Different Impacts on the Heart After COVID-19 Infection and Vaccination: Insights From Cardiovascular Magnetic Resonance

Abstract

Introduction: Myocarditis-like findings after COVID-19 (coronavirus disease 2019) infection and vaccination were reported by applying cardiovascular magnetic resonance (CMR). These results are very heterogenous and dependent on several factors such as hospital admission or outpatient treatment, timing of CMR, and symptomatic load. This retrospective study aimed to identify differences in myocardial damage in patients with persistent symptoms both after COVID-19 infection and vaccine by applying CMR.

Materials and methods: This study entails a retrospective analysis of consecutive patients referred for CMR between August 2020 and November 2021 with persistent symptoms after COVID-19 infection or vaccination. Patients were compared to healthy controls (HC). All patients underwent a CMR examination in a 1.5-T scanner with a scan protocol including: cine imaging for biventricular function and strain assessment using feature tracking, T2 mapping for the quantification of edema, and T1 mapping for diffuse fibrosis and late gadolinium enhancement (LGE) for the detection and quantification of focal fibrosis. Patients were divided into a subacute COVID-19 (sCov) group with symptoms lasting < 12 weeks, post-COVID-19 (pCov) group with symptoms > 12 weeks, and patients after COVID-19 vaccination (CovVac).

Results: A total of 162 patients were recruited of whom 141 were included for analysis. The median age in years (interquartile range (IQR)) of the entire cohort was 45 (37-56) which included 83 women and 58 men. Subgroups were as follows (total patients per subgroup, median age in years (IQR), main gender): 34 sCov, 43 (37-52), 19 women; 63 pCov, 52 (39-58), 43 women; 44 CovVac, 43 (32-56), 23 men; 44 HC (41 (28-52), 24 women). The biventricular function was preserved and revealed no differences between the groups. No active inflammation was detected by T2 mapping. Global T1 values were higher in pCov in comparison with HC (median (IQR) in ms: pCov 1002ms (981-1023) vs. HC 987ms (963-1009; p = 0.005) with other parings revealing no differences. In 49/141 (34.6%) of patients, focal fibrosis was detectable with the majority having a non-ischemic pattern (43/141; 30.4%; patients) with the subgroups after infection having more often a subepicardial pattern compared with CovVac (total (% of group): sCov: 7/34(21%); pCov 13/63(21%); CovVac 2/44(5%); p = 0.04).

Conclusion: Patients after COVID-19 infection showed more focal fibrosis in comparison with patients after COVID-19 vaccination without alterations in the biventricular function.

Keywords: COVID-19; cardiovascular magnetic resonance; fibrosis; late gadolinium enhancement; mapping; vaccination.

FIGURE 1

Graphical overview representing median time between COVID-19 infection or vaccination and cardiovascular magnetic resonance (CMR) examination. Time is represented as days on the X-axis. Data are given as median (squares) and interquartile range (whiskers indicate 25th and 75th percentile, respectively) except for Li et al. (9), which are represented as mean (diamond) and standard deviation (arrows pointing outward). Red colors highlight the time ranges of this study.

FIGURE 2

Flowchart detailing the patients excluded for each subgroup.

FIGURE 3

T1, T2, and extracellular volume (ECV) values for the patient cohort and healthy controls. Boxplot representation of the mapping values for T1 in ms (A), T2 in ms (B), and ECV in% (C) for patients after COVID-19 infection (subacute and post-COVID-19), after COVID-19 vaccination, and healthy controls (from left to right in each panel). Whiskers represent minimal and maximal values with boxes representing 25th percentile, median, and 75th percentile (from bottom to top). Significant values for general tests were followed by subgroup comparison. A p-value of < 0.05 was regarded as statistically significant.

FIGURE 4

Focal fibrosis detected by late gadolinium enhancement imaging in the patient cohorts. Presented are total and percentages of findings (findings/cohort size) in pie charts. Different subtypes of late gadolinium enhancement (LGE) patterns are indicated by colors with a legend on the lower right side (lime green = no LGE; red = LGE positive; brown = ischemic pattern; orange = non-ischemic pattern; dark blue = subepicardial LGE; light blue = intramyocardial LGE; purple = RV insertion point). Significant differences were found between subepicardial LGE findings in the subacute COVID-19 group and the COVID-19 vaccination group (p = 0.04) and between the post-COVID-19 group and the COVID-19 vaccination group (p = < 0.001). No differences were found between the infection subgroups (p = 0.99) for subepicardial LGE. Other pairings revealed no differences. (A) Subepicardial scar in the basal inferolateral part. (B) Subepicardial scar in the basal lateral part.