key: cord-0852792-8bhahzys authors: Abdelnabi, Mahmoud; Eshak, Nouran; Saleh, Yehia; Almaghraby, Abdallah title: Coronavirus Disease 2019 Myocarditis: Insights into Pathophysiology and Management date: 2020-06-17 journal: Eur Cardiol DOI: 10.15420/ecr.2020.16 sha: 2d01e03da42b763c9a0f7d5daeacfd58fd522ce1 doc_id: 852792 cord_uid: 8bhahzys The world is dealing with a global pandemic of severe acute respiratory coronavirus 2 (SARS-CoV-2). Coronavirus disease 2019 (COVID-19), which is the illness caused by SARS-CoV-2, is overwhelming healthcare systems around the world. Although the main clinical manifestations of COVID-19 are respiratory symptoms, several reports have noted myocarditis, cardiomyopathy, arrhythmias and cardiac arrests as COVID-19 complications. Here, the authors highlight the current understanding of the pathophysiology of myocarditis related to COVID-19 and its management. point-of-care ultrasound is often readily available. Although cardiac magnetic resonance would provide more information than an echocardiogram, its use is limited because of prolonged acquisition time, the need for breath-holding and, given that COVID-19 is highly contagious, the requirement for deep cleaning after use. 4 If myocarditis is still suspected and cardiac magnetic resonance cannot be performed, ECG-gated CT with contrast would be a reasonable option. Since many COVID-19 patients will undergo a chest CT at some point, adding the cardiac component to the CT is a feasible technique to use to obtain valuable information. If none of these modalities provide the information needed, an endomyocardial biopsy would be warranted. The current European Society of Cardiology (ESC) position statement recommends treating patients with acute myocarditis complicated by cardiogenic shock with inotropes and/or vasopressors and mechanical ventilation. 5 Additionally, in patients requiring longer-term support, extracorporeal membrane oxygenation (ECMO) and ventricular assist devices should be used. Generally, glucocorticoid and immunoglobulin therapy are discouraged in acute myocarditis. In a systematic review, Chen et al. reported that corticosteroids did not reduce mortality. 6 Moreover, a systematic review of IV immunoglobulins as acute myocarditis therapy showed insufficient evidence to support their routine use. 7 Partly because of these data, the ESC recommends that immunosuppression should be started only after ruling out an active infection. 5 Interestingly, three case reports have noted successful management of COVID-19 fulminant myocarditis using mainly immune-modulators and supportive measures. Zeng et al. reported the successful treatment of a patient with COVID-19 presenting with fulminant myocarditis, ARDS and multiple organ dysfunction syndrome using ventilatory support, high-flow oxygen, lopinavir-ritonavir antiviral therapy, interferon alpha-1b, methylprednisolone, immunoglobulin and ECMO with gradual improvement of left ventricular ejection fraction (LVEF). 8 Hu et al. described successful management of fulminant myocarditis using methylprednisolone, immunoglobulin, inotropes and diuretics with gradual improvement of LVEF and cardiac biomarkers over several weeks. 9 Inciardi et al. described a case of peri-myocarditis as the sole manifestation of COVID-19, without interstitial pneumonia, with gradual improvement of symptoms and LVEF using hydroxychloroquine, lopinavir/ritonavir, methylprednisolone, inotropic support and diuresis. 10 In general, the use of corticosteroids and IV immunoglobulins are not supported by the guidelines for the management of acute myocarditis. However, in the very few patients who have been diagnosed with COVID myocarditis, management with immunomodulators showed positive results. This suggests that the core pathophysiologic process of COVID-19-related cardiac injury is linked to a cytokine storm. SARS-CoV-2: a potential novel etiology of fulminant myocarditis COVID-19 and the cardiovascular system Clinical predictors of mortality due to COVID-19 based on an analysis of data of 150 patients from Wuhan, China Recognizing COVID-19-related myocarditis: the possible pathophysiology and proposed guideline for diagnosis and management Current state of knowledge on aetiology, diagnosis, management, and therapy of myocarditis: a position statement of the European Society of Cardiology Working Group on Myocardial and Pericardial Diseases Corticosteroids for viral myocarditis A systematic review of intravenous gamma globulin for therapy of acute myocarditis First case of COVID-19 complicated with fulminant myocarditis: a case report and insights Coronavirus fulminant myocarditis saved with glucocorticoid and human immunoglobulin Cardiac involvement in a patient with coronavirus disease 2019 (COVID-19)