Comparison of the type and prevalence of cardiac involvement among children hospitalized with COVID-19 and Multisystem Inflammatory Syndrome in Children: A cross-sectional study (preprint)

Background: Since the outbreak of COVID-19 in late 2019, more than 772 million individuals have been infected. There are numerous reports and studies about the complications and effects of this viral disease on different systems of the body. One of the important complications of COVID-19 in children is a condition named “Multisystem Inflammatory syndrome in Children (MIS-C)” which has some manifestations similar to Kawasaki disease or sepsis. Methods: In this study, we retrospectively compared the cardiac complications of COVID-19 and MIS-C in individuals under 18 years old of age, admitted to the Children’s Hospital of Bandar-Abbas, Iran, in an 18-months period of time. Results: The prevalence of mitral regurgitation in MIS-C and COVID-19 groups was 36.4% and 15.6%, respectively. The prevalence of tricuspid regurgitation in MIS-C and COVID-19 groups was 62.8% and 34.6%, respectively. The prevalence of positive result for troponin enzyme level in MIS-C and COVID-19 groups was 24.2% and 7.4%, respectively. Conclusion: This study showed that the prevalence of cardiac involvement in MIS-C patients was greater than COVID-19 patients. Additionally, the most cardiac complications among these groups of patients were tricuspid regurgitation and mitral regurgitation.

Postcardiac injury syndrome caused by radiofrequency catheter ablation of persistent atrial fibrillation: severe pulmonary arterial hypertension with severe tricuspid regurgitation: a rare case report and literature review.

BACKGROUND: Postcardiac injury syndrome (PCIS) is an easy-to-miss diagnosis, but it is not an uncommon complication. The phenomenon of echocardiography (ECHO) showing both severe pulmonary arterial hypertension (PAH) and severe tricuspid regurgitation (TR) is indeed rare in PCIS after extensive radiofrequency ablation. CASE PRESENTATION: A 70-year-old male was diagnosed with persistent atrial fibrillation. The patient received radiofrequency catheter ablation due to his atrial fibrillation being refractory to antiarrhythmic drugs. After the anatomical three-dimensional models were created, ablations were performed on the left and right pulmonary veins, roof linear and bottom linear of the left atrium, and the cavo-tricuspid isthmus. The patient was discharged in sinus rhythm (SR). After 3 days, he was admitted to the hospital for gradually worsening dyspnea. Laboratory examination showed a normal leukocyte count with an increased percentage of neutrophils. The erythrocyte sedimentation rate, C-reactive protein concentration, interleukin-6, and N-terminal pro-B-type natriuretic peptide were elevated. ECG exhibited SR, V1-V4 of precordial lead P-wave amplitude which was increased but not prolonged, PR segment depression, and ST-segment elevation. Computed tomography angiography of the pulmonary artery revealed that the lung had scattered high-density flocculent flakes and a small amount of pleural and pericardial effusion. Local pericardial thickening was seen. ECHO showed severe PAH with severe TR. Diuretics and vasodilators did not relieve the symptoms. Tumors, tuberculosis, and immune system diseases were all excluded. Considering the patient's diagnosis of PCIS, the patient was treated with steroids. The patient recovered on the 19th day post ablation. The patient's condition was maintained until 2 years of follow-up. CONCLUSIONS: The phenomenon of ECHO showing severe PAH with severe TR is indeed rare in PCIS. Due to the lack of diagnostic criteria, such patients are easily misdiagnosed, leading to a poor prognosis.

Hyepereosiniphilic syndrome and COVID-19: 2 case reports.

BACKGROUND: Nearly half of the patients with hypereosinophilic syndrome (HES) have cardiovascular involvement, a major cause of mortality. COVID-19 infection can lead to cardiac involvement, negatively impacting the clinical course and prognosis. We reported two patients with HES complicated by COVID-19, with cardiac involvement and valve replacement. CASE PRESENTATION: Our first patient was a 27-year-old woman admitted due to dyspnea and signs of heart failure. She had severe mitral stenosis and mitral regurgitation on the echocardiogram. Corticosteroid therapy improved her symptoms initially, but she deteriorated following a positive COVID-19 test. A repeated echocardiogram showed right ventricular failure, severe mitral regurgitation, and torrential tricuspid regurgitation and, she underwent mitral and tricuspid valve replacement. Our second patient was a 43-year-old man with HES resulted in severe tricuspid stenosis, which was improved with corticosteroid treatment. He underwent tricuspid valve replacement due to severe valvular regurgitation. He was admitted again following tricuspid prosthetic mechanical valve thrombosis. Initial workups revealed lung involvement in favor of COVID-19 infection, and his PCR test was positive. CONCLUSION: COVID-19 infection can change the clinical course of HES. It may result in a heart failure exacerbation due to myocardial injury and an increased risk of thrombosis in prosthetic valves or native vessels due to hypercoagulability.

