Improvement of clinical symptoms and cardiac abnormalities detected by cardiac magnetic resonance imaging in patients with long COVID syndrome after guideline-oriented therapy (preprint)

Patients with cardiovascular long COVID syndrome and cardiac magnetic resonance (CMR) scans were included prospectively into the Vienna PostCoV Registry between March 2021 and March 2023 (EC: 1008/2021, clinicaltrials.gov NCT05398952; n=240). Clinical symptoms, age and sex, time between COVID-positivity and vaccination and CMR, as well as CMR findings were recorded. After medical treatment, clinical assessment and CMR was repeated in 67 patients with pathological CMR findings showing myopericarditis, pericardial effusion or cardiac functional abnormalities. Blood pressure and condition-adapted heart failure treatment led to a significant increase in left ventricular ejection fraction. Low-moderate doses of NSAIDs for 3 months significantly reduced pericardial effusion. Clinical symptoms improved markedly with a decrease in CMR abnormalities.  In conclusion, medical treatment of cardiac/cardiovascular long COVID syndrome related to CMR abnormalities led to significant improvement in ejection fraction and decreased pericardial effusion, and were associated with improvements in the cardiovascular long COVID complaints.

Cardiac Outcome of Children With SARS-CoV-2 Related Multisystem Inflammatory Syndrome.

OBJECTIVE: To study the cardiac outcomes of patients with multisystem inflammatory syndrome in children (MIS-C) after 6-month of diagnosis. METHODS: This review of hospital records was conducted on MIS-C patients (aged <21 year) who completed a six-month follow up. The baseline demographic, clinical, laboratory, and treatment characteristics during the acute phase, and echocardiographic findings during follow-up were collected. RESULTS: 116 patients (61.2% male, median age 7 years) with MIS-C were included in the study. At the time of admission, cardiac abnormalities were present in 70.7% of MIS-C patients, and the most common cardiac abnormalities were valve failure (50.9%), followed by ventricular dysfunction (39.7%), and pericardial effusion (23.3%). Six month after diagnosis, cardiac abnormalities were found in 10.3% of patients, and patients had lower rates of ventricular dysfunction (P<0.001), valve failure (P<0.001), pericardial effusion (P<0.001), and coronary involvement (P<0.001) as composed to the baseline. Intravenous immunoglobulin (IVIG) and steroid treatment significantly reduced the odds of occurrence of ventricular dysfunction (P=0.002), valve failure (P=0.004), and low ejection fraction (P=0.002) in comparison to IVIG treatment. CONCLUSION: While most MIS-C patients had abnormal echocardiographic findings at admission, only 10.3% of patients had cardiac abnormalities during follow up.

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. METHODS: A prospective observational study was conducted including all consecutive children with suspected MIS-C referred to the cardiology services. RESULTS: 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: 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.

Pediatric Pericarditis: Update.

