COVID-19 Associated Fulminant Myocarditis in a Fully-Vaccinated Female: A Case Report with Clinical Follow-up.

Background: Myocarditis is considered a serious adverse event after COVID-19 infection. The risk and severity of myocarditis after COVID-19 disease decreased significantly in the vaccinated population. We present a case of cardiac magnetic resonance proven fulminant myocarditis following COVID-19 disease in a young female who was previously vaccinated with 2 doses of the BIBP (Sinopharm) vaccine. Case summary: A 29-year-old female was referred to the hospital with acute chest pain, dyspnea, and nausea. Her electrocardiogram revealed ST-segment elevation in anterolateral leads with reciprocal changes in inferior leads. She was primarily diagnosed with ST-elevation myocardial infarction following spontaneous coronary artery dissection (SCAD) according to her age and gender. Her coronary angiography was normal. RT-PCR nasopharyngeal swab was positive for SARS-COV-2 infection. According to her history and excluding coronary artery diseases, she was clinically diagnosed with myocarditis and received corticosteroids, IVIG, and colchicine. She was discharged in a favorable condition after 11 days of hospitalization. Cardiac magnetic resonance imaging confirmed the diagnosis of myocarditis according to the updated lake Louise criteria. On her 4-month follow-up, she was asymptomatic, and her echocardiography showed improvement in biventricular function. Discussion: The diagnosis of myocarditis caused by COVID-19 infection may be challenging as the symptoms of myocarditis, and COVID-19 disease may overlap. It should be considered when patients have acute chest pain, palpitation, elevated cardiac biomarkers, and new abnormalities in ECG or echocardiography. Cardiac MRI is a non-invasive gold standard modality for diagnosing and follow-up of myocarditis and should be used in clinically suspected myocarditis. The long-term course of myocarditis following COVID-19 disease is still unclear, but some evidence suggests it may have a favorable mid-term outcome.

Cardiac effects of multisystem inflammatory syndrome in children: One-year follow-up.

AIM: Cardiovascular involvement is common among children with multisystem inflammatory syndrome (MIS-C) and can cause shock and death. In this study, we evaluated the early and long-term cardiac effects of MIS-C. METHODS: In this observational cohort study, we included all children treated for MIS-C from October 2020 to November 2021 in the Department of Paediatric Infectious Disease at Cukurova University School of Medicine Hospital. The patients underwent serial echocardiographical evaluation during hospitalisation and at 1, 3, 6 and 12 months after discharge. The patients were evaluated using Holter monitorisation between 4 and 6 months and using cardiac magnetic resonance imaging at 6 months and thereafter. RESULTS: Twenty-six patients diagnosed with MIS-C and with a median age of 84 months were included. Cardiac involvement was found in 19 (73.1%) patients. At initial echocardiographic evaluation, the mean ejection fraction value of the patients was 56.7% (range: 30-75). Coronary artery dilatation was detected in two (7.7%) patients, and mitral regurgitation persisted in only one patient by month 3. Treatment was started in two (7.7%) patients due to ventricular arrhythmia. Cardiac magnetic resonance imaging was performed in 13 (50%) patients at a median of 6 months (range: 5-9). The cardiac magnetic resonance imaging findings were consistent with possible interstitial fibrosis in two (7.7%) patients. CONCLUSION: Our results showed that cardiac involvement of patients improved rapidly with treatment, as indicated by previous studies. However, during the 1-year follow-up, frequent extraventricular systole was detected in two patients, one of whom initially did not show cardiac involvement. Moreover, possible interstitial fibrosis was detected in the cardiac magnetic resonance imaging (MRI) evaluation of two patients. In particular, we believe that these findings may be useful to evaluate critically ill paediatric patients and patients with severely low EF with cardiac MRI in their follow-up.

Selection of the best of 2022 in cardiac imaging

This review article aims to summarize the role of cardiac imaging regarding the most relevant technical and knowledge advances published within the last year. Although diagnosis and detection of cardiac involvement due to coronavirus disease maintain a prominent place, other interesting hot topics have been raised. Among the most relevant, it is noteworthy to highlight the prognostic utility of different parameters obtained by advanced imaging techniques in the field of valvular heart disease, cardiovascular prevention or cardio-oncology, the prominent role of imaging in the first diagnostic step of the new Chest Pain guidelines or the exponential growth of percutaneous structural interventionism, where further knowledge is demanded in terms of patient selection, procedure timing or predictors of success. Finally, artificial intelligence is a promising tool already in our hands, we hope that diagnostic precision and interpretation time will improve thanks to these technological advances. Copyright © 2022 Sociedad Espanola de Cardiologia

Cardiac Imaging in Myocarditis: Current Evidence and Future Directions.

