Accomplice or bystander? The role of COVID-19 in a case of peripartum cardiomyopathy

Background: Peripartum cardiomyopathy (PPCM) is a rare cardiomyopathy with systolic dysfunction that presents in late pregnancy. A number of coronavirus disease 19 (COVID-19)-related myocarditis cases have been reported. In a pandemic situation, the coexistence of COVID-19 and PPCM can be relatively frequent, making it difficult to assess the weight of the individual components on the heart condition. Case Presentation: A 34-year-old girl develops COVID-19 at the 31st week of pregnancy. In the following 2 weeks she recovered and, after 4 days from the disappearance of symptoms, she gave birth without complications. Three weeks after delivery she presented to the ED with worsening dyspnea and elevated troponine and BNP values. Echocardiogram showed severe biventricular systolic dysfunction, mitral regurgitation, pulmonary hypertension and biventricular thrombosis. She was treated with oxygen, diuretics, heparin and transferred to our center. Cardiac MRI showed dilation and severe biventricular dysfunction with positive LGE and T1 mapping values diffusely increased. A treatment with betablockers, Sacubitril/valsartan, anti-aldosterone drugs, ivabradine and bromocriptine was started. An Endomyocardial biopsy (EMB) was performed showing a picture consistent with dilated cardiomyopathy and a final diagnosis of peripartum cardiomyopathy was made. However, after a few days the molecular biology report arrived showing EMB positivity for Sars-Cov-2 and Parvovirus B19. The patient was discharged and after 6 months she is well and a control MRI showed complete recovery of biventricular systolic function. Discussion: Cardiovascular complications of COVID-19 are well known and cases of related myocarditis have been reported. Anatomopathological and biopsy studies show the presence of Sars-Cov-2 in the heart of a significant number of patients with COVID-19, however the virus is often found at the interstitial level, suggesting in most cases more an endothelial localization than a real invasiveness of cardiomyocytes. It is not impossible that a patient with PPCM could be simultaneously affected by Sars-Cov-2. Only a multidisciplinary clinical, imaging, histological, functional evaluation and a congruent follow-up can help to understand the weight of the single etiological components on cardiac dysfunction. Conclusions: We described a case of a patient with PPCM and concomitant cardiac localization of COVID-19 with severe acute biventricular dysfunction. (Figure Presented).