Клинические и морфологические особенности повреждения миокарда и течения фульминантного миокардита на фоне СOVID-19, диагностика и тактика лечения

In a review article based on my own clinical experience of managing patients with acute myocardial injury and fulminant myocarditis, taking into account expert recommendations on the clinical treatment of myocardial damage associated with novel coronavirus infection a National clinical geriatric medical research center, division of cardiovascular diseases, the Chinese geriatrics society, Department of cardiology, Beijing Medical Association and European clinics discusses the pathogenesis, diagnosis and treatment of myocardial damage and FM patients, infected with SARS-CoV-2 in the context of the COVID-19 pandemic. Clinical features and diagnostic criteria are presented, including screening tests of markers of myocardial damage in the form of a highly sensitive troponin test, a natriuretic peptide. The article discusses in detail the pathogenesis and mechanisms of myocardial damage, including immune mechanisms, cytokine storm, systemic inflammation with macro- and microvascular dysfunction and the development of myocardial dysfunction with acute heart failure, hypotension, cardiogenic shock and/or life-threatening heart rhythm disorders caused by hypoxia and metabolic disorders at the cellular level. Features of the clinical course of fulminant myocarditis in infected patients (SARS-CoV-2) in the conditions of the COVID-19 pandemic are presented. For the first time, a detailed histo-morphological analysis of pathological myocardial injuries and complications is presented on the basis of unique autopsy material on post-mortem diagnostics of various pathoanatomic autopsies of those who died from COVID-19 in Moscow. Based on the clinical, functional and morphological material, the Protocol of etiopathogenetic treatment is presented. The basis of standard therapy is considered antiviral drugs, immunoglobulin G, the use of monoclonal antibodies to interleukin-6, anticoagulants, glucocorticoids, depending on the clinical situation, cardioprotectors and symptomatic treatment are recommended to maintain the heart, which in combination can achieve a certain clinical effectiveness. As adjuvant cardioprotective targeted therapy, the sodium salt of phosphocreatine is considered in order to preserve the myocardium, maintain its contractility and vital activity.В обзорной статье обсуждаются вопросы патогенеза, диагностики и лечения повреждения миокарда и фульминантного миокардита у больных, инфицированных SARS-CoV-2, в условиях пандемии COVID-19. Представлены клинические особенности и диагностические критерии, включающие скрининговые тесты маркеров повреждения миокарда в виде высокочувствительного тропонинового теста, натрийуретического пептида. Детально обсуждаются вопросы патогенеза и механизмы повреждения миокарда, включающие иммунные механизмы, цитокиновый шторм, системное воспаление с макро- и микроваскулярной дисфункцией и развитием дисфункции миокарда с острой сердечной недостаточностью, гипотензией, кардиогенным шоком и/или жизнеугрожающими нарушениями ритма сердца, обусловленные гипоксией и метаболическими нарушениями на клеточном уровне. Представлены особенности клинического течения фульминантного миокардита у больных, инфицированных SARS-CoV-2, в условиях пандемии COVID-19. Впервые представлен детальный гистоморфологический анализ патологических повреждений миокарда и осложнений на основе уникального аутопсийного материала по посмертной диагностике многообразных патологоанатомических вскрытий умерших от COVID-19 в Москве. На основании клинико-функционального и морфологического материала представлен протокол этиопатогенетического лечения. В зависимости от клинической ситуации для поддержания работы сердца в качестве метаболической адъювантной кардиопротективной таргетной терапии рассматривается натриевая соль фосфокреатина с целью поддержания сократительной способности и жизнедеятельности миокарда. Для улучшения прогноза у больных с COVID-19, перенесших острое повреждение миокарда, фульминантный миокардит, в протокол лечения рекомендовано введение кардиопротективной терапии, которая в комбинации со стандартной терапией позволяет достичь клинической эффективности

Features of the cell composition of inflammatory infiltrate in different phases of diffuse alveolar lung damage with COVID-19

Background. Acute respiratory distress syndrome (ARDS) with COVID-19 has a worse prognosis than ARDS with other diseases. Mortality from ARDS with COVID-19 is 26.0 — 61.5%, and due to other causes — 35.3—37.2%. Objective. To find of the correlation between polymorphonuclear leukocytes (PMNs), lymphocytes, and macrophages in the cellular composition of the inflammatory infiltrate at different stages and phases of diffuse alveolar damage (DAD) with COVID-19, analyzing the autopsy material. Material and methods. The lung tissue of 25 patients who died from ARDS with COVID-19 without a secondary bacterial or mycotic infection, another thanatologically significant pathology of the lungs, was studied. To study the cellular composition of the inflammatory infiltrate and the dynamics of its changes a double immunohistochemical analysis of the expression of antibodies to CD15, CD3, and CD68 was used. Results. The inflammatory infiltrate and intraalveolar exudate in the exudative phase of DAD was represented by 56.8% of PMNs (CD15-positive cells; hereinafter — the average value of the percentage of positive cells to the total number of cells of the inflammatory infiltrate), 6.9% — lymphocytes (CD3-positive cells) and 19.5% macrophages (CD68-positive cells). In the early stage of the proliferative phase: 14.1% PMNs, 38.7% lymphocytes and 13.5% macrophages. In the late stage of the proliferative phase: 11.3% PMNs, 14.5% lymphocytes and 39.3% macrophages. Conclusions. In the exudative phase of DAD a statistically significant predominance of PMN was revealed, which could determine the main volume of lung damage and the severity of ARDS with COVID-19. In the early stage of the proliferative phase of DAD, a statistically significant change in the composition of the inflammatory infiltrate was revealed to compare with the exudative phase: a significant decrease in the content of PMNs relative to the total number of cells in the inflammatory infiltrate; an increase in the number of lymphocytes, which is probably associated with the start of organization and repair processes. In the late stage of the proliferative phase of DAD, compared with its early stage, was revealed a statistically significant increase in the number of macrophages in ratio. © 2022, Media Sphera Publishing Group. All rights reserved