Key result
MIS-A criteria linked to absolute ~76% reduction in VA-ECMO in fulminant COVID-19 myocarditis.
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Why the study?
Adults infected with SARS-CoV-2 can develop fulminant myocarditis with or without meeting MIS-A criteria, suggesting distinct phenotypes exist.
Do clinical outcomes, disease severity, and immunological profiles differ between patients with fulminant COVID-19-related myocarditis who fulfill MIS-A criteria versus those who do not?
Cohort (n=38)
No
Do clinical outcomes, disease severity, and immunological profiles differ between patients with fulminant COVID-19-related myocarditis who fulfill MIS-A criteria versus those who do not?
Absolute Event Rate: 16% vs 92%
p-value: p=<0.0001
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“Of note, MIS-A - cases, owing to the high risk of refractory cardiogenic shock, should be urgently referred to a center with VA-ECMO capability and closely monitored to avoid a too-late cannulation known to be associated with poor outcome.”
“The patients who were negative for the [MIS] criteria had a very explosive presentation.”
MIS-A criteria successfully differentiate two phenotypes of fulminant COVID-19-related myocarditis, with MIS-A- patients presenting an explosive cardiogenic shock with exceptionally high VA-ECMO requirement.
Background Adults who have been infected with SARS-CoV-2 can develop a multisystem inflammatory syndrome (MIS-A), including fulminant myocarditis. Yet, several patients fail to meet MIS-A criteria, suggesting the existence of distinct phenotypes in fulminant COVID-19–related myocarditis. Objectives This study sought to compare the characteristics and clinical outcome between patients with fulminant COVID-19–related myocarditis fulfilling MIS-A criteria (MIS-A+) or not (MIS-A−). Methods A monocentric retrospective analysis of consecutive fulminant COVID-19–related myocarditis in a 26-bed intensive care unit (ICU). Results Between March 2020 and June 2021, 38 patients required ICU admission (male 66%; mean age 32 ± 15 years) for suspected fulminant COVID-19–related myocarditis. In-ICU treatment for organ failure included dobutamine 79%, norepinephrine 60%, mechanical ventilation 50%, venoarterial extracorporeal membrane oxygenation 42%, and renal replacement therapy 29%. In-hospital mortality was 13%. Twenty-five patients (66%) met the MIS-A criteria. MIS-A− patients compared with MIS-A+ patients were characterized by a shorter delay between COVID-19 symptoms onset and myocarditis, a lower left ventricular ejection fraction, and a higher rate of in-ICU organ failure, and were more likely to require mechanical circulatory support with venoarterial extracorporeal membrane oxygenation (92% vs 16%; P < 0.0001). In-hospital mortality was higher in MIS-A− patients (31% vs 4%). MIS-A+ had higher circulating levels of interleukin (IL)-22, IL-17, and tumor necrosis factor-α (TNF-α), whereas MIS-A− had higher interferon-α2 (IFN-α2) and IL-8 levels. RNA polymerase III autoantibodies were present in 7 of 13 MIS-A− patients (54%) but in none of the MIS-A+ patients. Conclusion MIS-A+ and MIS-A− fulminant COVID-19–related myocarditis patients have 2 distinct phenotypes with different clinical presentations, prognosis, and immunological profiles. Differentiating these 2 phenotypes is relevant for patients’ management and further understanding of their pathophysiology.
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Barhoum et al. (2022) conducted a cohort in Fulminant COVID-19-related myocarditis (n=38). Fulfillment of MIS-A criteria (MIS-A+) vs. Absence of MIS-A criteria (MIS-A-) was evaluated on Requirement for mechanical circulatory support with venoarterial extracorporeal membrane oxygenation (VA-ECMO) (p=<0.0001). Patients with fulminant COVID-19-related myocarditis meeting MIS-A criteria had a significantly lower requirement for VA-ECMO compared to MIS-A- patients (16% vs 92%, p<0.0001).
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