PURPOSE OF REVIEW: While there have now been a variety of large reviews on adult pericarditis, this detailed review specifically focuses on the epidemiology, clinical presentation, diagnosis, and management of pediatric pericarditis. We have tried to highlight most pediatric studies conducted on this topic, with special inclusion of important adult studies that have shaped our understanding of and management for acute and recurrent pericarditis. RECENT FINDINGS: We find that the etiology of pediatric pericarditis differs from adult patients with pericarditis and has evolved over the years. Also, with the current COVID-19 pandemic, it is important for pediatric clinicians to be aware of pericardial involvement both due to the infection and from vaccination. Oftentimes, pericarditis maybe the only cardiac involvement in children with COVID-19, and so caregivers should maintain a high index of suspicion when they encounter children with pericarditis.  Large-scale contemporary epidemiological data regarding incidence and prevalence of both acute and recurrent pericarditis is lacking in pediatrics, and future studies should focus on highlighting this important research gap. Most of the current management strategies for pediatric pericarditis are from experiences gathered from adult data. Pediatric multicenter trials are warranted to understand the best management strategy for those with acute and recurrent pericarditis. CASE VIGNETTE: A 6-year-old child with a past history of pericarditis almost 2 months ago comes in with a 2-day history of chest pain and fever. Per mother, he stopped his steroids about 2 weeks ago, and for the last 2 days has had a temperature of 102F and has been complaining of sharp mid-sternal chest pain that gets worse when he lies down and is relieved when he sits up and leans forward. On examination, he is tachycardic (heart rate 160 bpm), with normal blood pressure for age. He appears to be in pain (5/10), and on auscultation has a pericardial friction rub. His lab studies are notable for elevated white blood cell count and inflammatory markers (CRP and ESR). His electrocardiogram reveals sinus tachycardia and diffuse ST-elevation in all precordial leads. His echocardiogram demonstrates normal biventricular function and a trace pericardial effusion. His cardiac MRI confirms recurrent pericarditis. He is started on indomethacin and colchicine. He has complete resolution of his symptoms by day 3 of admission and is discharged with close follow-up.

Primary Cardiac Angiosarcoma With Pulmonary Metastasis in a Young Female: A Case Report and Review of Literature (preprint)

Background: Sarcomas are the most prevalent type of malignant primary cardiac tumor. Clinical presentation differs according to the size and location of the tumor and involvement  of other structures. Case presentation: In this article, we present a 38 years old lady as a case of primary cardiac angiosarcoma with a huge challenge in diagnosis and management of the disease. On the 4th of June 2020, she emergently presented to the hospital with the chief complaint of cough and tachypnea, diarrhea, and malaise, and a history of blunt chest trauma three weeks ago. Based on the presentation and transthoracic echocardiography which was compatible with cardiac tamponade, emergent pericardiocentesis was performed. The first imaging showed bilateral pleural effusion, pericardial effusion, and no significant parenchymal lung involvement, which was not compatible with rheumatologic diseases or COVID-19. Based on cardiac CT angiography and evidence of dye entrance to the peri-right atrial area, right atrial free wall rupture was suspected as the cause of the massive pericardial effusion. Following multidisciplinary consensus, she underwent cardiac surgery; in addition to the 3*3 cm right atrium free wall rupture repair, concomitant sampling from the lung nodules, lymph nodes, pericardium, and also the surrounding tissue of the right atrium ruptured defect was performed. Based on immunohistochemistry, the diagnosis was compatible with cardiac angiosarcoma with metastasis to the lung. Due to the advanced stage of the tumor, oncologists advised against chemotherapy or radiotherapy and she went through palliative care. Finally, after a 53-day ICU stay and due to right-sided heart failure, the patient unfortunately died. Conclusion: COVID-19 pandemic has brought diagnostic challenges regarding differentiating SARS-CoV-2 infection from other diagnostic entities. On the other hand, due to the rarity and fatality of primary cardiac angiosarcomas, early diagnosis and possible management seem crucial for prolonged survival. Involving cardiac angiosarcoma in the initial differential diagnosis could warrant timely diagnosis and assessment of various therapies for cure or palliative care.

The relationship between pericardial effusion and pulmonary involvement, prognosis, mortality in COVID-19 patients.

