Echocardiographic features of COVID-19 patients without significant baseline cardiovascular disease.

Objective. To assess the relationship between the severity of COVID-19 in patients without significant baseline cardiovascular pathology and various echocardiographic parameters of myocardial dysfunction. Material and methods. 46 patients with COVID-19 were included in our study: 33 patients of moderate severity and 13 - with severe disease. On days 1 and 9 upon admission, all patients underwent an echocardiographic study with standard assessment of the both ventricles function, as well as an assessment of their global longitudinal strain (GLS). Comparison of the studied parameters was carried out both between groups of patients and within each group in dynamics. Results. On day 1patients in the severe group had higher values of the systolic gradient on the tricuspid valve (22.0 [21.0;26.0] vs 30.0 [24.0;34.5] mm Hg, p = 0.02), systolic excursion of the plane of the tricuspid ring (2.3 [2.1;2.4] vs 2.0 [1.9;2.2] mm, p = 0.016), E/e' ratio (9.5 [7.7;8.9] vs 7.5 [6.8;9.3], p = 0.03). At day 9 among patients in the severe group, there was a decrease in end-diastolic (111.0 [100.0;120.0] vs 100.0 [89.0;105.0] ml, p = 0.03) and of end-systolic (35.5 [32.0;41, 2] vs 28.0 [25.0;31.8] ml, p < 0.01) volumes of the left ventricle. There was a decrease in GLS of the both ventricles compared to general accepted values. In dynamics, there was an increase in the GLS of the right ventricle in both groups, but it was more pronounced among severe group of patients (day 1 -18.5 [-15.2;-21.1] vs -20.2 [-15.8.1;-21.1] %, p = 0.03). The troponin levels were in the normal range. Conclusion. In COVID-19 patients without significant baseline cardiovascular pathology, there is a transient decrease in longitudinal strain of both ventricles, even in the absence of clinical and laboratory signs of acute myocardial injury.Copyright © Creative Cardiology 2021.

Multisystem Inflammatory Syndrome in Children Requiring ECMO: Anticoagulation strategies and Lessons Learned

Intro: Multisystem Inflammatory Syndrome in Children (MIS-C) is a post-infectious inflammatory response after exposure to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) which can cause acute cardiac dysfunction requiring mechanical circulatory support (MCS). MCS utilization for MIS-C is complicated by a propensity for thrombosis, which threatens circuit integrity. This study describes a cohort of MIS-C patients requiring MCS, their outcomes, and the anticoagulation strategies utilized. Method(s): A retrospective case series of patients diagnosed with MIS-C needing veno-arterial extracorporeal membrane oxygenation (VA-ECMO) at Children's Healthcare of Atlanta from March 1, 2020 to June 30, 2022. VA-ECMO variables, laboratory data, complications, and outcomes were collected. Result(s): Seven patients (all male) with severe MIS-C required VA-ECMO for acute cardiac dysfunction. Median age was 13 years (range 4-15 years). Median ICU stay was 13 days (range 6-17 days) with a median ECMO duration of 7 days (IQR 3-8 days) and median mechanical ventilation duration of 8 days (IQR 5-11 days). All seven patients survived to hospital discharge with good neurologic outcomes. Median time to qualitatively normal ventricular function by echocardiogram was 9.5 days (IQR 3-21 days). Heparin was initially used in 6 patients, bivalrudin initially used in 1 patient, and 1 patient converted from heparin to bivalirudin for refractory systemic thrombosis. Median heparin dose was 206u/kg/d (IQR 192-276u/kg/d) with median anti-Xa levels of 0.75 (IQR 0.1-1.1) and median daily PTT 102 seconds (IQR 83-107 seconds). Median daily PTT of patients receiving bivalirudin was 86 seconds (80-93 seconds). Median R-values by thromboelastography were 38 seconds (IQR 25-55 seconds). Two patients required catheter directed thrombolysis with tissue plasminogen activator (t-PA) for refractory intracardiac thrombi, both were initially started on heparin. Significant cannula thrombosis occurred in 2 patients, 1 initially started on heparin and 1 initially on bivalrudin. Bleeding resulting in compartment syndrome occurred in one patient on heparin requiring fasciotomy of the upper extremities, this patient was not receiving t-PA. Conclusion(s): Anticoagulation management for MIS-C patients requiring ECMO is fraught with challenges. A successful management strategy may necessitate higher heparin assay levels, the use of direct thrombin inhibitors for refractory thrombosis, and the deployment of catheter directed thrombolysis. In this case series, CDT was safely and successfully used in two patients. Further studies are required to understand the optimal anticoagulation strategy for these patients to minimize complications.

