key: cord-0793861-fczy1z6b
authors: Yousefi-Koma, Abbas; Naghashzadeh, Farah; Figtree, Gemma A.; Patel, Sanjay; Karimi Galougahi, Keyvan
title: Multi-modality imaging of inflammation and ischemia for assessment of myocardial injury in Covid-19
date: 2020-06-19
journal: J Nucl Cardiol
DOI: 10.1007/s12350-020-02233-x
sha: 4b461feb7a9d7b66e5798790f26b93859e5f884a
doc_id: 793861
cord_uid: fczy1z6b

nan

Coronarvirus disease-2019 (Covid-19) is associated with cardiovascular manifestations including type 2 myocardial injury, acute coronary syndromes, and acute/fulminant myocarditis, contributing to an overall worse prognosis.

A 69-year-old woman with a history of hypertension presented with dyspnea and chest pain at the peak of Covid-19 pandemic. ECG revealed left-bundlebranch block (long-standing) ( Figure 1 ) and chest pain quickly resolved with medical therapy. Polymerase chain reaction (PCR) assay was positive for Covid-19. Chest CT revealed bilateral ground-glass opacities consistent with Covid-19 ( Figure 1 ). Peak troponin was 40 ng/ml (\ 0.02 ng/ml). Echocardiography revealed septal, anterior, and apical hypokinesis. Lopinavir-ritonavir, dual anti-platelet therapy, statin, losartan, and beta-blocker were started. She had an overall uncomplicated course of Covid-19. Due to complete resolution of pain and active Covid-19, angiography was deferred for when she was deemed non-infective.

To assess for myocarditis versus myocardial infarction/injury, on admission day 7, 18 FDG-PET with 18-h fasting protocol was performed showing avid uptake in septum, anterior wall, and apex ( Figure 2) . A subsequent 99m Tc-MIBI-SPECT revealed rest perfusion defects in the same segments ( Figure 2 ) (stress imaging not performed due to possible infarct).

While segmental FDG uptake (due to inflammation) with matching perfusion defects (due to inflammatory microvascular dysfunction) are typical for myocarditis, 1 in this context secondary to Covid-19 shown to cause myocarditis and cardiac microvascular involvement 2 ; acute inflammatory response to myocardial infarction precipitated by Covid-19 may generate a similar pattern. 3 This perfusion-metabolism mismatch should not be misinterpreted with myocardial uptake indicating myocardial viability in an ischemic left anterior descending (LAD) artery territory since the prolonged fasting protocol suppresses myocardial glucose uptake. 3 Angiography performed when the patient became PCR negative with resolution of pulmonary involvement revealed severe LAD artery disease (Figure 3) , confirming anterior wall infarction precipitated by Covid-19 that was treated with percutaneous coronary intervention. 

Concordant findings on myocardial perfusion SPECT and cardiac magnetic resonance imaging in a patient with myocarditis

Pulmonary and Cardiac Pathology in Covid-19: The First Autopsy Series from New Orleans. medRxiv

Pitfalls of (18)F-FDG PET for evaluating myocardial viability

Sanjay Patel: Educational grants-Abbott Vascular and Novartis, consultancy fees-Abbott Vascular, Novartis, and Aspen. Gemma Figtree: Consultancy fees-Janssen, CSL. Other authors declare no conflict of interest.