The autopsy results of two people who died of post-vaccine myocarditis were described in an important article. I think that these two deaths were tragic, and I call for calm in the wake of this article. I would like to explain the nature of the analysis presented in this article, which is intended for healthcare workers to figure out why COVID vaccine is associated with myocarditis.
The authors collaborated with the Connecticut State Medical Examiner's office and several universities to analyze the hearts of two teenagers who were found dead three and four days after they received the vaccine. Due to the limitations of federal law, the desires of families, the lack of resources, and the actual absence of real pathologists in some medical examiner offices, only very few autopsy reports are available. The shortage of board certified pathologists is a very serious issue that deserves its own article, but we should focus on myocarditis here.
Here is a partial list of the causes of myocarditis.
The research group looked at the hearts by eye, basic testing, and by microscope slides. One boy was normal weight and the other was obese, and the heart of the first boy was of normal size and appearance. The large and dilated heart of the second boy is a red flag to the cardiologist that something happened long before the present time. Why long before? The text on heart disease in infants, children, and adolescents states that myocarditis is not capable of causing significant heart damage in a few days or weeks.
The boys had no obvious symptoms and were found dead. While there are mechanisms by which this may happen, professional cardiologists know that there is not enough evidence to say that myocarditis was the cause of death. An overnight EKG documenting an arrhythmia is needed. An example of a situation where there is enough proof to prove the cause of cardiac arrest is commotio cordis, where a baseball player is hit by a baseball on his or her chest specifically near the heart.
Figure 1. The mechanism of Commotio cordis. There is a citation about the AHA.
Both children had no evidence of prior COVID infections, and the next part of the analysis was a microscope. There were findings of inflammation with histiocytes with the first child. He was tested for two genetic defects of unknown significance. The second child's cellular findings supported the diagnosis of myocarditis in both cases. The authors concluded that stress cardiomyopathy was likely present in these children because of their specific pattern of injury. If compared to classical myocarditis findings, the cellular findings in these cases were unusual.
Things get more controversial at this point. I will mostly be editorializing based on what I know about cardiology in the rest of this analysis. The report should be used to give ideas to future investigators to eventually get us to a definitive answer. The report doesn't identify the cause of myocarditis solely by the slides presented. I would love for there to be a complete analysis, but time and resources are not always available.
Readers may have heard of Takotsubo cardiomyopathy, a disorder in which the heart is shaped like a Japanese octopus trap.
The Wikimedia Commons has a schematic diagram of a heart suffering from Takotsubo cardiomyopathy.
After a lot of life stressors, the left ventricle of the heart balloons out and contracts poorly, which is classically seen. Older adults and women are more likely to have takotsubo cardiomyopathy. The general public doesn't know that we give catecholamine to heart surgery patients nearly all the time to support heart function, sometimes for several days, and the recipients don't all go on to develop. The findings shown should not be taken into account.
In a few days, dilated ventricles and extensive fibrosis do not develop. These problems are usually the result of weeks or months of the heart trying to heal after being damaged. Fibrosis means tissue replacement with scar tissue that can't contract and can't help pump blood. The process could be a genetic cardiomyopathy, myocarditis, or an inborn error of metabolism. There are many viruses that could have been bad actors. These children were killed by a heart rhythm problem that could have been caused by any of these processes. None of these processes require vaccinations.
They mention genetic tests. The classic example of a problematic heart is hypertrophic cardiomyopathy, which is caused by a genetic flaw. The heart has become thick because of a genetic flaw. The first teen's heart appeared normal, but the second teen's heart was large and dilated. The first teen described a few genes but they weren't well-studied enough to know what they meant. When we are asked to figure out why a child has a large and poorly functioning heart, this happens all the time. Sometimes we get normal gene tests in hearts that are malfunctioning. One of the most common ways that children come to us as children's cardiologists for diagnosis is by looking into their own heart health. The diagnosis may be subtle, and the two people who died had no prior medical records. It is very common for dilated cardiomyopathy and myocarditis to have minimal symptoms until the heart starts having trouble meeting daily needs. It is difficult to figure out why a bad heart is a bad heart.
The authors did not mention an analysis of the conduction system, which could have given valuable insight as to the cause of any potential end-stage heart rhythm disorder.
We don't report blood analyses of frozen samples because they could have advanced our understanding of the disorder. The science of detecting specific cell types using certain molecule that glow in the dark is called immunodeficiency. Only a few hospitals have the ability to run these.
The data doesn't support reporting that these children died of postvaccine myocarditis. More analysis is needed. Cardiomyopathies of other types could have been involved in the pathological findings. This should serve as a stepping stone for other investigators to perform more in-depth analyses, as it is not yet possible to make sweeping conclusions based on this paper alone.
What are our options and recommendations based on the knowledge added by these two deaths? My opinions are based on evidence.
The cause of postvaccine myocarditis is unknown, but the immunology community has a few ideas. The majority of patients who sustain post-vaccine myocarditis do well, and the treatment regimen for myocarditis has an extremely long track record of safety. Greater collaboration between immunologists, cardiologists, and pathologists could help us get some definitive answers on why this happens and how to decrease the risk in future mRNA vaccination technologies, which are currently being conducted for other diseases.
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