Inhaled Nitric Oxide in Acute Severe Pulmonary Hypertension and Severe Acute Respiratory Distress Syndrome Secondary to COVID-19 Pneumonia: A Case Report.

BACKGROUND Inhaled nitric oxide (iNO) is used as a treatment for pulmonary arterial hypertension (PAH). Severe hypoxia with hypoxic vasoconstriction caused by severe acute respiratory distress syndrome (ARDS) can induce pulmonary hypertension with hemodynamic implications, mainly secondary to right ventricle (RV) systolic function impairment. We report the case of the use of iNO in a critically ill patient with bilateral SARS-CoV-2 pneumonia and severe ARDS and hypoxemia leading to acute severe PAH, causing a ventilation/perfusion mismatch, RV pressure overload, and RV systolic dysfunction. CASE REPORT A 36-year-old woman was admitted to the Intensive Care Unit with a severe ARDS associated with SARS-CoV-2 pneumonia requiring invasive mechanical ventilation. Severe hypoxia and hypoxic vasoconstriction developed, leading to an acute increase in pulmonary vascular resistance, severe to moderate tricuspid regurgitation, RV pressure overload, RV systolic function impairment, and RV dilatation. Following 24 h of treatment with iNO at 15 ppm, significant oxygenation and hemodynamic improvement were noted, allowing vasopressors to be stopped. After 24 h of iNO treatment, echocardiography showed very mild tricuspid regurgitation, a non-dilated RV, no impairment of transverse free wall contractility, and no paradoxical septal motion. iNO was maintained for 7 days. The dose of iNO was progressively decreased with no adverse effects and maintaining an improvement of oxygenation and hemodynamic status, allowing respiratory weaning. CONCLUSIONS Sustained acute hypoxia in ARDS secondary to SARS-CoV-2 pneumonia can lead to PAH, causing a ventilation/perfusion mismatch and RV systolic impairment. iNO can be considered in patients with significant PAH causing hypoxemia and RV dysfunction.

Large tricuspid valve thrombus complicating COVID-19 pneumonia.

BACKGROUND: Hemostatic disturbances with coronavirus disease 2019 (COVID-19) can predispose to tricuspid and right heart thrombi in very rare instances. AIM: We describe a 29-year-old female patient without a previous cause of thrombosis who developed large tricuspid valve thrombus (TVT) and moderate-to-severe tricuspid regurgitation (TR) during the course of COVID-19 infection. MATERIALS AND METHODS: Persistant fever and tachycardia with thrombocytopenia and high d-dimer increased the index of suspicion. The diagnosis was made by bedside transthoracic echocardiography (TTE) and cardiac magnetic resonance (CMR). Surgery was performed for thrombectomy and tricuspid valve replacement with a tissue valve. DISCUSSION AND CONCLUSION: Detection of TVT in COVID-19 patients on the basis of high index of suspicion, bedside TTE and noninvasive CMR helps early surgical treatment and subsequent reduction of mortality and hospital stay.

Whooping cough complicating pulmonary hypertension in pregnancy.

We report a case of a previously fit woman who presented at 26 weeks into her fourth pregnancy with a dry cough. Following a nasopharyngeal swab, she was diagnosed with a pertussis infection, and treated with antibiotics. A chest X-ray showed right atrial dilatation and an echocardiogram was scheduled outpatient. However, after re-presenting with worsening cough and dyspnoea, an inpatient echocardiogram was performed which suggested elevated pulmonary pressures with significant tricuspid regurgitation, as confirmed by subsequent cardiac catheterisation. She had an elective caesarean section at 34 weeks and underwent repeat right heart catheterisation which revealed persistent, and likely pre-existing, pulmonary arterial hypertension. This case highlights the importance of thorough assessment of non-obstetric symptoms in pregnancy in formulating alternative differentials, even after a diagnosis has been made, to prevent potentially life-threatening conditions from being missed. It also shows that although often associated, respiratory and cardiac causes may coexist separately.

Cardiac involvement in a child post COVID-19: a case from Lebanon.

