferences with such a design and sample sizes, we believe that describing the experience of smaller and newly implemented ECMO centers serves as motivation to improve quality and also to plan for future episodes of pressure on health system.
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Background: Only recently studies have been able to demonstrate the safety and efficacy of purification therapies in inflammatory diseases. Here we present the management of a young (21y) male patient in severe cardiogenic shock due to COVID-19 perymyocarditis admitted to the ICU at Bolzano Central Hospital. November 30th 2020 the patient developed high fever (>40 C) and diarrhea. After unsuccessfully being treated orally with a macrolide he was admitted to a peripheral hospital the 4th of December. The day after he deteriorated, required transfer to the ICU, endotracheal intubation and pharmacological cardiovascular support (Norepinephrine, Levosimendan). Antimicrobial treatment was started with piperacillin/tazobactam, linezolid and metronidazole. Despite multiple radiological and microbiological diagnostic attempts the origin of this severe septic shock remained unclear. December 6th the patient was transferred to Bolzano Central Hospital for VA-ECMO evaluation. Method(s): The transesophageal echocardiography revealed 15-20% of EF, lactate (5,2 mmol/l), cardiac enzymes (TropT 1400 mcg/l) and inflammatory parameters (PCT 35 ng/ml, IL-6 685 pg/ml) were elevated. We performed cardiac monitoring via Swan-Ganz catheter. The cardiac index was 1,6 l/min/m2. The peak dosage for Norepinephrine reached 7,5mg/h (1,47 mcg/kg/min). At Bolzano ICU we facilitate the pharmacological therapy with milrinone, vasopressin and low dose epinephrine. Furthermore, we impost continuous hemodiafiltration with CytoSorb filter. Result(s): Only hours after the start of filtration therapy the patient improved and we were able to gradually reduce catecholamine therapy, lactate values decreased. A VA-ECMO implantation was no more necessary. December 10th, we saw a stable patient without ventilatory or cardiovascular support, at echocardiography we revealed a normal EF. Conclusion(s): Clinically we saw a young patient in severe septic/cardiogenic shock due to perimyocarditis. Yet diagnostic attempts (CT-scan, multiple blood/urinary/liquor cultures) remained negative. Despite multiple negative PCR tests for SARS-CoV2 infection we performed specific immunoglobulin analysis and received a positive result for IgM. We therefore conclude on a COVID-19 associated perymyocarditis. Furthermore, this case illustrates the potential benefit of cytokine filtration and elimination in COVID-19 patients with altered IL6 levels.
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Objectives: The nursing care is more complex in relation to new technologies, new diseases, new globally emergencies. In relation to technology, nurses acquired more competences in relation to advanced therapy, in respiratory, circulatory, and renal support. The nursing workload increases in complexity and in responsibilities, without a staff increasing in relation to nursing activities. ECMO was widely applied to manage acute respiratory distress syndrome and circulatory failure, in case of cardiac arrest or cardiogenic shock, configuring as a therapy bridge to decision, to restore, to transplant or to nowhere. During the last years, nurses were involved to a rapid and continuous changing, to respond adequately to new health challenges, understanding or not their role and responsibilities in globally health care system. Nurse manages different variables, well represented by nursing activities score, but in nursing ECMO care, these variables are more complicated, in relation to ECMO device and to ECMO patient. What is the globally perception of nurses involved in ECMO care? Methods: A literature review was applied on PubMed. The inclusion criteria were all articles about ECMO, including pediatric and/or adult population, with a publication less than ten years. Result(s): A total of sixteen articles were found, with reduction to ten for relevance. The excluded articles talked about non ECMO care or patient;s perceptions. Articles included in the research talk about nursing perceptions (40%), education (30%), ethics in ECMO care (20%), professional experience in ECMO Covid (10%). Conclusion(s): The nursing perception on ECMO nursing care are different. They recognize the central role in ECMO care, but over workload, without staff increasing, less peer support, a low teamwork and personal differences in technical and non-technical skills increase some barriers to nursing perception of themselves. Nurses allocate their competence on experience and continuous training, but also a good teamwork and a professional recognition by other health care professions or by nursing supervisors can increase nursing perception and reduce the abandonment of nursing profession.
