How Safe Are Children With Covid-19 From Cardiac Risks? Pediatric Risk Assessment, insights from Echocardiography and Electrocardiography

Introduction: Approximately 40 million individuals worldwide have been infected with SARS-CoV-2, the virus responsible for the novel coronavirus disease-2019 (COVID-19). Despite the current literature about the cardiac effects of COVID-19 in children, more information is required. We aimed to determine both cardiovascular and arrhythmia assessment via electrocardiographic and echocardiographic parameters. Methods: We evaluated seventy children who were hospitalized with COVID-19 infections through laboratory findings, electrocardiography (ECG), and transthoracic echocardiography (TTE). Results: We observed significantly increased levels of Tp-Te, Tp-Te/ QT, and Tp-Te/QTc compared with the control group. 25 of 70 (35.7%) patients had fragmented QRS(fQRS) without increased troponin levels. On the other hand, none of the patients had pathologic corrected QT(QTc) prolongation during the illness or its treatment. On TTE, 20 patients had mild mitral insufficiency, among whom only five had systolic dysfunction (ejection fraction <55%). There was no significant difference between the patient and control groups, except for isovolumic relaxation time(IVRT) in terms of mean systolic and diastolic function parameters. IVRT was significantly lower than in the control group. Conclusions: Despite all the adult studies, the effects of COVID-19 on myocardial function are not well established in children. The thought that children are less affected by the illness may be a misconception.

Improving Treatment for Patellar Instability to Reduce Recurrence and Cartilage Degradation

A lateral patellar dislocation is a traumatic event associated with cartilage degradation and a high risk of progression to patellofemoral osteoarthritis. The study focuses on identification of patients likely to progress to recurrent dislocations, characterization of cartilage degradation due to delaying surgical intervention until after recurrent dislocations, and evaluation of reconstruction of the medial patellofemoral ligament (MPFL) as a surgical tool to restore patellar stability.

Inflammatory heart disease after covid-19 vaccination: A preliminary cardiac mri perspective

Introduction: On June 2, 2021, 6 case reports of myocarditis after the Pfizer COVID-19 vaccine surfaced. Each case had a cardiac MRI (CMR) study using T2 weighted and delayed gadolinium imaging. CMR was performed for post-vaccine symptoms. Although valuable, these data do not shed light on the prevalence of this post-vaccine occurrence. This study was designed to assess the prevalence of inflammatory heart disease(IHD) in a group of patients who had a CMR after receiving a COVID-19 vaccine. Hypothesis: Evidence of myocarditis may occur on cardiac MRI after all types of COVID-19 vaccine. Methods: From January 1 to June 8, 2021 303 patients underwent a CMR at Sharon Regional Medical Center. The date of vaccination, type of vaccine and COVID testing results and date for each of these patients were ascertained. All patients who were vaccinated prior to the CMR exam constituted the study population. IHD by CMR was defined as abnormality of 2 or more pulse sequences of the Modified Lake Louise Criteria(MLLC) of 2018: T2 STIR, Delayed enhancement after gadolinium, and prolongation of myocardial or pericardial T1 or T2 relaxation times. The number of patients with CMR evidence of IHD was tabulated for Pfizer, Moderna and Johnson&Johnson(J&J) vaccines. Results: Of 303 patients with a CMR during the study period, 77 were vaccinated prior to CMR. The mean time between vaccination and CMR was 41 days. 42 patients had a Pfizer vaccine, 30 had Moderna and 5 received J&J. 10 Pfizer receipants had IHD findings on CMR(24%), as did 7 of Moderna(23%) and 2 of J&J(40%). 13 patients had a positive COVID test prior to vaccination and IHD was present on CMR in 9 patients(69%) in this subgroup, while only 8 of 63(13%) without a positive COVID-19 test before vaccination showed evidence of IHD. Conclusions: Although retrospective, these data provide valuable information about the occurrence of IHD after COVID-19 vaccination using CMR imaging. A similar percentage of patients vaccinated with any of the 3 vaccines appear to subsequently show evidence of IHD on CMR, more so if previously COVID positive. However, evidence of IHD on post-vaccine CMR does not definitively establish causality. CMR exams before and after COVID-19 vaccination using MLLC will be required to prove a cause-effect relationship.

