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.

Comprehensive collection of COVID-19 related prosthetic valve failure: a systematic review.

Since the beginning of the SARS-CoV-2 (COVID-19) pandemic, correlation of venous thromboembolism (VTE) and COVID-19 infection has been well established. Increased inflammatory response in the setting of COVID-19 infection is associated with VTE and hypercoagulability. Venous and arterial thrombotic events in COVID-19 infection have been well documented; however, few cases have been reported involving cardiac valve prostheses. In this review, we present a total of eight cases involving COVID-19-related prosthetic valve thrombosis (PVT), as identified in a systematic review. These eight cases describe valve position (mitral versus aortic) and prosthesis type (bioprosthetic versus mechanical), and all cases demonstrate incidents of PVT associated with simultaneous or recent COVID-19 infection. None of these eight cases display obvious non-adherence to anticoagulation; five of the cases occurred greater than three years after the most recent valve replacement. Our review offers insights into PVT in COVID-19 infected patients including an indication for increased monitoring in the peri-infectious period. We explore valve thrombosis as a mechanism for prosthetic valve failure. We describe potential differences in antithrombotic strategies that may offer added antithrombotic protection during COVID-19 infection. With the growing population of valve replacement patients and recurring COVID-19 infection surges, it is imperative to explore relationships between COVID-19 and PVT.

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.

Editor-in-Chief's Top Picks From 2022.

Each week, I record audio summaries for every paper in JACC, as well as an issue summary. This process has become a true labor of love due to the time they require, but I am motivated by the sheer number of listeners (16 million plus), and it has allowed me to familiarize myself with every paper that we publish. Thus, I have selected the top 100 papers (both Original Investigations and Review Articles) from distinct specialties each year. In addition to my personal choices, I have included papers that have been the most accessed or downloaded on our websites, as well as those selected by the JACC Editorial Board members. In order to present the full breadth of this important research in a consumable fashion, we will present these abstracts in this issue of JACC, as well as their Central Illustrations and podcasts. The highlights comprise the following sections: Basic & Translational Research, Cardiac Failure & Myocarditis, Cardiomyopathies & Genetics, Cardio-Oncology, Congenital Heart Disease, Coronary Disease & Interventions, Coronavirus, Hypertension, Imaging, Metabolic & Lipid Disorders, Neurovascular Disease & Dementia, Promoting Health & Prevention, Rhythm Disorders & Thromboembolism, and Valvular Heart Disease.1-100.

Genetic causal relationship between COVID-19 and valvular heart diseaseidentified by a two-sample Mendelian randomization study (preprint)

Background Many COVID-19-infected patients have been observed to develop unexplained valvular heart disease (VHD), and the association between COVID-19 and VHD remains inconclusive. Therefore, we conducted a two-sample Mendelian randomization study to infer causality between COVID-19 and VHD from a genetic perspective using COVID-19 genetic tools.Methods This study used genetic variables and summary statistics from COVID-19 and VHD genome-wide association studies (GWAS). Single nucleotide polymorphisms (SNPs) were selected based on the assumption of instrumental variables (IVs). The inverse-variance weighted (IVW) method was used as the main analysis method to summarize the causal effects between exposure and outcome, while the weighted median and weighted mode methods were used as secondary methods. MR-Egger was used to test for horizontal pleiotropy, and the Q-test was used to test for heterogeneity. Sensitivity analysis was conducted using leave-one-out method. Scatterplots, forest plots, and funnel plots were used to visualize the results of MR analysis.Results In this study, seven COVID-19-related SNPs were selected as IVs, and the IVW [odds ratio (OR) = 1.16, 95% confidence interval (CI) = 1.04 − 1.28, P = 0.008], weighted median (OR = 1.21, 95% CI = 1.06 − 1.39, P = 0.006), and weighted mode (OR = 1.27, 95% CI = 1.05 − 1.54, P = 0.047) analysis methods suggested a causal effect of COVID-19 on CHD. MR-Egger indicated no evidence of horizontal pleiotropy (P = 0.589), and the Q-test suggested no heterogeneity (IVW, P = 0.349). Sensitivity analysis indicated robustness of the MR analysis results.Conclusions MR analysis revealed a causal effect of COVID-19 infection on the occurrence of VHD, indicating that patients with COVID-19 had a higher risk of VHD.

