Ongoing Dizziness Following Acute COVID-19 Infection: A Single Center Pediatric Case Series.

BACKGROUND: Dizziness is a common concern discussed at adolescent medical visits. In this series, we describe 9 pediatric patients with postacute sequelae of severe acute respiratory syndrome coronavirus disease 2 (SARS-CoV-2) who presented with persistent, debilitating dizziness for weeks to months after their acute infection. METHODS: Among the 9 patients, median age was 14 years (range: 11 to 17), 6 were female, and 8 had not received any SARS-CoV-2 vaccines. Five patients met diagnostic criteria for postural orthostatic tachycardia syndrome (POTS) by active standing testing and benefited from a combination of nonpharmacologic therapy (NPT) and medication. RESULTS: NPT alone did not improve symptoms in any patients. Patients who did not meet conventional criteria for POTS, but continued to have symptoms despite NPT compliance, also demonstrated subjective improvement in dizziness when medications were initiated. The majority of patients experienced improvement in dizziness and quality of life, including returning to sports teams and a regular school schedule. CONCLUSIONS: A review of the postacute sequelae of SARS-CoV-2 literature demonstrates increasing recognition of a subset of patients who develop autonomic dysfunction, including POTS, although the etiology and prognosis are not completely understood. Our case series aims to highlight the phenomenon of dysautonomia after acute SARS-CoV-2 infection and its response to therapy.

Early nutritional influences of cardiovascular health.

INTRODUCTION: Increasing evidence shows that nutritional choices during children's formative years, including prenatally, impacts the development of adult onset cardiovascular diseases (CVDs), such as hypertension, myocardial infarction, or stroke. AREAS COVERED: This literature review aims to synthesize the current body of evidence on nutritional factors, from conception through adolescence, which may influence a person's risk factors for future development of CVD. EXPERT OPINION: Given the escalating healthcare costs associated with CVD, it is imperative that medical professionals and scientists remain steadfast in prioritizing and promoting early CVD prevention, even within the first few years of life. Though not the only contributing risk factor, diet is a modifiable risk factor and has been shown to have a profound impact on the reduction of cardiovascular morbidity and mortality in adult literature. Nutritional choices should be targeted on multiple levels: prenatally with the mother, individually with the patient, in conjunction with their family unit, and also within the broader community wherein they reside. Healthcare providers can play a key advocacy role for local and national food environment policy changes.

Clinical and electrophysiological properties of atrial tachycardia after pediatric heart transplantation.

BACKGROUND: Pediatric heart transplant recipients are at an elevated risk for development of atrial tachycardia (AT); however, the underlying mechanisms and long-term outcomes are unclear. OBJECTIVE: We hypothesized that occurrence of AT in pediatric heart transplant recipients would be associated with a higher frequency of adverse events during follow-up. METHODS: A single-center retrospective review of all pediatric heart transplant recipients with suspected AT between 1997 and 2017 was performed. Unaffected controls were matched with cases for age and transplant era. Clinical characteristics and long-term outcomes were compared between groups. RESULTS: Of 294 heart transplant recipients, 13 with AT at electrophysiology study (4.4%) were identified and compared with 29 controls. The most common mechanism was focal (11), followed by atrial flutter (two), and electrical reconnection of a surgical atrial anastomosis (two). Focal AT was only observed in the right atrium or atrial septum, and was frequently found on or near the crista terminalis. Relative to controls, cases exhibited more frequent clinical evidence of rejection (9/13 vs 10/29, P  =  0.037). For patients with AT, there was a higher rate of death/retransplant among cases (log-rank P  =  0.022), which remained significant in multivariate analysis. CONCLUSION: In this cohort, the most common form of AT after pediatric heart transplantation was focal, with predilection for sites near the crista terminalis. Transplant patients with AT experienced a higher rate of clinical rejection and the composite end-point of retransplantation or death relative to unaffected controls.

Understanding the Correlation Between DSA, Complement Activation, and Antibody-Mediated Rejection in Heart Transplant Recipients.

BACKGROUND: Donor-specific HLA antibodies (DSA) are associated with increased rates of rejection and of graft failure in cardiac transplantation. The goal of this study was to determine the association of preformed and posttransplant development of newly detected DSA (ndDSA) with antibody-mediated rejection (AMR) and characterize the clinical relevance of complement-activating DSA in heart allograft recipients. METHODS: The study included 128 adult and 48 pediatric heart transplant patients transplanted between 2010 and 2013. Routine posttransplant HLA antibody testing was performed by IgG single-antigen bead test. The C3d single-antigen bead assay was used to identify complement-activating antibodies. Rejection was diagnosed using International Society for Heart and Lung Transplantation criteria. RESULTS: In this study, 22 patients were transplanted with preexisting DSA, and 43 patients developed ndDSA posttransplant. Pretransplant (P < 0.05) and posttransplant (P < 0.001) ndDSA were associated with higher incidence of AMR. Patients with C3d + DSA had significantly higher incidence of AMR compared with patients with no DSA (P < 0.001) or patients with C3d-DSA (P = 0.02). Nine (36%) of 25 patients with AMR developed transplant coronary artery disease compared with 17 (15.9%) of 107 patients without AMR (P < 0.05). Among the 47 patients who received ventricular assistant device (VAD), 7 of 9 VAD+ patients with preformed DSA experienced AMR compared with 7 of 38 VAD+ patients without preformed DSA, indicating presensitization to donor HLA significantly increased the risk of AMR (P < 0.01). CONCLUSIONS: Preformed and posttransplant ndDSA were associated with AMR. C3d + DSA correlates with complement deposition on the graft and higher risk of AMR which may permit the application of personalized immunotherapy targeting the complement pathway.

Single-Center Experience Using Selexipag in a Pediatric Population.

Pulmonary arterial hypertension (PAH) is a rare and progressive disorder. Current treatment in the pediatric population includes phosphodiesterase 5 inhibitors (PDE-5i), endothelin receptor antagonists (ERA), and both inhaled and intravenous prostacyclin pathway agonists. As of December 22, 2015 the first oral prostacyclin pathway agonist, selexipag (Uptravi®), was FDA approved in the US. In this case series, we discuss our single-center experience using selexipag in a pediatric population, composed of both patients with idiopathic PAH, and patients with congenital heart disease and PAH.

Unrepaired Tetralogy of Fallot with Absent Pulmonary Valve in a Mildly Symptomatic 16-Year-Old Boy.

Absent pulmonary valve is a rare and severe variant seen in only 3% to 6% of patients with tetralogy of Fallot. Fetuses with this combined condition who survive through birth typically need intervention in infancy or early childhood because of respiratory distress, heart failure, or failure to thrive. We describe the unusual case of a mildly symptomatic 16-year-old boy with these conditions who underwent successful primary repair. Our search of the medical literature yielded fewer than 5 cases of tetralogy of Fallot with absent pulmonary valve (or variants with an absent left pulmonary artery) and survival without repair into later adolescence or adulthood.