Mid- and long-term atrio-ventricular mechanics in children after recovery from asymptomatic or mildly symptomatic SARS-CoV-2 infection

Background

Clinical manifestations of children's coronavirus disease-2019 (COVID-19) were initially considered less severe compared with adult patients. However, there is now increasing evidence of a “long-tail” of COVID-19 related symptoms lasting for several months after recovery from the acute infection. Long COVID-19-related symptoms and mechanisms are poorly characterized and understood, with several phenotypes reported, often driven by long-term tissue damage (such as lung, heart and brain) and pathological inflammation due to viral persistence and/or immune deregulation.

Purpose

The objective of this study was to evaluate atrio-ventricular mechanics, by means of two-dimensional speckle-tracking echocardiography, in previously healthy children recovered from asymptomatic or mildly symptomatic severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection in a long-term follow-up.

Methods

We analysed a cohort of 157 paediatric patients, mean age 7±4 years, who had a confirmed diagnosis of SARS-CoV-2 infection and were asymptomatic or mildly symptomatic for COVID-19. Patients underwent standard transthoracic echocardiogram and speckle tracking echocardiographic study 148±68 days after diagnosis. One hundred seven age, sex, and body surface area comparable healthy subjects were used as control group.

Results

Left ventricular ejection fraction was within normal limits in postCOVID-19 cases and CTRL with no significant differences between the two groups (postCOVID-19: 65.6±4% vs CTRL: 65.0±5%, p=0.182).

Left ventricular (LV) global longitudinal strain (postCOVID-19: −20.5±2.9%; CTRL: −21.8±1.7%; p<0.001) was significantly reduced in cases compared with CTRLs. An amount of 11 (7%) postCOVID-19 cases showed impaired GLS values < −17% and 95 subjects (60%) presented with a strain lower than −16% in more than 2 segments. These subjects did not show any difference regarding symptoms or serological findings. Moreover, GLS was significantly reduced in children with disease's onset during the second wave of COVID-19 pandemic, compared with those during the first wave (second wave: −20.2±2.6%; first wave: −21.2±3.4%; p=0.048). Finally, peak left atrial systolic strain was within the normal range in the postCOVID-19 group with no significant differences compared to CTRL (postCOVID-19: 49.1±12%; CTRL: 49.5±18%).

Conclusions

SARS-CoV-2 infection may affect left ventricular deformation in children despite an asymptomatic or only mildly symptomatic acute illness. Our data show an amount of 60% of children, recovering from asymptomatic or mildly symptomatic COVID-19, with still mild subclinical systolic cardiac impairment in the mid- and long-term follow-up after the infection. This subtle impairment was seen to be worse in children recovering from the second wave of COVID-19 compared to the first one.

A follow-up is needed to verify the reversibility of these alterations and their impact on long-term outcomes.

Funding Acknowledgement

Type of funding sources: None.

The impact of dominant ventricle morphology and accessory ventricle size on clinical outcomes after Fontan procedure

Objectives

the physio-pathological role of the morphological ventricular dominance (left, FSLV; right, FSRV), and the hemodynamic contribute of an accessory ventricular chamber (AVC), in patients with functional single ventricle (FSV) after Fontan operation are still uncertain due to conflicting data. We analyzed a cohort of Fontan patients to assess and correlate such anatomical features to late clinical outcomes.

Methods

We enrolled all patients after a Fontan procedure who underwent a cardiac magnetic resonance (CMR) and a cardiopulmonary exercise test (CPET) in the previous 3 years. Clinical, CMR and CPET data from the last follow-up visit were retrieved to analyze whether the size of any AVC and the morphological ventricular dominance (FSLV vs FSRV) were correlated with clinical outcomes (NYHA, need for reinterventions or cardiac transplantation, mortality, arrhythmias, liver disease and protein-losing enteropathy) and functional parameters (including FSV ejection fraction and presence of late gadolinium enhancement, LGE, on CMR and peak metabolic equivalents, pMETs, and peak oxygen consumption, pVO2, at CPET). All statistical tests were two tailed and significance was set at 0.05.

