Recurrent course of post-inflammatory cardiopathy: lessons from past epidemics

Viruses are the most common etiological agents of myocardium inflammation. Today the Severe Acute Respiratory Syndrome coronavirus (SARS-CoV-2) causes a high incidence of myocarditis and pericarditis. As a hypothetical scenario, we present a clinical case of a patient who underwent viral myocarditis on the background of SARS in 2004, with recurrent myocarditis in ARVI, the last of which was initiated by SARS-CoV-2. A 61-year-old male patient, in 2004 contacted a representative of the People's Republic of China and after 4 days felt the symptoms of ARVI. Before the viral disease, he had excellent health, the absence of cardiovascular diseases and pathological heredity. Fever 38–39 °C, myalgia, headache, general malaise, dry obsessive cough persisted for a week. After the addition of shortness of breath, he was hospitalized. According to the data of X-ray and computed tomography, infiltrates of the lungs of both of the "frosted glass" type were revealed. According to the clinic and laboratory data, a diagnosis of severe “atypical viral pneumonia” was made, and a diagnosis of viral myocarditis was suggested. Echocardiography showed a decrease in the left ventricular ejection fraction up to 50% for the first time, without signs of coronary heart disease based on the results of further examination. Dry cough disturbed in the next 4 months, LVEF 48–50% and 1 functional class of heart failure persisted for 10 years. The patient had a flu with mild respiratory symptoms in 2015, but it triggered a recurrence of myocarditis. The examination revealed a decrease in LVEF up to 35%, the progression of dilatation of the heart cavities also without signs of coronary heart disease according to the results of the treadmill test and coronary angiography. Post-inflammatory cardiopathy progressed relatively quickly during the year. The minimum LVEF was 23%; a cardioverter-defibrillator was implanted for secondary indications; radiofrequency ablation of fascicular tachycardia was performed. It was followed by another period of stabilization: 2 functional class of heart failure, ICD shocks did not occur. The patient underwent COVID-19 with minimal respiratory symptoms in March 2021. It provoked another recurrence of myocarditis, diagnosed with an increase in troponin, cerebral natriuretic peptide, CRP, ESR and increasing heart failure during 3 months. Persistent paroxysms of atrial fibrillation with a decrease of LVEF 15% and anasarсa. A successful radiofrequency isolation of the pulmonary vein was performed in 2021. By November 2021, in the absence of paroxysms, it was possible to achieve compensation for heart failure up to class 1 according to Vasilenko–Strazhesko and NYHA, LVEF 28%.

In order to understand the recurrent nature of myocarditis against the background of various respiratory viral infections, an analysis of the literature was carried out, including the described cases of myocardial inflammation against the background of the predecessors of the SARS-CoV-2 strain: SARS-CoV-1 and MERS. We also reviewed the data on the diagnosis of viral myocarditis in the realities of this pandemic. It reveals a large heterogeneity of signs of inflammation of the heart muscle according to different diagnostic methods and large interobserver variability, and challenges us about the need to revise the criteria for myocarditis in the case of COVID-19.

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