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Background: Patients with cancer are at a higher risk of getting infected with the severe acute respiratory syndrome coronavirus 2 owing to their immunocompromised state. Providing care to these patients amidst the first wave of the coronavirus disease-2019 (COVID-19) pandemic was extremely challenging. Objective(s): This study was aimed at evaluating the clinical profile and disease-related outcomes of pediatric patients with hematological illnesses and cancer. Material(s) and Method(s): This retrospective study was conducted at a tertiary care center in North India during the first wave of the pandemic from March 2020 to December 2020. Children aged up to 18 years, who were treated for a hematological illness or malignancy or underwent hematopoietic stem cell transplantation (HSCT) and tested positive for COVID-19 regardless of symptoms were included in the study. Baseline demographic data related to the age, diagnosis, treatment status, and chemotherapy protocol used were collected. Outcomes including the cure rates, comorbidities, and sequelae were recorded. Result(s): A total of 650 tests for COVID-19 were performed for 181 children;22 patients were found to be COVID-19 positive. The most common diagnosis was acute leukemia (63.6%). None of the patients developed COVID-19 pneumonia. The majority of patients had asymptomatic infection and were managed at home. Among those with a symptomatic infection, the most common symptoms were fever and cough. A total of 3 (13.6%) patients needed oxygen therapy, one developed multisystem inflammatory syndrome of children leading to cardiogenic shock. Three patients required intensive care or respiratory support;all the patients had favorable clinical outcomes. The median time from the onset of COVID-19 to a negative result on the reverse transcription-polymerase chain reaction test was 21.3 days. Cancer treatment was modified in 15 patients (68.2%). Conclusion(s): Our results suggest that children with hemato-oncological illnesses rarely experience severe COVID-19 disease. The impact of the first wave of COVID-19 primarily manifested as disruptions in the logistic planning and administration of essential treatment to these children rather than COVID-19 sequelae.Copyright © 2021 Cancer Research, Statistics, and Treatment Published by Wolters Kluwer - Medknow.
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Coronavirus disease 2019 (COVID-19) is a viral infection caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). COVID-19 may have a mild presentation, with few symptoms, or progress to a severe condition, characterized by generalized inflammation, systemic microvascular involvement, coagulopathy, and pulmonary and cardiovascular complications. Men present with more severe symptoms than women, especially men who are older and who present with comorbidities such as hypertension, diabetes mellitus, and a history of atherosclerotic diseases. Owing to its association with endothelial dysfunction, inflammation, thrombosis, and microvascular obstruction, SARS-CoV-2 infection can cause lesions in several organs, including the myocardium and the coronary arterial bed, which can result in clinical manifestations involving the cardiovascular system. In this mini review, we summarize the effects of SARS-CoV-2 infection on the cardiovascular system in both children and adults and characterize the various clinical manifestations associated with this disease.
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Background/Aims Adult-onset Still's disease is a systemic inflammatory disease of unknown aetiology. Post-COVID-19 vaccine adult-onset Still's disease has been reported and was associated with only mild myocarditis. Here we report the first case of adult-onset Still's disease after mRNA COVID-19 vaccination presenting with severe myocarditis with acute heart failure and cardiogenic shock. Methods We described the case history of the patient. Results A 72-year-old Chinese woman developed gradual onset of fever, shortness of breath, sore throat, generalised arthralgia, malaise and poor appetite 15 days after receiving the first dose of BNT162b2 mRNA COVID-19 vaccine. Physical examination revealed fever, bilateral ankle oedema and elevated jugular venous pressure. Significant investigation results are shown in Table 1. Extensive viral panel tests (including enterovirus, influenza and cytomegalovirus) were all negative. Echocardiography showed severely reduced left ventricular ejection fraction of 20%. The acute heart failure was complicated by cardiogenic shock requiring intensive care unit admission. Myocarditis was later diagnosed. Although the heart condition subsequently improved, there were persistent fever and arthralgia, as well as the development of generalised maculopapular skin rash. In view of that, series of investigations were performed, which revealed persistent neutrophilic leucocytosis, hyper-ferritinaemia and liver function derangement, while autoimmune panel was grossly unremarkable and septic/viral workup was negative (Table 1). Contrast PET-CT scan showed no features of malignancy. Adult-onset Still's disease was diagnosed, and the patient was treated with oral prednisolone 40mg daily. The patient's condition responded to the treatment;the fever subsided and the leucocyte count and inflammatory markers were normalised, and she was subsequently discharged. Three months after discharge, the patient was clinically well with prednisolone tapered down to 5mg daily. Reassessment echocardiogram showed full recovery with LVEF 60%. Conclusion Severe myocarditis with acute heart failure and cardiogenic shock is a possible initial presentation of adult-onset Still's disease after mRNA COVID-19 vaccination. After exclusion of more common aetiologies, it is important to consider adult-onset Still's disease as one of the differential diagnoses in the presence of compatible features following COVID-19 vaccination, such that appropriate and timely workup and treatment can be offered. (Table Presented).