Results

we enrolled 50 patients: 29 had FSLV (58%), FSRV in 21 (42%). Median age at evaluation was 19.5 years [IQR 15–26]; median follow-up was 16 years [4–42]. NYHA class III or IV was present in 6%, while 4 (8%) underwent a re-do Fontan, 2 (4%) entered transplantation waiting list and one of these received a transplant. 2 patients (4%) died at follow-up. Statistical analysis showed that the accessory chamber was larger (&gt;20 cc/m2) in FSLV than in FSRV (p=0.01). In the post-operative period, FSRV was associated with higher incidence of low-cardiac output syndrome (p=0.043). In the long-term, there was no statistically significant difference in major clinical outcomes or NYHA class between the two groups. FSLV was associated with a better cardiac function (median FSV ejection fraction 56% vs 52%; p=0.041), less extent of LGE [p = 0.022], better functional capacity expressed by METs (14.1 vs 12.3; p=0.01) and pVO2 (1.625 ml/min vs 1.233 ml/min; p=0.033). An AVC was detected in all: its size was &lt;5 ml/m2 in 31%, 5–20 ml/m2 in 47%, and &gt;20 ml/m2 in 22%. A larger AVC was associated with higher need for postoperative ECMO support (p=0.007), while size of AVC was not associated to any statistically difference in clinical outcomes, cardiac function and functional capacity.

Conclusions

In Fontan circulation, a FSLV is correlated to better clinical and functional outcomes when compared to FSRV. On the other side, an AVC appears to be not significantly related to any clinical disadvantage. However, the immediate postoperative course may be influenced negatively by the presence of a larger AVC.

Funding Acknowledgement

Type of funding sources: None.

P151 RIGHT VENTRICULAR MECHANICS IN PATIENTS AFFECTED BY PULMONARY VALVE STENOSIS, BEFORE AND AFTER PERCUTANEOUS PULMONARY VALVULOPLASTY

Aim of the Study

To evaluate the mechanical changes of the right ventricle in patients undergoing balloon pulmonary valvuloplasty using transthstandard transthoracic echocardiography (TTE) and speckle–tracking echocardiography (STE) and to investigate the correlation between haemodynamic and echocardiographic parameters before and after treatment.

Materials and Methods

43 pediatric patients (19 males), mean age 3,2±4,9 years with severe pulmonary valve stenosis and indication for percutaneous balloon valvuloplasty were recruited. All patients underwent TTE and STE with analysis of right ventricle global longitudinal strain (RVGLS) one day before and after the procedure. For each patient were collected invasive parameters during balloon valvulopasty.

Results

After the procedure, there was an immediate reduction of both peak–to–peak transpulmonary gradient (Dp post) and ratio between the systolic pressure of right and left ventricle (RV/LV ratio) with a drop of 29,3±14,67mmHg and 0,43±0,03, respectively. Post–procedural echocardiography showed peak and mean transvalvar pressure gradient drop (50±32,23 and 31±17,97, respectively). The degree of pulmonary valve regurgitation was mild in 8% of patients before the procedure, following the intervention it reached 29% with a statistically significant increase (p = 0,007). However, moderate and severe regurgitation remained stable after the procedure. There was a significant improvement of Fractional Area Change (FAC) after the procedure (40,11% vs 44,42%, p = 0,01). TAPSE (p = 0,60) and longitudinal strain (p = 0,31), did not improve significantly after intervention. Finally, pre–procedural invasive RV/LV ratio showed good correlation to echocardiographic transvalvular peak and mean pressure gradient (R = 0,375, p = 0,019 and R = 0,40, p = 0,012, respectively), as well as with FAC (R = 0,31 p = 0,05), TAPSE (R = 0,62 p &lt; 0,001)and RVGLS (R = 0,46 p = 0,01)

Conclusions

Percutaneous balloon pulmonary valvuloplasty represents an efficient and safe procedure. Right ventricular global systolic function improved following afterload reduction, while longitudinal systolic function did not show improvement immediately after intervention. Finally, invasive preprocedural RV/LV ratio demonstrated better correlation with echocardiographic evaluation of stenosis degree and right ventricular function compared to invasive peak–to–peak pressure gradient. Therefore, RV/LV ratio should be preferred for the assessment of pulmonary valve stenosis.

P154 EVOLUTION OF ECHOCARDIOGRAPHIC AND CARDIAC MRI ABNORMALITIES DURING FOLLOW–UP IN PATIENTS WITH PREVIOUS MIS–C DIAGNOSIS

Background

Cardiovascular manifestations in the acute phase of MIS–C are frequent. However, there is lacking evidence regarding late cardiological follow–up of this cohort of patients. The aim of our study was to describe the early and late cardiac abnormalities in patients with MIS–C, assessed by standard echocardiography (TTE), speckle tracking echocardiography (STE), and cardiac MRI (CMR).