Acute respiratory distress syndrome after SARS-CoV-2 infection on young adult population: international observational federated study based on electronic health records through the 4CE consortium ARDS after SARS-CoV-2 infection on young adult (preprint)

Purpose : In young adults (18 to 49 years old), investigation of the acute respiratory distress syndrome (ARDS) after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has been limited. We evaluated the risk factors and outcomes of ARDS following infection with SARS-CoV-2 in a young adult population. Methods : A retrospective cohort study was conducted between January 1st, 2020 and February 28th, 2021 using patient-level electronic health records (EHR), across 241 United States hospitals and 43 European hospitals participating in the Consortium for Clinical Characterization of COVID-19 by EHR (4CE). To identify the risk factors associated with ARDS, we compared young patients with and without ARDS through a federated analysis. We further compared the outcomes between young and old patients with ARDS. Results : Among the 75,377 hospitalized patients with positive SARS-CoV-2 PCR, 1001 young adults presented with ARDS ( 7.8% of young hospitalized adults). Their mortality rate at 90 days was 16.2% and they presented with a similar complication rate for infection than older adults with ARDS. Peptic ulcer disease, paralysis, obesity, congestive heart failure, valvular disease, diabetes, chronic pulmonary disease and liver disease were associated with a higher risk of ARDS. We described a high prevalence of obesity (53%), hypertension (38%- although not significantly associated with ARDS), and diabetes (32%). Conclusion : Trough an innovative method, a large international cohort study of young adults developing ARDS after SARS-CoV-2 infection has been gather. It demonstrated the poor outcomes of this population and associated risk factor.

Presentation, characteristics, treatments and outcomes of mechanically ventilated patients with COVID-19 in Bulgaria (preprint)

Background: The first surge of coronavirus disease 2019 (COVID-19) cases in Bulgaria occurred in the fall of 2020. To accommodate the rising number of critically ill patients, new intensive care units were formed in several hospitals. Here we describe the clinical presentation, patient characteristics, treatments and outcomes of mechanically ventilated COVID-19 patients in a newly formed COVID-19 ICU at a tertiary cardiac center in Sofia, Bulgaria. Methods: This is a retrospective observational study of mechanically ventilated COVID-19 patients admitted to Sveta Ekaterina University Hospital in Sofia, Bulgaria, between November 4th, 2020 and January 6th, 2021. Data were collected from electronic and written patient records and charts. Results: We identified 38 critical care patients admitted with respiratory failure and treated with mechanical ventilation at our COVID-19 ICU during this period. The median age was 66 (IQR 57-76, range 27-89) and 74% were male. Most patients, 36 (95%), had at least one comorbidity. The most common comorbidities were hypertension, valvular heart disease, ischemic heart disease and diabetes mellitus. Overall, 27 (71%) patients had a concomitant cardiac disease other than hypertension and 24% were recent cardiac surgical patients. Inotropic support was required in 29 (76%) patients, renal replacement therapy in 12 (32%) patients and prone positioning and ECMO were used in 5 (13%) and 2 (5%) patients respectively. The median duration of mechanical ventilation was 7.5 (IQR 5-14) days overall and 9 (IQR 6-13) days for survivors. At 30-days 28 (74%) of patients had died. Overall, 32 (84%) patients died in hospital and only 6 (16%) patients were discharged home. Conclusions: During the first major surge of COVID-19 cases in Bulgaria, despite the wave arriving later than in other countries, the healthcare system was largely unprepared. In our setting, mortality in critically ill patients requiring mechanical ventilation was very high at 85%. There may be several factors contributing to these results, namely the predominance of cardiovascular comorbidities in our patient population, the strained ICU capacity and the lack of medical personnel to provide adequate intensive care to such complex patients.

The impact of COVID-19 pandemic on aortic valve surgical service: a single centre experience.

BACKGROUND: The coronavirus-disease 2019 (COVID-19) pandemic imposed an unprecedented burden on the provision of cardiac surgical services. The reallocation of workforce and resources necessitated the postponement of elective operations in this cohort of high-risk patients. We investigated the impact of this outbreak on the aortic valve surgery activity at a single two-site centre in the United Kingdom. METHODS: Data were extracted from the local surgical database, including the demographics, clinical characteristics, and outcomes of patients operated on from March 2020 to May 2020 with only one of the two sites resuming operative activity and compared with the respective 2019 period. A similar comparison was conducted with the period between June 2020 and August 2020, when operative activity was restored at both institutional sites. The experience of centres world-wide was invoked to assess the efficiency of our services. RESULTS: There was an initial 38.2% reduction in the total number of operations with a 70% reduction in elective cases, compared with a 159% increase in urgent and emergency operations. The attendant surgical risk was significantly higher [median Euroscore II was 2.7 [1.9-5.2] in 2020 versus 2.1 [0.9-3.7] in 2019 (p = 0.005)] but neither 30-day survival nor freedom from major post-operative complications (re-sternotomy for bleeding/tamponade, transient ischemic attack/stroke, renal replacement therapy) was compromised (p > 0.05 for all comparisons). Recommencement of activity at both institutional sites conferred a surgical volume within 17% of the pre-COVID-19 era. CONCLUSIONS: Our institution managed to offer a considerable volume of aortic valve surgical activity over the first COVID-19 outbreak to a cohort of higher-risk patients, without compromising post-operative outcomes. A backlog of elective cases is expected to develop, the accommodation of which after surgical activity normalisation will be crucial to monitor.