Venovenous extracorporeal membrane oxygenation and late ductal stenting for infant with transposition of the great arteries, pulmonary stenosis and SARS, -CoV-2 pneumonia

Introduction: The SARS-CoV-2 pandemic has affected medical decision-making in all practice areas, including the pediatric cardiac intensive care unit (CICU), sometimes necessitating the use of innovative management strategies. Venovenous extracorporeal membrane oxygenation (VV-ECMO) and, particularly, late ductal stenting are infrequently applied interventions in the CICU. Here we present a critically ill infant with d-transposition of the great arteries (d-TGA), ventricular septal defect (VSD), pulmonary stenosis (PS), and patent ductus arteriosus (PDA), in which VV-ECMO and late ductal stenting were utilized successfully in the setting of active SARS-CoV-2 infection to treat worsening PS and pulmonary venous desaturation, thereby delaying surgical intervention and its associated risks during active infection. Case Description: A 3 month old male with d-TGA, VSD, and PS, initially managed with a balloon atrial septostomy at birth, was admitted to the CICU after presenting with respiratory distress and hypoxemia. He was found to be SARS-CoV-2 positive, requiring only nasal cannula initially. Admission echocardiogram demonstrated known d-TGA, VSD, severe pulmonary stenosis (peak gradient 95-110mmHg), unrestrictive atrial communication, and preserved systolic function. A tiny, hemodynamically insignificant PDA was also noted. While admitted, the patient exhibited intermittent, severe desaturations requiring escalating respiratory support. He was started on a prostaglandin infusion with aim to promote additional pulmonary blood flow through the PDA, thereby limiting the severity and frequency of desaturations. However, the patient ultimately became severely hypoxemic, despite multiple interventions to improve oxygenation. Echocardiogram at this time demonstrated preserved ventricular function, so the decision was made to escalate to VVECMO therapy. Following ECMO cannulation, the patient's hypoxemia quickly resolved, and he remained hemodynamically stable. Given the persistence of his PDA and the desire to avoid the risks of cardiac surgery in the setting of acute COVID infection, percutaneous intervention to augment pulmonary blood flow was attempted. Despite its diminutive size, his PDA was able to be successfully cannulated and stented the day after ECMO initiation. He was able to be quickly weaned from ECMO support and was decannulated the following day. He was subsequently extubated and ultimately discharged home with planning for definitive surgical intervention underway. Discussion(s): Here we present an interesting case of an infant with d-TGA, VSD, PS, and PDA in which VV-ECMO and PDA stenting were successfully applied to treat acute hypoxemia in the setting of SARS-CoV-2 infection and severe pulmonary stenosis. These therapies may be considered in appropriate patients for whom the risks of cardiac surgery are significant.

Profile of Cardiac Involvement in Children After Exposure to COVID-19

OBJECTIVE: To evaluate the incidence and pattern of cardiac involvement in children post-COVID (coronavirus disease) infection in a tertiary care referral hospital in India. METHOD(S): A prospective observational study was conducted including all consecutive children with suspected MIS-C referred to the cardiology services. RESULT(S): Of the 111 children with mean (SD) age was 3.5 (3.6) years, 95.4% had cardiac involvement. Abnormalities detected were coronary vasculopathy, pericardial effusion, valvular regurgitation, ventricular dysfunction, diastolic flow reversal in aorta, pulmonary hypertension, bradycardia and intra-cardiac thrombus. The survival rate post treatment was 99%. Early and short-term follow-up data was available in 95% and 70%, respectively. Cardiac parameters improved in majority. CONCLUSION(S): Cardiac involvement post COVID-19 is often a silent entity and may be missed unless specifically evaluated for. Early echocardiography aided prompt diagnosis, triaging, and treatment, and helps in favorable outcomes.

Dynamics of global and segmental strain as a marker of right ventricular contractility recovery in patients after COVID-19 pneumonia.

Aim. To study the changes of morphological and functional right ventricular (RV) parameters depending on the severity of coronavirus infection 2019 (COVID-19) pneumonia over long-term follow-up. Material and methods. A total of 200 patients (men, 51,5%, mean age, 51,4+/-10,9 years) were examined at 2 control visits (3, 12 months after receiving two negative polymerase chain reaction tests). Patients were divided into following groups: group I (n=94) - lung tissue involvement >=50% according to inhospital chest computed tomography (chest CT), group II (n=106) - lung tissue involvement <50% according to chest CT. Results. The groups were comparable in key clinical and functional parameters 3 months after COVID-19 pneumonia. Speckle tracking echocardiography (STE) revealed a significant increase in following global longitudinal strain (LS) parameters: RV free wall endocardial LS (-22,7+/-3,2% and-24,3+/-3,8% in group I, p<0,001;-23,2+/-3,5% and-24,5+/-3,4% in group II, p<0,001), and RV endocardial LS (-21,0+/-3,1% and-22,5+/-3,7% in group I, p<0,001,-21,5+/-3,2% and-22,6+/-3,3% in group II, p=0,001). Significant increase of segmental endocardial LS was revealed in group I in the basal segments of RV free wall (-26,2+/-5,1% and-28,1+/-5,1%, p=0,004) and interventricular septum (IVS) (-16,2 [13,9;19,5]% and-17,5 [14,6;21,4]%, p=0,024), IVS middle segment (-20,3+/-4,1% and-21,5+/-4,8%, p=0,030), as well as in group II in the apical segments of RV free wall (-21,9+/-6,7% and-24,4+/-5,2%, p=0,001) and IVS (-23,7+/-4,7% and-24,9+/-4,8%, p=0,014). Conclusion. Recovery of RV function during a 12-month follow-up period in patients with both severe and moderate/mild lung involvement in COVID-19 was detected using the STE method.Copyright © 2023, Silicea-Poligraf. All rights reserved.