Myocarditis is defined as a non-ischemic inflammatory disease of the myocardium. It remains a challenge to diagnose given non-specific symptoms and lack of specific blood biomarkers. Cardiac imaging plays an important role in the evaluation of myocarditis with unique strengths and limitations of different imaging modalities, including cardiac magnetic resonance imaging, echocardiography, cardiac computed tomography, and positron emission tomography. The purpose of this review is to discuss the strengths and limitations of various cardiac imaging techniques in the evaluation of myocarditis, review imaging findings in specific causes of myocarditis including COVID-19 and after vaccination, evaluate the role of imaging in differentiating myocarditis from potential mimics and differential considerations, identify current gaps in knowledge, and propose future directions.

Myocarditis in children after COVID-19 vaccine.

Three healthy adolescents presented with myocarditis confirmed on cardiac magnetic resonance imaging after receiving Pfizer-BioNTech COVID-19 vaccine. All patients were hemodynamically stable and had good short-term outcomes. Long-term outcomes are yet to be determined. Larger studies are needed to determine whether an association between Pfizer-BioNTech COVID-19 vaccine and myocarditis exists.

Diffused Myocardial Inflammation in COVID-19 Associated Myocarditis Detected by Cardiac Magnetic Resonance Imaging in Post-COVID Patients

Objective: To determine the frequency of myocarditis in patients recovered from COVID-19 infection. Study Design: Analytical Cross-sectional study. Place and Duration of Study: Cardiac Magnetic Resonance Imaging Department, Armed Forces Institute of Cardiology/ National Institute of Heart Disease (AFIC/NIHD), Rawalpindi Pakistan, from Jul 2020 till Apr 2022. Methodology: All patients who underwent Cardiac Magnetic Resonance Imaging after recovery from COVID-19 were enrolled. Non-probability consecutive sampling technique was used for sample selection and was calculated on the basis of G-power. Data of patients fulfilling the inclusion criteria was selected. All PCR positive cases of COVID-19 who recovered from COVID-19 and completed their 12 days of isolation not exceeding 60 days of 1st Polymerase chain reaction positive, and who have any symptoms of shortness of breath, fatigue and chest pain with reduced left ventricular ejection fraction (LVEF) on 2D-echocardiogram were included in the study. Data was recorded, stored, and analyzed by using SPSS version-21. Quantitative data was reported as Mean±SD. Categorical variables were reported as frequency and percentage. To determine the association between different variables Chi square test was used. Results: A total 83 patients were included in this study who recovered from COVID-19 and underwent Cardiovascular magnetic resonance. Mean age of the patients was 39.17±12.9 years. 67(80.72%) were male while 16(19.28%) were females. 50(60%) had myocarditis after recovery from COVID-19. This study showed statistically significant association of all the Cardiovascular magnetic resonance imaging findings with Myocarditis (p<0.05) at 95% confidence interval and 5% margin of error. Conclusion: Early detection of COVID-19 related myocarditis will help in better management of patient. In such patients, cardiac Magnetic Resonance Imaging is the modality of choice, since it allows for noninvasive assessment of myocardial edema and fibrosis, as well as therapeutic guidance and improved patient outcomes. © 2022, Army Medical College. All rights reserved.

Cardiac magnetic resonance T2* mapping in patients with COVID-19 pneumonia is associated with serum ferritin level?

