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Fulminant Myocarditis Temporally Associated with COVID-19 Vaccination

  • Myocardial Disease (A Abbate and M Merlo, Section Editors)
  • Published:
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Abstract

Purpose of Review

Coronavirus disease-2019 (COVID-19) vaccines have been related to rare cases of acute myocarditis, occurring between 1 in 10,000 and 1 in 100,000 individuals, approximately. Incidence of COVID-19 vaccine-associated myocarditis varies with age, sex, and type of vaccine. Although most patients with acute myocarditis temporally associated with COVID-19 vaccines have an uneventful course, a small subpopulation presents with cardiogenic shock (termed fulminant myocarditis [FM]). This review explored the prevalence, clinical presentation, management, and prognosis of COVID-19 vaccine-associated acute myocarditis, specifically focusing on FM and comparing patients with fulminant versus non-fulminant myocarditis.

Recent Findings

Cases of FM represent about 2–4% (0 to 7.5%) of COVID-19 vaccine-associated acute myocarditis cases, and mortality is around 1%, ranging between 0 and 4.4%. First, we identified 40 cases of FM up to February 2023 with sufficient granular data from case reports and case series of COVID-19 vaccine-associated acute myocarditis that occurred within 30 days from the last vaccine injection. This population was compared with 294 cases of non-fulminant acute myocarditis identified in the literature during a similar time. Patients with FM were older (48 vs. 27 years), had a larger proportion of women (58% vs. 9%), and mainly occurred after the first shot compared with non-fulminant cases (58% vs. 16%). The reported mortality was 27% (11 out of 40), in line with non-vaccine-associated fulminant myocarditis. These data were in agreement with 36 cases of FM from a large Korean registry. Herein, we reviewed the clinical features, imaging results, and histological findings of COVID-19 vaccine-associated fulminant myocarditis.

Summary

In conclusion, COVID-19 vaccine-associated FM differs from non-fulminant forms, suggesting potential specific mechanisms in these rare and severe forms. Mortality in vaccine-associated FM remains high, in line with other forms of FM.

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Abbreviations

AM:

Acute myocarditis

CMRI:

Cardiac magnetic resonance imaging

COVID-19:

Coronavirus disease 2019

EMB:

Endomyocardial biopsy

FM:

Fulminant myocarditis

HTx:

Heart transplantation

IL-1RA:

Interleukin-1 receptor antagonist

IRR:

Incidence rate ratio

LGE:

Late gadolinium enhancement

LVEF:

Left ventricular ejection fraction

MCS:

Mechanical circulatory support

MYTHS:

MYocarditis THerapy with Steroids

NSAIDs:

Non-steroidal anti-inflammatory drugs

SCD:

Sudden cardiac death

VA-ECMO:

Venous arterial extracorporeal membrane oxygenator

VAERS:

Vaccine Adverse Event Reporting System

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Funding

Dr. Ammirati received a grant from the Italian Ministry of Health (GR-2019–12368506; principal investigator of the investigator-driven MYTHS [Myocarditis Therapy with Steroids] trial) and a grant from the European Union, NextGenerationEU - Mission 6/ Component 2 / Investment 2.1 /PNRR - CUP H43C21000140006 (PNRR-MAD-2022–12376225) and is a consultant for Kiniksa, Cytokinetics and AstraZeneca. Dr. Conti is supported by the Italian Ministry of Health grant GR-2019–12368506. Dr. Palazzini has been supported by the Italian Ministry of Health grant GR-2019–12368506, and he is supported by the Italian Ministry of Health and NextGenerationEU, PNRR-MAD-2022–12376225.

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Authors and Affiliations

  1. De Gasperis Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Transplant Center, Milan, Italy

    Enrico Ammirati, Nicolina Conti, Matteo Palazzini & Andrea Garascia

  2. Department of Health Sciences, University of Milano-Bicocca, Monza, Italy

    Enrico Ammirati

  3. Cardiovascular Department, Association Socio Sanitary Territorial Santi Paolo e Carlo, Milan, Italy

    Matteo Rocchetti, Andrea Spangaro & Alberto Cereda

  4. Institute of Cardiology, Spedali Civili di Brescia and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, Azienda Socio-Sanitaria Territoriale (ASST), University of Brescia, Brescia, Italy

    Laura Lupi

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Contributions

E.A., N.C., M.P., M.R., A.S., L.L., and A.C. wrote the main manuscript text E.A. prepared Figure 1. A.G. reviewed and edited the manuscript text. N.C., M.P., M.R., A.S., and A.C. prepared the tables. All Authors reviewed the manuscript.

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Correspondence to Enrico Ammirati.

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Ammirati, E., Conti, N., Palazzini, M. et al. Fulminant Myocarditis Temporally Associated with COVID-19 Vaccination. Curr Cardiol Rep 26, 97–112 (2024). https://doi.org/10.1007/s11886-024-02021-w

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