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Background: COVID-19 tends to have a harsher course in the elderly population, which can include the development of arrhythmias, including supraventricular tachycardia (SVT). Due to lack of sufficient data, we studied baseline patient characteristics, comorbidities, and outcomes of SVT in octogenarians admitted with COVID-19, using the 2020 National Inpatient Sample (NIS). Objective(s): We aimed to study the patient characteristics and outcomes of SVT in octogenarians admitted with COVID-19, using the 2020 National Inpatient Sample (NIS). Method(s): Octogenarians (ages 80-89 years, inclusive) with COVID-19 were recruited from the 2020 NIS (April 1st 2020 - December 31st 2020). A diagnosis of SVT was identified via the ICD-10 code "I47. 1". Patient characteristics that can influence the presence of SVT were identified via logistic regression models. The adjusted odds ratios (aOR) having cardiogenic shock or mortality among COVID-19 positive octogenarians with SVT were also explored. Result(s): Our study consisted of 240570 octogenarians who tested positive for COVID-19. 2.2% of them (5250 cases) also had a diagnosis of SVT during their hospitalization. Among them, Females (aOR 0.919, 95%CI 0.868-0.973, p<0.01) were more likely to develop SVT. Racial disparities were also observed as Blacks (aOR 1.234, 95%CI 1.137-1.338, p<0.01) had higher odds of having SVT, whereas Hispanics (aOR 0.898, 95%CI 0.819-0.984, p=0.021) had lower odds compared to Whites. Comorbidities such as chronic pulmonary disease (aOR 1.106, 95%CI 1.037-1.179, p<0.01), and heart failure (aOR 1.122, 95%CI 1.053-1.195, p<0.01) also led to higher odds of SVT. Lower odds were seen among those with diabetes (aOR 0.852, 95%CI 0.802-0.905, p<0.01), obesity (aOR 0.839, 95%CI 0.764-0.921, p<0.01), or smoking history (aOR 0.892, 95%CI 0.835-0.954, p<0.01). The use of mechanical ventilation (aOR 2.829, 95%CI 2.638-3.034, p<0.01) or non-invasive ventilation (aOR 1.755, 95%CI 1.615-1.907, p<0.01) showed higher odds of developing SVT. Finally, patients with SVT had increased risk of cardiogenic shock (aOR 1.510, 95%CI 1.206-1.891, p<0.01) and mortality (aOR 1.166, 95%CI 1.085-1.253, p<0.01). Conclusion(s): Multiple factors influenced the presence of SVT among octogenarians who had COVID-19. SVT in these patients was associated with higher incidences of cardiogenic shock and mortality. Additional focus targeting patient care and further research to better understand the mechanisms behind these variations may help improve outcomes. [Formula presented]Copyright © 2023
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Background: Atrial fibrillation and/or flutter is a common comorbidity in hospitalized patients with COVID-19. Objective(s): We aimed to assess the effect of atrial fibrillation and/or flutter on the outcomes of COVID-19 patients in a nationally representative sample. Method(s): We conducted a population-based analysis utilizing data from the national inpatient sample database. Hospitalized adults >= 18 years who were hospitalized with COVID-19 during the year 2020 were included. We used multivariate logistic regression models to investigate the outcomes in patients who had atrial fibrillation or flutter. Result(s): Among 1,018,115 (Nationally weighted sample) admissions with COVID-19, 154795 cases (15.2%) had atrial fibrillation and/or flutter. Patients with atrial fibrillation and/or flutter had significantly higher adjusted odds of all-cause in-hospital mortality (Odds Ratio [OR], 1.78 [confidence interval (CI), 1.75-1.80]), acute stroke (OR, 1.96 [CI, 1.85-2.07]), acute coronary syndrome (OR, 1.43 [CI, 1.37-1.48]), acute heart failure (OR, 4.24 [CI, 4.15-4.34]), cardiogenic shock (OR, 3.07 [CI, 2.85-3.30]), need for vasopressors (OR, 2.14 [CI, 2.06-2.22]), cardiac arrest (OR, 1.95 [CI, 1.89-2.02]), need for mechanical ventilation (OR, 1.79 [CI, 1.77-1.82]), acute kidney injury (OR, 1.25 [CI, 1.23-1.27]), major bleeding (OR, 1.82 [CI, 1.73-1.92]) compared to those patients without atrial fibrillation or flutter. On subgroup analysis, the risk for mortality was highest among atrial flutter (OR, 2.91), followed by atrial flutter and fibrillation group (OR, 2.38), followed by only atrial fibrillation group (OR, 1.71) (P value <0.001 for all) when compared to non-atrial fibrillation, non-atrial flutter in patients with COVID-19. Conclusion(s): Atrial fibrillation and flutter are associated with higher inpatient mortality and worse outcomes in COVID-19 patients. [Formula presented]Copyright © 2023