The coronavirus disease of 2019 (COVID-19)-related myocardial injury is an increasingly recognized complication and cardiac magnetic resonance imaging (MRI) has become the most commonly used non-invasive imaging technique for myocardial involvement. This study aims to assess myocardial structure by T2*-mapping which is a non-invasive gold-standard imaging tool for the assessment of cardiac iron deposition in patients with COVID-19 pneumonia without significant cardiac symptoms. Twenty-five patients with COVID-19 pneumonia and 20 healthy subjects were prospectively enrolled.Cardiac volume and function parameters, myocardial native-T1, and T2*-mapping were measured. The association of serum ferritin level and myocardial mapping was analyzed. There was no difference in terms of cardiac volume and function parameters. The T2*-mapping values were lower in patients with COVID-19 compared to controls (35.37 [IQR 31.67-41.20] ms vs. 43.98 [IQR 41.97-46.88] ms; p < 0.0001), while no significant difference was found in terms of native-T1 mapping value(p = 0.701). There was a positive correlation with T2*mapping and native-T1 mapping values (r = 0.522, p = 0.007) and negative correlation with serum ferritin values (r = - 0.653, p = 0.000), while no correlation between cardiac native-T1 mapping and serum ferritin level. Negative correlation between serum ferritin level and T2*-mapping values in COVID-19 patients may provide a non-contrast-enhanced alternative to assess tissue structural changes in patients with COVID-19. T2*-mapping may provide a non-contrast-enhanced alternative to assess tissue alterations in patients with COVID-19. Adding T2*-mapping cardiac MRI in patients with myocardial pathologies would improve the revealing of underlying mechanisms. Further in vivo and ex vivo animal or human studies designed with larger patient cohorts should be planned.

Cardiac magnetic resonance findings in acute and post-acute COVID-19 patients with suspected myocarditis.

INTRODUCTION: Cardiac injury is commonly reported in COVID-19 patients, resulting associated to pre-existing cardiovascular disease, disease severity, and unfavorable outcome. Aim is to report cardiac magnetic resonance (CMR) findings in patients with myocarditis-like syndrome during the acute phase of SARS-CoV-2 infection (AMCovS) and post-acute phase (cPACS). METHODS: Between September 2020 and January 2022, 39 consecutive patients (24 males, 58%) were referred to our department to perform a CMR for the suspicion of myocarditis related to AMCovS (n = 17) and cPACS (n = 22) at multimodality evaluation (clinical, laboratory, ECG, and echocardiography). CMR was performed for the assessment of volume, function, edema and fibrosis with standard sequences and mapping techniques. CMR diagnosis and the extension and amount of CMR alterations were recorded. RESULTS: Patients with suspected myocarditis in acute and post-COVID settings were mainly men (10 (59%) and 12 (54.5%), respectively) with older age in AMCovS (58 [48-64]) compared to cPACS (38 [26-53]). Myocarditis was confirmed by CMR in most of cases: 53% of AMCovS and 50% of cPACS with negligible LGE burden (3 [IQR, 1-5] % and 2 [IQR, 1-4] %, respectively). Myocardial infarction was identified in 4/17 (24%) patients with AMCovS. Cardiomyopathies were identified in 12% (3/17) and 27% (6/22) of patients with AMCovS and cPACS, including DCM, HCM and mitral valve prolapse. CONCLUSIONS: In patients with acute and post-acute COVID-19 related suspected myocarditis, CMR improves diagnostic accuracy characterizing ischemic and non-ischemic injury and unraveling subclinical cardiomyopathies.

Admission and follow-up cardiac magnetic resonance imaging findings in BNT162b2 Vaccine-Related myocarditis in adolescents.

BACKGROUND: There is limited data on the pattern and severity of myocardial injury in patients with COVID-19 vaccination associated myocarditis. OBJECTIVE: We aimed to define the myocardial damage occurring after BNT162b2 vaccination, raise awareness about adverse reactions developing after vaccination, and determine the patterns and scope of Cardiac magnetic resonance imaging (MRI) findings. PATIENTS/METHODS: A total of 9 patients diagnosed with vaccine-associated myopericarditis were followed up. RESULTS: The mean age of the patient at diagnosis was 15.3 ± 1.0 (range: 14-17) years, and all patients were male. Seven patients presented with myocarditis symptoms after their second vaccine dose, one patient presented with pericarditis symptoms after his first dose, and the other patient presented with myocarditis symptoms after his booster dose. The median time at presenting to the hospital was 3 (range: 2-22) days. Seven (77.7%) patients had abnormal electrocardiography (ECG) findings, and the most prevalent finding was diffuse ST-segment elevation. Initial cardiac MRI results were abnormal in all patients, where 8 (88.8%) patients had late gadolinium enhancement, and 5 (55.5%) had myocardial edoema. Three patients showed local left ventricular wall-motion abnormalities. In their follow-up MRIs 3-6 months later, myocardial edoema was present in 2 (28.5%) patients, while late gadolinium enhancement was present in all patients (7/7, 100%, 2 patients did not have control MRI time). Hypokinetic segments were still present in one of the 3 patients. No negative cardiac events were observed in the short-term follow-up of any patient. CONCLUSION: Further follow-up evaluation and larger multicenter studies are needed to determine the clinical significance of persistent cardiac MRI abnormalities.