Low prevalence of arrhythmias among healthcare workers who recovered from COVID-19

INTRODUCTION The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) can cause multiple cardiologic complications such as myocardial injury, cardiogenic shock and arrhythmias. In patients admitted to an intensive care unit (ICU), sinus tachycardia and atrial fibrillation are the most commonly reported arrhythmias. However, data on the prevalence of arrhythmias after symptomatic SARS-CoV-2 infection is limited. Using 48-hour electrocardiographic (ECG) Holter monitoring, we aimed to analyse the incidence and types of arrhythmias among healthcare workers who recovered from SARS-COV-2 infection. MATERIAL AND METHODS The study involved 34 healthcare workers from the university hospital, who had SARS-CoV-2 infection confirmed by pharyngeal swab up to 4 months before study onset and who did not need an ICU stay due to the illness. Each subject underwent a 48-hour ECG monitoring and completed a questionnaire on the course of the disease. Cardiac magnetic resonance imaging (CMR) was performed and the presence of potential arrhythmias substrate was assessed. RESULTS We recruited 24 women and 10 men (47% were doctors) in the mean age of 37 ± 11 years old who underwent symptomatic SARS-CoV-2 infection, but did not require hospitalization during illness. The mean time from the positive swab test to the start of 48-hour ECG monitoring was 2.9 ± 0.9 months. The most frequently reported (in 100%), though sparse, were supraventricular premature contractions (SVPCs) (mean 46 ± 64 per person/day). Atrial fibrillation or atrial flutter were not recorded, however supraventricular tachycardia (SVT) was found in 18% of subjects, and the range of the highest frequency of SVTs was 124-179 bpm. There were no ventricular tachycardia episodes. Ventricular premature contractions (VPCs) were found in 28% of participants but were usually sparse (mean number per person 98 ± 252/day). Six participants had more than 100 VPCs/day, and in 1 it exceeded 1000/day. No one had QTc interval longer than 438 ms. 48-hour ECG monitoring revealed a tendency towards sinus tachycardia during activity time, however, the daily rhythm modulation was diminished in only 15% of participants. Significantly higher maximal daily heart rate (P <0.05) was observed in 29% of subjects in whom CMR revealed the presence of late gadolinium enhancement (LGE). The presence of LGE or extended T1 and T2 relaxation times from CMR were not predictors of the increased number of VPCs or SVPCs (P >0.05). No significant atrioventricular conduction disturbances were recorded. CONCLUSIONS The prevalence of arrhythmias in the mid-term observation of not-hospitalized COVID-19 survivors is low. During prolonged 48-hour ECG monitoring of healthcare workers, neither life-threatening nor clinically significant arrhythmias were recorded. Therefore, the arrhythmic burden after infection with SARS-CoV-2 should be considered as marginal.

COVID-19 temporally related multisystem inflammatory syndrome (MIS-C) and cardiovascular involvement assessed with cardiac magnetic resonance (CMR). Experience of the children hospital of Palermo

Introduction: MIS-C is a hyperinflammatory syndrome that follows exposure to SARS-CoV-2 by 2-6 weeks. However, some aspects remain unclear, such as cardiac involvement. Objectives: to evaluate the role and effectiveness of cardiac magnetic resonance (CMR) in heart involvement in children affected by MIS-C;to review the expert groups' clinical experience in the field. Methods: we describe a case series of 7 children (age: 2-11 years), admitted to the tertiary care Children Hospital G. Di Cristina, Palermo, between December 2020 and May 2021 with clinical symptoms meeting the criteria for the diagnosis of MISC-C. All the patients showed findings of cardiac involvement without coronary artery lesions. Transthoracic echocardiography demonstrated temporary systolic dysfunction that lasted for 2-5 days. CMR was performed during the recovery phase or after the discharge (the median time to CMR was 10-30 days after the onset of illness). CMR was performed with a 1,5 Tesla scanner (GE Signa Explorer). 5/7 didn't undergo CMR study during the acute phase because they were clinically unstable and needed general anesthesia or sedation. The protocol included, before intravenous contrast media injection, retrospective ECG-Gated fiesta cine sequences (short axis, 4, 3 and 2 chamber views), sequences for edema, and hyperemia T2 -short tau inversion recovery (Stir) (repetition time =1689ms, echo time55.10 ms). Myocardial edema was evaluated by following the Lake Louise criteria. Because normal value in native T1 mapping and T2 relaxation time in children have poor reference, myocardial edema was characterized by increased signal intensity on T2-weighted imaging and myocardial damage by non-ischemic patterns late gadolinium enhancement. Study for evaluating myocyte necrosis and fibrosis: Late gadoliniumenhanced 2D inversion recovery sequences performed at 6 min following intravenous contrast medium administration (0,2 mmol/kg). Results: In 5/7 patients, T2-Stir sequences didn't show myocardial edema and hyperemia. Mean indexed left ventricular end-diastolic volume (iLVEDV), indexed left ventricular end-systolic volume (iLVESV), and indexed left ventricular stroke volume (iLVSV) were within normal range corrected for BSA. In 2 patients CMR showed late gadolinium enhancement in non-ischemic pattern. 1 patient, studied in subacute phase, after steroids and IVIG treatment, showed ventricular apical septum and lateral wall myocardial oedema, without fibrosis and an imaging compatible with focal acute myocarditis. Ventricular systolic function was normal. 1 patient, studied 1 month after the acute phase, and showed myocardial fibrosis. Conclusion: international literature reports that children with MIS-C develop a transitory myocardial impairment, resembling myocarditis, with full recovery in most of them. Until now, the pathophysiology of the event is still object of debate. CMR is an excellent noninvasive diagnostic tool for the diagnosis and follow-up of myocarditis. Furthermore, CMR can predict prognosis and recognize children at high risk to develop arrhythmias and unfavorable events. CMR is a codified method highlighting specific features of myocardial damage: inflammation, edema, necrosis, contractile scar impairment, and pericardial effusion. 6/7 didn't demonstrate myocardial oedema, probably because the CMR was performed during the recovery.