Aim    Comprehensive studies on the coexistence of COVID-19 and pericardial effusion (PEff) are limited. In this study, we investigated the relationship between pneumonia severity and PEff, predisposing factors, and the effect of PEff on clinical prognosis and mortality in COVID-19 patients.Material and methods    Between March and November 2020, 5 575 patients were followed up in our pandemic hospital due to COVID-19. 3 794 patients with positive polymerase chain reaction (PCR) test results and thoraxcomputerized tomography (CT) imaging at admission were included in the study. The clinical and demographic characteristics, CT images, hematological and biochemical parameters of these patients were retrospectively examined. Pulmonary involvement of 3794 patients was divided into three groups and its relationship with PEff was investigated retrospectively.Results    There were 560 patients who did not have pulmonary involvement, 2 639 patients with pulmonary involvement below 50 %, and 595 patients with 50 % or more pulmonary involvement. As pulmonaryinvolvement or the severity of the disease increased, male gender and advanced age become statistically significant. The mean age of patients with PEff was higher, and PEff was more common in males. Patients with PEff had more comorbid diseases and significantly elevated serum cardiac and inflammatory biomarkers. The need for intensive care and mortality rates were higher in these patients. While the in-hospital mortality rate was 56.9 % in patients with PEff and pulmonary involvement above 50 %, in-hospital mortality rate was 34.4 % in patients with pulmonary involvement above 50 % and without PEff (p<0.001).The presence of PEff during admission for COVID-19 disease, the appearance of PEff or increase in the degree of PEff during follow-up were closely related to mortality and prognosis.Conclusion    As the severity of pulmonary involvement or the clinical severity of the disease increased, PEff occurred in patients or the degree of PEff increased. The clinical prognosis of patients presenting with PEff was quite poor, and the frequency of intensive care admissions and mortality were significantly higher. PEff was an important finding in the follow-up and management of patients with COVID-19, and it reflected the clinical prognosis.

Pericardial Involvement in Severe COVID-19 Patients.

Background and Objectives: SARS-CoV-2 has an extensive tissue tropism due to its ability to attach to the surfaces of cells through different receptors, leading to systemic complications. In this article, we aim to present the prevalence of pericardial effusions in patients with severe COVID-19, to identify the risk factors/predictors for pericardial involvement, and to evaluate its impact on overall mortality. Materials and Methods: We enrolled 100 patients with severe COVID-19 in our observational cohort study and divided them in two groups: Group A (27 patients with pericardial effusion) and Group B (73 patients without pericardial effusion). We recorded demographic and lifestyle parameters, anthropometric parameters, clinical parameters, inflammation markers, respiratory function parameters, complete blood count, coagulation parameters, and biochemical serum parameters. All patients were evaluated by computer tomography scans within 48 h of admission. Results: The median age was 61 years in both groups and the male/female ratio was 3.5 vs. 2.8 in Group A vs. Group B. We identified mild pericardial effusion (3-4 mm) in 62.9% patients and moderate pericardial effusion (5-9 mm) in 37.1% patients, with a median value of 4 [3;6] mm. The patients with pericardial effusion presented with higher percentages of obesity, type-2 diabetes mellitus, arterial hypertension, and congestive heart failure, without statistical significance. Increased values in cardiac enzymes (myoglobin, CK, CK-MB) and LDH were statistically associated with pericardial effusion. The overall mortality among the participants of the study was 24% (24 patients), 33.3% in Group A and 20.8% in Group B. Conclusions: Pericardial effusion has a high prevalence (27%) among patients with severe forms of COVID-19 and was associated with higher mortality. Pericardial effusion in our study was not associated with the presence of comorbidities or the extent of lung involvement. Overall mortality was 60% higher in patients with pericardial effusion.

Acute pericarditis in patients receiving coronavirus disease 2019 vaccines: a case series from the community.