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Case Report: It is well documented that Coronavirus Disease 19 (COVID-19) patients who suffer cardiac injury have a higher mortality rate, however the exact mechanism of cardiac injury and potential complications are still unknown. Takotsubo Cardiomyopathy (TCM), which was first described in 1990 in Japan, is characterized by a transient systolic and diastolic left ventricular dysfunction with a range of wall motion abnormalities predominantly affecting women often following an emotional or physical trigger. Though TCM is seen less commonly as a cardiac complication of COVID-19, with increasing rates of cardiovascular events due to COVID-19, TCM should be taken into consideration as a potential diagnosis for a COVID-19 positive patient. Case Description: The case of a 75-year old female with a history significant for hypertension, type 2 diabetes mellitus, hyperlipidemia, and gastroesophageal reflux disease presented to the Emergency Department after a ground level fall and subsequent left hip pain. Upon primary survey, EKG showed persistent sinus tachycardia in the 130-150s, with intermittent borderline dynamic changes and a troponin that was mildly elevated at 0.10, and an initial false negative COVID-19 test. Preoperative echocardiogram showed normal left ventricle size, no regional wall abnormalities, and a left ventricular ejection fraction (LVEF) of 60-65%. In post-operative care, EKG illustrated dynamic changes in the form of ST elevation in the lateral precordial leads, as well as an increase in the cardiac troponins, from 0.07 to 3.51. A subsequent echocardiogram illustrated a drop in her ejection fraction from 60-65% to 30-35%, with evidence of left ventricular systolic dysfunction that was not noted on previous echocardiograms. Following the Mayo clinic diagnostic criteria, this patient met the diagnostic criteria for TCM, as evident by new electrocardiograph findings, non-obstructive cardiac catherization findings, echocardiogram findings illustrating transient left ventricular systolic dysfunction, modest elevations in cardiac troponins as well as the patient being a post-menopausal female. Subsequent echocardiogram on 2 week follow up showed a rebound in her ejection fraction to 50-55%. Discussion(s): Possible outcomes of TCM include cardiogenic shock, respiratory failure, and death. It is imperative that clinicians consider TCM as a possible diagnosis when treating COVID-19 patients that may be exhibiting cardiac complications. Frequent ECG monitoring and a vigilant differential should include TCM in patients presenting with COVID-19.
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The Nigerian Cardiovascular Symposium is an annual conference held in partnership with cardiologists in Nigeria and the diaspora to provide updates in cardiovascular medicine and cardiothoracic surgery with the aim of optimising cardiovascular care for the Nigerian population. This virtual conference (due to the COVID-19 pandemic) has created an opportunity for effective capacity building of the Nigerian cardiology workforce. The objective of the conference was for experts to provide updates on current trends, clinical trials and innovations in heart failure, selected cardiomyopathies such as hypertrophic cardiomyopathy and cardiac amyloidosis, pulmonary hypertension, cardiogenic shock, left ventricular assist devices and heart transplantation. Furthermore, the conference aimed to equip the Nigerian cardiovascular workforce with skills and knowledge to optimise the delivery of effective cardiovascular care, with the hope of curbing 'medical tourism' and the current 'brain drain' in Nigeria. Challenges to optimal cardiovascular care in Nigeria include workforce shortage, limited capacity of intensive care units, and availability of medications. This partnership represents a key first step in addressing these challenges. Future action items include enhanced collaboration between cardiologists in Nigeria and the diaspora, advancing participation and enrollment of African patients in global heart failure clinical trials, and the urgent need to develop heart failure clinical practice guidelines for Nigerian patients.