Materials and Methods

32 consecutive patients with confirmed MIS–C diagnosis were enrolled in this study. Clinical, laboratory and microbiological data were collected for all patients. At disease onset, all children underwent standard transthoracic echocardiography, STE with analysis of left ventricle global longitudinal strain (GLS) and 23 (75%) of them performed CMR. Patients underwent complete cardiological evaluation, including echocardiography and STE at two months (T1) and six months (T2) after diagnosis. CMR was repeated at six months after diagnosis.

Results

Mean age was 8.25±4years (range 1.3–17.7). Cardiovascular symptoms were present in 45.8% of cases. Thirteen children (40.6%) shared Kawasaki Disease–like symptoms, and 5 (15.6%) needed ICU admission. All patients showed an hyperinflammatory state. Tn–I was elevated in 20 (62.5%) and BNP in 28 (87.5%) patients. Median time to STE evaluation was 7 days and to CMR 18 days since fever onset. Mean LVEF at baseline was 58.8±10% with 10 patients (31%) below 55%. STE showed reduced mean LV GLS (–17.4±4%). Coronary dilation was observed in 9 (28,1%) patients. On CMR, LGE with nonischemic pattern was evident in 8/23 patients (35%). Median time to T1 and T2 evaluation was respectively 48.5 and 207 days. Follow–up data showed statistically significant improvement in left ventricular systolic function compared to acute phase. LVEF improved rapidly at T1 (62.5 ± 7.5 vs. 58.8±10.6%, p value 0.044) with only three patients (10%) below ≤ 55% at T1 and one patient (4%) at T2. LV GLS remained impaired at T1 (–17.2 ± 2.7 vs.–17.4 ± 4, p value 0.71), and significantly improved at T2 (–19±2.6% vs. –17.4±4%, p value 0.009). LV GLS was impaired (&gt;–18%) in 53% of patients at baseline and T1, while only 13% showed LV GLS reduction at T2. CMR, performed 6 months after diagnosis, showed LGE persistence in 33.4% of cases.

Conclusions

Even though, early cardiac involvement significantly improves during follow–up, subclinical myocardial damage seems to be still detectable 6 months follow up in one third of MIS–C patients.

Exercise stress echocardiography in paediatric and adolescent patients

Funding Acknowledgements

Type of funding sources: None.

INTRODUCTION

Exercise stress echocardiography (ESE) is still underused in paediatric patients, and very little data is available for congenital heart diseases (CHDs).

PURPOSE

To describe the current application of ESE in our Paediatric Cardiology Departments.

METHODS

Data from patients who underwent ESE in our Centres, including baseline and under stress symptoms, vital parameters, ECG, and echocardiograms were retrospectively analyzed and compared, as well as clinical management plans formulated based on ESEs results.

RESULTS

Forty-five patients from Centre 1 (median age 16 years), including 87% of patients with CHDs, and 20 patients from Centre 2 (median age 11 years), mainly tested to rule out myocardial ischemia, were included. Among patients from Centre 1, 28 had previously been treated surgically, 6 percutaneously and 11 were under follow-up. Indications for ESE/patients’ native diagnosis are illustrated in the picture.

Centre 1: Exercise was maximal in 17 patients, with 2 of them having symptoms at the peak of exercise. It was stopped beforehand in 28 patients because of dyspnea (3) and muscle fatigue (25). No arrhythmia was detected. ESE was considered as positive in 14 patients; after that, 3 patients underwent percutaneous interventions, 2 underwent cardiac surgery, 3 received indication for cardiac catheterization, 4 for advanced cardiac imaging and 2 for exercise restriction and medical therapy.

Centre 2: Fifteen patients (75%) completed the exercise, and none of them developed symptoms. In the remaining 25%, exercise was stopped because of muscle exhaustion. No arrhythmia was detected, and all the ESEs were negative.

Comparing the cohorts, no significant differences in terms of ejection fraction were noticed at rest and under stress. Patients in cohort 1 were older (p = 0,002), they achieved lower average maximal heart rate (p = 0,0001), performed less lasting exercise (p = 0,05) and ESE was maximal less frequently (p = 0,005). Lastly, they had significant changes in clinical decisions (p = 0,004).

CONCLUSIONS

ESE is a feasible and promising technique in paediatric cardiology, particularly in children with congenital heart diseases, and could influence significantly clinical management plans. Abstract Figure.

OUP accepted manuscript

Aims

Methods and results

Conclusion

Exercise stress echocardiography in children and teenagers with congenital heart diseases

Background

Exercise Stress Echocardiography (ESE) is currently applied to paediatric patients mainly to detect myocardial ischemia and few data is available for congenital heart diseases (CHDs).

Purpose

The aim of this study is to describe the current application of ESE in our Departments.

