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Syracuse offensive lineman Airon Servais had questions about the potential effects of myocarditis. He had heard about it in the news, as the Big Ten utilized a study showing its link to COVID-19 to justify the postponement of its fall season. Before opting into the 2020 season, he talked to multiple cardiologists to understand its effects.

“After having conversations like that, I feel a lot more comfortable moving forward,” Servais said.

Dr. Michael Ackerman is a genetic cardiologist at Mayo Clinic. He specializes in genomics and genotype-phenotype relationships in heritable cardiovascular diseases leading to sudden death. This includes myocarditis, which is an inflammation of the heart that’s linked to COVID-19. Ackerman answered The Daily Orange’s questions about its risk to athletes. 

The Daily Orange: How is myocarditis linked to COVID-19 and what are the concerns with it?

Dr. Michael Ackerman: There are thousands of diagnoses of myocarditis in the United States each year before COVID. It’s a big deal. It’s the third-leading cause of sudden death in young people. Each year, there will be about 50 to 100 athletes from Little League to (the) professional level who will die suddenly. Of those, five to 10 of them will have died from myocarditis. We know what causes this inflammation of the heart muscle, which can lead to weakening of the heart muscle and heart failure.

D.O.: Are there any other viruses that can cause myocarditis?

M.A.: Yes, there are. Long before coronavirus, there are over 20 viruses that have been implicated with the ability for this kind of heart damage that we call myocarditis. We know that almost half, around 40% to 50%, of all cardiac transplant recipients require transplants because of the damage done by myocarditis. It is a very important entity but it is one that has been around long before coronavirus. This virus is yet another virus with the capability of infecting the heart muscle and potentially damaging the heart muscle. It’s created even more anxiety during this COVID-19 pandemic.

D.O.: How does this apply to young and healthy athletes who don’t have pre-existing conditions?

M.A.: For those individuals who are asymptomatic or minimally symptomatic, this myocarditis thing is a non-issue. That’s because the virus hasn’t reached or done any damage to that viral infected person. It’s a very small number of otherwise healthy young people where the viral infection of SARS-CoV-2 is going to reach the heart, penetrate the heart, or do any measurable damage. Myocarditis taking center stage with athletes and discussing athletes risk is probably a bit overstated.

Dr. Michael Ackerman of the Mayo Clinic said that athletes who have myocarditis will likely be sidelined for about three months. Courtesy of SU Athletics

D.O.: What happens if an athlete gets SARS-CoV-2 myocarditis?

M.A.: If someone gets SARS-CoV-2 myocarditis, it’s potentially a big deal. But any other potential viral myocarditis is also a big deal. If there’s a substantial level of heart damage rendered, we could be talking (about) life-support devices and cardiac transplantation. That is so much the exception, rather than the rule in any myocarditis. This coming flu season, influenza can infect and damage the heart muscle. It’s really a matter of perspective and weighing everything in the balance. 

D.O.: The Big Ten is using a study that said, “High sensitivity Troponin — a sensitive marker for cardiac cellular injury — was detected in 71% of the patients, and cardiac MRI revealed evidence of cardiac inflammation and/or scarring in 78% of the patients.” You’re not an athletic director or a school president, but what is your reaction to them using that study to justify canceling the season?

M.A.: Conferences who cancel the season may have very good reasons for doing so. If they sized up the weight of the evidence and said to stop for now, that’s justifiable. Other conferences say, “We’ve weighed everything in the balance and we’re going to press on carefully, but we can switch to no again if need be.” Both of those decisions can be equally right or appropriate. My point was to ask officials to look under the hood to see if there’s enough evidence in relation to the heart. 

In other words, if the conference received enough evidence to say that we reached a tipping point because of a heart issue, then I cry foul. Look under the hood. Look at the strength of the evidence. If you look carefully enough, there’s simply not enough evidence to assign that much weight to COVID-19 and the heart as the driving reason for a season termination. If the conference said, “Even if we removed the heart issue, we would have agreed to cancel,” I would’ve said, ‘Great.’ I’m not an expert for those reasons, so I can’t speak on it.

D.O.: We’ve seen examples of players, like Georgia State freshman quarterback Mikele Colasurdothe, who sit out after a COVID-19 and myocarditis diagnosis. Is myocarditis something that stays with you forever or does it eventually go away?

M.A.: There will be many athletes this fall and even after coronavirus is done that get myocarditis, so we know the drill as sports cardiologists. If you come down with clinical myocarditis, we then do tests and see that the heart is involved. At that point, no matter what the cause for the athlete getting myocarditis, that athlete is shut down for about three months. That’s by guidelines that have been vetted long before coronavirus. 

The whole point of the three months is to make sure the virus has run its course, to make sure whatever heart abnormality had normalized and reversed so that the heart looked essentially stable again. That’s true whether it was influenza (flu), the adenovirus (common cold) or whether it’s now SARS-COVID-2. 

What’s now becoming a problem is that an athlete tests positive for COVID but they otherwise feel fine. Because of the added concern around myocarditis, we’re now more likely to give them a cardiac MRI, for which that MRI might light up and show “abnormal findings.” So then we put them in the penalty box, even though they have no symptoms. If we hadn’t done it, we may have never known about these findings. In other words, we’re being more cautious and conservative than we need to be. We don’t get a cardiac MRI during flu season if an athlete catches the flu and shows no symptoms of myocarditis. We don’t know what happens two weeks after influenza, two weeks after the common cold as to the number of asymptomatic people that might show a cardiac MRI finding.

This interview has been lightly edited for brevity and clarity. 

Published on September 2, 2020 at 11:51 pm

Contact Adam: adhillma@syr.edu | @_adamhillman