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COVID-19 , Cardiomyopathies , Heart Failure , Humans , Pandemics , Heart Failure/diagnosis , Heart Failure/therapy , Heart Failure/epidemiology , Heart , Cardiomyopathies/epidemiologyABSTRACT
SARS Cov-2 infection causes Multi-Inflammatory Syndrome in Children (MIS- C), a serious condition that affects children. We report an 18-year-old Turkish male who was diagnosed with MIS-C and successfully treated. He was diagnosed with MIS-C and required invasive mechanical ventilation due to cardiogenic shock, after what he recovered. With a high temperature, rash, and conjunctival hyperemia, the patient was taken to the emergency department. He had no symptomatic COVID-19 in his medical history, although he had had contact with a COVID-19 positive patient in the near past. Physical examination revealed an erythematous maculopapular rash on the back and neck, as well as hepatosplenomegaly. SARS-CoV-2 IgM and IgG positivity were detected in the rapid antibody test. Following the procedure, rectal bleeding and tachypnea developed. Inflammation indicators and pro-BNP levels both increased. With echocardiogenic examination, the ejection fraction decreased from 50-55 percent to 35%. He needed invasive mechanical ventilation. As a result, the case was classified as MIS-C with predominant cardiac and gastrointestinal involvement. The patient was discharged after a successful multidisciplinary approach. Although COVID-19 infection in children and adolescents is asymptomatic or minimally symptomatic, clinicians should be aware of post-infection autoimmune complications.
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Introduction: Myocarditis commonly results from viral infections, which causes inflammation of the heart muscles. This could lead to adverse outcomes such as prolonged hospitalizations, cardiogenic shock, cardiac arrest, and event death. Studies have shown that COVID-19 could lead to myocarditis. However, the differences between COVID-19 myocarditis and non-COVID-19 myocarditis have not been explored. Hypothesis: We hypothesized that adverse hospital outcomes such as in-hospital mortality, cardiogenic shock, cardiac arrest, mechanical ventilation, and acute respiratory distress syndrome would be higher among hospitalizations for COVID-19 myocarditis, compared to non-COVID-19 myocarditis. Method(s): We conducted a retrospective analysis of data collected in California State Inpatient Database (SID) during 2019 and 2020. We included data from all hospitalizations for COVID-19 myocarditis during 2020 and compared with data from all hospitalizations for non-COVID-19 myocarditis during 2019. ICD-10-CM diagnosis codes were used to identify procedures and conditions. Cox proportional and logistic regression analyses were done to compare the outcomes between the two groups. Result(s): A total of 1,165 non-COVID-19 myocarditis and 575 COVID-19 myocarditis hospitalizations were included for the analysis. Nearly 45% of COVID-19 myocarditis hospitalizations were >=65 years, while 52.3% of non-COVID-19 myocarditis hospitalizations were between 18-44 years of age. The rates of in-hospital mortality (4.2% versus 31.5%, P<0.001), cardiac arrest (2.0% versus 8.8%, P<0.001), mechanical ventilation (10.4% versus 41.2%, P<0.001), and acute respiratory distress syndrome (0.3% versus 17.5%, P<0.001) were significantly higher among COVID-19 myocarditis hospitalizations, compared to non-COVID-19 myocarditis hospitalizations. Kaplan Meier survival analysis showed that survival rates among COVID-19 myocarditis hospitalizations were significantly lower than non-COVID-19 myocarditis hospitalizations, compared to non-COVID-19 myocarditis hospitalizations (logrank P<0.001). Cox proportional regression analysis showed that in-hospital mortality (hazard ratio [HR], 2.15;CI: 1.41-3.28) was significantly higher among COVID-19 myocarditis hospitalizations. Logistic regression analysis showed that the odds of cardiac arrest (odds ratio [OR], 3.23;95% CI: 1.75-5.94), mechanical ventilation (OR, 5.65 95% CI: 4.09-7.81), and acute respiratory distress syndrome (OR, 72.56;95% CI: 21.52-244.68) were significantly higher among COVID-19 myocarditis hospitalizations. Conclusion(s): Our study using a large administrative database found that COVID-19 myocarditis compared to non-COVID 19 myocarditis affected older individuals and was associated with greater rates of in-hospital mortality and adverse hospital outcomes. These findings highlight the different nature of COVID related myocarditis compared to other forms of acute myocarditis.Copyright © 2022