Dynamics of global and segmental strain as a marker of right ventricular contractility recovery in patients after COVID-19 pneumonia.

Aim. To study the changes of morphological and functional right ventricular (RV) parameters depending on the severity of coronavirus infection 2019 (COVID-19) pneumonia over long-term follow-up. Material and methods. A total of 200 patients (men, 51,5%, mean age, 51,4+/-10,9 years) were examined at 2 control visits (3, 12 months after receiving two negative polymerase chain reaction tests). Patients were divided into following groups: group I (n=94) - lung tissue involvement >=50% according to inhospital chest computed tomography (chest CT), group II (n=106) - lung tissue involvement <50% according to chest CT. Results. The groups were comparable in key clinical and functional parameters 3 months after COVID-19 pneumonia. Speckle tracking echocardiography (STE) revealed a significant increase in following global longitudinal strain (LS) parameters: RV free wall endocardial LS (-22,7+/-3,2% and-24,3+/-3,8% in group I, p<0,001;-23,2+/-3,5% and-24,5+/-3,4% in group II, p<0,001), and RV endocardial LS (-21,0+/-3,1% and-22,5+/-3,7% in group I, p<0,001,-21,5+/-3,2% and-22,6+/-3,3% in group II, p=0,001). Significant increase of segmental endocardial LS was revealed in group I in the basal segments of RV free wall (-26,2+/-5,1% and-28,1+/-5,1%, p=0,004) and interventricular septum (IVS) (-16,2 [13,9;19,5]% and-17,5 [14,6;21,4]%, p=0,024), IVS middle segment (-20,3+/-4,1% and-21,5+/-4,8%, p=0,030), as well as in group II in the apical segments of RV free wall (-21,9+/-6,7% and-24,4+/-5,2%, p=0,001) and IVS (-23,7+/-4,7% and-24,9+/-4,8%, p=0,014). Conclusion. Recovery of RV function during a 12-month follow-up period in patients with both severe and moderate/mild lung involvement in COVID-19 was detected using the STE method.Copyright © 2023, Silicea-Poligraf. All rights reserved.

Dynamics of global and segmental strain as a marker of right ventricular contractility recovery in patients after COVID-19 pneumonia.

Aim. To study the changes of morphological and functional right ventricular (RV) parameters depending on the severity of coronavirus infection 2019 (COVID-19) pneumonia over long-term follow-up. Material and methods. A total of 200 patients (men, 51,5%, mean age, 51,4+/-10,9 years) were examined at 2 control visits (3, 12 months after receiving two negative polymerase chain reaction tests). Patients were divided into following groups: group I (n=94) - lung tissue involvement >=50% according to inhospital chest computed tomography (chest CT), group II (n=106) - lung tissue involvement <50% according to chest CT. Results. The groups were comparable in key clinical and functional parameters 3 months after COVID-19 pneumonia. Speckle tracking echocardiography (STE) revealed a significant increase in following global longitudinal strain (LS) parameters: RV free wall endocardial LS (-22,7+/-3,2% and-24,3+/-3,8% in group I, p<0,001;-23,2+/-3,5% and-24,5+/-3,4% in group II, p<0,001), and RV endocardial LS (-21,0+/-3,1% and-22,5+/-3,7% in group I, p<0,001,-21,5+/-3,2% and-22,6+/-3,3% in group II, p=0,001). Significant increase of segmental endocardial LS was revealed in group I in the basal segments of RV free wall (-26,2+/-5,1% and-28,1+/-5,1%, p=0,004) and interventricular septum (IVS) (-16,2 [13,9;19,5]% and-17,5 [14,6;21,4]%, p=0,024), IVS middle segment (-20,3+/-4,1% and-21,5+/-4,8%, p=0,030), as well as in group II in the apical segments of RV free wall (-21,9+/-6,7% and-24,4+/-5,2%, p=0,001) and IVS (-23,7+/-4,7% and-24,9+/-4,8%, p=0,014). Conclusion. Recovery of RV function during a 12-month follow-up period in patients with both severe and moderate/mild lung involvement in COVID-19 was detected using the STE method.Copyright © 2023, Silicea-Poligraf. All rights reserved.

