Two Fatal Cases of Stress-induced Cardiomyopathy in COVID-19 Patients

A 78-year-old woman presented with fever and sore throat for the previous 7 days. She was admitted to another hospital due to worsening dyspnea. Initial vital signs at admission were as follows: blood pressure, 114/76 mmHg, heart rate, 112 beats/min; respiratory rate, 24 breaths/min; and body temperature, 38.4°C. After admission, her systolic blood pressure dropped to 80 mmHg and her oxygen saturation was 60%. She was transferred to the intensive care unit and treated with a ventilator. Then, the patient was transferred to our hospital for further treatment. Initial chest X-ray showed diffuse infiltration of whole lung fields (Figure 1A). The electrocardiogram showed sinus rhythm with right bundle branch block, and initial echocardiography was normal LV systolic function without regional wall motion abnormality. Because her oxygen requirement worsened after admission, the attending physician decided to apply a veno-atrial type extracorporeal membrane oxygenator (ECMO). On the second hospital day, new T wave inversion appeared (Figure 1B), and transthoracic echocardiographic examination showed apical ballooning with severe LV systolic function (Figure 1C and D, Movie 1). Her troponin-I was 277.2 pg/mL (reference, 2.3–17.5 pg/mL) and N terminal pro B-type natriuretic peptide was 2,033 pg/mL (reference, < 314 pg/mL). She was treated with antiviral agents and an ECMO with supportive care, and apical ballooning disappeared after 7 days. Although the attending physician tried to remove the ECMO and ventilator, the patient died with worsening stiffness of the lung on her 54th hospital day.

Figure 1
The initial chest X-ray shows diffuse infiltration of whole lung fields (A). Electrocardiogram taken on the second hospital day demonstrates T wave inversion on the precordial leads (V1–V5, B), and transthoracic echocardiographic examination reveals apical ballooning with severe left ventricular systolic function (C: parasternal long axis view, and D: apical 4 chamber view; Movie 1).

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A 73-year-old woman presented with fever and cough for the previous 13 days. She was previously healthy without underlying cardiovascular disease. Initial vital signs at admission were as follows: blood pressure, 148/78 mmHg, heart rate, 70 beats/min; respiratory rate, 28 breaths/min; and body temperature, 37.6°C. Her chest X-ray showed the typical diffuse ground-glass appearance that suggests viral pneumonia (Figure 2A), and computerized tomographic examinations revealed diffuse infiltration of bilateral lung fields (Figure 2B). After admission, her systolic blood pressure dropped to 54 mmHg, and her heart rate was reduced to 43 beats/min. The echocardiographic examination demonstrated apical ballooning with dyskinetic movement and severe LV systolic dysfunction (Figure 2C and D, Movie 2). Her troponin-I was increased from 30.4 pg/mL to 1,037.9 pg/mL, and creatine kinase-MB type was elevated from 0.8 ng/mL to 6.7 ng/mL (reference, < 6.2 ng/mL). The patient died after 3 days due to profound hypotension despite intensive care with ventilator therapy.

Figure 2
The initial chest X-ray demonstrates the typical diffuse ground-glass appearance that suggests viral pneumonia (A), and the computerized tomographic examinations show diffuse infiltration of bilateral lung fields (B). The echocardiographic examination reveals apical ballooning with dyskinetic movement and severe left ventricular systolic dysfunction (C: apical 4 chamber view, and D: apical 2 chamber view; Movie 2).

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Movie 1

Echocardiographic examination of case 1.

Movie 2

Echocardiographic examination of case 2.