Methods

Data from patients who underwent ESE in our two centres were retrospectively analysed, as well as clinical management plans formulated based on ESEs results.

Results

Fifty-five patients (median age 15 years) were included. Among them, 19 had been previously treated surgically, 6 percutaneously and 30 were under follow-up.

Indications for ESE were: hypertension and/or evaluation of aortic arch gradient in patients treated surgically (5) or percutaneously (1) for aortic coarctation (ACo); aortic/subaortic gradient in bicuspid aortic valve (BAV) after balloon valvuloplasty (4), Ross (1), or under follow up (1); right ventricular and pulmonary valve function in Tetralogy of Fallot (3) and after percutaneous treatment of pulmonary atresia (1); atrio-ventricular valves gradient (1 for tricuspid dysplasia and 1 for left cor triatriatum); single ventricle function (1); pulmonary artery gradient (2) and myocardial ischemia (6) after Arterial Switch; rule out myocardial ischemia in coronary anomalies (4), chest pain (9), Kawasaki disease (KD 9), syncope (1) and in patients with ectopic beats under exercise (2); rule out dynamic obstruction in hypertrophic cardiomyopathy (HCM, 3).

The exercise was maximal in 28 patients, with 2 of them having symptoms at the peak of exercise. In the other patients, peak heart rate ranged from 52% to 84% of targeted values. Mean exercise duration and reached Watts were 10 minutes and 112, respectively. Reasons for ending exercise were muscle fatigue in 25 patients and dyspnoea in 2 patients. No arrhythmia was detected.

Clinical management changed in 10 of patients after ESE (20%), all having CHDs. Three patients underwent percutaneous interventions; 1 aortic balloon valvuloplasty, 1 stent dilation and 1 pulmonary valve replacement; 2 underwent surgery (1 aortic valve replacement and 1 subaortic membrane resection), 4 underwent further imaging including cardiac computed tomography (1), cardiac magnetic resonance (2) and cardiac catheterization (1); 1 received indication for restriction from intense physical activities.

Conclusions

ESE has an important clinical role in patients with congenital heart diseases, impacting clinical management.

Funding Acknowledgement

Type of funding sources: None. Indications for ESEChangements in clinical management

Left ventricle longitudinal strain alterations in asymptomatic or mildly symptomatic pediatric patients with recent SARS-CoV-2 infection

Funding Acknowledgements

Type of funding sources: None.

Background

Evidence suggests that clinical manifestations of children’s COVID-19 may be less severe. However, it has been described the pediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2 (PIMS-TS) which resembles other inflammatory conditions (i.e. Kawasaki disease). Patients affected by PIMS-TS showed cardiac involvement with myocardial injury, reduced left ventricle systolic function and coronary artery abnormalities. Little is known regarding cardiac involvement in pediatric patients with asymptomatic or mildly symptomatic SARS-CoV-2 infection.

Methods

We analyzed 23 pediatric patients (13males, 56%) with diagnosis of SARS-CoV-2 infection based on PCR analysis of nasopharingeal swab (NPS), and asymptomatic or only mildly symptomatic for COVID-19. Patients underwent standard transthoracic echocardiogram (TTE) within 2-3 month from diagnosis and after negative NPS for SARS-CoV-2. We performed offline analysis with GE EchoPAC software to measure global longitudinal strain (GLS) of the LV using 2D speckle tracking imaging. Therefore, we compared the results with a matched group of 23 controls (13males, 56%).

Results

Cases and controls were similar regarding age (5.9 ± 4.1years vs. 6.4 ± 4.4 years, p = 0.63), body surface area (0.98 ± 0.3m2 vs. 0.8 ± 0.4m2, p = 0.17), LV FS (37.9 ± 5.9% vs. 36.4 ± 8.3%, p = 0.74) and LV biplane EF (63.9 ± 5.2% vs. 66.4 ± 5.3%, p = 0.11). GLS analysis showed significant strain reduction of the LV mid-wall segments and of the basal anterior, posterior and septal inferior segments among cases compared to controls. Furthermore, in the case group there were 7 subjects (30%) with a strain below 16.5% in at least 3 segments.

Conclusion

SARS-CoV-2 infection may affect LV deformation in asymptomatic or only mildly symptomatic children, showing a peculiar pattern with lower longitudinal strain in all mid-wall segments of LV compared to control subjects. The clinical significance of this findings is unclear and follow-up is needed to verify the reversibility of this alterations.

