Comparative Study of the Myocardium of Patients from Four COVID-19 Waves

Background: Few studies have compared COVID-19 patients from different waves. This study aims to conduct a clinical and morphological analysis of patients who died from COVID-19 during four waves.

Methods: The study involved 276 patients who died from COVID-19 during four waves, including 77 patients in the first wave, 119 patients in the second wave, and 78 patients in the third wave. We performed a histological examination of myocardium samples from autopsies and additionally analyzed the samples by PCR. We conducted immunohistochemistry of the myocardium for 21 samples using antibodies against CD3, CD45, CD8, CD68, CD34, Ang1, VWF, VEGF, HLA-DR, MHC1, C1q, enteroviral VP1, and SARS-CoV-2 spike protein. We also did immunofluorescent staining of three myocardial specimens using VP1/SARS-CoV-2 antibody cocktails. Further, we ran RT-ddPCR analysis for 14 RNA samples extracted from paraffin-embedded myocardium. Electron microscopic studies of the myocardium were also performed for two samples from the fourth wave.

Results: Among the 276 cases, active myocarditis was diagnosed in 5% (15/276). Of these cases, 86% of samples expressed VP1, and individual cells contained SARS-CoV-2 spike protein in 22%. Immunofluorescence confirmed the co-localization of VP1 and SARS-CoV-2 spike proteins. ddPCR did not confidently detect SARS-CoV-2 RNA in the myocardium in any myocarditis cases. However, the myocardium sample from wave IV detected a sub-threshold signal of SARS-CoV-2 by qPCR, but myocarditis in this patient was not confirmed. Electron microscopy showed several single particles similar to SARS-CoV-2 virions on the surface of the endothelium of myocardial vessels. A comparison of the cardiovascular complication incidence between three waves revealed that the incidence of hemorrhage (48 vs. 24 vs. 17%), myocardial necrosis (18 vs. 11 vs. 4%), blood clots in the intramural arteries (12 vs. 7 vs. 0%), and myocarditis (19 vs. 1 vs. 6%) decreased over time, and CD8-T-killers appeared. Immunohistochemistry confirmed the presence of endotheliitis in all 21 studied cases.

Conclusions: This study compared myocardial damage in patients who died during three COVID-19 waves and showed a decrease in the incidence of endotheliitis complications (thrombosis, hemorrhage, necrosis) and myocarditis over time. However, the connection between myocarditis and SARS-CoV-2 infection remains unproven.

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References

Smadja D, Mentzer S, Fontenay M, Laffan M, Ackermann M, Helms J . COVID-19 is a systemic vascular hemopathy: insight for mechanistic and clinical aspects. Angiogenesis. 2021; 24(4):755-788. PMC: 8238037. DOI: 10.1007/s10456-021-09805-6. View

Wolfisberg S, Gregoriano C, Struja T, Kutz A, Koch D, Bernasconi L . Comparison of characteristics, predictors and outcomes between the first and second COVID-19 waves in a tertiary care centre in Switzerland: an observational analysis. Swiss Med Wkly. 2021; 151:w20569. DOI: 10.4414/smw.2021.20569. View

Mitrofanova L, Konovalov P, Krylova J, Polyakova V, Kvetnoy I . Plurihormonal cells of normal anterior pituitary: Facts and conclusions. Oncotarget. 2017; 8(17):29282-29299. PMC: 5438730. DOI: 10.18632/oncotarget.16502. View

Varga Z, Flammer A, Steiger P, Haberecker M, Andermatt R, Zinkernagel A . Endothelial cell infection and endotheliitis in COVID-19. Lancet. 2020; 395(10234):1417-1418. PMC: 7172722. DOI: 10.1016/S0140-6736(20)30937-5. View

Deng H, Tang T, Chen D, Tang L, Yang X, Tang Z . Endothelial Dysfunction and SARS-CoV-2 Infection: Association and Therapeutic Strategies. Pathogens. 2021; 10(5). PMC: 8151812. DOI: 10.3390/pathogens10050582. View

Smeeth L, Thomas S, Hall A, Hubbard R, Farrington P, Vallance P . Risk of myocardial infarction and stroke after acute infection or vaccination. N Engl J Med. 2004; 351(25):2611-8. DOI: 10.1056/NEJMoa041747. View