Cardiac Biomarkers in 2022 - A Vital Tool for Emergency Care

The role of cardiac biomarkers in diagnosing acute myocardial infarction is undoubted. In the 2020 guidelines of the European Society of Cardiology, the measurement of cardiac peptides to gain prognostic information has a class IIa indication in all patients with ACS. In emergency care, ruling out a non-ST elevation myocardial infarction requires documentation of normal levels of cardiac biomarkers, which remain stable or have very small variations within several hours. This review aims to summarize the current knowledge and recent progresses in the field of cardiac biomarker discovery, from their routine use in emergency rooms to their prognostic roles in modern risk assessment tools. Integrated approaches combining cardiac troponin with other biomarkers of ventricular dysfunction or inflammation, or with modern cardiac imaging in emergency care are also presented, as well as the role of modern algorithms for serial troponin measurement in the modern management of emergency departments.

Clinical profile and outcome of multisystem inflammatory syndrome in children (MIS-C) associated with COVID-19 infection: a single-center observational study from South India

Background: Multisystem inflammatory syndrome in children (MIS-C) is a post-infectious sequelae of acute COVID-19 infection affecting children. This study was done over a period of 12 months from December 2020 to November 2021 to describe the clinical presentation, laboratory abnormalities, and outcome of children with MIS-C. Method(s): Seventy-eight children below 12 years of age who satisfied the WHO diagnostic criteria for MIS-C were included in the study. Clinical parameters were recorded at admission. Relevant laboratory investigations, radiological studies, and outcome were documented. Result(s): The most commonly affected age group was 6-12 years with a female predominance. COVID RTPCR was negative in all patients. Most cases presented 2-6 weeks after the onset of acute COVID-19 infection. Lethargy, poor feeding, vomiting, abdominal pain, loose stools, cough, and cold are common symptoms of MIS-C syndrome in children and the common signs were rash, conjunctival congestion, hypotension, tachycardia, tachypnea, and hypoxemia. Gastrointestinal system was the commonly affected followed by the hepatic, renal, and cardiovascular systems. Coronary artery abnormalities were seen in 20% of cases. IVIg was the mainstay of therapy used in 95% of patients. Mortality was 1.3%. Cases responded well to IVIg and steroids. Conclusion(s): Overall, the short-term outcome was favorable with low mortality in our study cohort. One-fifth of children had coronary artery abnormalities during acute phase underscoring the need for long-term follow-up. Copyright © 2022, The Author(s).

Right Ventricular Hemodynamics in COVID Patients With Shock

Introduction: Patients with serious COVID infections frequently develop shock. Their right-sided hemodynamic profiles have not been well characterized. Method(s): In a prospectively collected database including 1997 patients hospitalized for COVID pneumonia from March 2020 to March 2021, 368 had shock requiring vasopressors. 327 had echocardiography to assess ventricular function and stroke volume based on clinical indications. LVEF (LV ejection fraction) and RVFAC (RV fractional area change) were measured using Simpson's rule, stroke volume (SV) by aortic Doppler, and RVSP (RV systolic pressure) from tricuspid regurgitation velocity;187 had evaluable data on all parameters. Patients were divided into groups with low or preserved RVFAC (RVFAC or RVFAC , cutoff <e35%), and low or normal cardiac index, (CI, CI or CI cutoff <e2.2 L/min/m2 ). Result(s): Mean age: 65+/-12, LVEF 59.5+/-12.8, RVFAC 35.3+/-10.6, CI 2.41+/-0.89. Overall hospital mortality in this cohort with shock was 80%. Mean RVSP was 38.8+/-12.2, PEEP 11.0+/-3.7. 43% of patients had low RVFAC (<35%), and RVFAC correlated with other measures of RV function such as tricuspid annular peak systolic excursion (TAPSE) and lateral tricuspid annulus peak systolic velocity (S'). Higher RVSP correlated with lower CI (r=0.134, p= 0.016) but not with PEEP (r=0.03, p=0.70). Mortality did not differ significantly among groups, (p=0.19 by ANOVA) but was highest in the group with low RVFAC and low CI. (Figure) Conclusion(s): RV dysfunction is common in patients with severe COVID-19 and shock. Although RV dysfunction is probably associated with a worse prognosis, outcome in COVID may be tied to pulmonary recovery. Whether treatment targeted at RV dysfunction will improve outcome remains uncertain.

Cardiovascular manifestation in multisystem inflammatory syndrome in children temporally associated with COVID-19-single center experience