We report on an 8-year-old boy, who presented to the emergency department at our institution with fever, generalised oedema and hypotension. Investigations revealed anaemia, thrombocytopenia in addition to elevated serum inflammatory markers, a negative COVID-19 PCR test and a positive COVID-19 IgG. His echocardiography was consistent with carditis in otherwise morphologically normal heart with depressed cardiac function, moderate-to-severe mitral valve regurgitation, moderate tricuspid regurgitation with an estimated right ventricular systolic pressure half systemic, trace aortic regurgitation, bilateral small pleural effusions, distended inferior vena cava and normal coronaries. He was started on inotropic support, intravenous immunoglobulin and methylprednisolone, and was transferred to the paediatric intensive care unit. To the best of our knowledge, this was the first case of multisystem inflammatory syndrome in children encountered in Lebanon. The presentation and management were thoroughly described in this article aiming to share our experience and to contribute to the rapidly emerging literature on this syndrome.

Video-assisted minimal access surgery for complicated mitral valve endocarditis, tricuspid valve insufficiency and progressive coronary disease after previous CABG - in the time of COVID-19: a case report.

BACKGROUND: The timing for heart surgery following cerebral embolization after cardiac valve vegetation is vital to postoperative recovery being uneventful, additionally Covid-19 may negatively affect the outcome. Minimally invasive methods and upgraded surgical instruments maximize the benefits of surgery also in complex cardiac revision cases with substantial perioperative risk. CASE PRESENTATION: A 68 y.o. patient, 10 years after previous sternotomy for OPCAB was referred to cardiac surgery on the 10th postoperative day after neurosurgical intervention for intracerebral bleeding with suspected mitral valve endocarditis. Mitral valve vegetation, tricuspid valve insufficiency and coronary stenosis were diagnosed and treated by minimally invasive revision cardiac surgery on the 14th postoperative day after neurosurgery. CONCLUSION: The present clinical case demonstrates for the first time that the minimally invasive approach via right anterior mini-thoracotomy can be safely used for concomitant complex mitral valve reconstruction, tricuspid valve repair and aorto-coronary bypass surgery, even as a revision procedure in the presence of florid endocarditis after recent neurosurgical intervention. The Covid-19 pandemic and prophylactic patient isolation slow down the efficacy of pulmonary weaning and mobilisation and prolong the need for ICU treatment, without adversely affecting long-term outcome.

Video-assisted minimal access surgery for complicated mitral valve endocarditis, tricuspid valve insufficiency and progressive coronary disease after previous CABG - in the time of COVID-19: a case report (preprint)

Background: The timing for heart surgery following cerebral embolization after cardiac valve vegetation is vital to postoperative recovery being uneventful, additionally Covid-19 may negatively affect the outcome. Minimally invasive methods and upgraded surgical instruments maximize the benefits of surgery also in complex cardiac revision cases with substantial perioperative risk. Case Presentation: A 68 y.o. patient, 10 years after previous sternotomy for OPCAB was referred to cardiac surgery on the 10 th postoperative day after neurosurgical intervention with suspected mitral valve endocarditis. Mitral valve vegetation, tricuspid valve insufficiency and coronary stenosis were diagnosed and treated by minimally invasive revision cardiac surgery. Conclusion: The present clinical case demonstrates for the first time that the minimally invasive approach via right anterior mini-thoracotomy can be safely used for concomitant complex mitral valve reconstruction, tricuspid valve repair and aorto-coronary bypass surgery, even as a revision procedure in the presence of florid endocarditis after recent neurosurgical intervention. The Covid-19 pandemic and prophylactic patient isolation slow down the efficacy of pulmonary weaning and mobilisation and prolong the need for ICU treatment, without adversely affecting long-term outcome.

Acute pulmonary hypertension and short-term outcomes in severe Covid-19 patients needing intensive care.

INTRODUCTION: Critically ill Covid-19 pneumonia patients are likely to develop the sequence of acute pulmonary hypertension, right ventricular (RV) strain, and eventually RV failure due to known pathophysiology (endothelial inflammation plus thrombo-embolism) that promotes increased pulmonary vascular resistance and pulmonary artery pressure. This study aimed to investigate the occurrence of acute pulmonary hypertension (aPH) as per established trans-thoracic echocardiography (TTE) criteria in Covid-19 patients receiving intensive care and to explore whether short-term outcomes are affected by the presence of aPH. METHODS: Medical records were reviewed for patients treated in the intensive care units at a tertiary university hospital over a month. The presence of aPH on the TTE was noted, and plasma NTproBNP and troponin were measured as markers of cardiac failure and myocardial injury, respectively. Follow-up data were collected 21 d after the performance of TTE. RESULTS: In total, 26 of 67 patients (39%) had an assessed systolic pulmonary artery pressure of > 35 mmHg (group aPH), meeting the TTE definition of aPH. NTproBNP levels (median [range]: 1430 [102-30 300] vs. 470 [45-29 600] ng L-1 ; P = .0007), troponin T levels (63 [22-352] vs. 15 [5-407] ng L-1 ; P = .0002), and the 21-d mortality rate (46% vs. 7%; P < .001) were substantially higher in patients with aPH compared to patients not meeting aPH criteria. CONCLUSION: TTE-defined acute pulmonary hypertension was frequently observed in severely ill Covid-19 patients. Furthermore, aPH was linked to biomarker-defined myocardial injury and cardiac failure, as well as an almost sevenfold increase in 21-d mortality.