[Position paper of the Italian Society of Cardiology (SIC) on COVID-19 vaccine priority in patients with cardiovascular diseases]. / Position paper della Società Italiana di Cardiologia (SIC): Priorità del vaccino COVID-19 nei pazienti con patologie cardiovascolari.

In over a year, the COVID-19 pandemic caused 2.69 million deaths and 122 million infections. Social isolation and distancing measures have been the only prevention available for months. Scientific research has done a great deal of work, developing in a few months safe and effective vaccines against COVID-19. In the European Union, nowadays, four vaccines have been authorized for use: Pfizer-BioNTech, Moderna, ChAdOx1 (AstraZeneca/Oxford), Janssen (Johnson & Johnson), and three others are currently under rolling review.Vaccine allocation policy is crucial to optimize the advantage of treatment preferring people with the highest risk of contagion. These days the priority in the vaccination program is of particular importance since it has become clear that the number of vaccines is not sufficient for the entire Italian population in the short term. Cardiovascular diseases are frequently associated with severe COVID-19 infections, leading to the worst prognosis. The elderly population suffering from cardiovascular diseases is, therefore, to be considered a particularly vulnerable population. However, age cannot be considered the only discriminating factor because in the young-adult population suffering from severe forms of heart disease, the prognosis, if affected by COVID-19, is particularly ominous and these patients should have priority access to the vaccination program. The aim of this position paper is to establish a consensus on a priority in the vaccination of COVID-19 among subjects suffering from different cardiovascular diseases.

Causes of death in people with cardiovascular disease: a prospective UK Biobank cohort study (preprint)

Cardiovascular disease (CVD) mortality has substantially improved over recent decades. Some evidence indicates this has been paralleled by an increasing proportion of non-cardiovascular mortality in people with CVD. However, the contemporary causes of death across a broad spectrum of CVDs, either alone or in combination, remains unclear. We analysed cardiovascular, infection, cancer and other causes of death prior to the COVID-19 pandemic in 493,280 participants in the prospective UK Biobank study. Studied CVDs included baseline: abdominal aortic aneurysm, atrial fibrillation, coronary artery disease, heart failure, hypertension, peripheral vascular disease, stroke, valvular heart disease and venous thromboembolic disease; we separately considered cardiovascular multimorbidity defined as the total number of these baseline CVDs. Crude mortality rates and Poisson regression analysis were used to quantify the absolute and relative risk of cause-specific death. Associations are reported as incidence rate ratios (IRR) with 95% CIs. During a median follow-up of 10.9 [IQR 10.1-11.6] years per participant, there were 27,729 deaths (20.4% primarily attributed to CVD, 53.6% to cancer, 5.0% to infection and 21.0% to other causes). As the number of co-morbid CVDs increased, the proportion of cardiovascular and infection-related deaths increased, whereas cancer and other deaths decreased. Accrual of multiple CVDs was associated with marked increases in relative risk of infection and cardiovascular death; versus those without CVD, people with three or more CVDs, the relative risk of cardiovascular death increased most (IRR 3.89; 95%CI 3.59-4.21), followed by infection (4.41; 3.44-5.64), with other (2.01; 1.72-2.35) and cancer (1.52; 1.35-1.72) being substantially less increased. All studied CVDs except atrial fibrillation were independently associated with increased risk of infection death, with heart failure (2.73; 1.60-4.66) and valvular heart disease (3.09; 2.38-4.00) posing the greatest risk. In conclusion, causes of death vary substantially between differing baseline CVDs, and according to the number of baseline CVDs, with non-cardiovascular deaths due to cancer and infection making an important contribution. Holistic and personalized care are likely to be important tools for continuing to improve outcomes in people with CVD.

