There is no doubt that COVID-19 could cause cardiac injuries (1-7), and cardiovascular imaging examination including Cardiac Magnetic Resonance Imaging (CMR) and Coronary Computed Tomography Angiography (CCTA) are helpful for detecting cardiovascular injury and exploring pathophysiological mechanisms of multiple cardiovascular disease include COVID-19 (3-7). Chen et al. (4) performed CMR in 25 COVID-19 patients with at least one marker of cardiac involvement [cardiac symptoms, abnormal electrocardiograph (ECG), or abnormal cardiac biomarkers] within the first 10 days of the onset of COVID symptoms, and found in patients with early-stage COVID-19, myocardial edema, and functional abnormalities are a frequent finding, while irreversible regional injury such as necrosis may be infrequent. However, considering the risk of infection associated with patient transport and imaging examination, it is not feasible to learn cardiovascular injury by multiple imaging examinations during the acute phase in most hospitals.
To provide imaging evidence and basis for revealing the pathogenesis of myocardial injury of COVID-19, CMR and CCTA were performed on recovered COVID-19 patients whose virus detection turned negative and clinical observation was done in our hospital prospectively. The selection criterions were as follows: (I) patients were previously confirmed of SARS-CoV-2 infection by reverse transcription and polymerase chain reaction (RT-PCR) swab test; (II) patients were considered recovered by the discharging criteria (a. normal temperature lasting longer than 3 days; b. resolved respiratory symptoms; c. substantially improved acute exudative lesions on chest CT images; d. two consecutive negative RT-PCR test results separated by at least 24 hours and was isolated for 14 days; (III) the recovery of respiratory function and being able to tolerate the special respiration requirements of CMR. This study was approved by the institutional review board of the Fifth Affiliated Hospital of Sun Yat-sen university (No.: K214-1).
Seven COVID-19 patients who recently recovered from COVID-19 infection were included. Patient characteristics, blood test results, treatment before discharge and CMR imaging findings are provided in Table 1.
|Case 1||Case 2||Case 3||Case 4||Case 5||Case 6||Case 7|
|Known Coronary artery disease||N||N||N||N||N||N||N|
|Chronic obstructive pulmonary diseases||N||N||N||N||N||N||N|
|Chronic renal diseases||N||N||N||N||N||N||N|
|Chronic liver diseases||N||N||N||N||N||N||N|
|Blood pressure, mmHg|
|Heart rate (highest), beats per min||85||71||67||86||70||72||94|
|Duration between confirming of COVID-19 to CMR examination (day)||54||59||27||48||51||43||54|
|Precordial chest pain||Acute||N||N||N||N||N||N||N|
|Blood test results|
|White blood cell count (×109/L)||3.5–9.5||21.24h||10.25h||4.43h||5.91h||5.14h||7.45h||12.2h|
|Lymphocyte count (×109/L)||1.1–3.2||0.97h||1.56h||1.14h||1.56h||1.48h||2.46h||1.71h|
|Platelet count (×103/L)||152–350||345h||182h||189h||274h||370h||269h||373h|
|Red blood cell count (×109/L)||3.8–5.1||3.75h||3.52h||4.05h||5.48h||4.42h||5.55h||4.77h|
|CRP (highest) (mg/L)||0.068–8.2||127.5h||45.79h||0.460h||19.52h||5.590h||0.210h||46.57h|
|Creatinine kinase–myocardial band, U/L||0–25||10.7h||15h||30.7h||34.9h||25.9h||26.8h||29.30h|
|Glutamic Oxaloacetic Transaminase, U/L||13–35||117h||80.10h||21.5h||29h||28.2h||19.3h||36.8h|
|Glyoxylate Aminotransferase, U/L||7–40||55.1h||100.8h||14.4h||25.2h||32.2h||13.0h||63.1h|
|Arterial oxygen saturation||0.93–0.98||0.622L||0.89L||0.981L||0.952L||0.982L||0.92L||0.959L|
|Revised arterial oxygen partial pressures||83-108||39.6L||56.7L||87.1L||38.6L||101L||87.2L||77.20L|
|Treatment before discharge|
|Use of corticosteroid||Y||N||N||N||N||N||Y|
|Nasal cannula oxygen||Y||Y||N||Y||Y||N||Y|
|Non-invasive ventilation or high-flow nasal cannula oxygen||Y||Y||N||N||N||N||N|
|ED Mass/BSA (g/m2)||56.19||93.61||52.97||52.46||41.75||60.02||56.34|
Six (85.71%) patients were found of myocardial injury. The final diagnosis are: Case 1: hypertensive cardiomyopathy, coronary artery disease (CAD), coronary artery fistula, ischemic injury of left ventricular basal lateral wall and myocarditis of left ventricular basal inferior and septal wall caused by Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) infection (Figure 1); Case 2: CAD, chronic total occlusion (CTO) of LAD and LCX, ischemic cardiomyopathy, left ventricular aneurysm, CAD induced ischemic myocardial injury under the condition of ischemia and hypoxia of COVID-19 (Figure 2); Case 3, 4, 5, 6: myocarditis caused by SARS-CoV-2 infection (Figure 3); CMR of Case 7 was negative.
Most studies of cardiovascular imaging in recovered COVID-19 patients used CMR only (3,5-7), myocardial edema, fibrosis, and impaired ventricular function are common, however the cause were not discussed by direct imaging evidence. We performed CMR and CCTA on patients 1 and 2 simultaneously, which make it possible to find out the cause. Our results show myocardial injury of COVID-19 patients persistent until early convalescent stage, and maybe caused by multiple factors, including myocarditis, ischemic injury caused by the condition of ischemia and hypoxia of COVID-19, they may occur at the same time and serious injury was more likely to occur in patients with a history of cardiovascular disease. Cardiovascular imaging examination including CMR and CCTA are helpful to confirm it and find out the cause.
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Cite this article as: Pan C, Luo L, Qin P, Ye Y, Ding X, Wu W, Zhang Z, Chen J, Li S. Cardiac imaging findings of recovered COVID-19 patients with increased myocardial injury biomarkers in acute phase—the role of Multimodal cardiovascular imaging examination. J Xiangya Med 2021;6:26.