ACUTE MYOCARDITIS AND ACUTE DECOMPENSATED HEART FAILURE WITH REDUCED EJECTION FRACTION IN COVID-19

Background

Myocarditis is one of the cardiac manifestations of coronavirus SARSCoV2^1,9. We present a case of myocarditis along with HFrEF resulting from COVID-19.

Case

A previously healthy 24-year-old man presented with nausea, vomiting, and diarrhea. Several days prior he had sought evaluation for fever and sore throat. COVID-19 PCR returned positive. Lung auscultation revealed bibasilar crackles. The remainder of the exam was normal. Vital signs revealed T 97 F, HR 151, BP 100/60mmHg, RR 20/min, SpO2 97% on RA. Labs showed WBC 30 X10n3 ul, BNP 4314 pg/ml, lactate 2.6 mmol/L, CRP 491 mg/L, Ferritin >1499ng/ml, D-dimer 2.2 mg/L, LDH 353 U/L, Procal 8.77ng/mL, Tnl 0.225 ng/ml.

Decision-making

The patient received metoprolol succinate 25 mg daily. A TTE revealed severe biventricular systolic dysfunction with LVEF 10%. ECG demonstrated sinus tachycardia with frequent PVC’s. Furosemide 20 mg IV was given but further diuresis and metoprolol were deferred because of hypotension. The patient was treated with convalescent plasma, remdesivir, dexamethasone, and Lovenox 0.5mg/kg BID but required transfer to the local cardiac center due to persistent hypotension and hypoxia. A Swan Ganz catheter was placed revealing SVR 779 dynes/sec/cm⁵, CO 6.16 L/min, CI 2.89 L/min/m^2. RA pressure of 10/4, PA pressure of 25/9/16, CVP 8, MVO₂ was 68%, PCWP of 21 mmHg. The patient clinically improved with norepinephrine infusion and a repeat TTE revealed LVEF 25%. He was sent home on furosemide 20 mg daily, metoprolol succinate 25 mg daily, lisinopril 2.5 mg daily, aspirin 81 mg daily, atorvastatin 40 mg daily and Rivaroxaban 20mg daily for 1 month with close follow up. Another TTE after 1 month demonstrated normal LV and RV size and LVEF 55%.

Conclusion

Our patient showed evidence of myocarditis and acute decompensated HFrEF in the setting of COVID-19. Echocardiography is a useful tool to assess cardiac function and guide management during hospitalization¹, Follow up TTE is extremely important to assess improvement in LVEF with resolution of the acute myocarditis. In retrospect, administering metoprolol in this patient should have been avoided as it may have precipitated worsening decompensated heart failure and hypotension.