Spectrum of Cardiac Involvement in COVID-19

Cardiac involvement in coronavirus disease 2019 (COVID-19) commonly accompanies multi-organ system failure with acute respiratory syndrome; however, infrequently myocarditis and pericardial effusions may be isolated, yet fulminant. In this report, we highlight significant variations in cardiac involvement and presentation among patients with COVID-19. This article reports two cases of fulminant myocarditis in COVID-19 positive patients who presented to our facility with contrasting symptoms, laboratory and imaging findings. A 65-year-old patient A had a more typical presentation including respiratory distress, chest pain, ST-segment elevations on electrocardiogram (EKG), lymphopenia, elevated levels of inflammatory markers and cardiac troponin I. A 34-year-old patient B presented with shortness of breath and chest pain similar to patient A; however, she had isolated cardiac involvement with systolic dysfunction and an acute pericardial effusion causing tamponade physiology. Inflammatory marker and cardiac troponin I levels for patient B were within normal range. Patient A had a rapid progression of multi-organ system failure leading to her death within 24 hours from presentation on maximal inopressor support. Patient B, however, is one of few reported cases of cardiac tamponade and veno-arterial extracorporeal membrane oxygenation (VA-ECMO) use in COVID-19 who underwent pericardiocentesis and was additionally managed with colchicine and steroids, leading to complete recovery in systolic function within three weeks from initial presentation. Isolated myocardial dysfunction and pericardial effusions in COVID-19 may have catastrophic sequalae even in the absence of elevated biomarkers described in literature. Therefore, early detection and management of cardiac involvement is warranted. Additionally, the role of mechanical circulatory support devices and VA-ECMO in COVID-19 needs further investigation.