Cardiac Magnetic Resonance Findings in Patients Recovered from COVID-19 Pneumonia and Presenting with Persistent Cardiac Symptoms: The TRICITY-CMR Trial.

The prevalence and clinical consequences of coronavirus disease 2019 (COVID-19)-related non-ischemic cardiac injury are under investigation. The main purpose of this study was to determine the occurrence of non-ischemic cardiac injury using cardiac magnetic resonance (CMR) imaging in patients with persistent cardiac symptoms following recovery from COVID-19 pneumonia. We conducted a single-center, cross-sectional study. Between January 2021 and May 2021, we enrolled 121 patients with a recent COVID-19 infection and persistent cardiac symptoms. Study participants were divided into those who required hospitalization during the acute phase of SARS-CoV-2 infection (n = 58; 47.9%) and those non-hospitalized (n = 63; 52.1%). Non-ischemic cardiac injury (defined as the presence of late gadolinium enhancement (LGE) lesion and/or active myocarditis in CMR) was detected in over half of post-COVID-19 patients (n = 64; 52.9%). LGE lesions were present in 63 (52.1%) and active myocarditis in 10 (8.3%) post-COVID-19 study participants. The majority of LGE lesions were located in the left ventricle at inferior and inferolateral segments at the base. There were no significant differences in the occurrence of LGE lesions (35 (60.3%) vs. 28 (44.4%); p = 0.117) or active myocarditis (6 (10.3%) vs. 4 (6.3%); p = 0.517) between hospitalized and non-hospitalized post-COVID-19 patients. However, CMR imaging revealed lower right ventricular ejection fraction (RVEF; 49.5 (44; 54) vs. 53 (50; 58) %; p = 0.001) and more frequent presence of reduced RVEF (60.3% vs. 33.3%; p = 0.005) in the former subgroup. In conclusion, more than half of our patients presenting with cardiac symptoms after a recent recovery from COVID-19 pneumonia had CMR imaging abnormalities indicating non-ischemic cardiac injury. The most common finding was LGE, while active myocarditis was detected in the minority of patients. CMR imaging abnormalities were observed both in previously hospitalized and non-hospitalized post-COVID-19 patients. Further research is needed to determine the long-term cardiovascular consequences of COVID-19 infection and the optimal management of patients with suspected post-COVID-19 non-ischemic cardiac injury.

Cardiac magnetic resonance follow-up of COVID-19 vaccine associated acute myocarditis.

Background: Mass COVID-19 vaccination campaigns have helped impede the COVID-19 pandemic. In rare cases, some vaccines have led to vaccine associated myocarditis in a specific subset of the population, usually young males. Cardiac magnetic resonance (CMR) can reliably diagnose vaccine associated myocarditis, but follow-up data of CMR proven acute myocarditis is scarce. Materials and methods: Nine patients with acute vaccine associated myocarditis underwent baseline and follow-up CMR examinations and were compared to baseline parameters at initial presentation and to a group of 20 healthy controls. CMR protocol included functional assessment, T1 and T2 mapping, T2 signal intensity ratio, strain feature tracking, and late gadolinium enhancement (LGE). Results: Myocarditis patients (n = 9, aged 24 ± 6 years, 8 males) underwent CMR follow-up after an average of 5.8 ± 4.3 months. All patients showed a complete resolution of visual myocardial edema while also demonstrating a reduction in overall LGE extent from baseline to follow-up (4.2 ± 2.1 vs. 0.9 ± 0.8%, p < 0.001), although visual LGE was still noted in all patients. Left ventricular ejection fraction was normal at baseline and at follow-up (58 ± 6 vs. 62 ± 4%, p = 0.10) as well as compared to a healthy control group (60 ± 4%, p = 0.24). T1 (1024 ± 77 vs. 971 ± 34 ms, p = 0.05) and T2 relaxations times (57 ± 6 vs. 51 ± 3 ms, p = 0.03) normalized at follow-up. Most patients reported a resolution of clinical symptoms, while two (22%) reported new onset of exertional dyspnea. Conclusion: Patients with COVID-19 vaccine associated acute myocarditis showed a complete, uncomplicated resolution of myocardial inflammation on follow-up CMR, which was associated with a near complete resolution of symptoms. Minor, residual myocardial scarring was present on follow-up LGE imaging. The long-term implications of the remaining myocardial scar-tissue after vaccine associated myocarditis remain unknown warranting further studies.