Background and Aim: Cardiovascular manifestations are common (35-100%) in multisystem inflammatory syndrome in children (MIS-C), including ventricular dysfunction, shock, coronary artery dilation, pericardial effusion and conduction abnormalities. Our study aimed to analyse cardiovascular involvement in our patients with MIS-C treated in our hospital. Method(s): The retrospective cohort study included all patients with MIS-C treated from April 2020 to December 2021 in the Mother and Child Health Institute of Serbia. In every case, cardiovascular manifestations were analysed: ventricular dysfunction, coronary artery dilatation, pericardial effusion, shock and ECG changes. Result(s): The study included 77 patients, 45 boys and 32 girls, aver-age years of age 9.3 +/- 4.8. Elevated cardiac troponin I and pro-BNP were observed in 35.9% and 87.8% of patients, respectively. Myocardial dysfunction was observed in half of our patients (50.6%), with an average ejection fraction of 50.5 +/- 8.9%. Children older than 10 years had 4 times higher chances for myo-cardial dysfunction (OR 4.3, 95%CI 1.6-10.8;p = 0.003). Shock syndrome had 21.1% of children on admission, while 5.3% devel-oped shock during the in-hospital stay. Transient coronary artery (CA) dilatation was observed in 6.5% of patients;left CA in 3 pts (Z score +2,95 +/- 0.3), right CA in one patient (Z score +2), and in one LCA and RCA (RCA Z score 2.6). Transient CA dilatations were observed only in patients with KD-like clinical presentation (5/54 pts). Mild pericardial effusion with spontaneous resolution was detected in 28.6% of children, while one female adolescent had severe pericardial effusion with threatening cardiac tamponade. On the standard ECG, 53% of children had negative T wave in inferior or/and precordial leads averagely on day 2 (IQR 1-3 day);transient QTc prolongation was registered in 46% of patients, averagely on day 7 (IQR 5-9). Sinus bradycardia and coronary rhythm were registered in 42.1% of patients, while premature ven-tricular beats were observed in 2.7% of pts. left ventricle thrombus was detected in one patient with normal echocardiography find-ing. In this patient, increased activity of Factor VIII and XII was proven. Conclusion(s): Cardiac manifestations are common and potentially life-threatening in MIS-C and should be assessed for at presenta-tion and during the clinical course as indicated.

Cardiovascular manifestations in multisystem inflammatory syndrome in children (MIS-C) associated with COVID-19

Background and Aim: Cardiac involvement in multisystem inflam-matory syndrome in children (MIS-C) associated with Coronavirus 2019 disease (COVID-19) is often observed with high risk of hearth failure. Early diagnosis and treatment are man-datory for a good outcome. The aim is to describe cardiovascular involvement, management and early outcome for patients with MIS-C and to analyze the differences in cardiovascular manifesta-tions between two groups: younger and older than 6 years old. Method(s): This retrospective observational study describes cardio-vascular clinical manifestations, laboratory findings, cardiac imag-ing, according to different age groups, and treatment in patients with diagnosis of MIS-C admitted to the Pediatric Istitute Giannina Gaslini between March 2020 and September 2021. Result(s): We collected 25 patients. Median age at onset of symptoms was 5 years old (interquartile range IQR, 3-12 y), 12 boys (56%). Immunoglobulin G antibodies were positive in 70% cases, Polymerase chain reaction (PCR) nasal/throat swab test for COVID-19 was positive in 15% cases, at the admission. The remaining cases had close contacts of COVID-19 positive cases. Predominant coronary artery abnormalities were observed in age group up to 6 years old (n.13) with development of small and medium aneurysms in half of cases and low rate of mild ventricular dysfunction. While children between 7-18 years of age present myopericardial involvement with ventricular dysfunction in 67% cases, from mild to moderate. Only two cases of transient coronary dilatation. Frequent electrocardiogram abnormalities: ventricular repolarization anomalies and reversibile QTc prolon-gation interval. Laboratory findings showed rised inflammatory markers and only mild elevation of cardiac enzymes compared to an early and significant NT-pro-BNP increase. All patients were treated with intravenous immunoglobulin and corticosteroids. Some cases needed anakinra. Aspirin and heparin was adminis-trated. No inotropes requied but only cardioprotective therapy. No need of Intensive Care Unit. Conclusion(s): This case-series shows the frequent cardiovascular involvement in MIS-C with a peculiar distribution, according to differents age's group: coronary artery anomalies in young ones, myopericardial disease in old ones. Prompt multi target anti-inflammatory therapy could have an effect to favorable outcome.

The Biologics in Multisystem Inflammatory System in Children

Multisystem inflammatory syndrome in children (MISC) is a hyperinflammatory state that occurs about two to four weeks after the SARS CoV-2 in the human body. It can potentially involve any organ and cause Kawasaki-like disease, shock with or without ventricular dysfunction, and fever with inflammation. The treatment includes some medications depending on the patient's situation. Asymptomatic children and mild COVID-19 do not need the anti-rheumatic agents. In some moderate and severe COVID-19, the management includes intravenous immune globulin (IVIG) and corticosteroids. The first trial of corticosteroid begins with low to moderate doses, and in refractory cases, it switches to high doses of intravenous methylprednisolone for 1 - 3 consecutive days. In contrast to classic Kawasaki disease, the second dose of IVIG is not recommended in IVIG-resistant cases because of volume overload. In refractory disease or in patients who cannot receive glucocorticoids, there may be rationality for the usage of biologic agents after consulting with a pediatric rheumatologist. The refractory disease could include any of the following: persistent fever more than 24 hours post-treatment., ferritin more than 1000 ng/mL posttreatment, worsening echocardiographic findings, and physician global discretion if the patient fails to improve. High dose Anakinra should be considered the first choice for treatment of MIS-C refractory to IVIG and glucocorticoids in patients with MIS-C and features of macrophage activation syndrome (MAS) or patients with contraindications to long-term use of corticosteroids. Infliximab may be used as an alternative biologic agent in these situations except in features of MIS-C and MAS. Furthermore, infliximab may be considered second-line therapy in patients with MIS-C who have persistent inflammation or myocardial dysfunction. Some researchers recommend it in conjunction with IVIG as initial therapy, although further data are needed.

