A case report of management of cardiomyopathy in a patient with prior COVID infection

The novel coronavirus (SARS-CoV-2) is responsible for the current pandemic and while most patients have mild symptoms, severe COVID-19 infections can have long-lasting symptoms. There is data to suggest that sequelae from COVID-19 persist for months. Viral myocarditis and cardiomyopathy related to COVID-19 have been described in the non-pregnant population. We present a case of a parturient presenting with left ventricular global hypokinesis and ejection fraction of 38% two months after initial COVID-19 infection. Pregnant patients with COVID-19related cardiomyopathy should be managed by a multidisciplinary team. We suggest considering SARSCoV-2 infection in parturients presenting with symptoms of decompensated heart failure.


Introduction
As of April 2021, the coronavirus SARS-CoV-2 has infected more than 134 million humans per the Johns Hopkins Coronavirus Resource Center. It has become apparent that while many patients have a mild course, severe COVID-19 infections can have both crippling and longlasting symptoms.
Cardiomyopathy and viral myocarditis, associated with COVID-19, have been described in the non-pregnant population [1]. However, there is limited literature related to cardiovascular sequelae of COVID-19 parturients [2]. We present a case of suspected COVID-19associated cardiomyopathy in a parturient and the multidisciplinary approach to achieve a safe Caesarean delivery. The patient gave written HIPAA authorization to write this case report.

Discussion
There is limited data on critically ill parturients with COVID-19, and COVID-19-related cardiomyopathy in pregnancy is even less well understood. This case highlights the additional challenge of diagnosing cardiomyopathy presenting in pregnancy. Because of the antenatal presentation, the temporal relationship to the prior COVID-19 infection and the normal BNP values, the authors felt this case of cardiomyopathy was related to COVID-19 versus peripartum cardiomyopathy or related to preeclampsia.
The clinical course of COVID-19 infection in pregnancy follows a trend similar to the general population with 86% of infections being mild, 9.3% severe, and 4.7% critical [4].
A multicenter study examined the clinical course of severe and critically ill pregnant patients with COVID-19 in the United States and found that 69% of patients admitted to the hospital had a severe course and 31% a critical course [5].
They reported one case of maternal cardiac arrest but no cases of cardiomyopathy. There is one prior report of two cases of COVID-19 related cardiomyopathy in pregnancy, where those two patients presented acutely with respiratory illness [2].
In a single center study in China, 19% of COVID-19 patients had evidence of myocardial injury, while a US case series revealed cardiomyopathy in 33% of patients with COVID-19 [6,7]. The presence of myocardial injury has also recently been documented in patients who recovered from COVID-19 illness, as in our patient. Indeed, severe myocarditis related to COVID-19 presents 2-3 weeks following initial infection [8]. Cardiac MRI studies suggest high prevalence of persistent cardiac involvement and infl ammation even two months after initial diagnosis [9]. It is hypothesized that myocardial injury in SARS-CoV2 infection is related to an infl ammatory response with hypercoagulability, downregulation of ACE-2 receptors, and increased circulating catecholamines [10]. Hypoxemia in the setting of diminished pulmonary function can exacerbate myocardial injury which may present as decompensated heart failure, myocardial infarction, and arrhythmia.
Physiologic changes of the cardiovascular, respiratory, and immune system during pregnancy increase the risk of severe infection. However, the outcomes of SARS-CoV2 infections in pregnancy are more favorable compared to SARS or MERS infections (case fatality rate of 0%, 18%, and 25% respectively) [11]. Nonetheless, it is unclear if pregnant patients with COVID-19 and multiple risk factors for cardiovascular disease are at higher risk of myocardial injury, hypertensionassociated heart failure, or peripartum cardiomyopathy. It is also unclear if hypertensive disorders predispose to or exacerbate myocardial injury related to COVID-19 similarly to peripartum cardiomyopathy [12]. With an EF of 38%, our patient is classifi ed as modifi ed World Health Organization class III with a maternal cardiac event rate of 19-27% [13]. The management of COVID-19-related cardiomyopathy is unclear. Patients at risk for cardiovascular disease in pregnancy should be managed by a multidisciplinary team (Obstetrician, Cardiologist and Anesthesiologist at a minimum) at an expert center. Patients with peripartum cardiomyopathy must be counseled on the possibility of recurrence of cardiomyopathy in subsequent pregnancies, even after full recovery. Induction of labor should be considered at 40 weeks gestation for all patients with cardiac disease [13]. Pulse oximetry and continuous electrocardiogram monitoring are recommended. An arterial line allows for continuous monitoring and quick responses to interventions and events. Epidural anesthesia can be used for labor as well as Cesarean delivery but should be carefully titrated in the setting of decreased ventricular function. In this case, a CSE was placed in the sitting position with continuous hemodynamic monitors that allowed for careful titration of medication in response to anticipated hemodynamic changes.
Intravenous fl uids must also be carefully managed.
As vaccination efforts improve, hopefully fewer pregnant patients will present with COVID-19 infections or be diagnosed as asymptomatic carriers when presenting to labor and delivery.