Carotid Artery Approach as an Alternative to Femoral access for Balloon Dilation of Aortic Valve Stenosis in Neonates and Infants

Purpose

to evaluate the efficacy of a right common carotid artery cutdown as alternative access in neonates and small infants requiring a balloon dilation of aortic valve stenosis. In infants, the femoral approach is limited by difficulties in advancing the catheter across the valve and by the risk of femoral artery injuries.

Methods

from January 1997 to July 2000, 16 infants at our department underwent balloon dilation through a carotid artery cutdown. Infant weight ranged from 2670 to 6450 g; mean weight 3967 g, and age ranged from 1 to 157 days, mean age 42,8 days. Fifteen of 16 infants had aortic valve stenosis; the remaining infant presented with a aortic coartation relapse.

Results

In 15 infants an adequate dilation of the valve was obtained with no complications. In only one infant an arterial intimal disconnection was caused by inadequate choice of surgical instruments. At the end of the procedure, the carotid arteries were reconstructed with interrupted 7-0 prolene stitches. There were no neurological sequaelae observed. All infants were followed-up and examined by echocolordoppler ultrasound: all carotid arteries were open with no significant stenosis.

Conclusion

Our experience confirms that the carotid access proposed in 1973 by Azzolina et al is a valid and safe alternative to the usual percutaneous femoral access. In particular it could be useful in neonates and infants were the size of femoral vessels could facilitate important and dangerous complications.

Carotid artery approach as an alternative to femoral access for balloon dilation of aortic valve stenosis in neonates and infants

PURPOSE

to evaluate the efficacy of a right common carotid artery cutdown as alternative access in neonates and small infants requiring a balloon dilation of aortic valve stenosis. In infants, the femoral approach is limited by difficulties in advancing the catheter across the valve and by the risk of femoral artery injuries.

METHODS

from January 1997 to July 2000, 16 infants at our department underwent balloon dilation through a carotid artery cutdown. Infant weight ranged from 2670 to 6450 g; mean weight 3967 g, and age ranged from 1 to 157 days, mean age 42,8 days. Fifteen of 16 infants had aortic valve stenosis; the remaining infant presented with a aortic coartation relapse.

RESULTS

In 15 infants an adequate dilation of the valve was obtained with no complications. In only one infant an arterial intimal disconnection was caused by inadequate choice of surgical instruments. At the end of the procedure, the carotid arteries were reconstructed with interrupted 7-0 prolene stitches. There were no neurological sequaelae observed. All infants were followed-up and examined by echocolordoppler ultrasound: all carotid arteries were open with no significant stenosis.

CONCLUSION

Our experience confirms that the carotid access proposed in 1973 by Azzolina et al is a valid and safe alternative to the usual percutaneous femoral access. In particular it could be useful in neonates and infants were the size of femoral vessels could facilitate important and dangerous complications.

Repair of congenital mitral valve dysplasia in infants and children: is it always possible?

OBJECTIVES

Surgical management of congenital malformation of the mitral valve (MV) in the pediatric age group remains a therapeutic challenge for the wide spectrum of the morphological abnormalities and the high incidence of associated cardiac anomalies. We reviewed our experience so as to assess whether MV conservative surgery is always advisable and its results are superior to MV replacement.

METHODS

Thirty-four consecutive children (20 male and 14 female) with a mean age of 5.9 years (range 45 days-18 years) treated surgically for congenital MV disease between January 1987 and June 1999. Four patients (11.7%) were under 12 months of age, while 21 patients (62%) were younger than 5 years. Twenty-two patients presented with MV incompetence (or prevalent incompetence), while 12 presented with stenosis (or prevalent stenosis). Associated cardiac lesions were present in 22 patients (62.8%).

RESULTS

Mitral valve reconstruction was possible in all. There were no operative deaths. Three patients required reoperation for MV restenosis (a re-repair in one and MV replacement with mechanical prosthesis in two) 4 months, 27 months and 5.6 years after repair with no operative deaths. There was only one late death for prosthetic valve thrombosis. Follow-up data reveal that the 33 surviving patients are asymptomatic and well 4 months-12 years (mean 72 months) after surgery. At 12 years, actuarial survival and freedom from reoperation are 96.8 and 85.9%, respectively. Echocardiography performed in all of them shows no or mild incompetence or stenosis in 26 (78%), while residual moderate MV incompetence persists in six.

CONCLUSIONS

Our experience indicates that MV reconstructive procedures in infants and children with congenital MV dysplasia may be effective and reliable with low mortality and low incidence of reoperation rate. Mitral valve repair should always be attempted, especially in infants, despite the frequent severity of MV dysplasia, to avoid the drawbacks of the currently available prostheses.