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INTRODUCTION: Patients with COVID-19 can develop myocarditis due to respiratory hypoxemia, hyperinflammation, as well as direct injury due to binding of the virus to the angiotensin-converting enzyme 2 receptors in myocyte. In this study we examined the association between myocarditis among COVID-19 hospitalizations and adverse hospital outcomes. HYPOTHESIS: We hypothesized that adverse hospital outcomes such as in-hospital mortality, cardiac arrest, cardiogenic shock, mechanical ventilation, and acute respiratory distress syndrome would be higher among COVID-19 hospitalizations with myocarditis. METHOD(S): The current study was a retrospective analysis of data collected in California State Inpatient Database (SID) during 2020. All hospitalizations for COVID-19 were included for the analysis. ICD-10-CM diagnosis was used to identify COVID-19 (U07.1) and myocarditis hospitalizations and other procedures and conditions. Propensity score match analysis, survival analysis, and conditional logistic regression were done to compare adverse clinical outcomes between COVID-19 patients with and without myocarditis. RESULT(S): A total of 164,368 COVID-19 hospitalizations were included for the analysis. Among them, 575 (0.4%) hospitalizations had myocarditis. Prior to propensity score matching, the rate of in-hospital mortality was significantly higher among COVID-19 hospitalizations with myocarditis (29.8% versus 14.0%, P<0.001). Even after propensity score matching, the rate of in-hospital mortality was significantly higher among the myocarditis group (30.0% versus 17.5%, P<0.001). Supporting this finding, survival analysis with log-rank test also showed that 30-day survival rates were significantly lower among those with myocarditis (39.5% versus 46.3%, P<0.001). Conditional logistic regression analysis showed that the odds of cardiac arrest (OR,1.90;95% CI, 1.16-3.14), cardiogenic shock (OR,4.13;95% CI, 2.14-7.99), mechanical ventilation (OR,3.30 (2.47-4.41), and acute respiratory distress syndrome (OR, 2.49;95% CI, 1.70-3.66) were significantly higher among those with myocarditis. CONCLUSION(S): Our study using a large administrative database found that myocarditis was associated with greater rates of in-hospital mortality and adverse hospital outcomes among COVID-19 patients. Early suspicion is important for prompt diagnosis and timely management.Copyright © 2022
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Background: Eosinophilic myocarditis is a rare inflammatory cardiomyopathy with a poor prognosis. SARS-CoV-2 (COVID-19) illness has been associated with myocarditis, particularly of lymphocytic etiology. Although there have been cases of eosinophilic myocarditis associated with COVID-19 vaccination, there have been few reported cases secondary to COVID-19 illness, with the majority being diagnosed via post-mortem autopsy. Case: A 44-year-old woman with no significant medical history other than recent COVID-19 illness 6 weeks prior presented with progressive dyspnea. Patient developed acute dyspnea and diffuse pruritic rash after taking hydroxyzine. Labs were significant for mild eosinophilia. Echocardiography showed biventricular systolic dysfunction with left ventricular ejection fraction of 40%, and a moderate pericardial effusion that was drained percutaneously. She underwent left heart and right heart catheterization showing elevated biventricular filling pressures, Fick cardiac index of 1.6 L/min/m2, and no coronary disease. She was started on intravenous diuretics and transferred to our facility for further management. Her course was complicated by cardiogenic shock requiring intra-aortic balloon pump (IABP) support. Mixed venous saturations continued to decline and the patient was placed on veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support. The patient underwent endomyocardial biopsy (EMB) showing marked interstitial infiltration of eosinophils and macrophages with myocyte injury (see image). She was intubated with mechanical ventilation as well due to worsening pulmonary edema and hypoxemia. She was started on intravenous steroids with improvement of hemodynamics and myocardial function and eventually VA- ECMO was decannulated to low-dose inotropic support which in turn was ultimately weaned after 3 days of mechanical support. Conclusion(s): Eosinophilic myocarditis is a rare