Microvascular Angiopathic Consequences of COVID-19

Abstract

The coronavirus disease-2019 (COVID-19) pandemic has rapidly spread across the world. The disease is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which first appeared in Wuhan, China in December, 2019. Ever increasing data is continuing to emerge about the impact of COVID-19 on cardiovascular tissue and other organ system. Clinical features associated with COVID-19 suggest that endothelial cell dysfunction and microvascular thrombosis are to a large extent contributing to resultant multi-organ complications. This review is aimed at highlighting the critical aspects associated with COVID-19 and its presumed microvascular angiopathic consequences on the cardiovascular system leading to multi-organ dysfunction.

Keywords: COVID-19; angiopathy; cardiac dysfunction; micovascular disease; vascular thrombosis.

Figure 1

Schematic summary of the COVID-19 microangiopathic consequences leading to myocarditis, non-occlusive STEMI, arrhythmia, heart failure, vascular thrombosis, and microvascular renal dysfunction.

Figure 2

Intraoperative trans-esophageal echocardiography (TEE) in a COVID-19 positive patient with myocarditis, acute pericardial effusion and cardiac tamponade. After bedside venous-arterial extracorporeal membrane oxygenation (VA-ECMO) cannulation was performed, the patient was taken to the operating room emergently for ventral cardiac window exposure and decompression of the pericardial effusion. (A) Preoperative mid-esophageal four chamber view demonstrated severely reduced global left ventricle (LV) function. (B,C) Similarly, mid-esophageal long axis view demonstrated severely reduced LV contraction. (D) Transgastric short axis view demonstrated under-filling of the LV. Patient was taken emergently to the operating room for cardiac window decompression of the pericardial effusion and a large pericardial effusion. An Impella device is seen in the LV.

Figure 3

Transthoracic echocardiography (TTE) in a COVID-19 positive patient who presented with acute bilateral pulmonary emboli and acute right sided heart failure requiring emergent veno-venous extracorporeal membrane oxygenation (VV-ECMO) cannulation. (A) Parasternal long axis view demonstrate a McConnell's sign: Right ventricle (RV) enlargement and hypokinesis with preserved apical contractility. (B) Optison enhanced images demonstrate RV enlargement, and paradoxical septal motion consistent with RV dysfunction.

Figure 4

Computed tomographic (CT) images of a COVID-19 positive patient who presented with bilateral lobar pulmonary embolism (white arrows; A–D), and right ventricular enlargement and bowing of the interventricular septum to the left, consistent with right heart strain (red line; E).