Clinical and Morphological Features of Myocardial Damage and the Course of Fulminant Myocarditis on the Background of СOVID-19, Diagnosis and Treatment Tactics

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Abstract


In a review article based on my own clinical experience of managing patients with acute myocardial injury and fulminant myocarditis, taking into account expert recommendations on the clinical treatment of myocardial damage associated with novel coronavirus infection a National clinical geriatric medical research center, division of cardiovascular diseases, the Chinese geriatrics society, Department of cardiology, Beijing Medical Association and European clinics discusses the pathogenesis, diagnosis and treatment of myocardial damage and FM patients, infected with SARS-CoV-2 in the context of the COVID-19 pandemic. Clinical features and diagnostic criteria are presented, including screening tests of markers of myocardial damage in the form of a highly sensitive troponin test, a natriuretic peptide. The article discusses in detail the pathogenesis and mechanisms of myocardial damage, including immune mechanisms, cytokine storm, systemic inflammation with macro- and microvascular dysfunction and the development of myocardial dysfunction with acute heart failure, hypotension, cardiogenic shock and/or life-threatening heart rhythm disorders caused by hypoxia and metabolic disorders at the cellular level. Features of the clinical course of fulminant myocarditis in infected patients (SARS-CoV-2) in the conditions of the COVID-19 pandemic are presented. For the first time, a detailed histo-morphological analysis of pathological myocardial injuries and complications is presented on the basis of unique autopsy material on post-mortem diagnostics of various pathoanatomic autopsies of those who died from COVID-19 in Moscow. Based on the clinical, functional and morphological material, the Protocol of etiopathogenetic treatment is presented. The basis of standard therapy is considered antiviral drugs, immunoglobulin G, the use of monoclonal antibodies to interleukin-6, anticoagulants, glucocorticoids, depending on the clinical situation, cardioprotectors and symptomatic treatment are recommended to maintain the heart, which in combination can achieve a certain clinical effectiveness. As adjuvant cardioprotective targeted therapy, the sodium salt of phosphocreatine is considered in order to preserve the myocardium, maintain its contractility and vital activity.


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About the authors

Olga S. Oynotkinova

Research Institute of Healthcare Organization and Medical Management

Author for correspondence.
Email: olga-oynotkinova@yandex.ru
ORCID iD: 0000-0002-9856-8643
SPIN-code: 7783-6965
Scopus Author ID: 33156677

Russian Federation, 26/28 Sivtsev Vrazhek str., 119002, Moscow

MD, PhD, Professor

Evgenii L. Nikonov

Pirogov Russian National Research Medical University

Email: drnikonov@mail.ru
ORCID iD: 0000-0002-5231-711X
SPIN-code: 5618-1533

Russian Federation, Moscow

MD, PhD, Professor

Oleg V. Zayratyants

A.I. Yevdokimov Moscow State University of Medicine and Dentistry of the Ministry of Healthcare of the Russian Federation

Email: ovzair@mail.ru
ORCID iD: 0000-0003-3606-3823
SPIN-code: 4817-1084

Russian Federation, Moscow

MD, PhD, Professor

Elena V. Rzhevskaya

Polyclinic No. 1 of the Office of the President of the Russian Federation

Email: nolamz@mail.ru
ORCID iD: 0000-0001-7194-8219
SPIN-code: 3216-2315

Russian Federation, Moscow

MD, PhD

Evgenii V. Krukov

Main Military Clinical Hospital Named after N.N. Burdenko

Email: Evgeniy.md@mail.ru
ORCID iD: 0000-0002-8396-1936

Russian Federation, Moscow

MD, PhD, Professor, Corresponding Member of the RAS

Michail I. Voevoda

Federal Research Center for Fundamental and Translational Medicine

Email: director@centercem.ru
ORCID iD: 0000-0001-9425-413X
SPIN-code: 6133-1780

Russian Federation, Novosibirsk

MD, Professor, Academician of the RAS

Olga M. Maslennikova

Central State Medical Academy

Email: o.m.maslennikova@gmail.com
ORCID iD: 0000-0001-9599-7381
SPIN-code: 5516-9979

Russian Federation, Moscow

MD, PhD, Associate Professor

Vera N. Larina

Pirogov Russian National Research Medical University

Email: larinav@mail.ru
ORCID iD: 0000-0001-7825-5597
SPIN-code: 3674-9620

Russian Federation, Moscow

MD, PhD, Associate Professor

Tatiana Y. Demidova

Pirogov Russian National Research Medical University

Email: t.y.demidova@gmail.com
ORCID iD: 0000-0001-6385-540X
SPIN-code: 9600-9796
Scopus Author ID: 7003771623

Russian Federation, Moscow

MD, PhD, Professor

Evgenii I. Dedov

Pirogov Russian National Research Medical University

Email: dedov-e-i@yandex.ru
ORCID iD: 0000-0002-9118-3708
SPIN-code: 8724-4940

Russian Federation, Moscow

MD, PhD

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Supplementary files

Supplementary Files Action
1.
Fig. 1. Diagnosis and treatment of fulminant myocarditis. ICU - resuscitation and intensive care unit, EF - fraction ejection, mechanical ventilation - artificial ventilation of the lungs, ECMO - extracorporeal membrane oxygenation, IABK - intra-aortic balloon counterpulsation, ACS - acute coronary syndrome, RRT - renal replacement therapy, BP - blood pressure

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2.
Fig. 2. Damage to the myocardium. Pronounced plethora microcirculatory bed. Stromal edema. Hematoxy staining lin and eosin, × 250: A, B - hypertrophy, dystrophic changes, lipofuscinosis, fragmentation, undulating course and necrosis of certain groups of cardiomyocytes; B - necrosis of individual cardiomyocytes, fibrin and erythrocytes in the lumen, swelling capillary vessel endothelium

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3.
Fig. 3. Myocardium. Congestion of the microcirculatory bed, fibrin organizing thrombus (arrow) in the lumen of a thin-walled vessel. Hematoxylin and eosin staining, × 120

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4.
Fig. 4. Myocarditis. Staining with hematoxylin and eosin, × 400: a - focal, mainly perivascular, lymph macrophage infiltration, dystrophic changes and necrosis of individual cardiomyocytes, stromal edema; b - diffuse lymphoplasma cell infiltration, vasculitis, stromal edema, degenerative changes and necrosis of individual cardiomyocytes

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