READING the WAVES: IDENTIFYING DISTINCT PHENOTYPES of MULTISYSTEM INFLAMMATORY SYNDROME in CHILDREN in A SINGLE CANADIAN CENTER during the 2020-2021 COVID-19 PANDEMIC

Background: The COVID-19-associated multisystem infammatory syndrome in children (MIS-C) is characterized by Kawasaki disease (KD)-like features and circulatory shock [1]. The genesis of SARS-CoV-2 variants triggered successive waves of mass infections followed by MIS-C outbreaks. Objectives: To compare MIS-C phenotypes across the waves of the COVID-19 pandemic. To identify predictors of pediatric intensive care unit (PICU) admission and treatment with biologic agents. Methods: Youth aged 0-18 years, fulflling the WHO case defnition of MIS-C, and admitted to the Alberta Children's Hospital during the COVID-19 pandemic (May 2020-December 2021) were included. Clinical, laboratory, imaging, and treatment data were captured (KD-like manifestations, signs of shock and/or hypotension, peak C-reactive protein (CRP) and ferritin, platelet count nadir, peak NT-proBNP and troponin, liver enzyme abnormalities, sodium and albumin nadir, echocardiogram fndings, biologic agents). Results: 57 consecutive MIS-C patients (median age 6 years, IQR 4-6;72% males) were included. 31 patients (54%) required PICU admission. All received immunoglobulins, 44 (77%) received corticosteroids, 8 patients (14%) were treated with biologic agents. Patients presenting during the third (mainly driven by Alpha variant) or fourth wave (mainly driven by Delta variant) presented with higher ferritin and NT-proBNP levels, and more liver enzyme abnormalities, hypoalbuminemia and thrombocytopenia compared to those presenting during the frst or second wave (Table 1, Figure 1). PICU admission was associated with the presence of shock/hypotension, higher CRP, ferritin, and NT-proBNP levels, lower albumin levels, and the presence of ventricular dysfunction on echocar-diogram (Table 1). A logistic regression model combining peak NT-proBNP, tro-ponin and ferritin levels explained 70% (Nagelkerke R2) of the variance in PICU admission and correctly classifed 91% of the cases. NT-proBNP was the sole signifcant contributor (p=0.017). Treatment with biologic agents was associated with higher CRP (mean 148.8 mg/l versus 251.7 mg/l;p=0.024) and ferritin (797 μg/l versus 1280 μg/l;p=0.049) levels. Conclusion: A shift in MIS-C phenotype was identifed across the successive COVID-19 waves, including the predominance of features associated with macrophage activation syndrome in later stages. These fndings may refect the impact of distinct SARS-CoV-2 variants. NT-proBNP emerged as the most important MIS-C feature predicting PICU admission, underscoring the importance of monitoring.

Right Ventricular Assessment in Critically Ill COVID-19 Patients and its Prognostic Importance

BACKGROUND: Cardiac injury is a prevalent complication and is associated with worse prognosis in COVID-19 patients. The increased cardiac workload resulting from respiratory failure and hypoxemia is a common mechanism of cardiac injury, and the right ventricle may bear the brunt of its impact. AIM: The present study aimed to determine the incidence and prognostic value of right ventricular (RV) dysfunction in COVID-19 patients admitted to the intensive care unit using conventional echocardiography parameters. METHODS: Patients were subjected to full history taking and clinical examination, computed tomography (CT) of the chest was done for all patients to assess the severity of lung infiltration, all patients received standard treatment according to Ministry of Health and Population COVID-19 treatment protocol recommendations. The echocardiographic assessment was done on all patients. RESULTS: The mean age of the patients was 61.10 ± 9.64 years (range 42–80 years). There were 36 (60%) males and 24 (40%) females. The nonsurvivor group consisted of 28 patients (46.7%), and the survivors consisted of 32 patients (53.3%). There was a statistically significant association between mortality and RV function regarding tricuspid plane systolic excursion, fractional area change %, RV basal diameter, and expiratory positive airway pressure. CONCLUSION: We concluded that in COVID-19 patients, RV function must be assessed and its prognostic importance recognized. RV dysfunction is not only a symptom of high pulmonary pressures, but it also contributes to cardiac insufficiency.

