Management and outcomes of myocarditis with cardiogenic shock due to multisystem inflammatory syndrome in adults following COVID-19 – a single center experience
Presenter
Dr. Retesh Bajaj, MBBS BSc PhD, University of Ottawa Heart Institute, Ottawa, ON, CANADA
Dr. Retesh Bajaj, MBBS BSc PhD1, Kush Patel, MBBS, BSc2, Charlotte Manisty, PhD2, Oliver Guttmann, MD2, Filip Zemrak, PhD2, Paula Longhi, PhD3, Alastair Proudfoot, MBBS, PhD4, Konstantinos Savvatis, MD, PhD2, Sachin Shah, MD5, Neha Sekhri, PhD, FRCP2, Federica Marelli-Berg, PhD3, Simon Tiberi, MD, FRCP2, Teresa Cutino-Moguel, PhD2 and Saidi A Mohiddin, MD, FRCP2, (1)University of Ottawa Heart Institute, Ottawa, ON, CANADA, (2)Barts Heart Centre, London, United Kingdom, (3)Queen Mary, University of London, London, United Kingdom, (4)St Bartholomew's Hospital, London, United Kingdom, (5)Barts Health NHS Trust, London, United Kingdom
Keywords: COVID-19, Cardiogenic Shock and Hemodynamic Support
Background
A multisystem inflammatory syndrome (MIS) associated with myocarditis and cardiogenic shock following COVID-19 infection has been described. We report our experience of managing cases identified with this condition at a tertiary cardiac center in London.
Methods
Digital records at Barts Heart Centre, London were examined to identify consecutive patients presenting with cardiogenic shock, systemic inflammation and previous but not concurrent COVID-19 (presence of antibodies and negative PCR for the virus) between 1
st March, 2020 and 15
th June, 2021.
Results
11 were identified: mean age 36±11 years, 10 (91%) male and 8 (73%) of Black ancestry. 8 (73%) had PCR-confirmed, symptomatic COVID-19 infection, a median of 32 days (range 22-120) prior to presentation with MIS; all had anti-SARS-CoV-2 antibodies. Cases were pyrexic (mean temperature 39.8±0.4
oC), with leukocytosis (mean white cell count 35.4 x 10
9 cells/ml), elevated ferritin (mean 5057±4632 mcg/L), C-reactive protein (mean 347±70 mg/L) and troponin T (mean 858±653 ng/L). Cardiogenic shock necessitated intensive care (ICU) therapy a median of 2 days (range 0-4) into admission [median LV ejection fraction 20% (range 5-35)]. 10 (91%) received inotropic support and corticosteroids; one received veno-arterial extracorporeal membrane oxygenation. LV recovery coinciding with reduction in inflammatory markers was seen within 72 hours of commencing steroids; the case not treated with steroids also demonstrated recovery. Complete LV normalization on cardiac imaging was seen in 10 cases (91%); severe LV dysfunction persisted in 1 case. All had cardiac MRI at 12±7 days into ICU admission; abnormal late gadolinium enhancement was seen in 7 (64%), all with a sub-epicardial/mid-wall pattern. All cases were discharged from ICU [median stay 8 days (range 4-25)] and from hospital.
Conclusions
MIS-associated cardiogenic shock appeared to have a favorable course in our unselected cohort treated with ICU support and corticosteroids, with the majority recovering cardiac function and no mortality. There appears to be an association with an immunological response to SARS-CoV-2. Further research into determinants of a harmful cellular or antibody response to COVID-19 is merited.