Impact of Diabetes in Patients Waiting for Invasive Cardiac Procedures During COVID-19 Pandemic (preprint)

Background: During COVID-19 pandemic, elective invasive cardiac procedures (ICP) have been frequently cancelled or postponed. Consequences may be more evident in patients with diabetes. Objectives: The objective was to identify the peculiarities of patients with DM among those in whom ICP were cancelled or postponed due to the COVID-19 pandemic, as well as to identify subgroups in which the influence of DM has higher impact on the clinical outcome. Methods: : We included 2,158 patients in whom an elective ICP was cancelled or postponed during COVID-19 pandemic in 37 hospitals in Spain. Among them, 700 (32.4%) were diabetics. Patients with and without diabetes were compared. Results: : Patients with diabetes were older and had a higher prevalence of other cardiovascular risk factors, previous cardiovascular history and co-morbidities. Diabetics had a higher mortality (3.0% vs. 1.0%; p=0.001) and cardiovascular mortality (1.9% vs. 0.4%; p=0.001). Differences were especially important in patients with valvular heart disease (mortality 6.9% vs 1.7% [p<0.001] and cardiovascular mortality 4.9% vs 0.9% [p=0.002] in patients with and without diabetes, respectively). In the multivariable analysis, diabetes remained as an independent risk factor both for overall and cardiovascular mortality. No significant interaction was found with other clinical variables. Conclusion: Among patients in whom an elective invasive cardiac procedure is cancelled or postponed during COVID-19 pandemic, mortality and cardiovascular mortality is higher in patients with diabetes, irrespectively on other clinical conditions. These procedures should not be cancelled in patients with diabetes.

Comparison of Direct Oral Anticoagulants Versus Warfarin in Patients With Atrial Fibrillation and Bioprosthetic Heart Valves.

There are limited data regarding direct oral anticoagulants (DOACs) for stroke prevention in patients with bioprosthetic heart valves (BHVs) and atrial fibrillation (AF). The objectives of this study were to evaluate the ambulatory utilization of DOACs and to compare the effectiveness and safety of DOACs versus warfarin in patients with AF and BHVs. We conducted a retrospective cohort study at a large integrated health care delivery system in California. Patients with BHVs and AF treated with warfarin, dabigatran, rivaroxaban, or apixaban between September 12, 2011 and June 18, 2020 were identified. Inverse probability of treatment-weighted comparative effectiveness and safety of DOACs compared with warfarin were determined. Use of DOACs gradually increased since 2011, with a significant upward in trend after a stay-at-home order related to COVID-19. Among 2,672 adults with BHVs and AF who met the inclusion criteria, 439 were exposed to a DOAC and 2233 were exposed to warfarin. For the primary effectiveness outcome of ischemic stroke, systemic embolism and transient ischemic attack, no significant association was observed between use of DOACs compared with warfarin (HR 1.19, 95% CI 0.96 to 1.48, p = 0.11). Use of DOACs was associated with lower risk of the primary safety outcome of intracranial hemorrhage, gastrointestinal bleeding, and other bleed (HR 0.69, 95% CI 0.56 to 0.85, p < 0.001). Results were consistent across multiple subgroups in the sensitivity analyses. These findings support the use of DOACs for AF in patients with BHVs.

Transcatheter Aortic Valve Implantation During the COVID-19 Pandemic.

Transcatheter aortic valve implantation (TAVI) outcomes during the coronavirus disease 2019 (COVID-19) pandemic have not been fully evaluated and some structural programs in the world have been suspended during this period. We sought to evaluate and compare clinical outcomes in patients undergoing TAVI in pandemic versus nonpandemic era. In a single center, we compared 198 TAVI patients performed during 2019 to 59 patients performed during the COVID-19 pandemic period (March 1st to June 30th, 2020). Primary outcome was procedural success according to VARC criteria and 30-day mortality rates. VARC-defined procedural success was high in both groups (93.3% vs 96.6%; p = 0.53). There were no differences in any vascular complications (26% vs 19%; p = 0.3), permanent pacemaker implantation (11.8% vs 15.3%; p = 0.63), and length of hospital stay (5.2 vs 4.2 days; p = 0.29). Thirty-day mortality was similar (3% vs 3.4%; p = 1.0). We had no documented COVID-19 disease in our patients during follow up. In conclusion, TAVI procedures can be performed effectively and safely during the COVID-9 pandemic, using a minimalist approach, early discharge, and by maintaining proper use of personal protective equipment.