Cardiovascular Manifestations of Patients with Long COVID

Abstract

Background: This study investigates the potential mechanisms behind changes in cardiac structure and function in long COVID patients. Methods: This study involved 176 consecutive outpatients in follow-up care (average age 55.9 years; 58.5% male) who experienced symptoms for over 12 weeks (average 6.2 ± 2.7 months), following coronavirus infection (COVID-19). Results: The patients with long COVID and cardiovascular manifestations were significantly more hospitalized (88.5% vs. 75.9%) and had longer hospital stays. Significant echocardiography changes were observed in the left ventricular ejection fraction (LVEF) (59.6 ± 5.4% vs. 62.5 ± 3.8%); longitudinal strain (LS) in the sub-endocardium and intra-myocardium layers (-20.9 vs. -22.0% and -18.6 vs. -19.5%); circumferential strain (CS) in the sub-epicardium layers (-9.6 vs. -10.5%); and CS post-systolic shortening (CS PSS) (0.138 vs. 0.088 s). Additionally, pathological cardiac magnetic resonance (CMR) findings were seen in 58.2% of the group of patients with long COVID and cardiovascular manifestation; 43.3% exhibited positive late gadolinium enhancement (LGE), 21.0% had elevated native T1 mapping, and 22.4% had elevated native T2 mapping. Conclusions: Most patients with long COVID showed structural and functional changes in their cardiovascular systems, primarily caused by prolonged inflammation. Using multimodality imaging is important for uncovering the mechanisms to predict chronic myocarditis, early-stage heart failure, and pre-ischemic states, which can lead to serious complications. Recognizing the specific cardiovascular phenotypes associated with long COVID is essential in order to provide timely and appropriate treatment.

Keywords: COVID-19; cardiovascular diseases; echocardiography; long COVID; multimodality imaging.

Figure 1

Protocol flowchart.

Figure 2

The levels of CS in patients with Long COVID were decreased. The lowest levels of CS were found in the epicardial layers. In this patient, the values in the inferior segments of the left ventricle were particularly changed (pink color).

Figure 3

Post-contrast findings of late gadolinium enhancement localized in sub-epicardial and mid-myocardial layers (white arrows).

Figure 4

Findings in native and post-contrast T1 mapping. In this patient with Long COVID: T1 native maps were normal, however T1 postcontrast maps were increased in anteroseptal segments in basal and mid level and in all segments in apical level of left ventricle. (Reference rate: base 1058.7 ± 53.7 ms, mid 1025.8 ± 36.9 ms, apex 1048.9 ± 57.1 ms) (reference rate: base 408.2 ± 53.6 ms, mid 420.5 ± 50.8 ms, apex 396.1 ± 48.3 ms).

Figure 5

Pathological findings in native T2 mapping (reference rate: base 48.1 ± 3.3 ms, mid 47.4 ± 3.2 ms, and apex 51.3 ± 4.2 ms).

Figure 6

Correlation of the T1 maps and post-systolic shortening of epicardium layers of circumferential strain.

Figure 7

Changes in cardiac structure and function—potential mechanisms.