Saito S, Asai Y, Matsunaga N, Hayakawa K, Terada M, Ohtsu H . First and second COVID-19 waves in Japan: A comparison of disease severity and characteristics. J Infect. 2020; 82(4):84-123. PMC: 7605825. DOI: 10.1016/j.jinf.2020.10.033. View

Maiese A, Frati P, Del Duca F, Santoro P, Manetti A, La Russa R . Myocardial Pathology in COVID-19-Associated Cardiac Injury: A Systematic Review. Diagnostics (Basel). 2021; 11(9). PMC: 8472043. DOI: 10.3390/diagnostics11091647. View

Mukerji S, Solomon I . What can we learn from brain autopsies in COVID-19?. Neurosci Lett. 2020; 742:135528. PMC: 7687409. DOI: 10.1016/j.neulet.2020.135528. View

10.

Salabei J, Asnake Z, Ismail Z, Charles K, Stanger G, Abdullahi A . COVID-19 and the cardiovascular system: an update. Am J Med Sci. 2022; 364(2):139-147. PMC: 8830924. DOI: 10.1016/j.amjms.2022.01.022. View

11.

Linschoten M, Peters S, van Smeden M, Jewbali L, Schaap J, Siebelink H . Cardiac complications in patients hospitalised with COVID-19. Eur Heart J Acute Cardiovasc Care. 2020; 9(8):817-823. PMC: 7734244. DOI: 10.1177/2048872620974605. View

12.

Mollinedo-Gajate I, Villar-Alvarez F, Zambrano-Chacon M, Nunez-Garcia L, de la Duena-Munoz L, Lopez-Chang C . First and Second Waves of Coronavirus Disease 2019 in Madrid, Spain: Clinical Characteristics and Hematological Risk Factors Associated With Critical/Fatal Illness. Crit Care Explor. 2021; 3(2):e0346. PMC: 7901790. DOI: 10.1097/CCE.0000000000000346. View

13.

Caforio A, Baritussio A, Basso C, Marcolongo R . Clinically Suspected and Biopsy-Proven Myocarditis Temporally Associated with SARS-CoV-2 Infection. Annu Rev Med. 2021; 73:149-166. DOI: 10.1146/annurev-med-042220-023859. View

14.

Buckley B, Harrison S, Fazio-Eynullayeva E, Underhill P, Lane D, Lip G . Prevalence and clinical outcomes of myocarditis and pericarditis in 718,365 COVID-19 patients. Eur J Clin Invest. 2021; 51(11):e13679. PMC: 8646627. DOI: 10.1111/eci.13679. View

15.

Tao Z, Chen B, Tan X, Zhao Y, Wang L, Zhu T . Coexpression of VEGF and angiopoietin-1 promotes angiogenesis and cardiomyocyte proliferation reduces apoptosis in porcine myocardial infarction (MI) heart. Proc Natl Acad Sci U S A. 2011; 108(5):2064-9. PMC: 3033313. DOI: 10.1073/pnas.1018925108. View

16.

Spiel A, Gilbert J, Jilma B . von Willebrand factor in cardiovascular disease: focus on acute coronary syndromes. Circulation. 2008; 117(11):1449-59. DOI: 10.1161/CIRCULATIONAHA.107.722827. View

17.

Fraser M, Agdamag A, Maharaj V, Mutschler M, Charpentier V, Chowdhury M . COVID-19-Associated Myocarditis: An Evolving Concern in Cardiology and Beyond. Biology (Basel). 2022; 11(4). PMC: 9025425. DOI: 10.3390/biology11040520. View

18.

Corman V, Landt O, Kaiser M, Molenkamp R, Meijer A, Chu D . Detection of 2019 novel coronavirus (2019-nCoV) by real-time RT-PCR. Euro Surveill. 2020; 25(3). PMC: 6988269. DOI: 10.2807/1560-7917.ES.2020.25.3.2000045. View

19.

Dallabrida S, Ismail N, Oberle J, Himes B, Rupnick M . Angiopoietin-1 promotes cardiac and skeletal myocyte survival through integrins. Circ Res. 2005; 96(4):e8-24. DOI: 10.1161/01.RES.0000158285.57191.60. View

20.

Andreoletti L, Bourlet T, Moukassa D, Rey L, Hot D, Li Y . Enteroviruses can persist with or without active viral replication in cardiac tissue of patients with end-stage ischemic or dilated cardiomyopathy. J Infect Dis. 2000; 182(4):1222-7. DOI: 10.1086/315818. View