Non-invasive coronary imaging in patients with COVID-19: A narrative review

Abstract

SARS-CoV-2 infection, responsible for COVID-19 outbreak, can cause cardiac complications, worsening outcome and prognosis. In particular, it can exacerbate any underlying cardiovascular condition, leading to atherosclerosis and increased plaque vulnerability, which may cause acute coronary syndrome. We review current knowledge on the mechanisms by which SARS-CoV-2 can trigger endothelial/myocardial damage and cause plaque formation, instability and deterioration. The aim of this review is to evaluate current non-invasive diagnostic techniques for coronary arteries evaluation in COVID-19 patients, such as coronary CT angiography and atherosclerotic plaque imaging, and their clinical implications. We also discuss the role of artificial intelligence, deep learning and radiomics in the context of coronary imaging in COVID-19 patients.

Keywords: Atherosclerosis; COVID-19; Coronary CT angiography; Coronary imaging.

Fig. 1

49 years old male patient underwent a CCTA (coronary CT angiography) for atipical chest pain. Images show mid- LAD soft, moderate plaque on multiplanar reconstruction (A, arrow) and cross-sectional view (B, arrow); this plaque does not present high risk features (positive remodeling, low attenuation, spotty calcification, napkin-ring sign). Histopathology on H&E is shown in C and D. C: atherosclerotic plaque with intraplaque hemorrhage (arrowhead) and neoangiogenesis with severe inflammation (arrow). D: Higher magnification of neoangigenesis inside the atherosclerotic plaque. The hemosiderin deposits, appearing as yellow–brown granules, are the sign of previous intraplaque hemorrhages.

Fig. 2

65 years old male patient underwent to CCTA for ventricular extrasystole and chest pain. Images show proximal LAD soft plaque with spotty calcification (feature of higher risk of rupture) on multiplanar reconstruction (A, arrow), cross sectional view (B, arrow) and on H&E (C) which shows the fibrous cap containing scattered inflammatory cells (C, arrows) a necrotic core contains a large calcification (C, arrowhead). Dusty calcium deposits are scattered throughout the necrotic core.

Fig. 3

81 years old female patient with history of COVID19 three months earlier, underwent cardiac computed tomography for atypical chest pain. LAD (A), LCx (B) and RCA (C) did not show any significant stenosis. However pulmonary embolism was observed in superior segment of right inferior lobe (arrow, D).

Fig. 4

65 years old male patient with history of dilated cardiomyopathy, multiple cardiovascular risk factors that was not able to perform MR due to old metal femoral stem. Calcified moderate stenosis was observed on mid-RCA (A), LAD (B) and moderate mixed plaque on proximal first marginal (C). Late iodine enhancement showed hyperenhancement of subendocradium in inferolateral wall (arrows, D) and papillary muscles (arrowheads, D), indicating necrosis/fibrosis/inflammation. H&E view of unstable atherosclerotic plaque (E), with necrotic core and spindle lipid deposits (arrows) and fibrous cap with diffuse inflammatory infiltrate (arrowheads).

Fig. 5

Example of coronary CT angiography cross sections with radiomics analysis in two sample patients. Fig. 5a showed a 61-year-old man presented at our department with typical chest pain with a vulnerable plaque in the mid left anterior descending artery. From left to right, first we have segmented the coronary arteries to locate the coronary plaque, then we have shown three representative first order texture parameters (total energy, entropy and kurtosis, which represent heterogeneity, randomness and flatness of an image respectively), describing the distribution of HU values within a target lesion. Conversely, Fig. 2b demonstrated an 82-years-old woman free of symptoms with an eccentric calcified plaque in the mid right coronary artery. Postprocessing imaging data was performed with dedicated software (Olea Sphere 3.0; Olea Medical, La Ciotat, France).