and under-recognized sequela of acute COVID-19 infection associated with high mortality rates. It requires prompt diagnosis and aggressive supportive care, including temporary mechanical circulatory support. There are few literature-reported cases of COVID-19 myocarditis requiring use of both IABP and VA-ECMO, none of which were used in biopsy-proven eosinophilic myocarditis, with most of these cases resulting in either fatal or unreported outcomes. Most cases of covid myocarditis required IV glucocorticoids therapy in conjunction with IVIG or interferon therapy. Here, we present a rare case of cardiogenic shock secondary to biopsy-proven eosinophilic myocarditis associated with recent COVID-19 illness with a survival outcome after temporary use of IABP and VA-ECMO support, as well as aggressive immunosuppressive therapy.Copyright © 2022
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Background: The role of genetic conditions in the development of cardiomyopathy is well established;however, recognition and referral for genetic testing remains underutilized. Systematic review of complex cases can increase general awareness in this area of practice. Here we describe the case of a patient with resolved severe stress induced cardiomyopathy (SIC), who was ultimately found to have heterozygous transthyretin-mediated amyloidosis (TTRA). Case: A 27-year-old man (family history positive for a brother status post heart transplant) presented with ataxia and cough due to legionella pneumonia. TTE showed left ventricular (LV) diastolic diameter of 6.2cm, LV ejection fraction 20-25%. He suffered rapid decompensation with mixed cardiogenic/septic shock requiring peripheral VA ECMO and Impella-CP placement. Course notable for brief cardiac arrest on hospital day (HD) 2, incidental diagnosis of COVID 19 on HD 14, conversion to VV ECMO on HD 15, and ECMO decannulation on HD 23. Repeat TTE prior to discharge showed normalization of biventricular function. Discussion(s): Despite resolution of refractory shock and normalization of biventricular function prior to discharge, the TTE finding of mild LV dilation and strong family history prompted outpatient pursuit of genetic testing which revealed a heterozygous TTRA mutation (val142ile). Work-up to assess cardiac involvement included: a 99m-technetium pyrophosphate scintigraphy found to be indeterminate, an aborted endomyocardial biopsy due to inability to smoothly advance a bioptome (presumably related to ECMO cannulation), and a cardiac MRI (pending at the time of this submission). If a cardiac phenotype is discovered, the patient will be started on targeted treatment of cardiac amyloid. Screening of first-degree family members has been initiated. Conclusion(s): Given the current state of under-diagnosis of genetic cardiomyopathies and its association with significant morbidity and mortality, it is prudent to consider genetic testing in young patients based on clinical history. Examples of clinical scenarios to prompt further testing include: anatomical findings (i.e. cardiac chamber enlargement, left ventricular hypertrophy), family history of cardiomyopathy, or clinical markers suggestive of alternative diagnoses (i.e. neuropathy, renal insufficiency, mediastinal lymphadenopathy). This thoughtful and algorithmic use of genetic testing may help improve long-term patient outcomes given improvements in both detection, family screening, and treatment for disease-specific cardiomyopathies.Copyright © 2022
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Background: The COVID-19 pandemic had influenced the patient's behavior and impacted the homeostasis to a pro-thrombotic niveau. Aim(s): The study aimed to follow the impact of COVID-19 on the incidence and prognosis of cardiogenic shock complicated initially acute myocardial infarction (CS-AMI). Method(s): We used data entered into a large national all-comers registry of coronary intervention over five years. From 1/2016 to 12/2020, 50,745 AMI patients were included, and 2,822 (5.6%) initially had CS. Result(s): The incidence of CS-AMI was significantly higher in the COVID period (2020) than the mean incidence in 2016-2019 (5.5% vs 6%, p=0.032). The difference was caused by significant increase of CS in acute STEMI (7.6% vs. 8.7%, p=0.011);it was 7.1% in 2016, 7.8% (2017), 7.6% (2018), 7.8% (2019), and 8.7% (2020). The CS complicated 2.3% (2016), 2.7% (2017), 2.7% (2018), 2.8% (2019), and 2.8% (2020) of NSTEMI. The observed rise in CS-STEMI incidence each month during