Post-COVID myocarditis diagnosed by endomyocardial biopsy and/or magnetic resonance imaging 2-9 months after acute COVID-19

Purpose: To study clinical features of myocarditis and its possible mechanisms (including persistence of SARS-Cov-2 in the myocardium) in the long-term period after acute COVID-19. Methods: Fifteen patients (8 male and 7 female, mean age 47.8±13.4, 24-65 years) diagnosed with postcovid myocarditis were included in the study. The diagnosis of COVID-19 was confirmed by positive PCR results in 40%, and seroconversion in all patients. The average time of admission after COVID-19 was 4 [3;7] months, from 2 to 9 months. The diagnosis of myocarditis was confirmed by cardiac MRI in 10 patients and by right ventricular endomyocardial biopsy (EMB) in 6 patients. The PCR for cardiotropic viruses and PCR with immunohistochemical study for SARSCov2 detection were used. All patients had study for anti-heart antibodies (AHA), EchoCG, and Holter ECG. Coronary atherosclerosis was excluded in all patients over 40 years (7 coronary angiography, 4 cardiac CT). Results: A clear association of the cardiac symptoms with a previous new coronavirus infection was noted in all patients. The symptoms started 1-5 months following COVID-19. MRI showed subepicardial and intramyocardial LGE, signs of hyperemia, increased T1 relaxation time, edema. AHA levels were increased 3-4-fold in 73%. Two variants of postcovid myocarditis were observed. 1. Arrhythmic variant (n=6) - newly developed frequent supraventricular or ventricular extrasystole, recurrent atrial fibrillation in the absence of systolic dysfunction. 2. Decompensated variant with biventricular heart failure (n=9): the mean LV EF was 34.1±7.8% (23 to 46%), LV EDD 5.8±0.7 cm, EDV 153.8±46.1 ml, pulmonary artery systolic pressure 40.7±11.2 mmHg. In one case, myocarditis was accompanied by IgG4- and ANCA-negative aortitis. SARS-Cov-2 RNA was detected in 4 of 5 myocardial biopsies (in one case the material in the study). The longest period of virus persistence after COVID-19 was 9 months. By using spike and nucleocapsid antibodies, coronavirus was detected in cardiomycytes and macrophages. Data of patients with morphologically proved myocarditis are presented in Table 1. Lymphocytic myocarditis was diagnosed and confirmed immunohistochemically (n=5);giant cell myocarditis with atrial standstill was detected in one more case (Fig. 1). Three patients had also signs of endocarditis, in two cases with parietal thrombosis. Conclusions: COVID-19 can lead to the subacute and chronic myocarditis of varying severity. Post-COVID myocarditis manifests itself in two main clinical forms - isolated arrhythmias and systolic dysfunction with heart failure. Post-COVID myocarditis is characterized by prolonged persistence of coronavirus (up to 9 months in this study, in most patients with decompensated variant) in combination with high immune activity (high titers of AHA), which should be considered as the main mechanisms of its longterm course. Treatment approaches for such myocarditis require investigation. (Figure Presented).

Magnetic graphene quantum dots facilitate closed-tube one-step detection of SARS-CoV-2 with ultra-low field NMR relaxometry.

The rapid and sensitive diagnosis of the highly contagious severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is one of the crucial issues at the outbreak of the ongoing global pandemic that has no valid cure. Here, we propose a SARS-CoV-2 antibody conjugated magnetic graphene quantum dots (GQDs)-based magnetic relaxation switch (MRSw) that specifically recognizes the SARS-CoV-2. The probe of MRSw can be directly mixed with the test sample in a fully sealed vial without sample pretreatment, which largely reduces the testers' risk of infection during the operation. The closed-tube one-step strategy to detect SARS-CoV-2 is developed with home-made ultra-low field nuclear magnetic resonance (ULF NMR) relaxometry working at 118 µT. The magnetic GQDs-based probe shows ultra-high sensitivity in the detection of SARS-CoV-2 due to its high magnetic relaxivity, and the limit of detection is optimized to 248 Particles mL‒1. Meanwhile, the detection time in ULF NMR system is only 2 min, which can significantly improve the efficiency of detection. In short, the magnetic GQDs-based MRSw coupled with ULF NMR can realize a rapid, safe, and sensitive detection of SARS-CoV-2.