BACKGROUND: International agencies reported that cases of pericarditis occur very rarely following the administration of coronavirus disease 2019 (COVID-19) vaccines. Herewith, we described a series of patients from the community diagnosed with acute pericarditis after vaccination. METHODS: We retrospectively included 28 patients (median age 51 years, 79% female) with or without a positive history of acute respiratory syndrome coronavirus 2 recovered infection who were diagnosed with acute pericarditis following the administration of COVID-19 vaccine. We excluded specific identifiable causes of pericarditis, including infectious, autoimmune, neoplastic and metabolic disease. Patients were referred for a complete cardiovascular evaluation. Transthoracic echocardiography (TTE) was performed and diagnosis of acute pericarditis was achieved according to current guidelines. RESULTS: There were 16 patients administered with Pfizer-BioNTech/Comirnaty vaccine, 8 with Moderna/Spikevax vaccine and 4 with Astra Zeneca/Vaxzevria vaccine. Nine patients had been previously diagnosed with COVID-19, while the others had no prior history of COVID-19. Eleven patients had no comorbidity while the others had between one and four comorbidities. Ten patients had a history of rheumatic or autoimmune diseases. Chest pain was present in 24 patients. Minor ECG abnormalities were detected in 10 patients, T-wave inversion in 6, and 7 patients had concave ST elevation. The majority of patients showed mild pericardial effusions at TTE. Only two patients exhibited large pericardial effusions. CONCLUSION: This case series shows a higher incidence of acute pericarditis in patients administered with COVID-19 vaccines than previously estimated, probably because of a more comprehensive assessment of clinical as well as echocardiographic parameters.

Medium-Term Cardiac Outcomes in Young People with Multi-system Inflammatory Syndrome: The Era of COVID-19.

Multi-system inflammatory syndrome in children (MIS-C) causes widespread inflammation including a pancarditis in the weeks following a COVID infection. As we prepare for further coronavirus surges, understanding the medium-term cardiac impacts of this condition is important for allocating healthcare resources. A retrospective single-center study of 67 consecutive patients with MIS-C was performed evaluating echocardiographic and electrocardiographic (ECG) findings to determine the point of worst cardiac dysfunction during the admission, then at intervals of 6-8 weeks and 6-8 months. Worst cardiac function occurred 6.8 ± 2.4 days after the onset of fever with mean 3D left ventricle (LV) ejection fraction (EF) 50.5 ± 9.8%. A pancarditis was typically present: 46.3% had cardiac impairment; 31.3% had pericardial effusion; 26.8% demonstrated moderate (or worse) valvar regurgitation; and 26.8% had coronary dilatation. Cardiac function normalized in all patients by 6-8 weeks (mean 3D LV EF 61.3 ± 4.4%, p < 0.001 compared to presentation). Coronary dilatation resolved in all but one patient who initially developed large aneurysms at presentation, which persisted 6 months later. ECG changes predominantly featured T-wave changes resolving at follow-up. Adverse events included need for ECMO (n = 2), death as an ECMO-related complication (n = 1), LV thrombus formation (n = 1), and subendocardial infarction (n = 1). MIS-C causes a pancarditis. In the majority, discharge from long-term follow-up can be considered as full cardiac recovery is expected by 8 weeks. The exception includes patients with medium sized aneurysms or greater as these may persist and require on-going surveillance.

Abnormal Echocardiographic Findings in Hospitalized Patients with Covid-19: A Systematic Review and Meta-analysis. / Achados Ecocardiográficos Anormais em Pacientes Internados com Covid-19: Uma Revisão Sistemática e Metanálise.

BACKGROUND: Coronavirus disease 2019 (Covid-19) can lead to severe respiratory distress and acute cardiac injury, but it is unclear how often it can cause cardiac dysfunction. OBJECTIVE: In this systematic review, we aimed to summarize the main echocardiographic findings in patients with Covid-19. METHODS: We systematically searched in PUBMED, EMBASE, LILACS and Cochrane databases, in addition MedRxiv and Scielo preprints from inception to July 21st, 2021. Studies reporting echocardiographic data in patients with Covid-19 were included. Demographic characteristics, previous cardiovascular disease (CVD), and echocardiographic findings were extracted. We performed a meta-analysis of proportions to estimate the main echocardiographic findings. The level of significance was p < 0.05. RESULTS: From 11,233 studies, 38 fulfilled inclusion criteria and were included in the meta-analysis. The estimated proportions of left ventricular (LV) systolic dysfunction were 25% (95%CI: 19, 31; I293%), abnormal global longitudinal strain 34% (95% CI 23, 45; I290%), righ ventricular (RV) systolic dysfunction 17% (95%CI 13, 21; I290%), pericardial effusion 17% (95%CI: 9, 26; I297%), and pulmonary hypertension 23% (95%CI: 15, 33, I2 96%). LV systolic dysfunction was directly associated with study-specific prevalence of previous abnormal echocardiogram (p<0.001). The proportion of patients in mechanical ventilation, indicating severity of disease, did not explain the heterogeneity in the proportions of LV dysfunction (p=0.37). CONCLUSION: Among hospitalized patients with Covid-19, LV dysfunction has been reported in one quarter, with smaller proportions of right ventricular dysfunction, pericardial effusion and pulmonary hypertension. However, there was a higher proportion of LV dysfunction among studies reporting the presence of prior heart disease, which suggests that cardiac dysfunction was mostly pre-existing.

