AN ALREADY SICK HEART: A CASE OF FATAL SARS-COV-2 MYOCARDITIS

Abstract

TOPIC: Cardiovascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) myocarditis has recently been described in case reports. A systematic review in early 2021 found fourteen case reports of myocarditis or myopericarditis secondary to this viral infection. We describe an interesting case of proven non-ischemic cardiac dysfunction in the setting of acute infection. Despite steroid treatment, which has been suggested to have favorable outcomes, our patient did not survive. CASE PRESENTATION: We present a case of a 77-year-old man with extensive electrophysiologic and ischemic cardiac disease who presented to the hospital for generalized weakness, malaise, and shortness of breath. The patient s cardiac history was significant for atrial flutter s/p ablation, coronary artery disease s/p coronary artery bypass graft in the distant past, peripheral artery disease s/p right lower extremity revascularization, and carotid stenosis s/p carotid endarterectomy. SARS-CoV-2 PCR test was positive. The patient had increasing hypoxia which required non-invasive ventilation and eventually, tracheal intubation and mechanical ventilation. The hospital course was complicated by the development of persistent chest pain associated with elevated cardiac enzymes. EKG showed diffuse ST-segment depressions. An echocardiogram revealed diffuse left ventricular hypokinesis and a reduced ejection fraction of 20% which was not present previously. In this setting, the patient was ruled in for acute coronary syndrome and underwent cardiac catheterization. Cardiac catheterization demonstrated patent grafts and no significant obstructive disease. A presumptive diagnosis of myocarditis was made. The patient s clinical status deteriorated despite optimal medical treatment, and he developed hemodynamically unstable atrial fibrillation that did not respond to pharmacologic treatment or cardioversion and resulted in cardiogenic shock and, ultimately, his death. DISCUSSION: SARS-CoV-2 myocarditis has been described in select case reports internationally. Many of these cases are described in patients with no previously identified comorbid conditions. This case suggests that in patients with underlying electrophysiologic dysfunction, SARS-CoV-2 myocarditis is associated with poor outcomes. CONCLUSIONS: The mechanism of the effect of SARS-CoV-2 on the heart is unclear and includes myocarditis or myopericarditis. In our patient, cardiac catheterization which was performed during his hospitalization confirmed no ischemic disease and suggested the presence of myocarditis which was ultimately fatal in the setting of refractory cardiogenic shock. Further research is needed into the optimal management of myocarditis associated with SARS-CoV-2. REFERENCE #1: Sawalha K, Abozenah M, Kadado AJ, et al. Systematic Review of COVID-19 Related Myocarditis- Insights on Management and Outcome. Cardiovasc Revasc Med. Feb 2021;23:107-113. REFERENCE #2: Purdy A, Ido F, Sterner S, et al. Myocarditis in COVID-19 presenting with cardiogenic shock: a case series. Eur Heart J Case Rep. Feb 2021;5(2):ytab028. REFERENCE #3: Fried JA, Ramasubbu K, Bhatt R, et al. The Variety of Cardiovascular Presentations of COVID-19. Circulation. 2020;141(23):1930-1936. DISCLOSURES: No relevant relationships by Sravani Gajjala, source=Web Response No relevant relationships by Stacey Jou, source=Web Response No relevant relationships by Zein Kattih, source=Web Response No relevant relationships by Rosaline Ma, source=Web Response No relevant relationships by Akhilesh Mahajan, source=Web Response No relevant relationships by Vinayak Shenoy, source=Web Response