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Review
. 2021 Sep 8;11(9):1647.
doi: 10.3390/diagnostics11091647.

Myocardial Pathology in COVID-19-Associated Cardiac Injury: A Systematic Review

Aniello Maiese  1   2 , Paola Frati  2   3 , Fabio Del Duca  3 , Paola Santoro  3 , Alice Chiara Manetti  1 , Raffaele La Russa  2   4 , Marco Di Paolo  1 , Emanuela Turillazzi  1 , Vittorio Fineschi  2   3
Affiliations
Review

Myocardial Pathology in COVID-19-Associated Cardiac Injury: A Systematic Review

Aniello Maiese et al. Diagnostics (Basel). .

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.

Keywords: COVID-19; SARS-CoV-2; autopsy; heart; heart failure; myocarditis; postmortem.

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Conflict of interest statement

The authors declare no conflict of interest.

Figures

Figure 1
Figure 1
Research results from 70 screened articles. Inclusion criteria included case reports, research articles, autopsy series reports, and papers written in the English language.
Figure 2
Figure 2
Comorbidities’ frequency in the subjects described in the articles included in this review (total n = 209). COPD indicates chronic obstructive pulmonary disease.
Figure 3
Figure 3
(A,B) Myocarditis with extensive myocyte necrosis, at different developmental stages (H&E, 60× and 20×, respectively). (C) Massive lymphocytic infiltration of the pericardium and perivascular area (H&E, 40×). Foci of acute myocyte necrosis (D) and regions undergoing tissue repair (E) (H&E, 100× and 80×, respectively). (F) Acute coronary thrombosis (H&E, 200×).
Figure 4
Figure 4
Myocarditis: immunohistochemistry demonstrating CD68 macrophage population (A) and CD8 expression (B).
See this image and copyright information in PMC

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