Fulminant myocarditis with COVID-19 infection having normal C-reactive protein and serial magnetic resonance follow-up.

A 44-year-old woman who was quarantined for 5 days after the diagnosis of coronavirus disease of 2019 (COVID-19) was transferred to our hospital with the complaint of chest pain. The patient was unvaccinated. Electrocardiography revealed ST elevation in the lateral leads. Echocardiographic biventricular dysfunction with oedematous wall thickening was identified. Cardiac enzyme levels were elevated; however, C-reactive protein (CRP) levels, and the coronary angiogram were normal. The patient required mechanical circulatory support to stabilize haemodynamics and was treated with remdesivir, baricitinib, and intravenous methylprednisolone. She recovered after 13 days of mechanical support. Serial cardiac magnetic resonance imaging revealed acute myocardial oedema and subsequent fibrosis. An endomyocardial biopsy on admission showed mild interstitial inflammatory infiltrates with endomyocardial fibrous thickening and mild interstitial fibrosis of the myocardium. Normal CRP levels suggested minor involvement of interleukin (IL)-6, supporting the efficacy of baricitinib.

Selection of the best of 2022 in cardiac imaging

This review article aims to summarize the role of cardiac imaging regarding the most relevant technical and knowledge advances published within the last year. Although diagnosis and detection of cardiac involvement due to coronavirus disease maintain a prominent place, other interesting hot topics have been raised. Among the most relevant, it is noteworthy to highlight the prognostic utility of different parameters obtained by advanced imaging techniques in the field of valvular heart disease, cardiovascular prevention or cardio-oncology, the prominent role of imaging in the first diagnostic step of the new Chest Pain guidelines or the exponential growth of percutaneous structural interventionism, where further knowledge is demanded in terms of patient selection, procedure timing or predictors of success. Finally, artificial intelligence is a promising tool already in our hands, we hope that diagnostic precision and interpretation time will improve thanks to these technological advances. Copyright © 2022 Sociedad Espanola de Cardiologia

Left main coronary artery atresia in a 2-year-old toddler with de novo heart failure: Case report and review of the literature.

Congenital coronary anomalies are among the rare disorders of the otherwise normal heart. A 2-year-old toddler was evaluated for de novo heart failure after a flu-like event 2 months before being suspicious of post-Covid-19 dilated cardiomyopathy. The cardiac magnetic resonance (CMR) technique displayed the basal to mid subendocardial to transmural scar, suggestive of an ischemic etiology. Further assessment with CT and invasive angiography confirmed the very uncommon left main coronary artery atresia (LMCAA) as the main cause of the patient's heart failure. This is not only the first reported LMCAA case that had undergone a CMR study but was also initially suspected with characteristic CMR findings.

Selección de lo mejor del año 2022 en imagen cardiaca

Resumen Este artículo de revisión pretende resumir el papel de la imagen cardiaca en cuanto a los avances técnicos y de conocimiento más relevantes publicados en el último año. Aunque la imagen cardiaca sigue ocupando un lugar destacado en el diagnóstico y en la detección de complicaciones de la afectación cardiaca por la infección por coronavirus, otros temas candentes están claramente de actualidad. Entre lo más relevante cabe destacar la confirmación de la utilidad pronóstica de parámetros obtenidos mediante técnicas de imagen avanzada en el campo de las valvulopatías, prevención cardiovascular o cardio-oncología, el papel destacado de la imagen en el primer escalón diagnóstico de las nuevas guías de dolor torácico o el crecimiento exponencial del intervencionismo estructural percutáneo, donde se hace necesario un mayor conocimiento en la selección de pacientes, el timing del procedimiento o los predictores de éxito. Por último, la inteligencia artificial es un aliado que ha llegado para quedarse, y esperemos que la precisión y la rentabilidad diagnósticas, así como los tiempos dedicados a la interpretación, mejoren gracias a este avance tecnológico. This review article aims to summarize the role of cardiac imaging regarding the most relevant technical and knowledge advances published within the last year. Although diagnosis and detection of cardiac involvement due to coronavirus disease maintain a prominent place, other interesting hot topics have been raised. Among the most relevant, it is noteworthy to highlight the prognostic utility of different parameters obtained by advanced imaging techniques in the field of valvular heart disease, cardiovascular prevention or cardio-oncology, the prominent role of imaging in the first diagnostic step of the new Chest Pain guidelines or the exponential growth of percutaneous structural interventionism, where further knowledge is demanded in terms of patient selection, procedure timing or predictors of success. Finally, artificial intelligence is a promising tool already in our hands, we hope that diagnostic precision and interpretation time will improve thanks to these technological advances.