Echocardiographic Findings in Adolescents Presenting for Sports Clearance Following COVID-19

Background: Multiple studies have investigated cardiovascular effects associated with COVID-19 in collegiate and professional athletes. The incidence of cardiovascular abnormalities in adolescents seeking a return to sports following COVID-19 is not well known. We performed a comprehensive analysis of clinical and subclinical function in a cohort of post-COVID individuals seeking clearance for sports participation. We hypothesized that adolescent athletes after COVID-19 would have subclinical functional abnormalities. Methods: We reviewed outpatient transthoracic echocardiograms obtained between 11/01/2020 and 12/31/2020 for clearance for return to activity/sports of patients aged 12-18 with a history of mild or moderate COVID infection (COVID group). Adolescents from the pre-COVID era with complaints of chest pain, shortness of breath, palpitations, or syncope served as controls (pre-COVID group). Conventional echocardiographic metrics were ed from clinical reports;two investigators retrospectively used speckle tracking echocardiography to obtain left ventricular global longitudinal strain (LV GLS), LV global circumferential strain (GCS), right ventricular global longitudinal strain (RV GLS), and RV free wall strain (FWS). Upper limit of normal for GLS was -18%. Wilcoxon rank-sum test was used to evaluate differences between the groups, and Spearman's rho was used to evaluate correlations. Multivariable linear regression following multiple imputation of minimal missing data was performed to evaluate associations. Results: Thirty-eight COVID and 36 pre-COVID subjects were enrolled. There was no significant difference in the groups' age and gender distributions (Table 1). Median time since COVID diagnosis in that cohort was 33.5 days (IQR 22 - 64). Symptoms were reported in 68.4% of that group with a borderline or abnormal ECG in 23.7%;1 patient had depressed left ventricular ejection fraction (LVEF) and associated abnormal strain, and 8 had abnormal LV GLS despite normal LVEF based on our cut-off of -18%. The COVID group had decreased LV GLS, LV GCS, RV FWS, and RV GLS in comparison to the pre-COVID group (Table 1, Figure 1). Within the COVID cohort, controlling for age and gender, neither abnormal ECG nor presence of symptoms was associated with abnormal LV GLS or GCS. Time since COVID diagnosis was not associated with conventional echocardiographic or strain metrics. The COVID group continued to have worse LV GCS and RV GLS after controlling for age and gender;LV GLS and RV FWS no longer correlated with COVID status in multivariable analysis. Conclusion: In adolescents with prior mild or moderate COVID illness, ventricular function by conventional metrics is not categorically different from those without a COVID history. However, differences in myocardial strain suggest subclinical dysfunction. Future studies should elucidate whether these myocardial strain abnormalities persist and whether they are predictive of adverse outcomes in these patients.

A Clinical Differentiation of Multi system Inflammatory Syndrome in Children (MISC) & Kawasaki Disease (KD)

Background: With the emergence of the COVID 19 pandemic, a new disease, Multisystem Inflammatory Syndrome in Children (MIS-C), has evolved. Increasing numbers of children are being reported to have MIS-C in the U.S. & worldwide. In the U.S., there are currently 2617 MISC cases reported. MIS-C & Kawasaki Disease (KD) have almost the same presentation, making clinical differentiation difficult. This study aims at differentiating KD & MIS-C, which could assist clinicians to determine which disease they could be dealing with in their practices. Methods: Clinical features & laboratory values were collected from published studies found by queries on PubMed & other websites. Reported values were selected from published systemic reviews, metaanalyses, & large retrospective chart studies. Results: In KD, the most prevalent clinical features are fever (100%) & the 5 KDdefining clinical features: oral mucosal changes (96.5%), rash (96%), non-purulent conjunctivitis (89%), extremity changes (75.6%), and cervical lymphadenopathy (62.7%). MIS-C also presents with fever (100%) but has lower prevalence of oral mucosal changes (23%), rash (38.2%), non-purulent conjunctivitis (44.0%), extremity changes (2.5%), & cervical lymphadenopathy (4%). MIS-C leads to higher rates of ventricular dysfunction (39.3%), myocarditis (23%), & shock. For cardiac biomarkers, MISC has elevated troponin I (x6 normal) & Beta Natriuretic Peptide (BNP) (x414 normal), while KD has elevations of troponin I (x1.9 normal) & BNP (x15 normal). MIS-C has higher elevations in ESR, CRP, and D-Dimer at x6, x30, and x40 from the normal values, respectively, while KD has elevations of x2.8, x2.1, x7.3 from the normal values, respectively. MIS-C is associated with neutrophilia, thrombocytopenia, & anemia in 22% of cases. KD is associated with mild neutrophilia & anemia. KD has thrombocytosis in the subacute phase (x1.46 normal). Conclusion: Our results demonstrated that there are overlaps & differences in clinical and laboratory features. Fever is present in both KD & MIS-C, however the 5 KD defining clinical features of KD are less frequent in MIS-C. MIS-C induces higher levels of troponin I & BNP, findings that could potentially explain for higher rates of ventricular dysfunction & myocarditis. MIS-C causes higher elevations in inflammatory markers & D-Dimers compared to KD. Uniquely, thrombocytopenia is commonly present in MISC rather than in KD. Differentiating KD & MIS-C can be challenging, but by focusing closely on the clinical & laboratory features, clinicians may be able to distinguish between the two &, therefore, deliver the most appropriate care to patients in their practices.