FUNDAMENTOS: A doença do coronavírus 2019 (Covid-19) pode levar à insuficiência respiratória grave e lesão cardíaca aguda, mas não está claro com que frequência ela pode causar disfunção cardíaca. OBJETIVOS: Nesta revisão sistemática, nosso objetivo foi resumir os principais achados ecocardiográficos em pacientes com Covid-19. MÉTODOS: Conduzimos uma busca sistemática nos bancos de dados PUBMED, EMBASE, LILACS e Cochrane, além de artigos não pulicados ( preprints ) no MedRxiv e Scielo desde o início até 21 de julho de 2021. Foram incluídos estudos que apresentaram dados ecocardiográficos de pacientes com Covid-19. Características demográficas, doença cardiovascular (DCV) prévia, e achados ecocardiográficos foram extraídos dos estudos. Realizamos uma metanálise de proporções para estimar os principais achados ecocardiográficos. O nível de significância foi p<0,05. RESULTADOS: Do total de 11 233 estudos, 38 preencheram os critérios de inclusão e foram incluídos na metanálise. A proporção estimada de disfunção sistólica do ventrículo esquerdo (VE) foi 25% (IC95%: 19, 31; I2 93%), strain longitudinal global anormal 34% (IC95% 23, 45; I2 90%), disfunção sistólica do ventrículo direito (VD) 17% (IC95% 13, 21; I2 90%), derrame pericárdico 17% (IC95%: 9, 26; I2 97%), e hipertensão pulmonar 23% (IC95%: 15, 33, I2 96%). Disfunção sistólica do VE foi diretamente associada com prevalência de ecocardiograma anormal prévio nos estudos (p<0,001). A proporção de pacientes em ventilação mecânica, indicando gravidade da doença, não explicou a heterogeneidade nas proporções de disfunção do VE (p=0,37). CONCLUSÃO: Entre os pacientes internados com Covid-19, a disfunção ventricular esquerda foi descrita em um quarto dos pacientes, com menores proporções de disfunção do ventrículo direito, derrame pericárdico e hipertensão pulmonar. No entanto, houve uma proporção mais alta de disfunção do VE nos estudos que relataram presença de doença cardíaca prévia, sugerindo que a disfunção cardíaca era predominantemente pré-existente.

[What's new in pericardial disease?] / Was ist neu bei Perikard-Erkrankungen?

Pericardial disease represents a large diversity of inflammation related injury of the pericardium. Multifactorial causes may contribute to acute and recurrent pericarditis, pericardial effusion without major hemodynamic compromise, cardiac tamponade or constrictive pericarditis. Currently, inflammatory pericardial pathologies are observed in cases of SARS-CoV-2-infection or after vaccination. Beside established anti-inflammatory therapeutic strategies with NSAID, corticosteroids and colchicine, auto-inflammation and inflammasomes seam to offer more specific targets for advanced treatment options.

Role of antibodies, inflammatory markers, and echocardiographic findings in postacute cardiopulmonary symptoms after SARS-CoV-2 infection.