the pandemic compared to the average incidence in non-pandemic years correlated with the substantial increase in the number of COVID infected/ hospitalized (Table 1). In these months, no changes in time delay to reperfusion layout were observed in CS-STEMI patients (Table 2). Except of less frequent history of previous PCI (13.9% and 8.2%, p<0.001), we found no significant differences in the followed CS-STEMI patient characteristics in 2016-2019 and 2020;men 72.7% and 75.4% (p=0.1), mean age (SD) 66.3 (12.3)yrs and 66.3 (12.2) yrs, Diabetes 20.9% and 19.1% (p=0.2), CKD 5.4% and 5.7% (p=0.4), previous CABG 4.5 and 4.2% (p=0.5), left main disease (14.3% and 16%, p=0.5), one vessel disease 24.9% and 32.1% (p=0.9), pre-PCI TIMI flow 0 64.4% and 66.2% (p=0.6), post-PCI TIMI flow 3 76.7% and 76.9%. The COVID pandemic didn't influence the proportions of pre-hospital resuscitated CS-AMI patients (57.5% and 58.7%, p=0.6) and those on mechanical ventilation (67.8% and 68.3%, p=0.8). The 30-day mortality trend of CS-AMI was 53.7% in 2016, 51.6% (2017), 49.7% (2018), 49.3% (2019), and 47.9% (2020). And in CS-STEMI it was 50.8%, 47.1%, 46.4%, 44.1%, and 45.3% (P2019 vs. 2020 =0.8), respectively. Conclusion(s): Data from a large national all-comer registry showed an increase in the proportion of patients admitted to hospitals with STEMI complicated by CS in the year of the COVID pandemic. The CS rise correlated with the increase in the COVID infected population. Factors other than the patient's cardiovascular risk profile or prolongation of a time delay to reperfusion influenced this trend. We suggest that the availability of health care and patient adherence may have affected the risks control. We did not observe any effect of the pandemic on CS-AMI mortality. (Figure Presented).
ABSTRACT
Background: During COVID-19 pandemic, the pattern of hospital admissions for acute ST-elevation myocardial infarction (STEMI) has been changing, and increased mortality and morbidity is being noted in these patients. Patient may present with acute myocardial infarction, myocarditis simulating a presentation like STEMI, coronary spasm, myocardial injury not fulfilling the criteria of type 1 & type 2 acute MI and cardiomyopathy. In this study we have tried to determine some important differences among the patients presented with STEMI during The COVID-19 pandemic versus non-COVID-19 era. Method(s): This prospective observational study was carried out in National Heart Foundation Hospital & Research Institute from 8thMarch,2019 to 7th March, 2021. Total 2531 patients were included. The study populations were divided into two groups. Group I: Acute STEMI patients presenting during pre COVID period (n=1385). Group II: Acute STEMI patients presenting during COVID period (n=1146). COVID period was calculated from 8th march, 2020 onward as first case of COVID -19 was detected on that day in Bangladesh. All patients presented with Acute STEMI was included in the study however NSTEMI-ACS, Unstable angina were excluded from the study. Result(s): Male was predominant in both groups. Regarding risk factors Hypertension, Obesity and family H/O of CAD was statistically significant (p<0.05). Acute STEMI patients presented lately during COVID-19 period probably due to lock down& lack of transport facility. Regarding coronary artery disease severity, vessel score was more during COVID period. SV-CAD were more during pre COVID period while DV-CAD & TV-CAD were more during COVID period. Gensini score was also calculated among the study populations, it was 57.21+/-28.42 and 63.16+/- 40.43respectively in group I and group I, which was statistically significant. Regarding treatment options of the patients, primary PCI was less during COVID period, however medical management, elective PCI and Thrombolysis were more during COVID era. Regarding in hospital outcome, acute LVF, cardiogenic shock were more during COVID period which were also statistically significant. [Formula presented] [Formula presented] Conclusion(s): During COVID -19, STEMI patients presented lately in comparison to pre COVID period. Coronary artery Disease were more severe during COVID period as evaluated by Vessel Score & Gensini Score. During COVID -19 period majority of patients got medical management& routine PCI were done more in comparison to primary PCI. In Hospital outcome of STEMI was worse during COVID-19 period in terms of acute LVF & cardiogenic shock. [Formula presented] [Formula presented] [Formula presented]Copyright © 2023