Intraoperative heparin resistance, severe tricuspid valve regurgitation and acute right ventricular failure following large right atrial myxoma excision in a post corona virus disease -2019 patient -- A case report (preprint)

ABSTRACT INTRODUCTION Tricuspid valve regurgitation (TR) and severe right ventricular (RV) systolic dysfunction may appear acutely after right atrial (RA) myxoma excision. Covid-19 infection may have a role in production of Heparin resistance. METHODS A case of post covid-19 infected RA myxoma was operated by surgical excision develop severe TR and acute right ventricular systolic dysfunction postoperatively for which Tricuspid valve ring annuloplasty was performed and RV was supported on Cardiopulmonary bypass (CPB). RESULTS RV dysfunction did not improve leading to cardiac arrest and death. Conclusion • Excision of RA myxoma can unmask the severe TR and severe RV systolic dysfunction not responsive to TV ring annuloplasty. • COVID-19 infection might have a role in production of heparin resistance. KEY WORDS: Covid-19, tricuspid annuloplasty, intraoperative heparin resistance, RV Dysfunction, cardiopulmonary bypass.

Observations on echocardiographic findings in patients with COVID-19 (preprint)

Background The novel coronavirus (SARS-CoV-2) has created global havoc by causing Coronavirus Disease 2019 (COVID-19). Cardiovascular involvement in COVID-19 varies from troponin rise or arrhythmia/myocarditis to fulminant cardiogenic shock. There is limited data on echocardiographic findings in such patients. We aimed to assess abnormal echocardiographic findings and contributory factors in patients with COVID-19.Methods We performed retrospective analysis of COVID-19 positive patients who underwent a transthoracic echocardiogram (TTE) at Sandwell and West Birmingham (SWBH) NHS Trust between March 2020 and May 2020. Patients were compared based on TTE changes and divided into two groups (abnormal TTE and normal TTE).Results 66 out of 463 patients with COVID-19 had a TTE. 46 patients (69.7%) had abnormal findings on their TTE. Tricuspid regurgitation was the most common abnormality observed (26 (56.5%) patients), followed by aortic regurgitation (13 (28.3%) patients) and mitral regurgitation (12 (26.1%) patients). Haemoglobin and LDH were predictors of abnormal TTE (Hb OR: 0.97, p = 0.049, LDH, OR: 1.00, p = 0.03). Significantly more patients in the abnormal TTE group died during their inpatient stay compared to normal TTE (p = 0.01). Having an abnormal TTE was an independent predictor of death on regression analysis (OR: 0.229, p = 0.034).Conclusions This is the first detailed observational study looking at echocardiographic changes in admitted COVID-19 patients irrespective of disease severity. The most common abnormality was valve regurgitation. Patients with abnormal TTE were more likely to die in hospital.

Impaired cardiac function is associated with mortality in patients with acute COVID-19 infection.

BACKGROUND: COVID-19 infection may cause severe respiratory distress and is associated with increased morbidity and mortality. Impaired cardiac function and/or pre-existing cardiovascular disease may be associated with poor prognosis. In the present study, we report a comprehensive cardiovascular characterization in the first consecutive collective of patients that was admitted and treated at the University Hospital of Tübingen, Germany. METHODS: 123 consecutive patients with COVID-19 were included. Routine blood sampling, transthoracic echocardiography and electrocardiography were performed at hospital admission. RESULTS: We found that impaired left-ventricular and right-ventricular function as well as tricuspid regurgitation > grade 1 were significantly associated with higher mortality. Furthermore, elevated levels of myocardial distress markers (troponin-I and NT pro-BNP) were associated with poor prognosis in this patient collective. CONCLUSION: Impaired cardiac function is associated with poor prognosis in COVID-19 positive patients. Consequently, treatment of these patients should include careful guideline-conform cardiovascular evaluation and treatment. Thus, formation of a competent Cardio-COVID-19 team may represent a major clinical measure to optimize therapy of cardiovascular patients during this pandemic.