Shortness of breath, chest pain, and palpitations occur as postacute sequelae of COVID-19, but whether symptoms are associated with echocardiographic abnormalities, cardiac biomarkers, or markers of systemic inflammation remains unknown. In a cross-sectional analysis, we assessed symptoms, performed echocardiograms, and measured biomarkers among adults more than 8 weeks after confirmed SARS-CoV-2 infection. We modeled associations between symptoms and baseline characteristics, echocardiographic findings, and biomarkers using logistic regression. We enrolled 102 participants at a median of 7.2 months following COVID-19 onset; 47 individuals reported dyspnea, chest pain, or palpitations. Median age was 52 years, and 41% of participants were women. Female sex, hospitalization, IgG antibody against SARS-CoV-2 receptor binding domain, and C-reactive protein were associated with symptoms. Regarding echocardiographic findings, 4 of 47 participants (9%) with symptoms had pericardial effusions compared with 0 of 55 participants without symptoms; those with effusions had a median of 4 symptoms compared with a median of 1 symptom in those without effusions. There was no strong evidence for a relationship between symptoms and echocardiographic functional parameters or other biomarkers. Among adults more than 8 weeks after SARS-CoV-2 infection, SARS-CoV-2 RBD antibodies, markers of inflammation, and, possibly, pericardial effusions are associated with cardiopulmonary symptoms. Investigation into inflammation as a mechanism underlying postacute sequelae of COVID-19 is warranted.

Radiological Imaging of Viral Pneumonia Cases Identified Before the COVID-19 Pandemic Period and COVID-19 Pneumonia Cases Comparison of Characteristics (preprint)

Background: Thoracic CT imaging is widely used as a diagnostic method in the diagnosis of COVID-19 pneumonia. Radiological differential diagnosis and isolation of other viral agents causing pneumonia in patients gained importance, especially during the pandemic period. Aims: We aimed to investigate whether there is a difference between the CT imaging findings characteristically defined in COVID-19 pneumonia and the findings detected in pneumonia due to other viral agents, and which finding may be more effective in the diagnosis. Study Design: The study included 249 adult patients with pneumonia found in thorax CT examination and positive COVID-19 RT-PCR test and 94 patients diagnosed with non-COVID pneumonia (viral PCR positive, no bacterial/fungal agents were detected in other cultures) from the last 5 years before the pandemic. It was retrospectively analyzed using the PACS System. CT findings were evaluated by two radiologists with 5 and 20 years of experience who did not know to which group the patient belonged, and it was decided by consensus. Methods: Demographic data (age, gender, known chronic disease) and CT imaging findings (percentage of involvement, number of lesions, distribution preference, dominant pattern, ground-glass opacity distribution pattern, nodule, tree in bud sign, interstitial changes, crazy paving sign, reversed halo sign, vacuolar sign, halo sign, vascular enlargement, linear opacities, traction bronchiectasis, peribronchial wall thickness, air trapping, pleural retraction, pleural effusion, pericardial effusion, cavitation, mediastinal/hilar lymphadenopathy, dominant lesion size, consolidation, subpleural curvilinear opacities, air bronchogram, pleural thickening) of the patients were evaluated. CT findings were also evaluated with the RSNA consensus guideline and the CORADS scoring system. Data were divided into two main groups as non-COVID-19 and COVID-19 pneumonia and compared statistically with chi-square tests and multiple regression analysis of independent variables. Results: Two main groups; RSNA and CORADS classification, percentage of involvement, number of lesions, distribution preference, dominant pattern, nodule, tree in bud, interstitial changes, crazy paving, reverse halo vascular enlargement, peribronchial wall thickness, air trapping, pleural retraction, pleural/pericardial effusion, cavitation and mediastinal/hilar lymphadenopathy were compared, significant differences were found between the groups (p < 0.01). Multiple linear regression analysis of independent variables found a significant effect of reverse halo sign ({beta} = 0.097, p <0.05) and pleural effusion ({beta} = 10.631, p <0.05) on COVID-19 pneumonia. Conclusion: Presence of reverse halo and absence of pleural effusion was found to be efficient in the diagnosis of COVID-19 pneumonia.