CMR findings in patients referred for suspected myocarditis following mRNA-based COVID vaccination compared with pre-COVID myocarditis referrals: A single-centre observational study.

Background: Vaccination is considered the key to overcome the COVID pandemic. For the first time mRNA-based vaccinations are used in humans. Case series suggested an increased risk of myocarditis after vaccination. This study sought to describe CMR findings in patients with suspected mRNA-vaccine associated myocarditis. Methods: A total of 33 consecutive patients referred for CMR work-up of suspected myocarditis associated with mRNA-based vaccination were included. A historical cohort of 135 consecutive patients referred for suspected myocarditis in the pre-COVID era served as control group. All patients underwent multi-parametric CMR including CINE and late gadolinium enhancement (LGE) imaging as well as parametric T1/T2 mapping of the left ventricular myocardium. Results: Patients referred for suspected vaccination-related myocarditis were more often female (55 % vs 32 %, p = 0.015) and demonstrated smaller LV dimensions as well as a better LV function compared to patients of the control group. CMR revealed a lower prevalence of non-ischemic LGE in patients with suspected vaccination-myocarditis (6 % vs 22 %, p = 0.04). However, among patients without LGE we observed a higher prevalence of an abnormal T1/T2 mapping result in patients with suspected vaccination-myocarditis compared to the control group (45 % vs 18 %, p = 0.010). Conclusion: In this small single-centre study, compared to myocarditis referrals in the pre-COVID era, patients currently referred for CMR work-up of suspected mRNA-vaccination-associated myocarditis demonstrated lower prevalence of LGE but higher prevalence of abnormal T1/T2 mapping. These hypothesis-generating observations may point towards a rather subtle myocardial damage and support the routine use of T1/T2 mapping in this indication.

Myocarditis associated with COVID-19 and its vaccines - a systematic review.

Since the beginning of the COVID-19 (Coronavirus Disease of 2019) pandemic, myocarditis has received much attention and controversy as one of the more worrisome cardiovascular complications. After the availability of highly effective COVID-19 mRNA vaccines in late 2020, myocarditis was also appreciated as an important vaccine-related adverse event. Though the overall frequency of clinically evident viral myocarditis is rare in the general population, young males show a higher predilection for COVID vaccine-induced myocarditis. The severity of COVID-19 viral myocarditis is variable, ranging from very mild to severe, while vaccine-induced myocarditis is usually mild, and rarely a severe or fatal disease. The diagnosis of either COVID-19 or vaccine-induced myocarditis is based on typical clinical features, laboratory investigations, and imaging, preferably with cardiac magnetic resonance. The management of COVID-19 myocarditis is supportive care for mild or moderate disease. For the rare patient who develops severe disease, advanced heart failure therapies such as mechanical circulatory support devices may have to be employed and can be lifesaving. Avoidance of strenuous exercise during the bout of myocarditis and its recovery phase is important. Despite the small but finite risk of vaccine-induced myocarditis, the benefits of protection against COVID-19 disease and its attendant complications far outweigh the risks.

Myocardial Injury and Altered Gene Expression Associated With SARS-CoV-2 Infection or mRNA Vaccination.

SARS CoV-2 enters host cells via its Spike protein moiety binding to the essential cardiac enzyme angiotensin-converting enzyme (ACE) 2, followed by internalization. COVID-19 mRNA vaccines are RNA sequences that are translated into Spike protein, which follows the same ACE2-binding route as the intact virion. In model systems, isolated Spike protein can produce cell damage and altered gene expression, and myocardial injury or myocarditis can occur during COVID-19 or after mRNA vaccination. We investigated 7 COVID-19 and 6 post-mRNA vaccination patients with myocardial injury and found nearly identical alterations in gene expression that would predispose to inflammation, coagulopathy, and myocardial dysfunction.