Myocardial Pathology in COVID-19-Associated Cardiac Injury: A Systematic Review
Aniello Maiese1,2, Paola Frati2,3, Fabio Del Duca3
1Department of Surgical Pathology, Medical, Molecular and Critical Area, Institute of Legal Medicine, University of Pisa, 56126 Pisa, Italy.
Insights
This review of COVID-19 autopsies reveals SARS-CoV-2 causes heart damage, including inflammation and microthrombosis. Survivors face increased cardiac risk due to these irreversible changes.
Area of Science:
- Pathology
- Cardiology
- Infectious Diseases
Background:
- Coronavirus disease 2019 (COVID-19), caused by SARS-CoV-2, can affect multiple organs due to widespread ACE2 receptor expression.
- Cardiac involvement is a significant concern in COVID-19 patients, necessitating a deeper understanding of its pathological basis.
- Postmortem analysis offers crucial insights into the direct effects of emerging infectious diseases on human organs.
Purpose of the Study:
- To systematically review postmortem findings in SARS-CoV-2 positive patients, focusing on cardiac involvement.
- To analyze pathological and immunohistochemical data to understand the mechanisms of COVID-19-related heart disease.
- To assess the long-term cardiac implications for COVID-19 survivors based on autopsy findings.
Main Methods:
- Systematic literature search from March 2020 to July 2021 in PubMed using terms: 'COVID-19', 'postmortem', 'autopsy', 'heart'.
- Inclusion of 16 English-written papers (case reports/series, original research) adhering to PRISMA guidelines.
- Analysis of pathological findings, immunohistochemical data, and clinical assessments from 209 SARS-CoV-2 positive patients.
Main Results:
- The primary cause of death was respiratory failure, with acute heart failure being the second most common cause.
- Key cardiac findings included dilatation, necrosis, lymphocytic infiltration, and microthrombosis in small coronary vessels.
- Immunohistochemistry showed a systemic inflammatory response with CD3+, CD8+ cytotoxic lymphocytes, and CD68+ macrophages.
Conclusions:
- SARS-CoV-2 infection can lead to irreversible cardiac damage, contributing to increased cardiac risk in survivors.
- COVID-19 induces a systemic inflammatory and prothrombotic state, impacting multiple organs, including the heart.
- Postmortem examinations are essential for understanding the pathology of novel diseases like COVID-19 and their organ-specific effects.
Abstract:
Coronavirus disease 2019 (COVID-19) can potentially affect all organs owing to the ubiquitous diffusion of the angiotensin-converting enzyme II (ACE2) receptor-binding protein. Indeed, the SARS-CoV-2 virus is capable of causing heart disease. This systematic review can offer a new perspective on the potential consequences of COVID-19 through an analysis of the current literature on cardiac involvement. This systematic review, conducted from March 2020 to July 2021, searched the current literature for postmortem findings in patients who were positive for SARS-CoV-2 by combining and meshing the terms "COVID-19", "postmortem", "autopsy", and "heart" in titles, abstracts, and keywords. The PubMed database was searched following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Sixteen papers met the inclusion criteria (case reports and series, original research, only English-written). A total of 209 patients were found (mean age (interquartile range (IQR)), 60.17 years (IQR, 54.75-70.75 years); 122 men (58.37%, ratio of men to women of 1:0.7%)). Each patient tested positive for SARS-CoV-2. Death was mainly the result of respiratory failure. The second most common cause of death was acute heart failure. Few patients specifically died of myocarditis. Variables such as pathological findings, immunohistochemical data, and previous clinical assessments were analyzed. Main cardiac pathological findings were cardiac dilatation, necrosis, lymphocytic infiltration of the myocardium, and small coronary vessel microthrombosis. Immunohistochemical analyses revealed an inflammatory state dominated by the constant presence of CD3+ and CD8+ cytotoxic lymphocytes and CD68+ macrophages. COVID-19 leads to a systemic inflammatory response and a constant prothrombotic state. The results of our systematic review suggest that SARS-CoV-2 was able to cause irreversible changes in several organs, including the heart; this is reflected by the increased cardiac risk in patients who survive COVID-19. Postmortem analysis (including autopsy, histologic, and immunohistochemical examination) is an indispensable tool to better understand pathological changes caused by emerging diseases such as COVID-19. Our results may provide more information on the involvement of the heart in COVID-19 patients.
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