COVID-19-Associated cardiac pathology at the postmortem evaluation: a collaborative systematic review

Abstract

Background: Many postmortem studies address the cardiovascular effects of COVID-19 and provide valuable information, but are limited by their small sample size.

Objectives: The aim of this systematic review is to better understand the various aspects of the cardiovascular complications of COVID-19 by pooling data from a large number of autopsy studies.

Data sources: We searched the online databases Ovid EBM Reviews, Ovid Embase, Ovid Medline, Scopus, and Web of Science for concepts of autopsy or histopathology combined with COVID-19, published between database inception and February 2021. We also searched for unpublished manuscripts using the medRxiv services operated by Cold Spring Harbor Laboratory.

Study eligibility criteria: Articles were considered eligible for inclusion if they reported human postmortem cardiovascular findings among individuals with a confirmed SARS coronavirus type 2 (CoV-2) infection.

Participants: Confirmed COVID-19 patients with post-mortem cardiovascular findings.

Interventions: None.

Methods: Studies were individually assessed for risk of selection, detection, and reporting biases. The median prevalence of different autopsy findings with associated interquartile ranges (IQRs).

Results: This review cohort contained 50 studies including 548 hearts. The median age of the deceased was 69 years. The most prevalent acute cardiovascular findings were myocardial necrosis (median: 100.0%; IQR, 20%-100%; number of studies = 9; number of patients = 64) and myocardial oedema (median: 55.5%; IQR, 19.5%-92.5%; number of studies = 4; number of patients = 46). The median reported prevalence of extensive, focal active, and multifocal myocarditis were all 0.0%. The most prevalent chronic changes were myocyte hypertrophy (median: 69.0%; IQR, 46.8%-92.1%) and fibrosis (median: 35.0%; IQR, 35.0%-90.5%). SARS-CoV-2 was detected in the myocardium with median prevalence of 60.8% (IQR 40.4-95.6%).

Conclusions: Our systematic review confirmed the high prevalence of acute and chronic cardiac pathologies in COVID-19 and SARS-CoV-2 cardiac tropism, as well as the low prevalence of myocarditis in COVID-19.

Keywords: COVID-19; Cardiac pathology; Myocarditis; Postmortem; SARS-CoV-2; Systematic review.

Fig. 1

Preferred Reporting Items for Systematic Reviews and Meta-analyses 2009 flow diagram.

Fig. 2

Bar chart showing reported comorbidities of deceased patients included in this cohort. CAD, coronary artery disease; CKD, chronic kidney disease; COPD, chronic obstructive pulmonary disease; MI, myocardial infarction. Data labels show the prevalence of reported comorbidities (can overlap in a single patient).

Fig. 3

Box-and-whisker plot of cardiac autopsy findings of studies with ≥5 patients as median percentage prevalence and associated interquartile ranges. CAD, coronary artery disease.