IDIOPATHIC ISOLATED RIGHT VENTRICULAR DYSFUNCTION IN THE SETTING OF RECENT COVID-19 INFECTION: A CASE REPORT

CASE: We describe a case of isolated acute right ventricular (RV) strain not attributable to pulmonary embolism (PE) or Acute Respiratory Distress Syndrome (ARDS) in the setting of recent COVID-19 infection. A 77-year-old male with medical history notable for type 2 diabetes, obesity, chronic kidney disease, obstructive sleep apnea, and chronic hypoxemic respiratory insufficiency with a last known left ventricular ejection fraction (LVEF) of 77% on admission with preserved RV function, and recent COVID-19 infection was admitted for septic shock secondary to a post-viral MRSA pneumonia 12 days after diagnosis with COVID-19. On day 5 of admission, after completion of antibiotic therapy and resolved shock, the patient developed relative hypotension and an oliguric acute kidney injury with creatinine of 1.9 (previously 1.0) and urine microscopy findings consistent with acute tubular necrosis. EKG at the time showed new incomplete right bundle branch block. On day 8 of admission, relative hypotension continued with an uptrend in creatinine to 4.8 despite adequate fluid resuscitation. EKG showed new complete right bundle branch block with high-sensitivity troponin peaking at 550 (previously 15). A transthoracic echocardiogram showed enlarged RV and isolated severe hypokinesis of the RV mid-free wall consistent with “McConnel's sign” and acute right heart strain, with poorly visualized left ventricle, but without regional wall motion abnormalities. CTA Chest evaluating through the segmental arteries ruled out acute PE. Acute coronary syndrome was ruled out with traditional and right-sided EKG. Oxygen requirements remained unchanged throughout the course of his admission. The patient was transferred to the ICU for undifferentiated shock requiring triple pressor therapy and eventually died from acute renal failure and volume overload. IMPACT/DISCUSSION: While RV strain secondary to ARDS and PE has been implicated in COVID-19 and found to be an independent predictor of mortality, there is limited literature describing isolated RV dysfunction in their absence. Increasing reports showing cardiac microthrombi in autopsies of COVID-19 patients suggest alternate etiologies of RV injury and suggest potential utility of empiric therapeutic anticoagulation in all patients presenting with COVID-19. Alternatively, direct viral injury isolated to the RV may be unique in COVID19. Additionally, “McConnell's sign” combined with enlarged RV is traditionally considered a specific marker of PE, with reported specificity of 94% in the original report. However, there are increasing reports shedding doubt on the specificity of this finding. CONCLUSION: This case demonstrates the need to consider alternate etiologies for RV dysfunction in COVID-19, including microthrombi and direct viral injury. Additionally, this case adds to the growing literature demonstrating the limitation of “McConnell's sign,” even in patients with high suspicion for PE.

BENEFICIAL EFFECT OF SODIUM-GLUCOSE CO-TRANSPORTER-2 INHIBITORS ON RIGHT VENTRICULAR SYSTOLIC FUNCTION IN PATIENTS WITH TYPE 2 DIABETES MELLITUS: A PILOT, OBSERVATIONAL STUDY

Objective: Cardiovascular disease remains the leading cause of mortality among patients with type 2 diabetes mellitus (T2DM). Sodium-glucose co-transporter-2 (SGLT-2) inhibitors is a new class of antidiabetics, conferring a significant cardiovascular risk reduction. However, underlying mechanisms are not fully understood. Right ventricular (RV) function is adversely affected early in the course of diabetes. Herein we sought to determine the effect of long-term use of SGLT-2 inhibitors on RV function. Design and method: In this pilot, observational study, we enrolled 20 patients with T2DM and stable antidiabetic and antihypertensive treatment over the last 6 months. Patients were planned to undergo a thorough echocardiographic assessment of RV function twice, before and 6 months after initiation of a SGLT-2 inhibitor. We set as primary efficacy outcome the change in tricuspid annular plane systolic excursion (TAPSE). Results: Mean age of participants was 62.8 ± 7.9 years, with a mean T2DM duration of 8.7 ± 6.1 years. Thirteen subjects were administered dapagliflozin, while the rest 7 were prescribed empagliflozin. Due to special regulations imposed in the context of coronavirus disease-19 (COVID-19) pandemic, mean treatment duration and follow-up period was 9.35 ± 3.4 months. SGLT-2 inhibitors led to a significant increase in TAPSE from 2.01 ± 0.23 to 2.12 ± 0.15 cm (p = 0.022). The result was significant for dapagliflozin (p = 0.015), while administration of empagliflozin resulted in a non-significant increase in TAPSE (p = 0.28). However, no significant difference between the two SGLT-2 inhibitors was shown (p = 0.7). Change in TAPSE was significant in subjects with prior history of cardiovascular disease (p = 0.024), while it was non-significant for subjects without previous cardiovascular disease (p = 0.26). Other parameters of RV function or RV dimensions were unchanged. Conclusions: This is the first study to assess the effect of long-term treatment with SGLT-2 inhibitors on RV function in subjects with T2DM, demonstrating a significant increase in TAPSE.