Life-Threatening Cardiac Tamponade Secondary to COVID-19 Treated with Uniportal Video-Assisted Thoracoscopic Surgery: A Case Report.

BACKGROUND The COVID-19 outbreak emerged in December 2019 in Wuhan, China. COVID-19 is caused by the SARS-CoV-2 coronavirus and mostly affects the respiratory system but can also affect other organs, including the cardiovascular system. Furthermore, the most common cardiac complications include severe left ventricular dysfunction, acute myocardial injury, and arrhythmias. Life-threatening cardiac tamponade and large pericardial effusion are exceedingly rare complications in patients recovered from COVID-19. Previously, this condition was treated with pericardiocentesis, colchicine, and corticosteroids. CASE REPORT We present the case of a 54-year-old man who recovered from a SARS-CoV-2 infection 7 days before presentation and describe a complicated pericardial effusion with life-threatening cardiac tamponade. To the best of our knowledge, this is the first case of pericardial effusion with cardiac tamponade that was successfully treated with single port or uniportal video-assisted thoracoscopic surgery with an excellent outcome. CONCLUSIONS Life-threatening cardiac tamponade with pericardial effusion is an exceedingly rare complication in patients recovered from COVID-19. Generally, patients diagnosed with pericardial effusion undergo a pericardiocentesis procedure. Although there are multiple treatment options for draining pericardial effusion, the recurrence rate with surgical pericardial window formation is the lowest. However, our patient underwent surgery using a uniportal video-assisted thoracoscopic surgery with an excellent outcome.

Cardiac manifestations and short-term outcomes of multisystem inflammatory syndrome in Middle Eastern children during the COVID-19 pandemic: a case series.

We herein report on a series of four patients presented to our tertiary care centre with features of multisystem inflammatory syndrome in children and cardiac involvement. Two of our patients had recent exposure to a COVID-19-positive patient, one had recent documented infection, and another had no known positive contact. All the patients were tested positive for severe acute respiratory syndrome coronavirus 2 immunoglobulin G antibody at the time of presentation. All of them fulfilled the diagnostic criteria according to the World Health Organization Centers for Disease Control or the British guidelines for MIS-C (fever for ≥3 days, multisystem involvement (at least two), elevated markers of inflammation, and no other alternative diagnosis).Cardiac involvement was variable ranging from isolated ectasia of the coronary arteries to full-blown pancarditis such as severe biventricular dysfunction, multi-valvar involvement, and pericardial effusion.All our patients received intravenous immunoglobulin (2 g/kg), methylprednisolone, and aspirin and some required inotropic support and ICU admission.Remarkably, all our patients showed significant improvement in their cardiac disease within a few days as evident on serial echocardiographic evaluation. However, we stress the need for long-term follow-up as one of our patients demonstrated mild LV myocardial scarring as evident by gadolinium late enhancement on a cardiac MRI.

Giant Aortic Aneurysm in Child with Cutis Laxa Syndrome: Unusual Presentation, New Surgical Technique.

Ascending thoracic aortic aneurysms are rare in childhood and typically are seen in the setting of connective tissue defect syndromes. These aneurysms may lead to rupture, dissection, or valvular insufficiency, so root replacement is recommended. Here, we present a 17-month-old girl who presented with fever, cough, and pericardial effusion. Initially, we suspected this could be a COVID-19 case, so a nasopharyngeal swap was performed. An ascending aorta aneurysm involving the aortic arch was confirmed by echo, and urgent ascending aorta and arch replacement were done by utilizing the descending aorta as a new arch. The final diagnosis came with cutis laxa syndrome. In similar cases, good outcomes can be achieved with accurate diagnosis and appropriate surgical management.