The Spectrum of COVID-19-Associated Myocarditis: A Patient-Tailored Multidisciplinary Approach

Peretto, Giovanni; Villatore, Andrea; Rizzo, Stefania; Esposito, Antonio; De Luca, Giacomo; Palmisano, Anna; Vignale, Davide; Cappelletti, Alberto Maria; Tresoldi, Moreno; Campochiaro, Corrado; Sartorelli, Silvia; Ripa, Marco; De Gaspari, Monica; Busnardo, Elena; Ferro, Paola; Calabrò, Maria Grazia; Fominskiy, Evgeny; Monaco, Fabrizio; Cavalli, Giulio; Gianolli, Luigi; De Cobelli, Francesco; Margonato, Alberto; Dagna, Lorenzo; Scandroglio, Mara; Camici, Paolo Guido; Mazzone, Patrizio; Della Bella, Paolo; Basso, Cristina; Sala, Simone

Background. Myocarditis lacks systematic characterization in COVID-19 patients. Methods. We enrolled consecutive patients with newly diagnosed myocarditis in the context of COVID-19 infection. Diagnostic and treatment strategies were driven by a dedicated multidisciplinary disease unit for myocarditis. Multimodal outcomes were assessed during prospective follow-up. Results. Seven consecutive patients (57% males, age 51 ± 9 y) with acute COVID-19 infection received a de novo diagnosis of myocarditis. Endomyocardial biopsy was of choice in hemodynamically unstable patients (n = 4, mean left ventricular ejection fraction (LVEF) 25 ± 9%), whereas cardiac magnetic resonance constituted the first exam in stable patients (n = 3, mean LVEF 48 ± 10%). Polymerase chain reaction (PCR) analysis revealed an intra-myocardial SARS-CoV-2 genome in one of the six cases undergoing biopsy: in the remaining patients, myocarditis was either due to other viruses (n = 2) or virus-negative (n = 3). Hemodynamic support was needed for four unstable patients (57%), whereas a cardiac device implant was chosen in two of four cases showing ventricular arrhythmias. Medical treatment included immunosuppression (43%) and biological therapy (29%). By the 6-month median follow-up, no patient died or experienced malignant arrhythmias. However, two cases (29%) were screened for heart transplantation. Conclusions. Myocarditis associated with acute COVID-19 infection is a spectrum of clinical manifestations and underlying etiologies. A multidisciplinary approach is the cornerstone for tailored management.